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Whereas biomedical literature tends to explain tuberculosis in terms of biological factors (e.g., bacterial infection),

humans, appeared to have been conquered in developed

global emergency. The recent resurgence of tuberculosis

losis-causing bacteria, Mycobacterium tuberculosis.

man, 1985), there was a resurge of the disease in the

ARTICLE IN PRESSforces us to reconsider the existing explanations of

tuberculosis.

developed countries and globally, it remained the

leading infectious killer of adults, affecting mainly

socially disadvantaged populations (e.g., the homeless,

the impoverished, minorities, and immigrants to the

United States) (Acevedo-Garcia, 2000; Brudney &*Tel.: +886-3-211-8800; fax: +886-2-2393-6696.

E-mail address: mjhohuang@yahoo.com.tw (M.-J. Ho).

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.socountries in the twentieth century by biomedicine armed

with powerful antibiotics. This downward trend of

tuberculosis cases began to reverse, however, in the late

1970s. For example, cases of tuberculosis in the United

States increased by 20.1 percent between 1985 and 1992

(New York City Department of Health, 2000). Globally,

tuberculosis remains the leading infectious killer of

adults, killing an estimated three million people per year

(WHO, 2001). In 1993, the World Health Organization

took the unprecedented step of declaring tuberculosis a

However, germ theory was based on laboratory experi-

ments and did not explain why only 2550 percent of the

humans exposed to M. tuberculosis become infected, or

why only 10 percent of those infected developed full-

blown tuberculosis (Dutt & Stead, 1999, p. 6). Further-

more, treatment of tuberculosis progressed slowly after

the discovery of M tuberculosis. Effective antibiotics

were not available until 1943 with the discovery of

streptomycin. Although an appropriate combination of

antibiotics could cure 95 percent of tuberculosis (Ise-politico-economic factors. Then how the public health establishment considers biological, cultural, environmental and

politico-economic factors will be examined through a case study of immigrant tuberculosis. While public health

facilities emphasize biological factors in the control of immigrant tuberculosis, an ethnographic study of tuberculosis

among Chinese immigrants in New York City provides detailed contexts that illustrate the cultural, environmental, and

politico-economic forces shaping tuberculosis and supports an emerging theorization of tuberculosis that encompasses

a heterogeneous collection of factors. Finally, a number of implications for public health interventions will be discussed.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Tuberculosis; Chinese immigrants; Illegal immigration; New York City

Introduction

Tuberculosis, not long ago the number one killer of

The dominant biomedical explanation of tuberculosis

was rst introduced in 1882, when Robert Koch

reported the isolation and cultivation of the tubercu-social scientists have examined various cultural, environmental, and politico-economic factors. In this paper,

sociocultural approaches to tuberculosis are reviewed according to their emphasis on cultural, environmental, andSocial Science & Medicin

Sociocultural aspects of tuband a case study of i

Ming-Jua Institute of Social and Cultural Ant

bSchool of Medicine, Chang Gung University, W

Abstract

The resurgence of tuberculosis in recent years has oblicscimed.2003.11.033(2004) 753762

culosis: a literature reviewigrant tuberculosis

Hoa,b,*

ogy, Oxford University, Oxford, UK

wa First Road, Kwei-Shan, Tao-Yuan, Taiwan

us to reconsider the existing explanations of the disease.

reviewed. These studies focus on the extent of the

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762754inuence of cultural, environmental and politico-eco-

nomic factors in contributing to the disease. The

strengths and weaknesses of each approach are dis-

cussed. In the following section, the ways in which the

public health establishment weighs biological, cultural,

environmental, and politico-economic factors is exam-

ined through a case study of immigrant tuberculosis.

Immigrant tuberculosis was selected as the focus of the

study because foreign-born persons contribute to over

half of the tuberculosis cases in the United States. While

public health facilities emphasize biological factors in

the control of immigrant tuberculosis, an ethnographic

study of tuberculosis among Chinese immigrants in New

York City provides detailed contexts that illustrate how

cultural, environmental and politico-economic forces

shape tuberculosis. In the nal section, an emerging

theorization of tuberculosis that encompasses a hetero-

geneous collection of factors, as well as the implications

for public health interventions, is discussed.

