In That Case Comment on “The Ethics of Isolation for Patients With Tuberculosis in Australia” by Jane Carroll, published in the Journal of Bioethical Inquiry 13(1).
Dinh Thi Nhung
Center for Creative Initiative in Health and Population, 48 Nguyen Khang St., Cau Giay District, Hanoi, Vietnam
Woolcock Institute in Vietnam, 147 Hoa Lu St., Ward 9, Ca Mau City, Vietnam
Xiang’s case study as described by Carroll highlights dilemmas that can occur once someone becomes sick with tuberculosis (TB) after he or she has migrated. Another problematical aspect of health and migration policy with regard to migrant TB screening is when hopeful migrants are detected with TB before they migrate. TB screening among populations who wish to migrate offloads the costs from a country with a low burden of TB and often increases the costs to a country with a high burden of TB. Hopeful migrants are left with a whole raft of issues to tackle, as shown in the following story of Mai, whose study in Australia was delayed in 2014 when she was diagnosed with TB during a health screening for a visa.
Mai is a woman with disabilities. After learning about a scholarship opportunity in Australia in mid-2014, she left her job to be able to participate as a full-time student in an English course prior to migration. She expected to leave Vietnam for Australia at the end of 2014. Following the language course, she prepared documents to apply for a visa, and this required her to submit herself for a health examination. The Department of Immigration and Border Protection requested her to return to the clinic where her initial medical examination had been performed, and this clinic referred her to another international migration organization. This organization then asked her to go to its clinic at a private hospital for a health examination.
The result came back that she was TB-positive. She was shocked by staff’s response. “The attitudes made me feel down, inferior, and [like it was my fault for having] a horrible disease. They scolded and accused me of not taking care of my own health, that I seemed too eager to go overseas, that I neglected my health. Actually, I am a person who takes great care of my health. If I had to choose between going overseas and my health, I would choose the latter. I did not show any symptoms of TB until I did this health examination. They talked to me as if I was very irresponsible of my own health,” exclaimed Mai.
The migration organization sent all of her test results and a referral letter to her hometown hospital. In the referral letter, it asked the local hospital to send documentation about the progress of Mai’s treatment. However, the local hospital made a formal request to the organization, separate from the referral letter, before it would send documents about her treatment progress to the organization.
After one month of treatment in the hospital, Mai reached a stage where she could check out and start maintaining her treatment at home with her doctor’s permission. However, she had to send the one-month treatment report as well as a treatment plan after leaving the hospital to the migration organization. This organization required that the report be signed and stamped by her doctor and the hospital where she received the treatment. The hospital staff refused to release the report unless they received a formal request from the migration organization explaining the reason for this information. The migration organization refused to send an official request letter. It said that it already sent the referral letter in which it mentioned the need for the treatment report. Therefore, Mai had to travel from her hometown to Hanoi to explain the situation and to try to obtain this formal request from the migration organization. When she came to meet staff at the migration organization, she knew she needed to wear a mask and she did wear a medical mask. Nevertheless, the staff told her that her mask was not thick enough. Visibly, the organization’s staff lacked the sensitivity for working with vulnerable groups. Their attitude made her afraid whenever she interacted with others.
The local hospital was supportive but strictly adhered to its regulations about sending medical records to other organizations. Consequently, Mai was trapped between the requirements of the migration organization and the local hospital and did not have enough power to persuade both parties to make the process easier for her. She ran around, asking for support from different places. After great efforts on Mai’s behalf, the scholarship program finally sent a formal request letter to the hospital.
Mai underwent a long and tiring eight-month treatment. She had already left her job and thus spent more than one year unemployed. She had been taking care of this issue on her own without any financial support. Things became very hard without an income or health insurance, which, under work arrangements in Vietnam, is covered only while one is employed. She had to pay more than US$500 to follow the procedure decided by the migration organization. The procedure was unnecessarily expensive, as she paid for screening tests in Hanoi as well as for similar tests in her hometown hospital again. Bearing the costs of such expenses would have been easier for her if she had been working. It also would have been easier and less expensive if the procedure was more supportive and less bureaucratic. Imagine, if like Xiang, Mai had a spouse and child or had been diagnosed with extensively drug-resistant tuberculosis (XDR-TB) and her treatment had been lengthened. Mai’s story in the country of origin and Xiang’s story in the migration destination country both highlight the adverse consequences that arise through TB treatment.
As an infectious disease, TB is a transnational problem and the responsibility is multinational. Perhaps all countries should put their money in one place, and TB patients, regardless of whether they are at home or abroad, could be sponsored to complete their treatment with resources from this universal fund.