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Passport And Visa Privileges In Global Health

Passport And Visa Privileges In Global Health

Years ago, in the 1990s, a young Indian community physician was thrilled to get a fully funded opportunity to attend a summer program in epidemiology at a leading American school of public health. He waited for hours outside the US Consulate for his visa interview. His ‘interview’ lasted seconds. His application was denied, with virtually no questions asked or documents examined. Well, that was my story. While I now have the privilege of living and working in Canada, I still remember that traumatic, demoralizing experience. I know that my experience was neither unique nor exceptional. It is, in fact, the norm in global health.

The field of global health is extraordinarily unequal, with privileged people and institutions in the global North dominating all aspects of global health. In fact, a majority of global health agencies are headquartered in US, UK and Europe, and most global health conferences are held in these countries. One form of privilege, the passports and visas people in high-income countries (HICs) carry, further worsens inequities in global health. And the Covid-19 pandemic has worsened inequities in global travel, making the playing field treacherously uneven.

Right now, triple-vaccinated people in the global North have declared the pandemic over, and are rushing to travel everywhere with an ‘urgency of normal,’ and organizing more and more in-person meetings and courses. While they can travel at short notice and not worry about visas for entering a large number of countries, the reality is vastly different for people in the global South. To begin with, the vaccine apartheid has left nearly 2.8 billion people, mostly people in low- and middle-income countries (LMICs), waiting for their first vaccine dose. Travel is more expensive now, visas are costly, often hard to get (or take forever), and vaccine proof and/or testing requirements are adding untold complexities and costs.

Global health was neither diverse nor global even before the pandemic, but now, there is a real risk that all global health events will start resembling Davos – elite, white people getting together in North American or European cities, to discuss issues that mostly impact Black and brown people in LMICs. There is a big risk that people in the global South will be left behind, or left trying to join hyrbid events via unreliable internet connections. As Ulrick Sidney pointed out in a blog post, too many people from the global South are “forced to forgo their seat at the table.” And the consequences are bad. As Dominique Vervoort wrote in a blog post, “without solutions to the under-addressed problem of visas in global health, universal health coverage will be an impossible goal.”

The visa process: unfriendly, expensive and frustrating

“Those who hold US, EU or British passports will never understand the pain, humiliation and frustration of trying to get a visa to their countries,” tweeted Rasna Warah, a Kenyan writer, book author, and journalist.

Ironically, she herself had written an article, 3 years ago, questioning the practice of holding conferences on Africa in Western countries. “Travelling abroad has become almost impossible for Africans, and this is simply unfair,” she said. “Why are we being denied the right to travel to whichever country we want yet an American or a Brit can waltz into this country without ever experiencing the kind of humiliation that Kenyans and other Africans are subjected to?,” she asked.

“As a health practitioner based in a low-income country, it is almost impossible to pick up my passport and baggage and head to the airport without planning 6 to 12 months in advance,” said Stephen Asiimwe, a Ugandan public health practitioner. “I have faced high visa fees, requirements to prove substantial ties to my home country – including needing to provide letters of support from my spouse, employer, parents, and senior government offices – and requests for countless documents including certified bank account statements, land titles and mortgages, airline and hotel bookings, and health and travel insurance,” he added.

Shashika Bandara, a Sri Lankan student, did his graduate training in the US, before moving to Canada to do his doctoral training. He recounted his visa experience with the US embassy. “I was initially yelled at, put on indefinite ‘administrative’ processing causing me to cancel my work trips, then in a second interview was asked if I was a spy, before receiving my visa,” he said.

Mehr Muhammad Adeel Riaz, a young Pakistani physician, had a traumatic visa denial experience while trying to attend the World Health Assembly (WHA) in Geneva. “Passport privilege is real,” he declared. “What is a swift walk for a privileged white kid with an EU passport is a marathon with a broken road and hurdles for a brown kid with a Pakistani passport,” he added. “When youth from high-income countries are jumping from plane to plane to attend global health meetings, research workshops & whatnot, we as global South youth cannot even think about that. As Pakistani, we have to plan months in advance. And there is no guarantee that we will get a visa. Our voices and our presence don’t seem to matter,” he lamented.

Mohammad Yasir Essar, a young Afghan student, concurs. “It is a privilege to be able to travel to seek new opportunities, something that many students like me are deprived of because of our passports,” he said. “It is very difficult for you to get visa,” is the first thing he is told, when anyone learns that he has an Afghanistan passport. He feels utterly demotivated with such reactions.