Literature review

In this section, previous studies examining the social

and cultural aspects of tuberculosis are reviewed. A

Medline search on keywordtuberculosis published in

three major sociomedical journals (Social Science &

Medicine, Medical Anthropology Quarterly, and Culture,

Medicine and Psychiatry) between January 1990 and

June 2003 was performed to compile the main body of

literature to be reviewed. In addition, relevant articles

cited in this core literature are also reviewed. In general,

previous sociocultural studies of tuberculosis can be

classied according to their focus on one of the

following factors: culture, environment, or politics. This

categorization serves as a heuristic device, a convenient

way of organizing the work on the sociocultural aspects

of tuberculosis by social scientists interested in healthDodkin, 1991; Dievler & Pappas, 1999; Dubos &

Dubos, 1996; Elender, Bentham, & Langford, 1998;

Farmer, 1997; Kistemann, Munzinger, & Dangerdorf,

2002). The association between low socioeconomic

status and tuberculosis acknowledged nowadays, was

also recognized in historical times (Cantwell et al., 1994;

Dubos & Dubos, 1996; Lerner, 1993; McKeown, 1976;

Spence et al., 1993).

The persistence of tuberculosis among the socially

disadvantaged and its resurgence in developed countries,

urges us to reconsider existing explanations and

management methods that tend to focus on the

biological cause. The main objective of this paper is to

address the need to incorporate sociocultural factors

into the explanations for and management of tubercu-

losis. In the rst section of this paper, previous studies

examining the socioculutral aspects of tuberculosis are(dened by the journal to include anthropologists,

demographers, economists, educationalists, ethicists,

geographers, philosophers, policy analysts, political

scientists, psychologists and sociologists), as well as by

health-care professionals and policy makers interested in

the relevance of the social sciences to medicine (e.g.,

epidemiologists, health educators, physicians, public

health practitioners).

Since the author is trained in anthropology, the

emphasis of this section focuses on anthropological

work. Nevertheless, examples are provided to show that

the analytic framework offered can as easily be applied

to studies of tuberculosis from a wide range of

disciplines. Studies placed in one category may share

characteristics with those of another, but each study is

classied according to its overall emphasis. It should be

noted, however, that there is an increasing number of

scholars (Coker, 2000; Farmer, 1997, 1999; G&y and

Zumla, 2002; Jaramillo, 1999; Porter & Grange, 1999;

Porter, Ogden, & Pronyk, 1999; Ogden, 2000) who

suggest that all three factors should be considered in any

sociocultural study of tuberculosis.

Cultural factors

Studies focusing on the cultural factors associated

with tuberculosis are frequently conducted by anthro-

pologists. In the tradition of ethnomedicine, these

studies classically address those beliefs and practices

relating to disease which are the products of indigenous

cultural development and are not explicitly derived from

the conceptual framework of modern medicine (Hughs,

1968). Ethnomedical studies contribute to a culturally

relativistic understanding of non-biomedical health

practices. Even the most exotic-appearing health beliefs

and behaviors are made understandable in the cultural

context in which they are found (Rubel & Hass, 1996,

p. 115). However, many medical anthropologists are

not free from the ethnocentric perspectives (Good, 1994,

p. 39).

In many anthropological studies that investigate the

cultural aspects of diseases, lay beliefs about illness are

often juxtaposed with biomedical knowledge about

disease. The former are viewed as culturally derived

while the latter represent objective reality. The implica-

tion follows then, that correcting false beliefs with

proper education would ensure compliance with biome-

dicine. Although medical anthropologists are increas-

ingly critical of this empiricist assumption, the majority

of recent anthropological studies of tuberculosis still

interpret cultural factors with implicit empiricism

(Barnhoorn & Adriaanse, 1992; Carey et al., 1997; Ito,

1999; Menegoni, 1996; Nichter, 1994; Steen & Mazonde,

1999; Vecchiato, 1997). Similar reactions to the cultural

factors inuencing tuberculosis illness can also be found

among papers written by researchers in other disciplines

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762 755(Khan et al., 2000; Liefooghe et al., 1995; Long et al.,

1999; Mata, 1985; New York Task Force on Immigrant

Health, 1995; Westaway, 1990).

