Every Breath You Take

On World TB Day we look at why detecting and curing Tuberculosis is an essential part of well managed migration. This essay is accompanied by illustrations from "The White Death", a book on TB in Moldova, by award-winning photographer Florian Bachmeier, who has provided an endnote.

By Joe Lowry and Dr Jaime Calderon, IOM Vienna
Photo credits: Florian Bachmeier

24 March 2017

When the German microbiologist Dr Robert Koch discovered the bacillus that causes tuberculosis back in 1882, the disease was the most feared on the planet. In Europe and the Americas, one in seven deaths were caused by TB, making it one of the biggest killers in history.

Thanks to Dr Koch’s discovery, celebrated every year on 24 March, TB is largely curable. Nowadays it causes 1.5 million deaths annually, but we know that if we let our guard down, TB could once again become a major global health problem. It can be in the very air we breathe, so crowded places like public transport, shopping malls and sport stadiums would – without the health surveillance, good nutrition and sanitation we take for granted – be locations of mass infection.

The way TB spreads sounds like a plot from a science fiction movie. A carrier only has to cough once to spread the bacillus far and wide. If it gets into a host whose immune system is weak, it can rapidly colonize the body, tearing tissue apart and creating holes in the lung.

The question is often posed as to why IOM is active in TB control and advocacy, especially in the Northern hemisphere, where the general perception is that TB is a disease of the past. There are two reasons, but they can be encompassed in one word: equality.

IOM is perhaps best known for helping to bring refugees from temporary camps and settlements to new homes and new lives in peaceful countries where they can live without fear of persecution or peril. There are many stages in this journey, from preparation, learning a new language, to hearing about a new culture, and being pronounced “fit for travel”. Most countries that take in refugees have to ensure that they are TB free.

We have built state of the art TB diagnostic laboratories and treatment centres in the most remote locations in order to ensure that people being resettled can meet the requirements of their new host countries. More than that, we then find ways to extend these services to local people in the catchment area.

This serves two purposes. It contains TB, as there is always contact between populations in refugee camps and people living nearby. It also ensures there is no resentment, and that everyone has the same access to better treatment. In this way, IOM has become one of the biggest TB diagnosis and treatment agencies in the world.

The second reason that we are active in TB work is because TB travels with people. If we fall ill in our own country, we seek advice and more often than not we receive simple treatment and get well again.

But consider the migrant; often young, confused, perhaps unable to speak the language of his or her new country. They fear getting ill and being unable to work as they have large extended families back home depending on them. They have no idea that (at least in theory, in most countries) they have same right to healthcare as the citizens of that country.

IOM works with governments to ensure that migrants know their rights, and can receive life-saving information in time. This makes absolute sense, as it keeps migrant workers healthy, often doing the low-paid and dangerous jobs that local people don’t want to do. More than that, it ensures that all communities are protected, and that migrants are not stigmatized as spreaders of disease.

Crowded and insanitary prisons are ideal spawning grounds for TB. Ironically, they are often the best chance vulnerable people have to get medical help. But in a cruel twist, on release they often move to new areas, and default on treatment. This can result in multi-drug resistant TB, as well as XDR TB, the extremely resistant strain which is practically incurable.

Anyone who was born in Europe or the former Soviet Union before 1980 knows that borders, those things that seem impenetrable, are actually impermanent. Countries that existed for centuries, then disappeared, have now reemerged. Others have united or gone their separate ways, some peacefully, some violently, causing massive population movements. Other borders exist on maps only, and people now can walk from state to state where once the line was drenched in blood.

For a dizzying few years in the 1990s it seemed people could wake up citizens of one county, and go to bed in a new one. Ethnic groups belonging to one country became stranded in others, which on occasions abandoned a common language. This meant that many people, often elderly or otherwise vulnerable, lost the certainties of work and healthcare as countries transitioned and economies nose-dived.

Today we live with the consequences of those rapidly-changing times. There are millions of people who fall outside the safety net of (often imperfect) health systems. They may also be on the move, looking for work, for security or for family members. Naturally, if they are infected with TB and outside of public health networks their disease will become fatal and infect others.

As TB takes a long time to treat (but treatment is almost always successful if begun in time and adhered to) it is imperative that people complete their treatment, which may take more than 12 months. If they default, their TB becomes resistant and may take years to cure, using powerful and expensive drugs. If that course is defaulted on, then the result is XDR TB (extremely drug resistant TB) which is nearly impossible to cure

These vulnerable people are often living on the ragged edge of society, open to substance abuse and high-risk sexual encounters. When a person’s immune system is compromised by HIV then TB can rip through them and also create coinfection which is almost always fatal.

What is sure, and what IOM stresses, is that people will always be on the move, whether or not there be borders. Ensuring a right to decent healthcare for all is a crucial plank in attaining the ideal of well managed migration for the benefit of all.

There are an estimated one billion migrants in the world today: 232 million international migrants and 740 million internal migrants

TB particularly affects poor and vulnerable populations; migrants are a
key affected population

Migration as a social determinant of health increases TB-related morbidity and mortality along all migration pathways.

In low and middle TB-burden countries, TB among foreign-born populations is often high, due to existing infection or reactivation of latent TB.

Endnote by Florian Bachmeier:

"My photo reportage shows the return of a disease called Tuberculosis. It is an opportunistic disease, and it occurs where hardship and poverty prevail. It is widespread in the Republic of Moldova where these photographs are from. I wanted to accompany the victims of the disease with my camera, capture their lives go a little piece of their hard way together with them.

"Yes, Moldova is one of the poorest countries in Europe, there is no industry worth mentioning,civil society does not exist in the form we know it, corruption is widespread and only a few fill their pockets at the cost of others. That is what it made it seem so shocking to me: a functioning and adequate tuberculosis control in these days can only be financed through massive economic support with the aid of international organizations like IOM and others.

"Tuberculosis, a treatable infectious disease that is no longer a threat to citizens in the western world, here is still a deadly disease, associated with poverty and underfunded health care systems. Now, after years of looking away, individual chances of recovery decrease in patients suffering from multi-resistant tuberculosis and most notably in those who develop the disease twice. TB causes misery and has fatal consequences, affecting almost all areas of the life of a person, a fact that is often concealed by epidemiological numbers."