Celestina Obiekea, a virologist at the Nigeria Centers for Disease Control, has seen her share of visa trauma. One of the most painful aspects of my journey so far has been visa denials to take part in global conversations where I have direct expertise. In fact, it got so painful that I began to condition myself to not reach for opportunities that would require visa application or approval processes,” she said.

“Global health is not global until is accessible to everyone,” said Andrés Quintero Leyra, a young Mexican physician. He argues that global health will remain a northern concept unless we create more efficient ways to assure accessibility to global health events. He pointed out that organisers of global health events such as WHA often do not allow enough time to get visas. Letters of invitation are often sent just a few days prior to the event, leaving people at risk of not even getting visa interviews in time, plus the economical burden of having to buy expensive flight tickets at the last minute, he explained.

“The sad reality regarding visa applications for people from the Global South is that any negative visa outcome (rejection or late approval) is always deemed the visa applicant’s fault,” said Marie-Claire Wangari, a young Kenyan physician. “This leaves the applicant with the tough call of whether they should re-apply or justify their visit to the country in question (can even be a global South country) or count their loses until the next visa application, similar to the legal scenario of ‘he who alleges must prove’,” she added.

Wangari and her colleagues recently wrote a paper in BMJ Global Health expressing concern that participation in global health meetings, such as the WHA, has historically been inequitable, with “limited representation of attendees from specific geographical locations, and those from certain socioeconomic, gender and ethnic backgrounds.” They pointed out that Geneva is a very expensive city, and that Switzerland requires a visa for attendees from over 150 countries.

For many countries, visa applications are a way to generate revenue. And visa outsourcing companies (e.g. VFS Global) have “turned the once costly endeavour of operating consulates and embassies into a money-making opportunity for cash-strapped immigration departments.” Even when visa applications are rejected, these companies still make money. And since most HICs tend to give short-term, single entry visas, people are forced to go back again and again to apply for new visas. This generates more revenue for companies and HIC governments.

A skewed global health job market

Passport and visa privileges go well beyond short-term visits or conferences. They profoundly shapes the global health job market and privileges people in HICs. It also ensures lack of diversity in major global health agencies.

“Most global health organisations are headquartered in HICs, and these offices do not readily sponsor work visas,” said Sonali Vaid, an Indian public health physician. This, she pointed out, skews staff composition in global health, from the get go. “We must shift the center of power and innovation in global health to LMICs,” she emphasized.

“Until we have solved the purely political problem that is passport privilege, global health will never be truly decolonised or equitable,” said Rihana Diabo, a global health professional from Burkina Faso. Like Sonali Vaid, she spoke about how people from the global South cannot easily work for powerful organisations. “The epicenters of global health practice are located in countries that make it extremely hard or impossible for third country nationals to obtain work permits, and have cumbersome visa application processes (the US, the UK, Canada, Switzerland). This limits the ability of organisations to recruit from the countries they support,” she added.

Global health journalism is not exempt

Like Rasna Warah, Vidya Krishnan, an Indian health journalist and book author, has had her share of passport and visa challenges while trying to report on global issues such as tuberculosis and the Rohingya refugee crisis. “It is not dramatic to state that white privilege dominates global health,” she said. “Career experiences for black and brown scientists, advocates, as well as journalists are radically different when they hinge on working through a maze of paperwork, exorbitant visa fees, and high registration charges for conferences. These hurdles contribute to keeping black and brown voices out of important knowledge-sharing and decision making venues,” she said.

How reciprocity is compromised

Even before Covid-19, I had pointed out that reciprocity was a major challenge in global health. Every year, large numbers of HIC trainees and researchers visit LMICs to engage in global health missions, clinical tourism, research and consultancy work. Reciprocity would require HIC institutions, in return, to host LMIC trainees and experts. This rarely happens, as I have described in my earlier 2-part series.

One of the major reasons for lack of reciprocity is passport and visa privilege. Not everyone has a passport that can open doors, and nearly all HICs have huge visa restrictions and entry barriers. Even when HIC institutions invite LMIC experts and offer to pay for their visits, they struggle to get visas and often pay a lot for them.

Potential solutions

It is clear that passport and visa privileges worsen global health inequities and result in global health events and programs that are neither diverse nor inclusive. If organizers of global health meetings and courses are serious about tackling this inequity, they need to go beyond just lamenting the lack of representation from people from the global South. They need to totally change the way they think about meetings, starting with where meetings are held, who is invited, who gets to speak, and what support they offer to those with lived experience.