An example of this was when researchers, afliated

with academic departments of public health Long,

Johansson, Diwan, and Winkvist (1999), organized

focus groups in four districts of Vietnam to explore

the beliefs of the Vietnamese people regarding

tuberculosis. They concluded that traditional erro-

neous beliefs in transmission routes may delay diag-

nosis and increase social stigma. Similarly, a survey

conducted by anthropologists Carey et al. (1997) in New

York State among 51 newly arrived Vietnamese refugees

highlighted the cultural factors associated with tubercu-

losis. The investigators stated: Respondents correctly

viewed TB as an infectious lung disease with symptoms

such as cough, weakness, and weight lossyManyrespondents incorrectly believed that asymptomatic

latent infection is not possible (Carey et al., 1997, p.

112, emphasis added). The study concluded that

targeted patient education is needed to address

misconceptions about TB among Vietnamese refugees

and to help ensure adherence to prescribed treatment

regimens (Carey et al., 1997, p. 112, emphasis added).

Folk beliefs are labeled incorrect; they are thought to be

misconceptions, whereas biomedical knowledge is

described with the adjective correct. The unstated

privileging of biomedicine and the empiricist assumption

of rationalism results in the simplistic conclusion that

correct behavior follows correct belief. Traditional

beliefs are viewed as barriers to the delivery of

biomedicine. Salvation, via biomedicine, follows

a conversion from indigenous beliefs to biomedical

knowledge.

In addition to questioning empiricist assumptions,

physician and anthropologist Paul Farmer (1997, 1999,

pp. 229261) has further criticized sociocultural studies

of tuberculosis that focus on cultural factors for

neglecting politico-economic forces shaping disease

distribution. In his study of multi-drug-resistant TB in

Haiti, Farmer found that economic factors chiey

determined compliance with treatment and argued that,

in settings similar to Haiti, social scientists should not

exaggerate cultural factors at the expense of more

signicant socioeconomic forces. Farmer eloquently

reviewed and criticized studies from South Africa (de

Villiers, 1991), Honduras (Mata, 1985), India (Barn-

hoorn & Adriaanse, 1992), and the Philippines (Nichter,

1994) to demonstrate the tendency to neglect socio-

economic constraints.

Despite the limitations of the cultural approach, it

should of course not be discounted. As the following

example shows, there are a few studies that clearly

demonstrate both the strengths and the limitations of

such an approach. Vecchiato (1997) conducted, from the

cultural viewpoint, a sophisticated anthropologicalstudy of tuberculosis in Ethiopia. He carefully avoided

the shortcomings described above and acknowledged a

range of non-cultural factors shaping the perception, the

treatment, and the spread of illness. The management

of actual illness episodes is shaped not solely by

culturally transmitted ethnomedical axioms, but also

by practical, nancial, social, structural and geographi-

cal considerations (Vecchiato, 1997, p. 195). Having

pointed out several weaknesses in the cultural approach,

Vecchiato (1997, p. 196) suggested that instead of

portraying traditional beliefs as a barrier to the delivery

of biomedicine, the strength of the cultural approach

comes from the ethnomedical concepts, such as con-

tagiousness and dietary improvement, which can be

brought to bear in shaping general health education.

Similarly, Poss (1998), a health science researcher,

conducted in-depth interviews with 19 Mexican migrant

farmworkers regarding their perceptions of tuberculosis

and found that their beliefs do not pose a barrier but are

compatible with biomedical screening and treatment.

