Income Inequality and Health

In this guest post, Ronald Labonté moves from describing the impact of income inequality on health to the implications of this relationship for both the Canadian and global context. He presents two sets of policy reforms necessary for acting on these contexts and illustrates the scope for Canadian engagement with both national and global policy options. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Acting to reduce health inequity: How much evidence is enough?

It is often asserted that more evidence is needed to take action on the social determinants of health. In this guest post Ted Schrecker identifies such claims as a key obstacle to achieving health equity. He argues that to overcome this obstacle, we must recognize that decisions about how much evidence is enough are irrevocably bound together with important ethical and political choices. Ted is a Professor of Global Health Policy at Durham University.

Paul Krugman: America’s Greatest Public Health Champion?

Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading […]

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No test, no visa: How mandatory immigration HIV testing makes Canada—and HIV—stand out as exceptional

In this guest post, Dr. Laura Bisaillon critiques the inner workings of the Canadian immigration system. She explores whether mandatory HIV testing is justified for prospective immigrants and challenges us to consider how broader socio-political relations shape such practices.

 What logic prevails that sees prospective immigrants and refugees to Canada submitted to a test that would be unlawful to impose on Canadians or permanent residents except by court order? Exploring answers to this troubling question is part of the puzzle that I unravelled in a recently completed social scientific study of the Canadian immigration system and analysis of state decision-making about the admissibility of applicants with HIV within this system. During 18 months of multilingual fieldwork in Montreal, Ottawa and Toronto, I met with over 60 people who described their experiences relating to mandatory HIV testing in the Canadian immigration process. This included HIV-positive applicant immigrants and refugees, nurses and other health providers, and lawyers and civil servants, among other actors.

When I present my research findings, I find that audiences are generally unaware that the Canadian state obliges applicants to submit to HIV testing as a pre-condition for applying to immigrate. Since 2002, Canada has required HIV testing of all persons aged 15 years and above who request Canadian permanent resident status (such as immigrant and refugee persons) and temporary resident status (such as migrant workers, students, and long-term visitors from certain countries; generally countries of the Global South). Citizenship and Immigration Canada manages testing within the immigration medical examination, and tuberculosis and syphilis are the two other conditions for which diagnostics are mandatory. It is not entirely surprising that the general population is unaware of HIV testing or other details of the immigration process. The immigration system is a large and opaque system that is organized as a perplexing and hard to navigate bureaucratic institution. These features make it difficult, time consuming and expensive for people to grasp and traverse. Canadian-born Canadians do not have to interact with the immigration system as immigrant hopefuls, and so its workings remain largely out of view and beyond the likelihood of critical assessment.

HIV testing is normalized as a good and necessary practice within biomedical ways of knowing and thinking about the world. The dominance of this position makes any problematizing of HIV testing difficult, and it also elides the socio-political and embodied contexts in which HIV testing happens. Approximately a half million Canadian immigration medical examinations are conducted annually worldwide. The vast majority of these take place outside of Canada, and the Canadian government actually knows little about the empirical conditions in which HIV testing occurs in these overseas locations. Findings from my research reveal problems, exclusions, and inequities within the practices associated with immigration HIV testing. Testing and practices to which it gives rise are routinized as something that ‘just must happen’ to people who aspire to be Canadians.

Empirical research findings show that there are practices associated with Canadian immigration HIV testing that are problematic. Problems occur for applicants with HIV, for contract physicians conducting HIV testing, and for the immigration system more broadly. For example, prospective immigrants are not necessarily aware they are being tested for HIV; there is a general absence of or inadequate personalized care at diagnosis with HIV; and, persons with HIV report not understanding that the immigration medical encounter is actually a filter where physicians are working within relations that are not therapeutic or in their subjective best interests.

