Exploring the Mutual Constitution of Racializing and Medicalizing Discourses of Immigrant Tuberculosis in the Canadian Press

TB as a Racialized Disease

When health is racialized it is assumed that the differences in health outcomes, health-related behaviors, and health risks can be explained primarily by presumably natural and neutral epidemiological categories such as race, ethnicity, culture, and immigration status (Ahmad, 1994). In the racializing discourses we researched, the risk of TB was linked, for example, to being Asian rather than to being an impoverished, malnourished, and stressed immigrant from Asia. Furthermore, in such discourses the lived experiences of visible minorities were essentialized, the significance of social factors and poverty-related issues in the activation of TB were erased, and the meaning of immigrant TB was located in the racialized immigrant body. In the preexisting and dominant discourses about everything that race signifies, “words and things” are mutually constituted (Sheridan, 2002, p. 25).

The “words and things” (Sheridan, 2002, p. 25) brought together in the following excerpts about immigrant TB as a racialized disease are race, immigrant, TB, and health risk. In 33% of the articles (n = 91), TB was represented as an exotic disease imported to Canada by immigrants and travelers. For example, it was reported that “‘everyone who breathes air’ should worry about the risk of contracting TB because of travel and migration” (Fayerman, 2002a, p. A5), and that “we are no longer immune to the diseases of the developing countries” (“Letter of the Day,” 1999, n.p.). TB was described as “the gift an open world holds for our future” (“No Need,” 1999, n.p.). TB was also characterized as a recently “resurrected killer” (“Tuberculosis Rises,” 2000, p. A18) brought to Canada “when people from developing or Third World countries immigrate to Canada or Canadians travel abroad” (Gilmour, 2001, p. B3). What materialized in press coverage was the threat of TB posed by the racialized immigrant body.

The notion of immigrant TB as a racialized disease residing in the immigrant body was also reinforced by the omission of an important epidemiological fact: Previously healthy immigrants usually develop the active disease several years after immigration (Public Health Agency of Canada, 2007). Readers were informed about this latency period in only 3% (n = 9) of all articles. Omitting this information might reinforce the mistaken notion that immigrants bring in contagious TB at the time of their arrival. The author of a letter to the editor called for the compulsory detention of all landed immigrants and refugees for a period of 6 weeks after their arrival by stating, “Lock them up!” (Chenevert, 2001, p. A15). This type of reaction does not make sense from an epidemiological perspective for two reasons: First, latent TB might not be activated for years, if at all; also, a 6-week detention period is not the solution, because only 5% of immigrants develop TB (Public Health Agency of Canada, 2007). Second, prolonged detention might have the reverse effect of stressing the immune system and triggering TB activation. However, although a public reaction such as this one does not make sense from an epidemiological perspective, it does from a critical discourse perspective. It illustrates how the lack of accurate information about TB can trigger the operation of racializing discourses.

The notion that TB is “a disease of the developing countries” (“Letter of the Day,” 1999, n.p.) that is being imported to Canada by travel and immigration was also reinforced by news coverage about fighting TB overseas. Messages such as, “We will never eliminate TB in Canada unless we do more to eliminate the disease in poorer countries where most of the cases are coming from” (Ogle, 2000, p. A4), or, “To protect ourselves locally, we must act globally” (Hutchings, 2002, n.p.), were included in 10% (n = 27) of the articles. Eliminating TB in low-income countries is an important global health goal in and of itself. The coverage of this goal, however, was linked to the racialized body (both in Canada and abroad) and the health risk the diseased body posed for Canadians. This racializing discourse operates to obscure the social reality that impoverished and underserved immigrant (and nonimmigrant) populations in Canada are at higher risk of developing or reactivating TB. The self-interested focus on Canada’s effort to fight TB overseas constructed TB as a racialized disease that put the healthy, nonracialized Canadian body at risk.

The racialization of immigrant TB was even more explicit in certain press reports. In these reports two stories were covered. In the first story, the focus was on a Burmese man who infected his Canadian health care provider with latent TB during an intubation procedure (Francis, 1999). In the second, a Peruvian man was threatened with jail for noncompliance with his therapy for drug-resistant TB (Kalogerakis, 2000). Immigrants and refugees from Tibet and the Caribbean were also singled out as TB carriers in several reports. Calling attention to an individual’s nationality or ethnicity when reporting these stories made an explicit connection between TB and the immigrant or racialized body. We argue that what makes these stories “news” is that they reinforce a racializing discourse about the immigrant body as a health threat. Furthermore, this type of reporting obscures the complex etiology of TB, and can also lead to discrimination against entire communities. Leung and Guan (2004), in reporting on their study of the press coverage of the 2003 outbreak of SARS in Toronto, argued that the racialization of SARS in the Canadian press contributed to discrimination and harassment of the Chinese and South Asian communities in schools, workplaces, public transportation, and homes. For these reasons, we believe that including information about the nationality and ethnicity of persons infected with TB is problematic at best, and should be withheld. This approach has been used successfully, such as when newspapers in Toronto withheld information about the skin color and ethnicity of alleged crime perpetrators to combat the racialization of crime (Henry & Tator, 2002). Therefore, there is reasonable precedent for enforcing this approach.

