Abstract
OBJECTIVES: To identify, explore and critique features of how practices associated with immigration medicine are socially organized. Specifically, how the work of designated medical practitioners (DMP) - physicians who conduct immigration medical examinations of prospective immigrants to Canada as contractors to the Canadian government department of Citizenship and Immigration Canada - is organized to occur in interactions with applicants who are diagnosed with the human immunodeficiency virus during the immigration medical examination.
METHODS: Findings from a theoretically informed empirical study using institutional and political activist ethnography inform this article. Data collection and analytic activities spanning 18 months included observational work in institutional settings, textual review, 61 interviews, and 2 focus groups in three Canadian cities.
RESULTS: The medical examination of prospective immigrants to Canada is not organized as a therapeutic relation of care and has little to do with medicine per se. The rationale structuring the work of DMPs is actually administrative responsibilities. The work achieved by the DMP positions her/him as a key figure and important decision-maker within the Canadian immigration system.
CONCLUSION: The work of doctors who practice immigration medicine gives rise to contradictions and ethical problems. These are largely unresolvable because of the way in which the labour process in which the DMP is implicated is coordinated. The social organization of immigration doctoring practices has serious consequences for prospective immigrants to Canada, for doctors themselves, and for the Canadian immigration system more broadly.
Key words: Critical methods, designated medical practitioners, HIV/AIDS, immigration medical examination, immigration medicine, mandatory HIV screening, sociology
Résumé
OBJECTIFS: Identifier, explorer et critiquer l’organisation sociale des pratiques qui relèvent de la médecine de l’immigration. En particulier, comment le travail du médecin désigné - médecins contractuels au département fédéral de Citoyenneté et Immigration Canada chargés de faire l’examen médical aux fins de l’immigration d’immigrants prospectifs - est organisé lors des interactions avec les demandeurs de résidence canadienne ayant reçu un diagnostic de séropositivité au virus d’immunodéficience humaine lors de l’examen médical de l’immigration.
MÉTHODES: Les résultats d’une étude théorico-empirique qui a employé l’ethnographie institutionnelle et l’ethnographie d’activisme politique comme méthodes d’enquête fondent cet article. Les activités de collecte et d’analyse des données ont eu lieu pendant 18 mois et étaient constituées d’observations dans divers lieux institutionnels; d’analyse de textes; 61 entrevues; et 2 groupes de discussion («focus groups ») dans trois villes canadiennes.
RÉSULTATS: L’examen médical des immigrants prospectifs au Canada n’est pas l’occasion d’une intervention thérapeutique, et a peu de rapport avec la médecine proprement dit. Le raisonnement clinique du médecin désigné est en fait remplacé par des responsabilités administratives. Le travail effectué par ces médecins fait en sorte que cet individu soit une personne clé et un preneur de décision important au sein du système de l’immigration canadien.
CONCLUSION: Les pratiques réalisées par les médecins désignés donnent lieu à des contradictions et problèmes éthiques. Il y a peu de chances à ce que ces derniers soient rectifiés en raison de la manière dont ce médecin est appelé à travailler. L’organisation sociale des pratiques de la médecine de l’immigration a des conséquences sérieuses tant pour les immigrants prospectifs au Canada que pour les médecins eux-mêmes et le système de l’immigration canadien de façon générale.
Mots clés: dépistage obligatoire pour le VIH, examen médical aux fins de l’immigration, médecine de l’immigration, médecins désignés, méthodes critiques, sociologie, VIH/sida
Footnotes
Author’s note: A version of this article, entitled “Breached medical ethics and the contradictions posed by doctors working for the state”, was presented on June 1, 2012 at the Canadian Sociological Association’s New Directions in the Sociology of Public Health Panel at the Congress of the Humanities and Social Sciences, Waterloo, ON.
