A review of Cordon Sanitaire or Healthy Policy? How Prospective Immigrants with HIV are Organized by Canada’s Mandatory HIV Screening Policy, by Laura Bisaillon.
“The work of street-level bureaucrats is mostly hidden from public view, so even attentive citizens do not necessarily know what is going on” (Lipsky 2010, p. xviii). Such is the expression of the sociologist Michael Lipsky in his seminal book on the 1970s’ US administrations Street Level Bureaucracy: Dilemmas of the Individual in Public Services (New York: Russell Sage Foundation, 1980. Thirtieth Anniversary Expanded Edition published in 2010). In her doctoral dissertation entitled, Cordon Sanitaire or Healthy Policy ? How Prospective Immigrants with HIV are Organized by Canada’s Mandatory HIV Screening Policy, Laura Bisaillon sets out to uncover and make visible the works and workings of the Canadian State’s medico-legal bureaucracy of mandatory immigration HIV detection, and the way this screening ‘organizes’ the lives of people who request Canadian permanent residence status. Bisaillon’s aim is to “produce a detailed and contextual understanding and analysis of the social organization of the day-to-day world of immigrants to Canada who are tested for and found to be HIV-positive as a result of Canada’s mandatory immigration HIV screening policy” (p. 43, italics in original). Using an approach called “institutional ethnography” (p. 105ff) associated with the work of Canadian sociologist Dorothy Smith, and a research position she names “standpoint politic” (p. 117), Bisaillon reveals the troubling and contradictory consequences of Canada’s HIV screening policy on immigrants and refugees; how these people, as “standpoint informants” (p. 43), experience this obligatory interaction with the state’s medico-legal apparatus.
Ed.Note: At Laura Bisaillon’s request, we are including a link to her dissertation, available to download from University of Ottawa’s dissertation repository.
The notion of standpoint informants that Bisallion coins is central to the understanding of her study. It designates the group of refugee and immigrant applicants she worked with in this research, and it “emphasizes that the research is anchored in their relevancies” (p. 43). Bisaillon explicitly “takes sides” with immigrants in her ethnographic investigation of the workings of the Canadian HIV policy and medial examination process, conceiving of her research as an activist intervention that produced “evidence informed recommendations” (p. 277). Through this work, Bisaillon aimed to change the Canadian HIV screening process in favour of those who have no choice but to comply with it to proceed with Canadian immigration. Her dissertation is an attempt to engage with what Stefan Ecks has called evidence-based medical anthropology. This work reflects sociological studies that critically examine evidence in policy-making and advocate for a plurality of evidentiary regimes (Helen Lambert), including qualitative approaches. (See Stefan Ecks, “Three Propositions for an Evidence-based Medical Anthropology” in Journal of the Royal Anthropological Institute 14, 2008, pp. 77-92; Helen Lambert, “Plural Forms of Evidence in Public Health: Tolerating Epistemological and Methodological Diversity” in Evidence & Policy: A Journal of Research, Debate and Practice 9, 2013, pp. 43-48.)
The dissertation is organized into eight chapters including the introduction and conclusion. It contains extensive glossaries, timelines, maps and tables relating to Canada’s mandatory immigration HIV screening policy, and numerous texts that informed the policy’s introduction in 2002. In this way, this study can be understood as an organizing device itself: bringing light and order to the chaos and opacity of the Canadian institutional landscape of public health and immigration and the entanglements associated with these.
In the Introduction, Bisaillon clearly states the aims, concerns, methods, field settings and problematic guiding her work. She argues and illustrates that “the Canadian state’s ideological work related to the mandatory HIV policy and mandatory screening ushers in a set of institutional practices that are highly problematic for immigrants with HIV” (p. 45). This study is not meant to be a “theoretical critique of mandatory screening” (p. 48). Rather, it sets out to show the material circumstances of peoples’ lives and the way a specific national policy organizes these lives. From this empirical stance, Bisaillon challenges the truth claims of the Canadian state, which understands and promotes immigration HIV screening as a healthy policy. She demonstrates how statistics and reporting systems based on quantitative data naturalize the HIV screening practice in a way that is disconnected from the everyday bureaucratic practice in medical offices and even more so from immigrants’ experiences with immigration medical screening procedures. Bisaillon sets out to provide “a counterweight to accounts relying on statistical data and authoritative reports; the basis of which are abstracted forms of knowing divorced from experience” (p. 60).
