Coloring the white plague: a syndemic approach to immigrant tuberculosis in Canada
By: Reitmanova & Gustafson
In this article, we adopt a syndemic approach to immigrant tuberculosis (TB) in Canada as a way
of challenging contemporary epidemiological models of infectious diseases that tend to
racialize and medicalize the risk of infections in socio-economically disadvantage populations
and obscure the role of social conditions in sustaining the unequal distribution of diseases in
A syndemic approach unravels social and biological connections which shape the distribution of
infections over space and time and is useful in deracializing and de-medicalizing these
epidemiologic models. The socio-historic framework allows us to examine social factors which,
refracted through medical science, were central to the development of TB control in Canada at
the beginning of twentieth century.
We expose the ideological assumptions about race, immigration, and social status which
underpin current policies designed to control TB within the immigrant population. We argue
that TB control policies which divert the attention from structural health determinants
perpetuate health and social inequities of racialized populations in Canada. Medical screening
and surveillance is an ineffective control policy because the proportion of TB cases attributed to
immigrants increased from 18 to 66% between 1970 and 2007.
More effective TB control policies require shifting the focus from the individual disease carriers
toward social inequities which underlie the problem of immigrant TB in Canada. In addition, de-
racialization and de-medicalization of the contemporary epidemiological models of infectious
diseases entail an in-depth exploration of how the categories of ethnicity, culture, and
immigration status are played out in everyday health-related experiences of racialized groups.
The first decade of twenty-first century was marked by several global outbreaks of deadly infections,
such as severe acute respiratory syndrome, avian influenza, cholera, swine flu, and Escherichia coli food
poisoning. The anxiety over deaths, physical suffering, and financial loss caused by these outbreaks
contributed to the growing sense of uncertainty and vulnerability to infectious diseases in the global
Traditional epidemiological studies of infectious diseases and the conditions which foster the outbreaks
rely heavily on the statistical analysis of disease occurrence and health behaviors to inform public health
policy and biomedical interventions. For this reason, this study applied a syndemic approach to the study of tuberculosis (TB) and the burden
of disease experienced by visible minority immigrants to Canada.
This study focused on TB and immigrants for several reasons: First, this chronic infectious condition
illustrates well the operation of concepts such as contagion and moral taint in the racialization and
othering of a population perceived to be an external threat.
Second, although the transmission and reactivation of TB is closely linked to social conditions of the
most socio-economically disadvantaged groups, the TB experience of visible minority immigrants has
garnered limited attention among Canadian researchers and policy-makers when compared to the TB
experience in Aboriginal communities.
Third, the well-documented history of TB and its control in Canada allows us to explore important
historical contingencies which shaped the current racialized and medicalized understanding of this
Therefore, immigrant TB provides an excellent case study for a retrospective examination of the
sociocultural and political factors which, refracted through medical science, were central to the
development of TB control in Canada at the beginning of twentieth century.
The syndemic approach permits this critical analysis because it is based on the assumption that some
infectious diseases operate on two mutually-reinforcing levels.
The first-level interaction occurs between two or more pathogens resulting in the locational or temporal
clustering of certain health problems. Two or more pathogens can interact on a biochemical and genetic
level and thereby accelerate their negative impact on the health of an individual. One of the most
threatening of such synergistic interactions occurs between the Human Immunodeficiency Virus (HIV)
and the bacteria responsible for TB.
TB enhances the progression of AIDS and is the most common cause of death among persons infected
with HIV. Conversely, HIV is considered the most powerful risk factor for contracting TB and its presence
accelerates the progression of TB disease in an infected individual.
The second-level of syndemic interaction exists between co-infections and harmful social and economic
conditions, which play an important role in fostering the occurrence of these co-infections and in
sustaining the unequal distribution of disease burden in disadvantaged populations.
A two-level syndemic approach to infections requires controlling the interaction of pathogens at the
biochemical and genetic levels as well as at the level of the social inequities that foster these co-
infections in disadvantaged populations.
To think syndemicly about infectious diseases means unraveling the biological, social, and historical
connections which shape the distribution of infections over space and time. The syndemic approach also challenges the contemporary understandings about the occurrence and
spread of infectious diseases that are shaped by essentializing discourses about human behaviors and
interactions. These discourses tend to racialize the risk of infectious disease by linking it with people’s
skin color, or cultural traditions and behavior norms preserved in specific communities and populations,
or in specific geographic regions.
This syndemic analysis makes several contributions to the current debate on the emergent epidemics of
infectious diseases. Syndemics are an understudied subject in public health research. To our knowledge,
there is no other study which would examine the problem of immigrant TB in Canada from the syndemic
It allows us to expose the colonialist assumptions about race, immigration, and social status which lie
behind the current policies designed to control TB within the immigrant population.
Current TB control policies focus exclusively on medical screening and surveillance of immigrants while
the role of social conditions in fostering the reactivation of TB among immigrants after their arrival tends
to be neglected.
The persistent neglect of poverty-related factors contributes to the unequal distribution of burden of TB
in Canada. A syndemic analysis of TB may challenge the way Canadian health policy-makers think about
the health risks associated with racialized immigrant populations and initiate discussions about more
effective and inclusive policies to improve the health of immigrants.
Immigrant TB in Canada
According to WHO, Canada has one of the lowest rates of TB incidence, prevelence, and mortality in the
However, a closer look at the national statistics reveals that the burden of TB is distributed unequally
among different populations.
The Aboriginal population represented about 20% (n_307) of all diagnosed cases compared with the
Canadian-born non-Aboriginals population that represented only 11% (n_170). While the proportion of
Aboriginal cases has remained unchanged since 1970s, the burden of TB cases in the other two
populations has changed significantly.
In 1970, the proportion of TB cases in the Canadian-born non-Aboriginal population represented almost
70% of all cases reported while the immigrant population accounted for only about 18% of all cases. In
the years between 1970 and 2007, the proportion of cases in the Canadian non-Aboriginals has declined
significantly while the proportion of immigrant cases has increased dramatically.
Almost 80% of immigrants in Canada arrive from Asia, the Pacific, Africa, the Middle East, and South and
Central America (CIC 2009), all regions with higher rates of TB prevalence, incidence, and mortality.
The highest proportion of TB cases in Canada could be found among immigrants coming from the
endemic areas in the Western Pacific (43%), South-East Asia (25%), Africa (14%), and South America (8%)
while immigrants from Central and Eastern Europe constituted about 7% and 3%, respectively. The compulsory pre-entry screening of immigrants for HIV in Canada was introduced in 2002. Persons
diagnosed with HIV are regarded as a public health threat and they are not allowed to immigrate to
Canada. This rule does not apply to refugees on the humanitarian grounds. Between 2002 and 2009,
4280 refugee claimants were diagnosed with HIV during pre-entry screening. The majority of these
persons came to Canada from Africa, the Middle East, the Americas, and Asia. The increased rate among
these immigrants was attributed to the impoverishment, decline of social services, rapid urbanization,
subordination of women, and violent conflicts in their birth countries. Howe