Acknowledgements: Through this article I remember Patrick Kristoff Truong (1969–2012) and thank Noulmook Sutdhibhasilp, Riz Quiaoit and Amutha Samgam of Asian Community AIDS Services in Toronto for their early support of this research. Thanks are extended to all informants who took part in this project, and to Ted Schrecker for his comments on drafts of this article. Research funding was provided by the Canadian Institutes of Health Research [grant number 200810IDR-198192-172991]; les Fonds de la recherche en santé du Québec [grant number 16588]; and the Ontario Metropolis Centre [Graduate Student Research Award].
Conflict of Interest: None to declare.
References
- 1.Walters V. Company doctors’ perceptions of and responses to conflicting pressures from labor and management. Soc Problems. 1982;30(1):1–12. doi: 10.2307/800180. [DOI] [PubMed] [Google Scholar]
- 2.Walters V. Company doctors: Standards of care and legitimacy: A case study from Canada. Soc Sci Med. 1984;19(8):811–21. doi: 10.1016/0277-9536(84)90398-8. [DOI] [PubMed] [Google Scholar]
- 3.Walters V. The politics of occupational health and safety: Interviews with workers’ health and safety representatives and company doctors. Can Rev Sociol Anthropol. 1985;22(1):57–79. doi: 10.1111/j.1755-618X.1985.tb00717.x. [DOI] [Google Scholar]
- 4.Yassi A. Occupational Disease and Workers’ Compensation in Ontario. Toronto, ON: Ministry of Labour; 1987. [Google Scholar]
- 5.Bisaillon L. Cordon sanitaire or healthy policy? 2012. [Google Scholar]
- 6.Bisaillon L. An analytic glossary for social inquiry using institutional and political activist ethnography. Int J Qualitative Methods. 2012;11(5):607–27. doi: 10.1177/160940691201100506. [DOI] [Google Scholar]
- 7.Campbell M. Institutional ethnography. In: Bourgeault I, de Dingwall R, Vrier R, editors. The Sage Handbook of Qualitative Methods in Health Research. Los Angeles, CA: Sage; 2010. [Google Scholar]
- 8.Smith G. Political activist as ethnographer. Social Problems. 1990;37(4):629–48. doi: 10.2307/800586. [DOI] [Google Scholar]
- 9.Carroll W. Marx’s method and the contributions of institutional ethnography. In: Frampton C, Kinsman G, Thompson A, Tilleczek K (Eds.), Sociology for Changing the World: Social Movements/Social Research. Black Point, NS: Fernwood Press, 2006.
- 10.Mykhalovskiy E, McCoy L. Troubling ruling discourses of health: Using institutional ethnography in community-based research. Critical Public Health. 2002;12(1):17–37. doi: 10.1080/09581590110113286. [DOI] [Google Scholar]
- 11.Deveau J. Workplace accommodation and audit-based evaluation process for compliance with the Employment Equity Act: Inclusionary practices that exclude. An institutional ethnography. Can J Sociol. 2012;36(3):151–72. [Google Scholar]
- 12.Smith G, Mykhalovskiy E, Weatherbee D. Getting ‘hooked up’: An organizational study of the problems people with HIV/AIDS have accessing social services. In: Smith D, editor. Institutional Ethnography as Practice. Lanham, MD: Rowman & Littlefield; 2006. [Google Scholar]
- 13.Rankin J, Campbell M. Managing to Nurse: Inside Canada’s Health Care Reform. Toronto, ON: University of Toronto Press; 2006. [Google Scholar]
- 14.DeVault M, McCoy L. Institutional ethnography: Using interviews to investigate ruling relations. In: Gubrium J, Holstein J, editors. Handbook of Interview Research: Context and Method. Thousand Oaks, CA: Sage; 2004. [Google Scholar]
- 15.McCoy L. Keeping the institution in view: Working with interview accounts of everyday experience. In: Smith D, editor. Institutional Ethnography as Practice. Oxford, UK: Rowman & Littlefield; 2006. [Google Scholar]
- 16.CitizenshipImmigration Canada. Access to Information and Privacy Division, Health Management Branch Database on HIV as of May 15. 2010. [Google Scholar]
- 17.Citizenship and Immigration Canada. OP [Overseas Processing] Medical Procedures, 2011. Available at: http://www.cic.gc.ca/english/resources/manuals/op/op15-eng.pdf (Accessed November 7, 2012).
