Despite the distinct increase of foreign born in the U.S population over the years, the systematic monitoring of health, disease patterns, and mortality among the immigrant population of diverse racial and ethnic origins remains greatly uncommon. There are several reasons that explains why this occurs: (1) immigrants are known to make up more of the lower socioeconomic class (2) cultural conflict such as eugenicist ideology that whites in the U.S subscribe to, and (3) the significant distinctions in cultural, ethnic, and linguistic diversity within the U.
S population makes it even more difficult to properly monitor immigrant health and well-being. These are the underlying reasons for differences in not only socioeconomic, but other circumstances that make tuberculosis (TB) rates significantly higher for foreign born vs native born.
Globally, tuberculosis remains the leading infectious disease, causing millions of deaths and reshaping populations. As we have read, even back in historical times, the majority of immigrants were known to be within the low socioeconomic class, and because of that were at a higher disadvantage of contracting TB, “foreign-born persons contribute to over half of the tuberculosis cases in the United States” (Ming-Jung Ho, 2004: 758).
The immigrant population has been and will continue to be disproportionately affected by TB. In a study done by Fujiwara, she examined the TB tide pools in New York City and discussed that “by 1997, the proportion of foreign-born cases exceeded those of US-born for the first time since New York City began collecting this information in 1980” (Fujiwara 2000:112).
Her research perfectly targeted the socioeconomic difficulties that are associated with foreign-born individuals and TB testing including: lack of general TB knowledge, social stigma, language barriers, and fear of governmental involvement.
Many immigrants back then and even to this day leave their country illegally to find refuge in the United States and so lack of documentation can hinder the willingness to get tested and treated. Additional factors such as problems with living situations, exposure to environmental hazards, limited access to health care, and lower incomes all weigh into the more difficult socioeconomic conditions foreign-born individuals experience. In addition to this argument, the McKeown thesis can be brought in to discuss just how much of a role social conditions have on the overall health of population. In his article he talks about resources being of utmost importance in two ways, first, “resources directly shape individual health behaviors by influencing whether people know about, have access to, can afford, and are supported in their efforts to engage in health-enhancing behaviors” (Link & Phelan 2002:730).
As we have seen time and time again from previous studies done, foreign-born immigrants are deprived of those exact resources Link and Phelan claim has a dramatic effect on one’s health behavior. So how can an immigrant individual, who is already at a disadvantage in every socioeconomical aspect hope to have access to such resources that shape healthy lifestyles? The second point they make is that resources along with social conditions “shape access to broad contexts such as neighborhoods, occupations, and social networks that vary dramatically in associated profiles of risk and protective factors” (Link & Phelan 2002:730). For example, low income individuals are more likely to reside in housing near more cramped, polluted, and poorly ventilated, and because of that are more susceptible to contracting infectious diseases such as TB. Even blue-collared workers are more at risk than their white-collar counterparts, working in occupations that are considered more dangerous. Infectious diseases such as TB thrive in the populations burdened by the struggles of social inequality, material depravity, malnutrition, and structural corruption. Everything that shapes a person to live a healthy lifestyle, obtain quality healthcare and acquire decent medical knowledge, is not as readily available as it is for those who are native born.
Despite the previous factors, it’s important to analyze the institutionalized cultural discrimination that negatively impacts the health and well-being of minority immigrants. A big factor in understanding the spread of TB, is analyzing the discourses about human interaction and behavior. These discourses lean on the side of racializing arguments by linking the risk of infectious diseases to the color of people’s skin, or even to one’s cultural traditions. In this study by Ho, she argued that when looking at explanations and management methods for TB, incorporating sociocultural factors was key. In her case study, we follow a 45-year old Chinese woman who immigrated to New York, which happens to be inhabited by thousands of undocumented Chinese immigrants. Her TB condition was already exasperated by her poor living conditions, but she had been also using traditional Chinese medicine to combat her American medication side effects.
