For those of us who work with patients, have been patients ourselves or conduct research, we are aware that tuberculosis (TB) is a completely curable infectious disease. Despite an imperfect vaccine, diagnostic challenges and lengthy treatment, good outcomes can be achieved for patients and contribute to efforts to eradicate TB with early diagnosis and effective drugs. This involves good access to healthcare.
In England, much like the rest of Europe, the vast majority of TB cases – 72% in 2017 – occur amongst migrants, largely coming from countries with a high incidence of TB. Due to devolution of health across the UK, I will discuss here the case as it stands in England. In response to concerns that England had a higher number of TB cases per population than almost all other Western European nations, a Collaborative Tuberculosis Strategy for England was launched in 2015 with the aim to achieve a year on year decrease in incidence and a reduction in health inequalities associated with TB.
The areas for improvement set out in the strategy included a focus on healthcare access and early diagnosis, a £10 million investment in a new national screening programme for recent migrants moving from high TB-burden countries as well as usual TB control strategies such as strengthening surveillance and improving contact tracing.
Meanwhile, in 2012, Theresa May – then home secretary and now Prime Minister - announced that the government intended on creating a “really hostile environment” for migrants living in the UK without the appropriate documentation. This hostile environment consisted of the infamous “go home vans” which encouraged people to report others or self-report to the home office and leave the country. Recently, increasing focus has been paid to mechanisms of the hostile environment which included increased monitoring in educational institutions, restrictions on renting and successive legislation to restrict healthcare access to undocumented migrants. Higher charges for care, hostile posters in health services, increased surveillance in hospitals and passing of patient information from the NHS to the Home Office to aid deportation all act as deterrents to healthcare access for migrants.
Whilst, like in many other countries, TB is exempt from charging, the deterrent effect begins well before a patient presents to healthcare services. Furthermore, my research shows that TB patients are unaware that TB treatment is free. People present with symptoms, not diagnoses and TB might not always be considered at the first or even subsequent encounter with clinicians during which time they could have been presented with a projected bill. Practices such as data-sharing undermine trust in a confidential health service which is of particular relevance to TB which is stigmatized in many different communities. The wider effects of the ‘hostile environment’ also have a potentially detrimental impact on TB control. With access to housing restricted by the ‘right to rent’ scheme, undocumented migrants are pushed into poorly maintained, overcrowded accommodation.
The TB community has a responsibility to speak out about these issues. Healthcare is a human right and this must be realised for all humans, not only those with citizenship status. If we are to continue to work towards eradicating TB globally, we must use our considerable resource to challenge those in power who construct policies aimed not at improving health, but rather to project a political position in relation to immigration. We must use our voice to advocate for everyone’s right to access healthcare, after all, whether labelled as economic migrant, citizen, refugee or undocumented – we are all human.
Respiratory registrar & MRC doctoral fellow, Queen Mary University of London
Campaigns with Medact Refugee Solidarity Group & Docs Not Cops for healthcare access rights for migrants.