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Social Science & Medicine 59 (2004) 753762

Sociocultural aspects of tuberculosis: a literature review

and a case study of immigrant tuberculosis
Ming-Jung Hoa,b,*
b

a
Institute of Social and Cultural Anthopology, Oxford University, Oxford, UK
School of Medicine, Chang Gung University, Wen-Hwa First Road, Kwei-Shan, Tao-Yuan, Taiwan

Abstract
The resurgence of tuberculosis in recent years has obliged us to reconsider the existing explanations of the disease.
Whereas biomedical literature tends to explain tuberculosis in terms of biological factors (e.g., bacterial infection),
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, and
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
humans, appeared to have been conquered in developed
countries 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
global emergency. The recent resurgence of tuberculosis
forces us to reconsider the existing explanations of
tuberculosis.
*Tel.: +886-3-211-8800; fax: +886-2-2393-6696.
E-mail address: mjhohuang@yahoo.com.tw (M.-J. Ho).

The dominant biomedical explanation of tuberculosis

was rst introduced in 1882, when Robert Koch
reported the isolation and cultivation of the tuberculosis-causing bacteria, Mycobacterium tuberculosis.
However, germ theory was based on laboratory experiments 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 fullblown tuberculosis (Dutt & Stead, 1999, p. 6). Furthermore, 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 (Iseman, 1985), there was a resurge of the disease in the
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 &

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2003.11.033

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M.-J. Ho / Social Science & Medicine 59 (2004) 753762

Dodkin, 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 tuberculosis. In the rst section of this paper, previous studies
examining the socioculutral aspects of tuberculosis are
reviewed. These studies focus on the extent of the
inuence of cultural, environmental and politico-economic factors in contributing to the disease. The
strengths and weaknesses of each approach are discussed. In the following section, the ways in which the
public health establishment weighs biological, cultural,
environmental, and politico-economic factors is examined 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 heterogeneous 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 health

(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 anthropologists. 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 implication follows then, that correcting false beliefs with
proper education would ensure compliance with biomedicine. Although medical anthropologists are increasingly 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

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(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 erroneous beliefs in transmission routes may delay diagnosis 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 tuberculosis. The investigators stated: Respondents correctly
viewed TB as an infectious lung disease with symptoms
such as cough, weakness, and weight lossyMany
respondents 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 (Barnhoorn & Adriaanse, 1992), and the Philippines (Nichter,
1994) to demonstrate the tendency to neglect socioeconomic 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 anthropological

755

study 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 geographical 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 contagiousness 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 ecological. 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 ecological approach, although it is referred to in some
textbooks as expanding upon the more general evolutionary 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 tuberculosis 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 hypothesized 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

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evolutionary perspective has been subject to substantial

criticism by certain anthropologists. The most vocal
critic of the ecological approaches in medical anthropology 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 environmental factors, studies linking tuberculosis and environmental 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 (AcevedoGarcia, 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 environment and tuberculosis but also enumerate a diverse
array of political and economic circumstances contributing 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. Instead, 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; Kistemann

et 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
the experience, distribution, and management of illness.
Historians have long noted the high incidence of
tuberculosis among disadvantaged populations (Dubos
& Dubos, 1996; Lerner, 1993; Marks & Worboys, 1997;
McKeown, 1976). According to the microbiologistturned-historian Dubos and Dubos (1996, p. 207),
tuberculosis was, in effect, the rst penalty that
capitalistic society had to pay for the ruthless exploitation 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 accessible, 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 biomedicine. In addition, many critical medical anthropologists 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: Incorporating political variables into every research design
because it is ideologically correct will transform anthropology 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 tuberculosis that focus on cultural, environmental, and

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politico-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 politicoeconomic factors, one report (CDC, 1989) suggests that
tuberculosis among high-risk populations could be
attributed to the socioeconomic conditions of nonimmigrants, such as poor housing and nutrition.
Yet, such adverse socioeconomic conditions are widespread among New York Citys Chinese immigrant
laborers, a topic to be elaborated on later. However, the
report did not place any signicance on these socioeconomic conditions in their explanation of immigrant
TB. Furthermore, the report anticipated that tuberculosis could be eliminated among socioeconomic disadvantaged groups merely through targeted delivery of
biotechnology, without improving socioeconomic conditions.
In terms of environmental factors, a report that
appeared in 1995 drew up a list of high-risk environments 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 environments 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 highrisk 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 more

