SPECIAL REPORT * DOCUMENT
Boycott casts shadow over San Francisco AIDS conference Andrew Orkin A statutory ban on the entry into the United States of people infected with the human immunodeficiency virus (HIV) has cast a shadow over the Sixth International AIDS Conference that will be held in San Francisco June 20-24. A growing list of countries, organizations, community groups and individuals have declared that they will boycott the event. Canadian organizations that will not be attending include the Canadian Red Cross Society, the Canadian Public Health Association, the Canadian Hemophilia Society, the Canadian AIDS Society, the Canadian AIDS Advisory Council and the government of Ontario. A number of prominent AIDS clinicians and researchers have also refused to attend. They include many members of the National Advisory Committee on AIDS (NAC-AIDS) and the HIV/ AIDS Research Program at the McGill Centre for Medicine, Ethics and Law in Montreal. At time of publication the
federal minister of health, Perrin Beatty, was considering a NACAIDS recommendation that the federal government join the boycott. He told Canadian Press that "from a public health point of view this sort of restriction makes no sense. It doesn't protect peoAndrew Orkin is a freelance writer and legal researcher based in Toronto and Montreal.
ple's health and it raises human rights issues which are very fundamental. If there aren't changes made we'll have to take a very serious look at Canada's position". Persons with HIV infection or AIDS are routinely refused entry to the United States under that country's Immigration and Nationality Act. Two limited exceptions were enacted in response to protests and will ease the admission of infected conference delegates. However, boycotters reject these special exceptions. They argue that restrictions discriminate against and stigmatize persons infected with HIV and drive those at risk of infection underground and out of reach of prevention and care. Dr. Normand Lapointe, an AIDS clinician and researcher at Hopital Ste-Justine in Montreal and the NAC-AIDS chairman, told CMAJ that NAC-AIDS decided to recommend a Canadian boycott after being approached by a number of organizations and after considerable debate. "At the international level, Canada always speaks out in favour of human rights. At the local level, a major result of the Fifth International Conference was that we must include those affected by this disease in the scientific process. We now have a PWA [person with AIDS] and two community group representatives on NAC-AIDS; at the clinical trial level we must
bring PWAs on board. If all this is central, PWAs have a full right to participate." At the international level, a who's who of Red Cross, AIDS, hemophilia, public health and development organizations, as well as medical associations and a handful of governments, have announced that they will not attend the San Francisco conference. These include the International League of Red Cross and Red Crescent Societies; the British, Canadian, French and Norwegian Red Cross societies; the British Medical Association, and Oxfam. The boycott creates a number of ironies. The theme of the Sixth International Conference is AIDS in the '90s: From Science to Policy. The scientific and public health communities have rejected exclusionary policies as unwarranted and unscientific. As well, San Francisco is the earliest epicentre of the AIDS epidemic in the developed world. The city and county of San Francisco, conference cosponsors, are renowned for their prompt, humane, and generous response to the epidemic San Francisco has been a refuge where infected Americans have gravitated. Finally, many of the organizations that have decided to boycott the conference are crucial partners in the delivery of community-based AIDS prevention and care. The conference, which is also sponsored by the University of CAN MED ASSOC J 1990; 142 (12)
California at San Francisco, the International AIDS Society, the American Foundation for AIDS Research (AmFAR) and the World Health Organization (WHO), will be held at San Francisco's premier conference hall, the Moscone Centre. Spokesman Dana van Gorder says the more than 500 organizers designed a program that "will give voice to issues and speakers from regions of the world and from impacted communities previously underrepresented in the dialogue about AIDS". Van Gorder reported that the boycott has had little apparent effect on registration, and none on the program. When this article was written, 7800 advance registrations and 4900 abstracts had been received, totals equivalent to those at last year's conference in Montreal; "over 10 000" registrants are expected to attend. Registrations from outside the US, however, have been markedly lower than expected. Dr. John Ziegler, chairman of the Organizing Committee, admits that "the conference may not achieve the mix of scientists and communitybased AIDS workers we envisioned".