Environmental factors

Let us now consider the sociocultural studies of

tuberculosis that focus on environmental factors. Within

the discipline of anthropology, studies investigating

environmental factors have often been labeled ecolo-

gical. The central interest of the ecological approach is

the relationship between the environment and organisms

within an evolutionary timeframe (Brown, Inhorn, &

Smith, 1996, p. 184; McElroy, 1990, p. 244). Few

anthropological studies of tuberculosis apply the ecolo-

gical approach, although it is referred to in some

textbooks as expanding upon the more general evolu-

tionary point of view. For example, it is speculated that

in prehistoric times, as a result of the domestication and

milking of cattle, mycobacteria causing bovine tubercu-

losis were spread from infected cattle to those who

drank the milk or ate the beef from these cattle (Roberts

& Manchester, 1997, p. 136). This conclusion is drawn

from an examination of skeletal change; yet it is neither

specic nor conclusive, since other diseases can leave

similar marks on human skeletal remains. Among

studies of how human interaction with the environment

changes disease patterns, some researchers have hy-

pothesized a connection between urbanization and an

increase in the incidences of tuberculosis (Diferdinando,

1999; Fenner, 1980, p. 17), and others have suggested

that improved living standards and nutrition lowered

mortality rates before antibiotics were available (Joske,

1980, p. 558, 561; McKeown, 1976).

The strength of the ecological approach lies in its

inclusion of environmental factors in illness analysis, its

synthesis of biological and cultural factors in shaping

sickness, and its incorporation of historical and

archaeological perspectives. However, its underlying

the experience, distribution, and management of illness.

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762756evolutionary perspective has been subject to substantial

criticism by certain anthropologists. The most vocal

critic of the ecological approaches in medical anthro-

pology is Merrill Singer, who published a provocative

article in Medical Anthropology Quarterly under the

title, Farewell to adaptationism: Unnatural selection

and the politics of biology (1996). In this article, Singer

argues that ecological models that use adaptation as a

conceptual tool are futile because they do not address

the political economy that shapes the environment to

which humans adapt. The differential survival pattern of

social groups is unnaturally selected by conditions

created to serve the interest of the dominant class.

In contrast to anthropological studies of environ-

mental factors, studies linking tuberculosis and environ-

mental factors emerging from other disciplines usually

acknowledge the importance of social forces in shaping

the disease-prone environment. Six articles in Social

Science & Medicine since 1990 focused on the inuence

of environmental factors on tuberculosis (Acevedo-

Garcia, 2000; Antunes & Waldman, 2001; Bhatia,

Dranyi, & Rowley, 2002; Elender et al., 1998; Klovdahl

et al., 2001; Packard & Epstein, 1991). These studies not

only illustrate the correlation between crowded environ-

ment and tuberculosis but also enumerate a diverse

array of political and economic circumstances contri-

buting to unhealthy environments. For instance, the

Chinese occupation of Tibet and the ight of refugees

resulted in crowding and a high incidence of tuberculosis

in monasteries and refugee camps (Bhatia et al., 2002).

Residential segregation between African-American and

white populations in the United States has resulted in

over-crowding and limited health care access together

with tuberculosis in minority areas (Acevedo-Garcia,

2000). Historians Packard and Epstein (1991) also argue

that colonial governments in Africa did not address the

environmental factors that generated tuberculosis. In-

stead, blacks had to be taught about the dangers of

living in over-crowded housing and eating nutritionally

inadequate diets, as if they chose to do so out of

perversity rather than economic necessity.

Politico-economic factors

Having discussed the criticisms offered by critical

medical anthropologists Farmer and Singer, critical

medical anthropology requires little by way of an

introduction. Clearly, the focus on politico-economic

factors is evident. However, in the main body of

literature reviewed in this section, most of the studies

which examine politico-economic factors are not written

by anthropologists (except Farmer, 1997, 1999; Farmer,

Robin, Ramilus, & Kim, 1991; Rubel & Garro, 1992)

but by clinicians, epidemiologists, historians and public

health practitioners (Brudney & Dodkin, 1991; Dievler

& Pappas, 1999; Dubos & Dubos, 1996; KistemannHistorians have long noted the high incidence of

tuberculosis among disadvantaged populations (Dubos

& Dubos, 1996; Lerner, 1993; Marks & Worboys, 1997;