757

than 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 population.
Methods
Five groups of informantspublic health workers,
Chinatown biomedical doctors, Chinatowns practitioners of traditional Chinese medicine, Chinese laborers, and Chinese tuberculosis patientsare included
in this study to yield a more comprehensive understanding 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, openended in-depth interviews, structured questionnaires,
illness narratives, reviews of medical records, and
analysis of epidemiological data. Participant observation was mainly carried out at Department of Health
outreach ofces and chest clinics; however, the researcher 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 interviews and questionnaires addressed patient explanations
concerning illness episodes: etiology, symptoms, pathophysiology, 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

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weakened 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 exhaustion, 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 stockbrokers 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 politicoeconomic 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 environments 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 and

sweatshops 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 complementary 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 immigrants 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 treatment while working long shifts to pay back smugglers
and survive in costly Chinatown, it is not difcult to
comprehend 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. tuberculosis 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. Multifactorial 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 course

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of disease while designing research protocols, often

thousands of miles away from the eld. The anthropologists role in tuberculosis research can be to provide
in-depth knowledge of the social, cultural, and
ecological context of the research settingyOnly with
detailed 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 different factors. Nonetheless, more social scientists are
advocating a multi-factorial model for tuberculosis. For
instance, although Farmer (1997) argued that tuberculosis 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 intellectual 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 theorization of tuberculosis and provides a detailed contextualization linking disease transmission to global
environmental, cultural, and politico-economic processes. 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 interdisciplinary perspectives. The review section demonstrates 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 anthropologists, for instance, would do well to learn from
critical medical anthropologists and consider the politico-economic forces shaping the environment. By step-

759

ping out of its disciplinary limits, anthropology can help

broaden the perspective of the medical discipline,
countering the tendency to privilege biomedicine because of an empiricist assumption. Furthermore, the
ethnographic data that anthropologists gather through
eldwork could verify and provide a context for a multifactorial 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-areabasedcould 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 important to recognize the possibility that immigrant tuberculosis may be related to adverse conditions in the
United States. While some cases of immigrant tuberculosis 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, sweatshops, 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 tuberculosis 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

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M.-J. Ho / Social Science & Medicine 59 (2004) 753762

upstream. What remain upstream, making people

vulnerable to TB, are the politico-economic factors.
Clearly, tuberculosis is associated with societys disadvantaged and marginal groups. Researchers have long
recognized the association between lower socioeconomic
status and a wide array of diseases, including tuberculosis (Cantwell et al., 1994; Dubos, 1987; Lerner, 1993;
McKeown, 1976; Spence et al., 1993). As Craddock
(2000, p. 13) eloquently states, Public health focus
today upon tuberculosis case surveillance and contacttracing may be responsible for stemming the rising tide
of cases, but the refusal to see poverty, homelessness, or
underemployment as signicant causal factors will lead
inevitably to new resurgences with every downturn in
the economy or diminution in public spending.

Uncited references
Baran (1957); Fleck and Ianni (1958); Goodman and
Leatherman (1998); Green (1999); Inhorn and Brown
(1997); New York Task Force on Immigrant Health
(1995); Singer (1989); Singer (1996); Wallerstein (1974);
Wiley (1992); Zhang and Elvin (1998).

Acknowledgements
This article is based on dissertation research supported by the New York City Department of Health, the
Wu Tzun-Hsian Foundation, and the Twenty-First
Century Scholarship. I wish to thank the anonymous
reviewers of this article, the patient informants, and the
following individuals: Dorothy Castille, Andrae Celtel,
Paula Fujiwara, Elisabeth Hsu, Chris Larkin, David
Parkin, Jessica Ogden, Stanley Ulijaszek, and many
more who kindly facilitated the research project upon
which this paper is based.

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