The dissertation is divided into two parts. The first part is composed of Chapters 2 to 4 that engage with the existing institutional, epidemiological, policy and public health literature on immigration HIV screening (Ch. 2); the study’s methodological and theoretical approach (Ch. 3); and, Bisaillon’s fieldwork and analytic practices (Ch. 4). In Chapters 5 to 7, Bisaillon turns to the substance of the analysis.
In Chapter 2, Bisaillon looks closely at Canada’s mandatory immigration HIV screening policy. This includes what screening consists of in practice, and the socio-historical context of this institutional practice. She demonstrates how biopolitics are inscribed into immigration laws, and how immigrants are governed in the name of the health and wealth of the Canadian nation. Bisaillon reviews research knowledge produced by state actors, and critically examines this knowledge. In doing this, she points out a research gap: the HIV screening policy had not been critically examined until her dissertation. The third chapter is an extensive methodological reflection in which Bisaillon details her approach, institutional ethnography, and explains the epistemological value for her study of a standpoint politic. Chapter 4 extends the methodological discussion. Careful details are provided about Bisaillon’s fieldwork practices, including interviews, observations, focus groups, and textual analysis. Data collection methods and the five analytic strategies employed are explained. These include organization around the analytic categories of work, talk, texts, people, and institutions.
In Chapter 5, Bisaillon develops an empirical analysis of the mandatory immigration HIV screening policy. She shows the multiple entanglements between immigration HIV screening and the Canadian immigration application process, and the way these processes ‘enroll’ immigrants through particular technologies such as HIV, viral load, and CD4 count tests; bureaucratic practices such as application forms and visits to Designated Medical Practitioners appointed by government; and, the work of various actors such as health practitioners, lawyers, and state bureaucrats, as per Michel Callon’s analysis. (See Michel Callon, “Some Elements of a Sociology of Translation: Domestication of the Scallops and the Fishermen of St Brieuc Bay” in John Law (ed.), Power, Action and Belief. A New Sociology of Knowledge? London: Routledge, 1985, pp. 196-229.) Using the example of HIV screening, Bisaillon shows what I have called the “institutional transparency” of immigrants; describing the heightened surveillance and control that is directed at them; lying at the intersection of numerous bureaucratic regimes with which immigrants are confronted. (See Janina Kehr, “L’épaisseur des vies sociales. A propos du dépistage de la tuberculose” in Joëlle Vailly, Janina Kehr and Jörg Niewöhner (eds.) De la vie biologique à la vie sociale. Approches sociologiques et anthropologiques. Paris: La Découverte, 2011, pp. 268-297.)
In Chapter 6, Bisaillon describes the Canadian state’s “inadmissibility work” as it is put into practice as a “text mediated work organization” (p. 184). The immigration HIV screening practice is organized through one particular law: the Immigration and Refugee Protection Act (IRPA) and its annexed texts and practices. This configuration favours an “administrative, case-oriented reasoning” (p. 185) of HIV screening practices, which are set up around three “discursive organizers” (p. 186): safety, cost and health. How these values are put into practice through medical, administrative, and legal work, including the evaluation and assessment of immigrants to Canada, is elaborated on in the ethnographic sections of this chapter. Chapters 5 and 6 provide a detailed account of the paper and medical technologies involved in enforcing a law-based policy. The analysis shows how the triage of immigrant applicants is informed by cost considerations in which immigrants are conceived as potentially costs burdens and administrative cases rather than individuals.