McKeown, 1976). According to the microbiologist-

turned-historian Dubos and Dubos (1996, p. 207),

tuberculosis was, in effect, the rst penalty that

capitalistic society had to pay for the ruthless exploita-

tion of labor. As the living conditions of urban laborers

improved in industrialized countries, the rate of

tuberculosis decreased in the rst half of the twentieth

century. However, funding for public health tuberculosis

control infrastructures was also reduced throughout the

latter half of the twentieth century as a result of the

considerable reduction in tuberculosis cases. Clinicians

Brudney and Dodkin (1991) studied 224 patients

admitted consecutively to a public hospital in New

York City in 1988 and identied four social factors

responsible for the resurgence of tuberculosis: the

decline in tuberculosis control programs, poverty,

homelessness, and alcoholism. Farmers study (1997)

of multi-drug-resistant TB in Haiti further argued that

economic factors chiey determined compliance with

treatment. He claimed the poor have no options but to

be at risk for TB and demonstrated that patients were

compliant when treatment programs were made acces-

sible, regardless of their traditional cultural explanations

of tuberculosis (Farmer, 1997, p. 349).

The politico-economic approach focuses our attention

on the structural factors shaping tuberculosis. This may

lead to a kind of structural determinism; however, since

the creativity of mankind to nd solutions to the

problems they face is often ignored with this approach.

Human beings are portrayed as helpless victims of

structural violence. Furthermore, many studies of the

politico-economic approach are biomedically centered

and relate poor health to the inaccessibility of biome-

dicine. In addition, many critical medical anthropolo-

gists take an activist stance and are eager to convert

policy makers, as well as fellow social scientists, to their

point of view. McElroy (1996, p. 521) has responded to

such attempt with the following statement: Incorpor-

ating political variables into every research design

because it is ideologically correct will transform anthro-

pology into an enterprise that is over-specialized and

trendy, and that moves from one fad to another.

Immigrant tuberculosis

Given the wealth of sociomedical studies of tuber-

culosis that focus on cultural, environmental, andet al., 2002; Naterop & Wolffers, 1999; Saunderson,

1995). All these studies share important features with

works of critical medical anthropology in emphasizing

the structural, political, and economic factors shaping

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762 757politico-economic factors, one might wonder how public

health establishments incorporate such issues in their

treatments. An analysis of texts relating to immigrant

tuberculosis in the Morbidity and Mortality Weekly

Report (MMWR), the major ofcial publication of the

leading public health institution in the United States,

that is, the Centers for Disease Control and Prevention

(CDC) reveals that sociocultural factors are touched

upon only slightly (Ho, 2001, pp. 3138). In terms of

cultural factors, though many public health workers in

New York City believed that foreign culture of

immigrant sufferers of tuberculosis impedes effective

treatment (Ho, 2001, pp. 58-75), reports on immigrant

tuberculosis in MMWR (CDC, 1989, 1990, 1995, 1999)

do not address this issue. With regard to politico-

economic factors, one report (CDC, 1989) suggests that

tuberculosis among high-risk populations could be

attributed to the socioeconomic conditions of non-

immigrants, such as poor housing and nutrition.

Yet, such adverse socioeconomic conditions are wide-

spread among New York Citys Chinese immigrant

laborers, a topic to be elaborated on later. However, the

report did not place any signicance on these socio-

economic conditions in their explanation of immigrant

TB. Furthermore, the report anticipated that tubercu-

losis could be eliminated among socioeconomic disad-

vantaged groups merely through targeted delivery of

biotechnology, without improving socioeconomic con-

ditions.

In terms of environmental factors, a report that

appeared in 1995 drew up a list of high-risk environ-

ments for tuberculosis that included prisons, nursing

homes, health-care facilities, homeless shelters, and

residential settings for human immunodeciency virus

(HIV)-infected persons. However, there is no mention of

how to reduce the risks within these environments. The

recommended treatment is to educate the population in

high-risk environments of the biomedical model so that

infected and diseased people can be treated with

antibiotics. In addition, environmental considerations

are not extended to immigrants, whose tuberculosis is

regarded as the result of infection in their home

countries rather than the product of high-risk environ-

ments in the US. The remainder of this section presents

a case study of tuberculosis among Chinese immigrants

in New York City, who describe their experiences, not in

their native countries, but in their migratory journey en

route to the United States, as well as in congested high-

risk environments in the US.