This is an example of how cultural factors affect the experience of an immigrant living in the United States. In most Asian cultures, the traditional medical beliefs and practices tend to have more priority over Western medicine. To this day, cultural factors continues to be a driving force that puts a wedge between the standard westernized medicine practice and those who practice other health beliefs. In a different survey done in New York, anthropologists concluded that “targeted patient education is needed to address misconceptions about TB among Vietnamese refugees and to help ensure adherence to prescribed treatment regimens” (Carey et al. 1997). Misconceptions of biomedical knowledge due to cultural barriers and restrictions contributes to the treatment and spread of illness. Another example is when researchers studied the effect of latent TB infection (LTBI) on immigrants in New York city, since most cases of active TB in foreign-born individuals result from a previously acquired infection. They suggested that knowledge, attitudes, and beliefs relating to TB disease have an impact on a patients’ willingness to comply to medical assistance.
Compared to the US-born participants, “foreign-born participants were more likely to believe that they were protected from TB disease” (Colson et al. 2010). The actual impact of attitudinal variables might seem insignificant, but it plays into a bigger role of perceiving modern medicine and finding it “unnecessary” and therefore less likely for one to complete a treatment program. Various studies have shown that within the immigrant population, there tends to be a general low level of knowledge concerning TB and how it’s transmitted. They also found that although a language discordance between a TB patient and their physician can hinder the process of getting tested, “there were no significant differences in referral or completion rates between the language concordant and dis-concordant groups” (Leng, Changrani & Gany, 2010). They did mention several flaws in their discussion, such as inaccurate charting and cultural beliefs that may have led to patient refusal for testing. All the other literature, with the exception of the last one can exemplify that medical adherence, especially for foreign born individuals, will always be a struggle due to language barriers, emphasis on kin relations and biomedical suspicion.
Compared to cultural influences, when discussing environmental factors, it is essential to examine the way that make migrants moving to low-incidence settings experience substantially higher rates of TB than the native-born population. An immigrants’ legal status can also have a detrimental effect on their TB progression. In several studies done in Canada, they applied a different way of approaching TB in the immigrant population, examining the racialization and medicalization aspect. The main focus of the studies was examining the various difficulties within their environment that immigrants had to face. They all talked about how being a member of a visible minority continues to play an important role in health results and health services. Reitmanova and Gustafson (2012) provided an excellent example of understanding the occurrence and spread of infectious diseases that are shaped by examining discourses about human behaviors and interactions, “the introduction of the Immigration Act required the immigrants with TB to be deported from Canada while the success of antibiotic treatment in the 1950s reinforced the medicalizing of TB in public health discourses and policy”.
They had found an antibiotic that worked for treating TB and yet still found an excuse to exile anyone who were immigrants. It just reinforces the argument that implementing specific TB control policies specific to race, reinforces the unequal distribution of TB burden that immigrants face. In the same article, it goes on to say “The genes of all nonwhite immigrants and white immigrants working class were constructed as inherently inferior, a belief that served to explain why these two groups were more predisposed to diseases than the supposedly superior white upper and middle class” (Reitmanova & Gustafson 2012: 410). Their goal was decreasing the amount of people with so called “inferior genes” who they believed would be more likely to fall victim to TB. They argued that to build a “healthy and pure” nation, it was essential to avoid bringing in those who were deemed unhealthy. The Canadian government even went as far as passing a new Act in 1906, which banned all immigrants with any type of infectious disease, whether it be TB, syphilis, or leprosy, from entering Canada. Back in the twentieth century, the racialization of immigrant communities put the blame on the individual immigrant and removed the significance of social/environmental factors. The policies that the government implemented did nothing to fix the social inequalities that made the migrant populations more vulnerable to TB.
In addition, with the re-emergence of tuberculosis comes the disproportionate burden placed on the migrants that lived in low-prevalence industrialized countries. Immigration and TB infectiousness were linked to each other, exacerbating social stigma. Ethnic minorities, including migrants pursuing economic gain and labor, asylum-seekers, refugees, both documented and undocumented, are all part of the group who are substantially more vulnerable to the disease. What makes it even harder, is that their access to health services is limited with the addition of social discrimination, isolation and poverty. With high levels of immigration from more less-developed countries, minimizing the spread of TB becomes more difficult, “the rate of infection amongst foreign-born migrants reaches ten or twenty times that of the autochthonous population, and represents 60% to 70% of the recorded cases” (Abarca et al. 2013). Even still, understanding immigrants’ perceptions of TB would help describe the social repercussions of a positive TB diagnosis. Many participants in the study talked about how their position as immigrants could negatively affect their health or even eventually increase their exposure to TB.