In a powerful blog post, Nihan Albayrak-Aydemir, a postdoc researcher at the London School of Economics and Political Science, counted the costs and missed research and career opportunities for passport-holders from the Global South. She offered several valuable suggestions, including:

  • organising events in countries that do not have harsh or cumbersome visa requirements or high currency values
  • booking reasonably-priced venues and activities with a range of accommodation options for various budgets when organising events
  • setting a submission/acceptance timeline that factors in the length of visa application procedures
  • offering online attendance and presentation opportunities to those who cannot travel as well as building more academic platforms and opportunities online
  • increasing the number and amount of grants available for international scholars
  • offering reduced membership or registration fees for those who cannot afford the full amount of the required payment

In their BMJ Global Health article, Parnian Khorsand and colleagues argue for global health conferences, especially WHO events, to devise and implement a strategy on diversity, equity and inclusion(DEI), and host the WHA at locations beyond Geneva. They also call for a rethink of global travel that adds enormously to greenhouse gas emissions.

In a recent analyis of conference equity in global health, Lotta Velin and colleagues urged conference organisers to “conduct independent conference equity evaluations and to publish this data in publicly available annual conference reports.” They also suggest relocating conferences to LMICs, offering scholarships, and enabling LMIC researchers through mentorship.

In a blog post, Erlyn Macarayan and Irene Torres, called for more funding support to early career researchers in the global South, to enable them to attend global meetings. They suggest a “pooled registration fund could perhaps help to progressively offer a special discount or even a fee waiver to junior experts from the Global South.”

Akhila Jayaram, a doctoral candidate at Cambridge University, suggests mobility agreements for researchers. “We need fast-track visas or visa waivers for a defined period of time (e.g. 12-18 months) so that you don’t need to keep applying continuously for visas,” she said.

Dian Blandina, an Indonesian doctor and PHM Global volunteer, had several helpful suggestions. She proposes more daily visa appointment slots and reduction of fees and number of required documents as a way of lowering initial barriers in the application process. “Providing a longer validity visa for established personnel would make it easier for those needing/wanting to attend annual gatherings,” she said. She also suggests that sponsor fees should be waived for civil society organizations and non-profits.

“Embassies of HICs need to have training for visa consulate officers on how to ethically treat and interact with applicants, especially in LMICs,” said Shashika Bandara. “They need to recognize the power hierarchy, cultural and language differences and create a humane, non-threatening environment without abusing their power,” he said.

This is a critical point. It is not that people in HICs never apply for visas. They sometimes do. But they are rarely humiliated and rejected the way people in LMICs are. And while HIC embassies are comfortable with keeping LMIC people’s passports for weeks while processing visas (effectively blocking them from all travel), people in HICs will be outraged if their passports were held for such long periods.

Allyship can help

In conclusion, to help improve the passport and visa inequities, global health agencies, including universities, in HICs must work harder to be allies to people in LMICs, and my previous piece on allyship offers some guidance. They must understand that passport and visa privileges make for a highly unequal and non-diverse global health field, and advocate with their governments about the need for easier, more compassionate, less expensive and faster visa processes. At a minimum, initiatives such as visa on arrival, or electronic visas could be implemented for major conferences and events.

Conference organizers can do their part by greatly reducing the conference fee for LMIC participants, offering more travel grants which also cover visa charges, and provider invitation letters several months in advance, to allow for visa processing. A strong institutional letter of support, clearly stating that all expenses will be covered, could greatly increase the chances of success.

Some countries (e.g. USA, UK, Canada, Europe) can be particularly challenging for visas. So, unless we want more Davos-like meetings, it is important to consider friendlier locations outside of these tranditional venues for global health meetings. And it is important to not give up on fully online and hybrid events, in our rush to return to ‘normal.’ Far too many people are struggling to travel at this time, and insisting on in-person events will leave them behind.

In a recent article, 20 global health teachers proposed ways to leverage the online format to centre voices from the global South, Indigenous scholars, and individuals with lived experience of oppression and resilience. They also suggest that remote teaching can help reach wider and diverse audiences. But, as Stephen Asiimwe pointed out to me, online meeting must be scheduled on days and times convenient for people in the global South, which is currently often not the case. And, importantly, there is no reason why online participation should become the default for people from the global South. This means we should also work harder to support in-person participation by people in the global South.

While none of these solutions will truly ‘decolonize’ global health or address all the power asymmetries inherent in global health, they could certainly improve the current unfair, unjust, and humiliating system that needlessly taxes and traumatizes people in the global South. But having watched the vaccine apartheid, widening inequities, and utter lack of global solidarity during this pandemic, I’m not very hopeful that rich nations can or will see beyond their myopia and self-centeredness to do what is right.

What do you think?

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