Background

Between 1985 and 1992, cases of tuberculosis in the

United States increased by 20.1 percent, from 22,201 to

26,673, with the largest increase occurring in New York

City (84.4 percent). The number of cases in the city morethan tripled from 17.2 per 100,000 in 1978 to 52.0 per

100,000 in 1992 (New York City Department of Health,

2000). This recent epidemic has been reported as two

tuberculosis epidemics, one among persons born in the

United States, among whom infection with the HIV and

various social problems (e.g., intravenous drug use,

homelessness) have been important contributing factors,

and the other among foreign-born persons who come to

the United States from countries with high rates of

tuberculosis (New York City Department of Health,

2000, p. 9). While the number of US-born cases has

declined since 1992, the proportion of immigrant TB

cases continued to increase, reaching 58 percent in 1999.

China has been the largest contributing source of

foreign-born cases. In addition, public health workers

have noted that Chinese laborers are disproportionately

affected among the general Chinese immigrant popula-

tion.

Methods

Five groups of informantspublic health workers,

Chinatown biomedical doctors, Chinatowns practi-

tioners of traditional Chinese medicine, Chinese la-

borers, and Chinese tuberculosis patientsare included

in this study to yield a more comprehensive under-

standing of how tuberculosis is perceived and managed

by Chinese immigrants in New York City. A number of

methods were used to collect data from these various

groups of informants: participant observation, open-

ended in-depth interviews, structured questionnaires,

illness narratives, reviews of medical records, and

analysis of epidemiological data. Participant observa-

tion was mainly carried out at Department of Health

outreach ofces and chest clinics; however, the research-

er also had the chance to participate in and observe the

daily lives of Chinatown immigrant workers, in addition

to their more specic medical activities. In-depth inter-

views and questionnaires addressed patient explanations

concerning illness episodes: etiology, symptoms, patho-

physiology, course of sickness, and treatment. Illness

narratives were gathered from sixty patients enrolled in

the Department of Health Directly Observed Therapy

program. These patients were invited to speak freely

about any aspect of their illness episodes.

Case study

Ms. Zeng is a 45-year-old lady from a village near

Fuzhou. Although she understood that her tuberculosis

involved a bacterial infection of her lungs, she told me

that neither the public health workers supervising the

Directly Observed Therapy nor the doctors in the chest

clinics have found the cause of my illness yet.

Gradually, Ms. Zeng revealed that she was vulnerable

to tuberculosis because her constitution has been

and survive in costly Chinatown, it is not difcult to

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762758weakened by a variety of factors. First, she was forced to

undergo sterilization operation while living in China.

Then she had to endure a difcult illegal migratory

journey, being crammed with over two hundred fellow

passengers into the bottom deck of a cargo ship for 3

months. They ate only a wheaten bun or a piece of dried

tofu each day. After the ship docked in Guatemala, they

were transported in an airtight banana cargo truck for

10 h and could hardly stand the smell of someone

suffering from diarrhea. They then had to trek through

the mountains, relying on mangos and other wild plants

for food, sleeping only a few hours each day. The

migratory journey, the crowding, the physical exhaus-

tion, and inadequate nutrition all contributed to her

weakened immunity and susceptibility to tuberculosis.

Once she arrived in New York City, her voyage ended

but the challenges to her health did not subside. For

illegal immigrants, the trip from China to New York

City cost over US$60,000 during the period of my

eldwork. It cost Ms. Zeng a bit less but her debts were

considerable and she also hoped to sponsor family

members in China who wanted to come to the United

States. She worked over 13 h/day in a poorly ventilated

Chinatown garment factory. She lived frugally: eating

rice porridge or wheaten buns, occasionally treating

herself to an egg, and rented a bed in an over-crowded

Chinatown tenement buildings. When she rst arrived,

Ms. Zeng rented a space under a stairway adjacent to a

sewage pipe. After 2 years, she graduated to share the

bottom of a bunk bed with another illegal laborer with

two other roommates sleeping on the upper bunk. For

that she paid US$150 per month. Shortly after she began

treatment in the Directly Observed Therapy program,

Ms. Zeng was evicted by her landlord. She had to sneak

into the garment factory where she worked to sleep for a

while before she could nd another place.

