‘But I am cured from TB!’ – The human cost of Tuberculosis prevention and deportation policy

He could not tell them about his lung scar, he was afraid to lose this opportunity, again. Upon pre-departure medical check-up he got stamped ‘unfit’ in 2011.

“I stopped applying for work since then because recruiting agencies here in the Philippines will not even entertain my application once I inform them about my TB history’, says Maynard, a professional from Philippines.’ My own government can not or would not even touch this issue.”

Maynard had previously worked in the UAE immediately after recovering from TB in 2009; yet 2 years later, he was labeled ‘unfit’ due to a scar on his lung that posed no hazard to others.

Tuberculosis is an age old disease that still manages to end lives in 21st century.
It’s an airborne, communicable disease that usually attacks the lung; however, it is capable of affecting other organs including the kidneys, brain and bones. But with accurate treatment, Tuberculosis can be successfully controlled and cured, regardless of the organ it infects.

We are aware an active TB patient manages to infect 10-15 people a year and it kills more than one person every minute almost over 3800 people every day. But we are unmindful how Tuberculosis impinges lives beyond human bodies.

They are still too many nations across the world including the major Gulf States are still fighting this ancient disease with primitive policies and practices. The Gulf Cooperation Council (GCC) consists of Bahrain, Kuwait, Qatar, UAE, Oman and Saudi Arabia – a geographic zone assumedly the largest receiver of temporary migrant workers in the world.

Many migrant workers (skilled-semi/non-skilled) work in key sectors labeled as TB and HIV risk sectors including (among others) “‘businesses with a large number of migrant workers, oil and gas industries/plantations and healthcare/construction sector”’.

To monitor health status and prevent diseases spreading by immigrant workers, the GCC formulated GAMCA to carry out a mighty plan. GAMCA or the ‘GCC Approved Medical Centers Association’ are the only medical facilities authorized to test and approve migrant employees’ work-placement in the Gulf. They are the only facilities authorized to test and clear migrants and function under standardized guidelines set by GCC nations. Many workers understand the need for GAMCA but they are completely flabbergasted by these polices.

Some argue these centers operate in a completely monopolistic manner and contravene national competition law. Others feel GCC nations have the right to protection against diseases but current GAMCA policies are not effective, on the contrary, erroneous and disingenuous.
“The main problem is most GCC nations did not provide GAMCA with any specific guidelines or standards in health screening. If you go to these clinics, you would not see any posters or leaflets showing their guidelines. Any spots or marks on one’s chest x-ray are labeled as TB, including marks and scars not even related to TB, for example, past infections from bronchitis or pneumonia.” notes Maynard.

Maynard is saddened his government does not take any measures either. “Our governments acts though as nothing irregular are happening”, he adds.

Maynard stopped working and underwent six months of treatment with additional preventative care when diagnosed with minimal pulmonary TB in 2008. Upon completing his treatment and declared completely cured by his doctors, he began searching for work overseas. His job application and medical reports were initially approved by a UAE company for a temporary job in 2009. Maynard informed the employer about his recent encounter with TB and employers assured him his past TB history would produce no problems in a pre-departure medical check up and gave a written consent. His visa was approved though after undergoing a lengthy process and he worked in UAE based on the contract period.

The guidelines in medical centers classify anyone as ‘unfit’ with a scar originating from past lung disease, pneumonia and/or TB history. And once a person is entered as ‘Unfit’ in their records, it’s impossible to amend it.
A second medical opinion is usually not measured and the process of changing ‘unfit’ to ‘fit’ is ambiguous at best if not unattainable; under some circumstances a waiver from employers might be considered but it’s not a widespread practice. The irony - it declares healthy person as ‘unfit’ and does not ask ‘unfit’ individuals to undertake treatment, clear their reports and re-apply.
Though, not all polices are uniform - certain gulf countries are slightly more specific, but they are more general and equally stringent across in the bloc.
Given GCC nations attract migrant workers in sectors vulnerable to TB and HIV. It’s exceedingly essential to include effective workplace programs and balanced health polices. This will help reduce stigma and discrimination, improve access to information, prevent further transmission and avert individuals from losing the jobs they rightfully secured.
'A Workplace program that comprehensively addresses TB and HIV prevention, diagnosis, treatment and care in high burden settings can effectively mitigate the impact of these diseases on the workforce and thus on productivity. The workplace is a win-win setting for TB management and TB/HIV co-management strategies.' states a report entitled “Working Together with Business 2012” by WHO and UNAIDS

It also asserts TB workplace programs contribute to enhancing workforce morale by providing them the expediency of better access to TB care service and savings related costs. Integrating HIV and /TB programs not only fulfills a legal responsibility - but also a moral obligation and responsibility to contribute to TB prevention. Also, meeting these obligations exhibits social commitment and respect towards businesses’ efforts toward demonstrating ‘corporate social responsibility’.

Formulating a TB/HIV workplace policy further guides to be conducted in a participatory manner with active involvement of worker’s representatives and senior management with a clear policy on return to work, continuity of treatment, privacy and /confidentiality.

Current policies and practices not only prevent healthy workers from working but also serve to deport individuals; even from countries where GAMCA does not function. ‘Maria’ was chosen to work as a flight-attendant for a big airline inside Qatar in 2010. She passed her medical test in her home country (Europe) including x-ray reports. Upon her arrival at Qatar she underwent HIV and other tests. For tuberculosis, skin tests, Mantoux test and x-ray reports were conducted.

