Recently, Mr. Derrick Burgess suggested that all immigrants be tested for HIV and/or AIDS.

Notwithstanding Mr. Burgess' claims that persons entering Bermuda with HIV can pose a severe strain on our taxpayers and the health-care system, there are a number of legal and ethical issues that surround making such a decision to test immigrants.

Endorsing these claims is politically tempting because politicians who support HIV testing can be portrayed as actively defending the interests of their constituents. Supporting such a decision would not affect them because those who are denied entry on the basis of their HIV status would, of course, never vote. I've taken some time to research the issue before responding to Mr. Burgess, and, while this response may be lengthy, I believe that each of the following areas of discussion must take place in Bermuda before we adopt such a policy.

HIV testing of immigrants could cause some serious harm. What immediately comes to mind is that it would play upon and reinforce deep-seated fears and prejudices. It is easy to perceive immigrants as unlike "us" and to stereotype their beliefs, values, and behaviours. It is also easy to characterise HIV as a disease that is rampant among strange people with strange ways of life. Discomfort with those who are perceived to be different, and fear of a horrible disease, are a powerful combination and powerful motivation for exclusion.

Moreover, that stigmatisation and rejection could spread to people with HIV who already live in Bermuda. Given this setting and these dangers, proposals for HIV testing of immigrants require careful ethical scrutiny. There are about 54 countries around the world that require such testing. Immigrants are expected to be tested for HIV infection or AIDS if they intend to stay for periods ranging from one to six months, or are attempting to enter such countries to reside and work.

In the United States, one of the most progressive countries in the world, people suspected of being HIV positive can be denied entry for even a vacation or business travel.

In some countries, it has been determined that HIV poses "a serious threat" to public health and safety. Who and what constitutes a threat to public health? Do all infectious diseases pose a threat to public health? If a risk is encountered in an occupational setting and that risk is an inherent part of that occupation, does it constitute a risk to public health, or is it an occupational health risk? Such legislation should not be interpreted as applying to people who are HIV positive unless they engage in behaviour likely to transmit the virus. In such circumstances, clearly these people are a threat to public health; in the absence of such behaviour they are not. Therefore, it is the possible behaviour of immigrants with HIV, not the disease itself, that poses a threat to public health. Casual sex encounters, much more likely with tourists and business travellers than with immigrants, who usually have families with young children and are seeking a new life, a home and work, will perhaps pose a greater risk.

The real point of a communicable disease, such as HIV, however, is that it is not the mere presence of the disease that constitutes a danger to public health, but the possible behaviour of the individual who has the disease. A person who is infected with HIV is capable of infecting others and so such person is a potential threat to public safety. The real question is whether that person is 'likely' to do so and, more importantly, whether the 'risk' that the person will do so is sufficiently offset by public health education programmes to consider such a person admissible under the proposed Immigration Act.

That behaviour is, quite appropriately, located in social context. HIV/AIDS already exists in Bermuda, and preventing its spread requires societal education about safe-sex precautions and individual adoption of these precautions. The public health challenge is collective. The responsibility for prevention does not devolve to immigrants alone, so if immigrants were to transmit the virus to others, the responsibility would not be theirs alone. To refuse admission to immigrants solely because they were HIV positive would be to deny society's collective responsibility for HIV/AIDS and to make immigrants scapegoats for society's failure to combat the disease more effectively.

A compelling reason for excluding immigrants with HIV is an economic one. Bermuda's health care system and social service organisations appear to be financially strapped and incapable of meeting the needs of everyone who lives on the Island now. How then can immigration policies that could impose an additional strain on these services be justified?

Every time someone makes an appointment to see a doctor and waits patiently to be seen, that person is delaying the provision of services to everyone who has a subsequent appointment. An immigrant who is also waiting to be seen by that same doctor would extend the delay. Does it thereby follow that admitting that immigrant would cause an "excessive demand" on Bermuda's health-care system? Would an immigrant, whose net contribution to the gross national product has outweighed any health care cost that that person engendered, constitute an excessive cost to the health care system?

An immigrant, who may be more productive than the average person, could contribute more in five years of work than that person would cost, even if he or she were to become ill and die of HIV-related disease. Presumably, such a test requirement would apply whether the potential candidate is a Nobel Laureate, a construction worker, cable layer, or a billionaire. An open question is whether a rich person, who could create tax revenues in excess of projected health care costs, would be more welcome than the cable layer, or construction worker?

The problem is exacerbated by the sweeping discretion accorded by some medical officers and some immigration officers. Without standardised procedures to assess medical inadmissibility and determinate criteria to appraise "excessive demands", their decisions will inevitably be inconsistent and inequitable. And prospective immigrants will have no redress. Widely accepted principles of law and bio-ethics require that HIV testing be conducted entirely on a voluntary basis, that is, only with the specific voluntary and informed consent of the individual. To institute mandatory testing for immigrants would be to single them out and treat them differently, and that special treatment would stigmatise them as people who are particularly dangerous, particularly irresponsible, or both. Treating them differently would play into and exacerbate existing prejudices and fears.

HIV testing done in foreign countries to provide medical documentation necessary to support an application for admission may not meet the standards required in Bermuda and other parts of the western world. The tests may not be accurate, and counselling about the nature of the testing and the implications of the test results could be absent or inadequate. For example, those being tested may not be told about the possibility of false positive results.

In addition, people living in countries with harsh, coercive, or punitive policies on HIV/AIDS and who wanted to come to Bermuda would have to make a difficult decision. They would be forced to choose between losing an opportunity to do this and taking a risk of what could happen to them in their country of origin if they were rejected as immigrants on the basis of their being HIV positive. In the absence of specific voluntary and informed consent to testing, high standards of accuracy in testing, and adequate counselling before and after testing, HIV testing for immigrants in Bermuda would not be ethically or legally acceptable.

The list of potentially costly medical conditions and risk factors for future illness, such as tobacco consumption and overuse of alcohol, could easily be extended. Consistency and fairness demand that they be treated in the same way. Therefore, it is inequitable to use cost as a reason to exclude people infected with HIV, for there are no similar exclusionary policies for those with other costly chronic diseases, such as heart disease or cancer.

In conclusion, allow me to make some recommendations:

The policy and practice of not deeming prospective immigrants who test HIV-positive as medically inadmissible on the grounds that they represent a danger to public health in Bermuda should be continued. The criteria for determining medical inadmissibility should not be formulated with respect to any specific disease or condition. Decisions about the medical admissibility of applicants for immigrant status should be made on an individual, contextualised basis. Decision-making procedures that are flexible, equitable, and sensitive to changing medical and social conditions display the moral concern and respect that is owed to everyone.

I sincerely hope that Bermuda does not adopt a policy of testing immigrants for entry to the island. What will be next? Will landlords then be allowed to exclude persons solely because they are HIV-positive? Will employers then remove any employee who is HIV-positive, or use such grounds to refuse to hire someone? Will children be denied a place in our education system solely on the basis of their relationship to an HIV-positive parent?

Will there be an increase in incidences where bus drivers and cab drivers deny access to transportation services because someone is suspected of being HIV-positive? Such a policy would intensify existing fears and prejudices surrounding HIV/AIDS and create a seriously negative impact on prevention and education efforts in Bermuda. I would be very interested in discussing these issues with any concerned person, resident or immigrant.

Michael Fox is executive director of the Allan Vincent Smith Foundation