It is ironic that Chinatown, inhabited by half a million

illegal Chinese immigrants (a conservative estimate), is

adjacent to New Yorks city government buildings and

only two subway stops from the greatest concentration

of banking wealth in the world. Manhattans stock-

brokers and civil servants walk right past undocumented

workers like Ms. Zeng on their way to lunch on wontons

or Peking duck. It is evident that global politico-

economic forces shape the unequal distribution of

wealth and work opportunities. A global class of

transnational workers has emerged that is vulnerable

to exploitation, ill health, and tuberculosis.

Many of the other tuberculosis patients interviewed

told similar stories (Ho, 2001). The threatening environ-

ments they described were not those identied in the

dominant public health discourse (namely, the countries

of origin) but the crowded boats, ill-ventilated trucks,

and holding places they experienced as they made their

way to the United States, not to mention the detention

centers and safe houses, the tenement buildings andcomprehend that global politico-economic inequality,

housing and working conditions in Chinatown as well as

exploitation by human trafckers and illegal employers

all must be addressed in an effort to control immigrant

tuberculosis.

Discussion

Current tuberculosis control programs focus on

treating the bacterial cause in high-risk groups such as

the immigrant population. However, the pathway from

health to tubercular disease is determined not only by

bacterial infection but by a multitude of factors.

Biomedicine has identied that exposure to M. tubercu-

losis is an essential factor in this path. However, having

been exposed to the mycobacterium, not everyone will

become infected. Furthermore, not everyone infected

progresses to the tuberculosis disease. There are other

important factors on the road leading to disease. Multi-

factorial epidemiological models that take into account

biological, cultural, ecological, and politico-economic

factors help explain why (Dunn & Janes, 1986; Janes,

Stall, & Gifford, 1986; Link & Phelan, 1995; Nations,

1986; Susser and Susser, 1996a, b).

Increasingly, anthropologists have become involved in

building multi-factorial disease models. Nations (1986,

p. 116), e.g., notes that anthropologists can help rank

the multitudinous statistical factors in epidemiological

analysis since the biologist will be hard pressed to

consider the totality of factors which bear on the coursesweatshops they encountered once they arrived. In

contrast to the biomedical suspicion that traditional

Chinese medical beliefs and practices may hinder or

delay biomedical treatment, traditional Chinese medical

practitioners and inhabitants of Chinatown describe

their holistic cultural beliefs and practices as comple-

mentary rather than inimical to biomedical treatment

for tuberculosis. For instance, Ms. Zeng mentioned that

only by using traditional Chinese medicine had she been

able to reduce the side effects of the medicines prescribed

by the Department of Health and so comply with the

treatment. In addition, traditional Chinese emphasis on

kin relations tends to have a positive effect on patient

compliance since family members support patients by

allowing them freedom from social responsibilities while

they recover.

Those are examples of how environmental and

cultural factors affect the experience of Chinese im-

migrants who contract tuberculosis in the United States.

With regard to politico-economic factors, it appears that

simply making antibiotics more readily available to

tuberculosis sufferers is inadequate. As Ms. Zeng

struggles to comply with Department of Health treat-

ment while working long shifts to pay back smugglers

ARTICLE IN PRESSM.-J. Ho / Social Science & Medicine 59 (2004) 753762 759of disease while designing research protocols, often

thousands of miles away from the eld. The anthro-

pologists role in tuberculosis research can be to provide

in-depth knowledge of the social, cultural, and

ecological context of the research settingyOnly withdetailed anthropological observations of people going

about life as usual is it possible to achieve a good

understanding of the complex causal chains in disease

etiology.

However, as reviewed earlier, sociocultural studies of

tuberculosis generally focus on only one factor (either

cultural, environmental, or politico-economic) without

illustrating the complex inter-relationships among dif-

ferent factors. Nonetheless, more social scientists are

advocating a multi-factorial model for tuberculosis. For

instance, although Farmer (1997) argued that tubercu-

losis in Haiti was mainly a question of economics, he

contended that cultural factors might be of overriding

signicance in other settings. Porter and Ogden (1998)

analyzed the inter-relationship of agent, host, and

environment and demonstrated the association between

social inequality and tuberculosis. In Social Science &

Medicine, Jaramillo (1999) argued that the current

tuberculosis epidemic has persisted because current

tuberculosis control programs focus exclusively on the

biological cause and fail to take into account an

integrated model of the causality of tuberculosis

including biological, behavioral, and socioeconomic

forces. Most recently, Gandy and Zumla (2002) have

called for a multi-factorial explanation of the resurgence

of tuberculosis, including the interaction between

biomedical, political, cultural, and economic factors.

