An IOM worker (right) with a TB patient at a health post in Mae La settlement, Northern Thailand. © IOM/Joe Lowry 2012
By Dr. Poonam Dhavan
As medical doctors, we are trained to identify disease agents, attack them with effective drug therapies and interrupt the natural history of infections that could lead to severe disability or even death for our patients.
As public health practitioners—we decide when more is needed. Disease control is not merely about one patient – it is about detection, treatment and care in the population or communities at large.
But as migration health experts, we face even more daunting challenges. How do we deal with, prevent, treat and control diseases and health conditions among people on the move – in sending, transit and receiving countries – satisfying immigration and health legislation, and ensuring equitable use of often scarce resources? And how do we address stigmatization and possible human rights violations?
In no public health topic are these questions more important than in the ongoing discourse on a post-2015 TB strategy. At its very core, TB is a disease of immense public health significance even within national boundaries, with some 22 countries classified as “High Burden” (i.e. out of every 100,000 people, 100 or more would have active TB disease). The rest are classified as mid-to-low burden.
TB is a social disease. If you think that it is simply caused by a micro-organism (Mycobacterium Tuberculosis), think again. TB infection is driven by social factors, focusing on the poor, marginalized and socially vulnerable.
And along comes this colossal and complex phenomenon called “migration,” which is itself a social determinant of health and influences infection with TB and the outcomes of the disease.
International migration is increasingly complex in its scope and impact on migrants themselves and communities of origin, transit and destination.
Worldwide, migrant numbers are on the rise, both internationally and within borders. If one overlays migration trends with TB estimates worldwide, interesting patterns emerge.
For instance, the top countries of origin for international migrants include several high TB burden countries, including India, the Russian Federation, Bangladesh, China, Pakistan, the Philippines, Afghanistan and Indonesia.
The largest numbers of foreign-born people in the United States and the European Union are from Asia and Africa, which are also currently regions with the highest incidence of TB.
As noted in the World Migration Report 2013, most migrants move from the South to the North (40%) and within countries in the South (33%). This has significant implications on infectious disease epidemiology and its spread between countries with different population health and health system profiles.
Not all migrants are the same. It is the most vulnerable, including refugees, undocumented migrants and people subjected to forced displacement who are most likely to succumb to latent TB (dormant infection without manifest disease), active TB and even multi-drug resistant TB (where routinely used anti-TB drugs are no longer effective).
The largest burden of TB infection and disease is borne by low and mid-income countries in Asia and Africa. This is also true in Eastern European countries that face a double whammy with HIV/TB co-infections and drug resistance.
Thus, if you are a highly skilled worker from a high TB burden country, even if your socioeconomic status allows for good health overall, your potential move to a low incidence TB country would be of concern to immigration and health authorities.
In most low incidence countries around the world, including North America and Europe, most incidence of TB is attributable to foreign-born populations.
But not all is “gloom and doom” in global TB control efforts – the latest Global TB Report (2013) noted that nearly half of all 22 high TB burden countries already have or are on track to meet the TB prevalence, incidence and mortality targets set out in the 2015 Millennium Development Goals (MDGs).
Yet there seems to be consensus among TB experts and National TB Programmes that this progress, to be sustainable, requires that we also reach some three million people (each year) who have TB infection, who either do not have access to diagnosis and care, or fail to avail themselves of these.
Other necessary strategic actions include addressing multi-drug resistant TB, HIV/TB co-infections, narrowing resource gaps and ensuring the rapid uptake of innovations. The proposed global post-2015 strategy for TB is designed around pillars of patient-centred care, supportive systems and intensified research and innovation.
So how and where do migrants fit in these developments? The World Health Organization (WHO) post-2015 TB strategy explicitly refers to the 2008 World Health Assembly (WHA) resolution 61.17 on Health of Migrants, and calls for collaboration among low- and high-incidence countries for TB monitoring and control, including and particularly among labour migrants.
This should enable countries that view migration as the crux of TB control to link TB National Strategic Plans with implementation mechanisms for the WHA 61.17. These include:
Migrants, refugees and displaced populations are also identified as ‘key affected populations’ in strategic investment guidance provided by the Global Fund to countries wishing to implement projects using its new funding model.
Going back to the questions at the beginning of this piece – as the leading global agency on migration issues, including migration health – IOM needs to engage closely with national TB programmes, international agencies, donors, civil society organizations and other partners to ensure migrants are integrated into TB response.
Priorities should depend on epidemiological and migration profiles in the respective countries. For example, for a low TB-incidence country that primarily receives immigrants and refugees, the focus is likely to be on systematic screening for TB among migrants – pre or post-entry – linked with appropriate treatment referrals and continuity of care, which should also cover latent infections, MDR-TB and HIV/TB co-infections.
Health services need to be designed with the migrant at the centre. They need to be culturally sensitive, without language and other healthcare access barriers, and ensure that refugees and migrants do not bear a disproportionate financial burden as a result of TB.
A high TB incidence country that experiences internal and/or temporary cross-border migration may have to ensure stronger linkages between existing TB programmes and immigration authorities.
Mention is needed here of the issues of marginalization, stigmatization and the possible deportation of migrants with present or previous history of TB. Treatment and care should respect migrants’ rights to health, without compromising confidentiality or criminalizing otherwise legal rights – especially in the case of documented labour migrants.
Read more on IOM’s position paper on TB and migration here.