Tuberculosis (TB) Knows No Borders: Examining the Intersection of Migration and TB
With millions on the move, migration can pose as a significant global health phenomenon. In 2017, there were an estimated 258 million migrants worldwide, an increase from 248 million in 2015 [1].
According to the International Organization for Migration (IOM), there is no universally accepted definition of ‘migrant’. ‘Migrant’ can be considered as an umbrella term which denotes a person moving across an international border, or within a state leaving their usual place of residence [2]. These groups are heterogenous in nature and may include, but are not limited to, labour migrants, international students, undocumented persons, refugees and asylum seekers [3]. The reasons for migration are plentiful. Some individuals leave their home countries for economic and social reasons such as human rights violations, while others escape political war or natural disasters.
Migration can have an impact on one’s health and this is evident in the case of Tuberculosis (TB). In Toronto, Ontario, many migrants are affected by TB. For example, 93% of the 287 people diagnosed with TB in 2017 were migrants or foreign-born [4]. A high incidence of TB among these populations in Toronto reflects the larger global TB burden. One quarter of the world has been infected with the TB bacteria and approximately 10 million people were diagnosed with TB in 2018, of which 1.5 million died [5]. Formally known as the white plague and consumption in the 1700s and 1800s [6], it is evident that in 2020, TB is alive and well despite it being a disease that has been around for centuries, and is completely preventable, treatable and curable. Now surpassing HIV, TB is considered the leading cause of death due to an infectious disease globally [5].
Being a migrant imposes serious risks for TB including multidrug resistant TB. Not only are migrants at a higher risk for developing TB, but they are also at risk for poor treatment outcomes [3]. So why are migrants considered a vulnerable and high-risk population? Country of origin and pre-migration, transit, and settling conditions can all play a role [3]. As we have seen through images in the media, many migrants travel in crowded conditions by boat, or are held in detention centres, which can be a breeding ground for the transmission of TB. Continuity of care and forced displacement may also pose challenges related to adherence and drug resistance [3]. For example, when patients leave Toronto for whatever purpose (e.g. moving back to their home country), they are provided with a limited supply of TB medications, a copy of their health records and the Ministry of Health is notified. However, what happens in terms of their care and treatment in their destination country is unknown. If the patient does not follow up appropriately, experiences a long interruption in treatment, or there is a lack of availability of TB medications, this can negatively impact their treatment outcomes.
Social and economic circumstances before and during migration may also be contributing factors for TB [3]. Many migrants are of lower socioeconomic status and TB is a disease that tends to disproportionately affect the poor. The stressors of migration can also lower one’s immune system causing a migrant to be more susceptible to TB. Furthermore, those who are undocumented may delay seeking care. In a study conducted in the United States of America , migrants who were undocumented were four times as likely to delay seeking care [8]. A delay in care can lead to an increased severity of the disease, and the potential transmission to others. As we can see, TB intersects with a migrant’s journey at many points.
There can be serious implications for migrants who fall ill with the disease particularly those with a precarious immigration status. Through my clinical nursing practice experiences in Toronto, patients have received catastrophic health care bills, experienced mental health challenges, stigma and isolation, loss of employment and temporary immigration status, and fear deportation. For example, I recall an incident where a live-in caregiver lost their job after informing their employer that they had been diagnosed with TB. The distress, blame, stigma, and guilt they felt was indescribable. Additionally, international students who have had to remain in isolation precautions and are unable to continue their studies, lose their student status. As a consequence of this loss, they are placed in limbo and theoretically are considered undocumented persons.
Despite Canada’s universal health care system, there have been a number of patients who have required hospitalizations for their TB care and were discharged with health care bills that cost them thousands of dollars. Furthermore, often those who have temporary immigration status and are required to have private health insurance, don’t receive coverage as some insurance companies consider TB to be a pre-existing medical condition. The World Health Organization’s End TB Strategy (2015) highlights that no TB-affected families should face catastrophic costs as a result of the disease [9], yet we continue to see this ongoing issue of being denied coverage in Toronto and around the globe.
So, what can we do to address this neglected disease that disproportionately affects migrant populations? We need political will and equitable policies so that no one experiences severe ramifications for a diagnosis that is highly stigmatized and often forgotten. Health is a human right, and everyone has a right to TB treatment and to health services regardless of their immigration status. Addressing the social determinants of health that commonly impact migrant populations and increases their vulnerability to TB should also be a priority. In an increasing globalized world, uniting to end TB has become more important than ever before as TB knows no borders.
Migration Terms [7]
Immigrant – an individual who moves to a country from their usual place of residence permanently.
Migrant – an individual who moves away from their usual place of residence for various reason within country or out of country either temporarily or permanently.
Asylum Seeker – an individual who seeks international protection who may or may not receive refugee status.
Refugee – an individual who leaves their country of origin as a result of well-founded fear of persecution for reasons such as race, political opinion, religion or membership of a particular social group. For this reason, they are unable to return to their country of origin.
References
[1] United Nations, Department of Economic and Social Affairs, Population Division. International Migration Report 2017: Highlights. (United Nations, 2017).
[2] International Organization of Migration. Who is a migrant? (2019). Available at: https://www.iom.int/who-is-a-migrant. (Accessed: November 10, 2019)
[3] Dhavan, P., Dias, H.M., Creswell, J., & Weil, D. An overview of tuberculosis and migration. International Journal of Tuberculosis and Lung Disease, 21, 61-623 (2017).
[4] Toronto Public Health. United to End Tuberculosis in Toronto: 2017 TB Program Report. (Toronto, Public Health, 2018).
[5] World Health Organization. Tuberculosis. Key Facts (2019). Available at https://www.who.int/news-room/fact-sheets/detail/tuberculosis (Accessed: November 10, 2019)
[6] Centre for Disease Control and Prevention. World TB Day 2018 (2018). Available at https://www.cdc.gov/tb/worldtbday/history.htm (Accessed: November 10, 2019)
[7]International Organization of Migration. Key Migration Terms (2019). Available at https://www.iom.int/key-migration-terms (Accessed: December 4, 2019)
[8] Asch, S., Leake, B., & Gelberg, L. Does fear of immigration authorities deter tuberculosis patients from seeking care? Western Journal of Medicine, 161, 373-376 (1994).
[9] World Health Organization. The End TB Strategy. (World Health Organization, 2015).