The seventh and final chapter is the ethnographic heart of the heart of the dissertation: careful, close accounts of immigrants’ experiences with the mandatory immigration HIV screening policy. Framed within a composite rhetorical form combining lengthy interview extracts and ethnographic analysis, we take part in the immigration medical interaction between Anna, an African immigrant, and a Designated Medical Practitioner named Dr. Geta. Bisaillon reveals features of what happens before, during, and after Anna’s medical examination for immigration purposes. On the one hand, we see what medicine looks like when put into practice by medical bureaucrats rather than by caring doctors. The result is a highly standardized paperwork practice designed for clients rather than patients; lacking the primordial counseling and caring work for applicant immigrants who test HIV-positive. On the other hand, Bisaillon details the amount of work immigrants do to succeed with their immigration application; from waiting for translation of documents and producing evidence to authenticate them; to the thinking and remembering work to articulate their case; and, to the financial savings work needed to proceed with an application process in the first place.
In the Conclusion of this dissertation, the main arguments and findings are discussed. The Canadian immigration medical examination “serves states’ rather than standpoint informant interests” (p. 269); a fact that Bisaillon wants to make clear and potentially change. To this end, she proposes “nine evidence-based recommendations” (pp. 277-280) that are listed at the end of this dissertation.
Besides the attentiveness to immigrants’ lives and the relevance of putting their experience with immigration medical procedures front and centre (in contrast to the Canadian state’s abstractions of such experiences), there is an additional aspect of Bisaillon’s dissertation is particularly noteworthy. That is, the work’s contribution to the field of political ethnographies of the state. Bisaillon’s study is an example of empirical work into law-based bureaucratic practices and their consequences. Such explorations and analyses are lacking in public health, and this is especially the case from within comparative perspectives. I found it particularly striking to see that national public health and immigration laws such as the Canadian IRPA continue to be powerful local organizing devices in times of globalized markets and international population mobility and immigration. I confirm this point of view through findings from my own research into tuberculosis screening policies in France and Germany. Policies as Canada’s mandatory HIV immigration screening policy or tuberculosis screening in other countries are illustrious examples of the continued salience of the nation state in global biopolitics.
Policies such as Canada’s mandatory immigration HIV screening policy usefully illustrate the point that conceptions of immigrants’ bodies differ internationally. Constructions of these bodies as external, costly threats in what one might call settler of New World nations such as Australia, Canada, New Zealand or the US contrast with European conceptions and immigration laws. In Europe, mandatory medical screening policies are testaments of exclusionary public health laws aimed at regulating ‘old’ diseases such as tuberculosis. To my knowledge, equivalent policies have never been enforced related to HIV in Europe. (See Janina Kehr, “Blind Spots and Adverse Conditions of Care: Screening Migrants for Tuberculosis in France and Germany” in Sociology of Health and Illness 34, 2002: pp. 251-265.) In fact, quite the contrary is observed in practice in Europe. France, for example, grants residence permits to applicant immigrants because where the person is HIV-positive via a process that has become known as the “humanitarian clause”. Didier Fassin has described this process as ‘biolegitimacy’: where the sick body becomes the legitimate means to acquire political rights. (Didier Fassin, “The Biopolitics of Otherness: Undocumented Foreigners and Racial Discrimination in French Public Debate” in Anthropology Today 17, 2001: pp. 3-7.) Differences between the public health policies and practices in the New and Old Worlds are not only consequence of local, regional, and national public health histories. These differences have as much to do with the evolving ways in which immigrants and their bodies are conceived and disposed of by Western nation states on both sides of the Atlantic Ocean.
Institute of the History of Medicine
University of Zurich
Eighteen months of institutional ethnographic fieldwork in Montreal, Ottawa and Toronto
Personal interviews, observations and focus groups
Review of informant documents, publicly available texts, and documents obtained through access to information requests
University of Ottawa. 2012. 381 pp. Doctoral Supervisors: Ronald Labonte and Dave Holmes.
Image: “The Nest” (2011), artwork by Morgan McConnell, Dangerboy Design. Used with permission.