TB as a Biomedical Disease

In the medicalization of health, disease is constructed as pathology caused by genetic, biological, and chemical processes that are expressed by the individual body as a constellation of clinical signs and subjective symptoms. Morgan (1998) defined medicalization as a problematic social process in which human experiences were intentionally and unintentionally reduced to pathological conditions that were treatable as medical problems. According to Morgan, one contributor to medicalization is the actions of individuals, groups, and institutions (such as policymakers, governments, and the media) which define appropriate social responses to conditions (such as immigrant TB) and advance particular ways of talking about and interpreting health and disease. We found that medicalizing discourses in the Canadian news coverage of immigrant TB operated in two ways: First, the significant role of social, economic, and political factors in the etiology and distribution of TB was understated; and second, responsibility for health and disease was located in the individual immigrant body.

In approximately 7% (n = 20) of the articles reviewed, the problem of TB was framed as a serious problem of the past that has been “nothing but eliminated from Europe and North America” (Thompson, 2003, p. A12). In such statements, the contemporary differences in the burden of TB between individual European countries and within different segments of the population living in Europe and North America were ignored. These differences largely paralleled the disparate socioeconomic standards in these countries (WHO, 2005). For instance, in Canada, TB is a serious problem for the Aboriginal population. The rate of 102 TB cases per 100,000 persons among the Inuit people (Aboriginals) in some northern parts of Canada was comparable to the TB rates in the Eastern Mediterranean and the Western Pacific regions (Public Health Agency of Canada, 2008; WHO, 2009). Nevertheless, the fact that TB was a persistent problem that burdened Aboriginals, the homeless, the poor, and those living with HIV/AIDS, as well as immigrants, was mentioned in only 14% (n = 38) of the articles. We acknowledge that this finding might be a function of our sample that was focused on immigrant TB, and that a sample including nonimmigrant Canadians might reveal a different picture, as suggested in the following paragraph.

Epidemiologic trends were cited in a few articles to show that socioeconomic factors, and particularly poverty, contributed to the risks of contracting or reactivating TB. In 8% (n = 23) of all articles, poverty was linked to active TB among the nonimmigrant population of Canada. In one article it was stated that “crowded living conditions, poorly ventilated shelters, and people whose immune systems have been sapped by hunger and hard living present a fertile field for infection” (“Fertile Ground,” 2004, p. A18). In another, it was reported that “the disproportionately high rates of TB among aboriginals underlies the fact of life many Canadians would rather not confront—life for many North American aboriginals is similar to life among those living in the world’s poorest countries” (Payne, 2000, p. C2). In a third article it was noted that “the desperate poverty of the Downtown Eastside [Vancouver] has created the type of closely confined, unsanitary conditions where TB most easily spreads” (Skelton, 1999, p. B1).

Although the existence of articles on the link between TB and poverty might seem encouraging, such reporting was generally limited to articles about Canadian-born populations. This is notable considering we restricted our sample to coverage of immigrant TB. Only nine articles (3%) dealt with issues of postmigration poverty. In one article, TB was described as “a disease of poverty” that “preys on marginal populations, on the weak and the sick” (Picard, 2002, p. F5). In another article it was reported that immigrants were found among the homeless who prefer to sleep in front of Toronto’s City Hall and on the streets because shelters for the homeless were overcrowded, violent, and ridden with diseases (“Can Expect,” 2005). In another article the postmigration experience in Canada was described this way:

In three articles it was stated that postmigration stress can reactivate TB; however, in only one article was a clear connection made between the postmigration experience and the problem of TB among immigrants. The Globe and Mail reported that the high burden of TB among this population “does not mean that immigrants and refugees bring TB with them” (Beiser, 1999, p. A17). In his article, Beiser explained that “the conditions newcomers live under when they come to a new country might be as important as prior exposure to pathogens in explaining any tendency to develop illness.” He also indicated that immigrants in New York at the beginning of the 20th Century suffered from a high burden of TB, “not because they were sick when they arrived, but because they were forced to work in badly ventilated workshops, ate a poor diet and lived in overcrowded tenements.”