The point is, mandatory immigration HIV testing makes Canada, as a nation—and HIV as a health condition—stand out as exceptional. Testing as a pre-condition for immigration is not inevitable. Unlike Canada, the vast majority of countries within the Organisation for Economic Co-operation and Development do not operate a policy designed to screen out applicants with HIV or that excludes persons who already take antiretroviral medication from the possibility of immigrating. Refugees and spouses are immigrant applicants who are not inadmissible on health grounds. Despite that in Canada HIV is increasingly compared to diabetes for its chronicity and manageability, this is true only under specific conditions, and, furthermore, refugees and immigrants interviewed for this research do not experience HIV according to such classification. Empirical findings show that in practice, HIV is, in fact, ‘othered’ and made exceptional within the Canadian immigration program. The addition of HIV testing in the immigration medical examination was the first change to the exam in about fifty years. No other condition attracts the degree of institutional scrutiny and surveillance that HIV does within the Canadian immigration process.

What role is there for the citizenry, health providers, and other actors? I suggest that legal reform work on the Canadian immigration system, with a specific focus on the place of HIV within this system, is a high priority. Research evidence such as the results generated through my study can provide an important empirical basis for this work. Second, persons who work with immigrant and refugee applicants with HIV are well placed to query the latter people about their experiences with immigration medical examination HIV testing as it occurs in Canada and overseas. Individual citizens and health providers can report irregularities and problems to Canadian-based civil society organizations with specific expertise in assessing and acting on unjust practices as these are directed to persons living with HIV, including the Canadian HIV/AIDS Legal Network ( and the HIV and AIDS Legal Clinic Ontario ( Last, we might bear in mind that the rationale for what we are asked to do in our work is not always readily evident, and sometimes what we are asked to accomplish is not defensible. In the case discussed here, it is not clear that mandatory HIV testing within the Canadian immigration medical examination is justified. By seeing our immediate workplaces and practices as parts of broader, complex socio-political relations, we are challenged to rethink how and in whose interests these places and practices work.


Fraser Institute on Health Care in Canada and Sweden: Selective Evidence, Even More Selective Conclusions

In this guest post, Ronald Labonté discusses a recent report from the Fraser Institute which compares the healthcare systems of Sweden and Canada. While the report aims to promote the privatization of the Canadian healthcare system, Labonté argues that its conclusions are ideologically driven and that the evidence it draws on must be considered in the wider sociopolitical context of both countries. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.


Thatcher’s Trickle-Up Economics Made Us Sick

In this guest post, Dr. Roberto DeVogli discusses the relationship between the policy agenda of Margaret Thatcher and important social determinants of health. A parallel is drawn between Thatcher’s economic reforms and the austerity policies plaguing Europe today. Dr. DeVogli is an Associate Professor at the Department of Public Health Sciences, University of California Davis […]


Trade and Public Health: What’s missing?

Expanding our understanding of the links between trade and health not only strengthens the call for better coherence between trade and health policy, but it is crucial to the success of this undertaking.


The Real American Exceptionalism: Our Lives Are Stressful, Unhealthy and Short

In this guest post, Dr. Mark Santow discusses American Exceptionalism in the context of a new report which shows the relative poor health status of Americans in relation to their international peers. Dr. Santow is an Associate Professor and Chair of the History Department at the University of Massachusetts-Dartmouth and blogs at Chants Democratic.


Curb the Spread of the Flu: don’t eat at restaurants that don’t provide paid sick leave

According to the Centers for Disease Control, the US is in the midst of the worst flu season it’s seen in a decade. In Boston, a state of emergency has been declared, where at least 18 people have died because of the flu. The CDC recommends that people with flu-like symptoms stay home and avoid […]


A top 5 list of the best public health top 10 lists

Commemorating each New Year is an endless supply of top 10 lists. When it comes to well-being, the majority of these lists portray very individualistic, very bio-medically skewed notions of health. This is a list of the top 5 public health top 10 lists which approach health with a greater consideration of the social determinants of health.

Structural Determinants of Health

Tackling Obesity: Should the UK take public health cues from the US?

The Royal College of Physicians says the UK needs its own Michelle Obama or Mayor Bloomberg to combat rising obesity, but are US leaders focused on the right messages when it comes to addressing expanding waistlines?


Walmart’s free healthcare plan and why strikers shouldn’t care

What are the health implications of Walmart’s new free healthcare program and what do they mean in the context of worker strife?

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