At last June's Fifth International AIDS Conference in Montreal, the opening ceremonies and scientific sessions were disrupted by AIDS activists, who criticized organizers for poor representation of the AIDS community in the program and governments for inadequate responses to the AIDS epidemic. Some registrants from the scientific community said afterwards that they would rather attend more exclusive and less noisy meetings; others suggested splitting the event into two conferences, one concerned with scientific issues, the other with social ones. Neither of these approaches was felt appropriate for AIDS, a disease in which science and policy are, as the travel issue demonstrates, inextricably and painfully bound. It has been known since the Montreal conference that travel restrictions would pose a problem when the event moved to San Francisco - a number of delegates in transit to Montreal through the US were delayed or detained by American officials. A resolution was passed in Montreal condemning such restrictions and "seeking assurances from the government of the US that all persons
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wishing to attend [the San Francisco conference] will be assured entry into the US regardless of HIV status". The conference call for abstracts states that "conference cosponsors condemn immigration policies that discriminate against people with HIV infection. These policies impede the freeflowing exchange of scientific information. We are working with the United States government to change these policies to facilitate entry of registered conference participants with HIV infection". An amendment to the law, the Roman Bill, is before Congress. It would give the US Public Health Service, rather than Congress, the authority to determine the list of exclusionary diseases. The hope is that exclusion would be based on scientific, not political, grounds. The Centers for Disease Control and the US Public Health Service have both stated that all diseases with the exception of infectious tuberculosis should be eliminated as criteria for exclusion. However, observers are less than sanguine about its chances of passage before the conference. Or at all. Conference organizers and sponsors have lobbied the government intensively for repeal of the entry ban. This effort included a letter-writing campaign to President George Bush that brought mail from 150 leading AIDS researchers, including Dr. Jonas Salk. Although unwilling to eliminate the exclusion provision, two exceptions to the restrictions were put in place. The first allows for a 30-day "HIV waiver" to attend scientific or medical conferences, seek medical treatment, conduct business or visit relatives. The second provides for special 10-day visas for HIV-infected delegates to the San Francisco conference and the World Hemophilia Conference, which will be held in Washington in August. These exemptions have been widely criticized because many
feel that restrictions on the mobility of people with HIV infection or AIDS are, as WHO has stated, "ineffective, impractical, wasteful" and discriminatory. Public health experts have concluded that travel restrictions, if applied absolutely, would at best "briefly retard" the spread of HIV into areas of low infection. It is argued that money spent identifying and excluding infected visitors would be better spent on education and prevention. The United States is not alone in enacting these restrictions. A recent study undertaken at the McGill Centre for Medicine, Ethics and Law found that 50 or more countries have enacted AIDS-related restrictions on the entry of would-be entrants infected with HIV. However, more than 70 countries apply no restrictions or have declared adherence to WHO policy and the provisions of the International Health Regulations, which do not provide for HIV-related restrictions. The US appears to be one of a handful of countries with blanket HIVspecific exclusionary policies. That list also includes Bulgaria, China, Finland, Libya and the Soviet Union. Dr. Margaret Somerville of McGill University observed at a recent Montreal conference on AIDS and the law that foreigners are least able to challenge the restrictive AIDS-related legislation that is often demanded by some sectors of society. The US law and the exceptions to it have placed AIDS researchers, clinicians, community and support workers and PWAs in an awkward position. According to Bill Flanagan, executive director of AmFAR, opinion is divided within the US on whether to attend the conference. "The restrictions enraged us all, but while a number of prominent organizations, such as the Gay Mens' Health Crisis and the NAMES Project International AIDS Me-
morial Quilt, are boycotting, many others feel that Americans should pressure the government, not the organizers of a nongovernmental conference." A prominent Harvard immunologist said she and many colleagues will be attending: "I think it's unethical on my part, but I will be going. It's the only opportunity I get each year to see colleagues in the field." While the visa issue is academic for Americans, the US restrictions have practical implications for many in Canada and elsewhere. The citizens of nine Western countries, including Canada, do not normally require visas to enter the US, but those infected with HIV are obliged to apply for waivers or special visas, thereby plainly disclosing their HIV status to American authorities. Dr. June Osborn, dean of the School of Public Health at the University of Michigan and chairman of the US National Commission on AIDS, has criticized the restrictions as raising serious confidentiality problems for those who apply for special visas. Initially, waivers were stamped into applicants' passports, for all intents and purposes becoming an international tattoo of HIV infection. This practice was modified after protests, and applicants may now request that the special visas be stamped onto a separate sheet. With respect to confidentiality, "all files regarding the waiver are classified and will be handled by US personnel or local employees with appropriate security clearance". NAC-AIDS chairman Lapointe said this particular assurance is one of the factors that persuaded him to boycott the conference. It is contained in a detailed five-page package of "information forHIV-infected delegates" that was sent to all registrants. It also contains details of a 24-hour toll-free legal hotline that conference organizers have set up in anticipation of the
need for emergency assistance. Dr. Martin Schechter of the University of British Columbia, a NAC-AIDS member, has decided to attend the conference. "Travel restrictions are discriminatory and unwarranted", he said. "Existing Canadian immigration law could be used to exclude an HIVinfected visitor from Canada, so it is somewhat hypocritical to make a statement with regard to the US law. Canada should change its law." Pointing out that the San Francisco conference is privately sponsored, Schechter said that he and other delegates are considering a proposal that all foreign delegates, seropositive and seronegative alike, apply for waivers and special visas "to protest the restrictions directly to the US government". Does he worry that he and other attenders will be perceived as boycott busters? "This would be upsetting", he replied. "In this area of work we show solidarity day in and day out." Solidarity with HIV-infected people, it seems, is what motivates both boycotters and attenders. Lapointe points out that in recommending that Canada boycott the conference, NAC-AIDS was "not making a negative vote against the US law; the regulation speaks for itself'. The move, he said, was "a manifestation of solidarity of the AIDS researchers with the PWA community". It is now clear that the protests and boycott are unlikely to persuade the US government to eliminate AIDS-related travel restrictions. The problem will not end with the closing ceremony at the sixth conference, however. The 1992 conference, to be sponsored by Harvard University, is to be held in Boston. The International AIDS Society and other principal sponsors are believed to be indicating that if law is not changed, the conference will be moved to a country free of the
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