In only 11% (n = 29) of all articles were the social determinants of TB reactivation mentioned, and some kind of policy change required. For example, Winnipeg Free Press reported that TB “cannot be brought under control without tackling the poor living conditions that foster its spread” (Fallding, 2004, p.A6). In this article it was stressed that “[i]t is vitally important for governments to provide more affordable housing, ease crowding in shelters and improve ventilation” (Fallding, p.A6). In another article published in The Globe and Mail, it was claimed that “TB had been pretty much eliminated in urban Canada by public health and social housing programs, only to be brought back by cutbacks focused on the bottom line” (Haeh, 1999, p. A18).

In eight articles (3%) it was noted explicitly that immigrants’ health status could be improved by addressing socioeconomic factors. As stated in one article, if the growing economic disparity and social polarization continue, “we are putting the whole population at risk, including low income families, children, new immigrants, refugees and the homeless” (Abbate, 2001, p. A14). In these types of articles, readers were informed that the socioeconomic inequalities that some immigrant groups in Canada experience have led to “the emergence of concentrated pockets of an immigrant underclass” and “the long-term ghettoization of immigrants” (Carey, 2002, n.p.). The relative lack of media attention explicitly linking postmigration poverty with the development of active TB strongly reflects and reinforces the discourse of TB as a biomedical rather than a social disease.

Mutual Constitution of Racializing and Medicalizing Discourses

The status of the immigrant body as health threat was produced by and through preexisting and mutually constitutive racializing and medicalizing discourses that materialized in press coverage and TB control policies. Canadian public health policy on TB control has relied heavily on the biomedical approach—screening, diagnosis, and treatment—to disease prevention. The screening and diagnostic processes include chest X-rays, sputum smears, and skin tests. Treatment of active TB consists of 95 to 120 dosages of several antibiotics administered to patients over a period spanning 6 to 9 months, depending on the type of TB. The medical surveillance of two groups of immigrants is continued for 3 to 5 years after the completion of antibiotic treatment: those who were treated for TB prior to their migration, and those who were diagnosed with latent TB postimmigration. The rationale for this surveillance is to prevent the spread of TB from the supposedly diseased immigrant body to the healthy nonimmigrant body.

Screening and surveillance of immigrants as the main solutions for controlling the spread of TB were mentioned in 45% (n = 122) of all articles. The need for addressing the social determinants of health for people affected with TB was identified in only 11% (n = 29) of articles. This finding is consistent with previously cited studies (Bell et al., 2006; Lawrence et al., 2008) in which the researchers examined the press coverage of immigrant TB in the United Kingdom and New Zealand. In the Canadian press it was suggested that the improvements in Canada’s “poor” and “fragmented” screening and surveillance systems must start with increased funding for more and better TB control programs overseas (Moore, 2000, p. A9). There were calls for better training of physicians both at home and abroad to improve the interpretation of X-rays used to diagnose TB (Prittie & Gollom, 2000).

Canada’s policy of allowing refugees with active TB to seek asylum was also questioned. In one letter to the editor, the author argued that “a high-minded refugee policy may be also an irresponsible public health policy” (“Where Public,” 1999, p. A14). The author recognized that “turning back refugees with dread communicable diseases rings harshly in the moral mind”; however, he asserted that “the alternative is morally worse” (“Where Public,” p. A14). In a number of articles it was suggested that immigrants with latent TB must be monitored more effectively by improving communication between immigration and health authorities, and by developing specific centralized TB control programs (Moore, 2000). Suggestions included calls to better educate immigrants about the benefits of disease surveillance and the provision of translators for those who could not speak English or French (the two official national languages). News space was also devoted to the idea of maintaining a national database of people who are in compliance with medical surveillance. Those who were found in noncompliance could then be punished by being denied a driving license or, in extreme cases, Canadian citizenship (Fayerman, 2002b). The author of another article proposed the establishment of a national genotype database of all persons diagnosed with latent TB to track the spread of the disease in Canada (“Track Newcomers,” 2006). Besides the proposed improvements to the medical surveillance system, the importance of vaccines (primary prevention) and antibiotics (tertiary prevention) was also stressed in the press, as these two factors have been credited with the success that the West has had in reducing the incidence of TB in the past century. Messages about drug therapy, such as “DOTS [directly observed therapy, short-course] holds the keys to wipe out TB” (Paul, 1999, p. A12), appeared relatively frequently in the analyzed articles.

By means of the selected excerpts from Canadian newspapers, we clearly illustrate how racializing and medicalizing discourses were mutually constituted in Canadian press coverage and Canadian health policy concerning immigrant TB. In these discourses the immigrants’ lived experiences were essentialized, the significance of social and other poverty-related issues in the activation of TB was obscured, and the belief that TB resides in the raced immigrant body, thus posing a health risk for nonimmigrant Canadians was reinforced.