They pointed out that an analytical challenge is to

combine an understanding of the diversity of local

contexts for disease transmission with a wider intellec-

tual framework engaged with processes of global

economic and political change.

This case study of tuberculosis among Chinese

immigrants in New York City answers such a challenge.

The ethnographic data support a multi-factorial theori-

zation of tuberculosis and provides a detailed con-

textualization linking disease transmission to global

environmental, cultural, and politico-economic pro-

cesses. Together with the literature review, the case

study has a number of implications for researchers,

policy makers, and health-care providers.

First, this paper describes the importance of inter-

disciplinary perspectives. The review section demon-

strates that comparisons between the researches of

various disciplines can shed light upon the limitations

and strengths of each approach. The strength of one

approach can help to compensate for the weakness of

another when they are combined. Ecological anthro-

pologists, for instance, would do well to learn from

critical medical anthropologists and consider the politi-

co-economic forces shaping the environment. By step-ping out of its disciplinary limits, anthropology can help

broaden the perspective of the medical discipline,

countering the tendency to privilege biomedicine be-

cause of an empiricist assumption. Furthermore, the

ethnographic data that anthropologists gather through

eldwork could verify and provide a context for a multi-

factorial model of diseases generated by other social

scientists or health researchers.

In addition to the theoretical contribution, the

ndings of this paper can be applied in a variety of

ways. Regarding cultural factors, most American public

health providers regard traditional Chinese medicine as

a barrier to the treatment of tuberculosis. The testimony

of Ms. Zeng demonstrates that traditional Chinese

medicine is compatible with and complementary to the

biomedical treatment of tuberculosis. Would it be

unthinkable to involve traditional Chinese medical

practitioners in New York Citys efforts to control

tuberculosis? Other cultural resources a public health

program could exploit are the immigrant emphasis on

health as capital and crucially important kin and

native-place networks. Since any interruption of the

immigrant laborers health threatens his livelihood, a

campaign to promote general health (with tuberculosis

screening an important component) might have greater

appeal than a campaign focusing solely on tuberculosis.

Tapping into local networkskin-based or native-area-

basedcould improve compliance rates, as cousins and

fellow Fujianese remind and help one another to take

medicine and visit the clinic.

When discussing environmental factors, it is impor-

tant to recognize the possibility that immigrant tuber-

culosis may be related to adverse conditions in the

United States. While some cases of immigrant tubercu-

losis occur when latent infections acquired in the home

country are reactivated, this paper calls for heightened

awareness of tuberculosis transmission among marginal

immigrants in host countries. To curtail immigrant

tuberculosis transmission in the US, over-crowded and

poorly ventilated living and working environments must

be improved. Such environments, with a high risk for

spreading tuberculosis, include detention centers, sweat-

shops, over-crowded apartments, gambling halls, senior

centers, and clinic waiting rooms.

While the above promotes the management of

environmental and cultural factors, it is also important

to address the politico-economic roots of tuberculosis.

Although antibiotics are necessary to save the lives of

tuberculosis sufferers, treatment alone is not sufcient to

curtail the disease. Antibiotics can be viewed as treating

the relatively proximate cause of tuberculosis, whereas

addressing the social conditions giving rise to tubercu-

losis targets the more distal links in the long causal

chain. A helpful visual analogy is that, while using

antibiotics may save people drowning downstream, we

must stop them from being thrown into the river

the economy or diminution in public spending.

This article is based on dissertation research sup-

which this paper is based.

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Sociocultural aspects of tuberculosis: a literature review and a case study of immigrant tuberculosisIntroductionLiterature reviewCultural factorsEnvironmental factorsPolitico-economic factors

Immigrant tuberculosisBackgroundMethodsCase study

DiscussionUncited referencesAcknowledgementsReferences