- 18.Minister of Justice Canada. Immigration and Refugee Protection Act (S.C., 2001, c. 27). Available at: http://laws-lois.justice.gc.ca/eng/acts/I-2.5/page-1.html (Accessed November 1, 2012).
- 19.Minister of Justice Canada. Immigration and Refugee Protection Regulations (SOR/2002-227). Available at: http://laws-lois.justice.gc.ca/eng/regulations/SOR-2002-227/index.html (Accessed November 7, 2012).
- 20.CitizenshipImmigration Canada. Operational Processing Instruction 2002–004. Ottawa, ON: Citizenship and Immigration Canada; 2002. [Google Scholar]
- 21.Citizenship and Immigration Canada (CIC). Citizenship and Immigration Canada HIV Policy: Background Information [PowerPoint slides; on file with author], January 12, 2011.
- 22.Minister of Public WorksGovernment Services Canada. Handbook for Designated Medical Practitioners. Ottawa: Health Management Branch, Citizenship and Immigration Canada; 2009. [Google Scholar]
- 23.ImmigrationRefugee Board of Canada. Personal Information Form. Ottawa: Immigration and Refugee Board of Canada; 2011. [Google Scholar]
- 24.CitizenshipImmigration Canada. Immigration Medical Assessment and Inadmissibility Under Health Grounds [Power Point slides; on file with author] 2010. [Google Scholar]
- 25.Coyte P, Thavorn K. When does an immigrant with HIV represent an excessive demand on Canadian health or social services? Aporia. 2010;2(3):6–17. doi: 10.18192/aporia.v2i3.2981. [DOI] [Google Scholar]
- 26.Bailey T, Caulfield T, Ries N. Public Health Law and Policy in Canada. Markham, ON: LexisNexis Canada; 2005. [Google Scholar]
- 27.Klein A. HIV/AIDS and Immigration: Final Report. Toronto, ON: Canadian HIV/AIDS Legal Network; 2000. [Google Scholar]
- 28.Canadian HIV/AIDS Legal Network. Canada’s Immigration Policy as it Affects People Living with HIV: Questions and Answers. Toronto: Canadian HIV/AIDS Legal Network; 2012. [Google Scholar]
- 29.Bisaillon L. Human rights consequences of mandatory HIV screening policy of newcomers to Canada. Health and Human Rights. 2010;12(2):119–34. [PubMed] [Google Scholar]
- 30.Bisaillon L. Mandatory HIV testing and everyday life: A look inside the Canadian immigration medical examination. Aporia. 2011;3(4):5–14. doi: 10.18192/aporia.v3i4.2933. [DOI] [Google Scholar]
- 31.Bisaillon L. Les impacts du cordon sanitaire ceinturant les frontières canadiennes. Remaides. 2012;81(13):xi–xv. [Google Scholar]
- 32.Canadian Medical Association. CMA Code of Ethics. Ottawa: CMA; 2004. [Google Scholar]
- 33.Esland G. Professions and professionalism. In: Esland G, Salaman G, editors. The Politics of Work and Occupations. Toronto: University of Toronto Press; 1980. [Google Scholar]
- 34.Physicians f H Rights. Dual Loyalties: The Challenges of Providing Professional Health Care to Immigration Detainees. Cambridge, MA: Physicians for Human Rights; 2011. [Google Scholar]
- 35.Diamond T. Making Grey Gold: Narratives of Nursing Home Care. Chicago, IL: University of Chicago Press; 1992. [Google Scholar]
- 36.Barrett R. The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness. Cambridge: University of Cambridge Press; 1996. [Google Scholar]