Feelings of stigmatization came from being categorized as an “at-risk group” and began within the health care systems. Some of the participants noticed that the physicians and other health care staff were treating immigrants differently and that immigration and TB infectiousness “mutually reinforced each other, magnifying feelings of being out of place and exacerbating the illness experience” (Bender, Andrews, & Peter, 2010). These feelings of stigma can not only heavily impact immigrants’ attitudes towards prevention, diagnosis and treatment but even have negative psychological effects. For example, when interviewed for the study, a male TB immigrant from Nigeria said “these days, if you have TB, they say it’s AIDS… some won’t even shake your hands or eat with you, the stigma is too much so people prefer to die” (Nnoaham et al., 2006). Fear of becoming infected, drove individuals to hide their diagnosis from loved ones, to isolate themselves and to weaken their already small social circle. The anticipated shame led them to make attempts to protect their personal and family honor. Examples such as these are why having a positive relationship with health care providers is a crucial element in TB management. The most common reason for high levels of stigma within the migrant community is because of the lack of medical knowledge and the perceived risk of transmission of the disease. Fundamental elements for treatment adherence need to incorporate cultural acceptance, personal understanding and immigrants’ trust in their physicians.
We’ve already looked at how foreign-born individuals faced cultural, linguistic, and socioeconomic barriers, but how a different view would be to look at how immigrants engaged with the healthcare system and their knowledge on TB. In a study done in the UK, they examined the reasons immigrants had for interacting with physicians. Those reasons included “a desire to receive a negative result to avoid stigma, gaining the right to stay legally in a country until treatment completion, confirmation of disease status and the desire to protect family members from the disease” (Humphreys et al., 2017). They also found that although their study groups were all aware of TB on a surface level, the level of knowledge on risk factors was variable. The biggest concern was that were common misconceptions on TB transmission and the thought that it was hereditary, while another believed that “the illness can be eliminated by eating healthy and with regular worship”.
This study revealed that low perception of individual risk of TB may be a more important factor to look at rather than the usual factors such as stigma, language barriers and cost of treatment. Some groups said that they didn’t think stigma was even a factor anymore, however, a few groups felt there was still stigma but only in terms of social isolation rather than internalized burden. The main theme seems to be that the participants did not think they were personally at risk of TB. What makes this study interesting, is that different migrant groups all have their own cultural influences and beliefs, which consequently, makes the issue more complex to explore. Although this was a different approach at analyzing TB adherence, this particular study had many limitations (various factors that influenced attitudes and beliefs such as age, sex, cultural background, religion) that ultimately did not provide concrete evidence to support their argument.
To conclude, understanding non-US-born populations’ opinions of TB and the obstacles that they face accessing the health system and sticking to a treatment program plays a critical role and should be considered when discussing TB detection and prevention. The United States has always had a long history of accepting migrants from all over the world, but as it goes to show, tuberculosis is a non-discriminatory infectious disease and is associated with society’s disadvantaged and marginal groups. Immigrants just so happen to be among the higher rates group. However, there is a clear link between lower socioeconomic status and TB mortality rates that has helped explain these rates. Social conditions such as food, clothing, and shelter, which might seem so miniscule, can drastically affect one’s health behavior and in turn make them more susceptible to infectious diseases such as TB.
The persistence of TB within the socially disadvantaged should be enough to reconsider TB management methods, and early access to health care and TB awareness are paramount to provide proper treatment methods. Currently, TB programs focus mainly on the biological element and treating the bacterial source with is just as important, but still only a small portion to the bigger end goal. To control the rise of immigrant tuberculosis in developed countries, the governments must acknowledge and take responsibility for addressing the causes underlying the socioeconomic, cultural, and environmental factors that consequently contributes to immigrant TB mortality. Addressing tuberculosis in these underserved populations, along with combining all aspects of TB observance is essential in eliminating the disease.