Maria’s x-ray report revealed a scar from a previous illness which automatically qualified her to be deported. Unaware about her supposed disease, Maria asked the results to be released and the grounds for her deportation explained. “‘When I asked for test results they said it’s some kind of secret; I could not understand why tests done on my own body were withheld from me” says Maria. ‘They put me on the plane and sent me back home” she adds.
She returned to her country wondering what serious illness has inflicted her body. After undergoing several tests, doctors concluded as latent TB.
An individual infected with TB bacterium develops a latent TB infection. The bacterium remains alive in the body but inactive to be contagious; they do not show TB symptoms and cannot spread to others – however, they are at risk of developing active infection and almost 3%-5% of latent TB becomes active in first years and 5%-10% in remaining years.
Also, developing an active TB depends a lot on the strength of the person’s immune system. In her home country, Maria took preventive medication for six months to ensure the bacterium is eliminated. She’s now healthy and currently working in another country.
But her ordeal did not cease there and her TB history came haunting her - again. She was offered a job as a flight-attendant in the UAE. Despite openly talking about her TB history, they implied there was nothing can be done as her visa application would be reject
Maria went on to elaborated about another case where a woman was supposedly given TB medication in the UAE and deported. Later, she discovered she did not have TB and she suffered substantial lever damage due to TB medication. Maria says not everyone wants to speak out and talk about painful details.

Maria’s fiancé is an Arab national working at a reputable position in UAE. They are both well-educated; she wants to start a family and prefers the multi-cultural environment in the Emirates.
But once more this became nearly unattainable. “I wish with my whole heart some day all will be changed. I don’t know how long it will take; but I know I am doing my best searching for help at World and Regional bodies working in this area.’ explains Maria. ‘It’s not easy - very few organization and media heeds our issues”.

Perhaps Qatar’s stringent check-ups revealed her dormant TB and ensured she receive treatment, however, hiding her medical reports violated her rights and could have possibly prevented her diagnosis and treatment of latent TB.

One of the prime assertions behind deporting or preventing individuals with TB history from working within the Gulf is the fear of possible relapse. Extensive research suggests only a small % of cases relapse and there’s much debate if recurring TB is caused by a relapse or being sick again with the same strain despite receiving treatment. A multitude of factors also contribute to chances of relapse including age, gender, occupation, habits, addiction, place of residence, weight, other health conditions i.e. diabetes, asthma, anemia etc.

TB is mainly an airborne bacterial infection ubiquitous around the world. There’s no substantial evidence suggesting that barring people with cured TB safeguard citizens from contracting TB.

Neither countries that recruit workers from low/middle-income nations nor countries that sends workers overseas can guarantee the workplace conditions for these migrants. Poor, unhygienic, overcrowded conditions are frequently associated with increased chances of relapse and mortality in TB patients.

Plethora of issues affecting migrant workers health and paucity of literature exploring their plight creates vaccum for flagrant abuse to continuously flourish. What countries have currently taken steps to improve is merely a fraction of what current condition necessitate. When laws are in place, they are not consciously enforced.

There’s a dire need to motivate policy makers to intently act on this issue. Arguing millions die from TB has not induced policy makers to dedicate available resources to end TB. Likewise, saying abuse takes place is sadly not enough to motivate change. We even often fail to vociferously acknowledge the existence of an issue - this is an apt example of one. We may not have all the magical answers instantly but working in partnership with advocates, governments, academics and researchers is the first step.

In a study recommendation published in 2009, Dr Sahall H. (KFSH) in Saudi Arabia pointed out the need to reverse deportation policy as fear of deportation leads to under-reporting and incomplete treatment among active TB patients.

Deportation also raises question about the condition of deportees, what happens when they return to their home countries? Who ensures they receive treatment? Do both host countries and countries of origin need to take on better stewardship against fighting TB?

“In UAE when they diagnose you with active TB, they will treat you first (2 months treatment) immediately followed by deportation. Now the problem is in the home countries of deported individuals - here in the Philippines nobody monitors their treatment for the remaining 4 months, you're on your own. That's failure in compliance with the DOTS program set by international authorities primarily by WHO.”’ adds Maynard.

Experts affirm it’s an GCC inter-ministerial issue not only a health ministry problem; it requires extensive discussion for a non-discriminatory, evidence based change in policy.

People are not innately discriminatory. The systems we create induce those behaviors. Give me two months and I will design a perfectly stigmatizing, discriminatory system where people are comfortable following irrational guidelines and acts callously. Likewise, it’s also possible to design a system that provides a clear protocol and ensures transparency by involving all actors, develop a community based empowered solution where core human rights principles are respected and patients voluntarily take responsibility for their cure/treatment.
STOP TB and WHO sees that a human rights approach to TB prevention, control and care is the optimal way to tackle TB. And calls for review and reform of laws and deportation policies that impede effective TB response, discriminates, and deprives access to care.

A Human rights approaches emphasizes appropriate treatments that meet patients’ needs, prevent the development of drug resistance, assert patients’ right to be free from discrimination (including in health care settings) and to be free from forced or coerced treatment.
“The reason why I want to speak is because I feel that this is inhuman and cruel,”’ says Maria. “‘My future husband is in UAE. We truly want to be together but this unclear situation makes our life uncertain terrible and sad.”

The question is – how much pain and distress do we need to cause before we transform this decades old system? End TB, End stigmatization - not lives, not livelihoods.