When the so-called Spanish Influenza started spreading in 1918, people locked themselves in their homes or even into small towns and tried to ride it out. It seemed to make sense – travelers could bring the virus with them, so wouldn’t keeping them out keep the deadly germ out, too?
It did not work, of course. No one could stay isolated for years on end while the virus and its descendants made its way through the population. People are still getting infected today by a distant descendant of that virus.
Humans are far too interconnected to be able to think that keeping others out will protect them from disease. Yet that attitude remains. So does the stigmatization and exclusion of migrants.
Dr. Alena Kamenshchikova, an assistant professor in the Care and Public Health Research Institute (CAPHRI) at Maastricht University in the Netherlands has been studying this very complicated intersection of language, migration, and disease spread – especially the spread of antimicrobial-resistant organisms, often called superbugs.
She says that all stigma does is force people to try to hide it when they are sick. Or, worse, they may take antibiotics inappropriately to try to treat themselves when they cannot get the proper healthcare they need. This inappropriate use of antibiotics can drive the rise of drug-resistant bacteria.
Listen as Dr. Kamenshchikova tells some startling stories about how keeping migrants of all kinds on the margins can endanger everyone around them.
Maggie Fox 00:00
Hello and welcome to One World, One Health with the latest ideas to improve the health of our planet and its people. I’m Maggie Fox. Planet Earth faces some big crises—pollution, climate change, and infectious diseases (both old and new). These problems are all linked and what humanity does is key to all of them. This podcast is brought to you by the One Health Trust with bite-sized insights into ways to help.
One thing humans do a lot is travel. People are crossing borders constantly, permanently for work, for tourism. Some want to go, some don’t. And people carry infections with them. When pandemics break out, or even smaller epidemics, it might be tempting to shut down borders and to shun strangers. But this seemingly rational reaction doesn’t actually do anyone much good. By the time a particular infection is spotted, it’s almost already spread and stigmatizing migrants can just make things worse for everyone.
In this episode, we’re chatting with Alena Kamenshchikova, assistant professor at Maastricht University in the Netherlands. She’s studying the extremely complex interplay between migration, the spread of drug-resistant germs, and language. Alena, thanks so much for joining us.
Alena Kamenshchikova 01:19
Thank you so much for inviting me. It’s really great to be here.
Maggie Fox 01:23
People are moving around the world all the time. Can you describe a little bit just how much movement there is?
Alena Kamenshchikova 01:30
So, I think it’s always interesting if you look to air traffic maps. So, if you just go to Google and google air traffic maps, you just see how many planes are moving every minute across the world. But it’s also important to think that the plane is not the only movement of transportation, right? You have trains, you have boats, you have cars. I live in the Netherlands, so, you have bicycles, and those are all movements of transportation which people use to move.
Maggie Fox 01:56
So, what does migration and movement have to do with the spread of drug resistance? It’s not so simple as migrants just carrying new germs around the world with them. Right?
Alena Kamenshchikova 02:07
Yes. So, that’s definitely not the case, I think. So, this we are talking about two very complicated phenomena. On the one hand is speaking about migration. And when we’re speaking about migrants, it’s avery heterogenous group of people, right? Migrants can be labor migration, it can be forced migration, so refugees and asylum seekers.
It can be circular migration:
If you live in Belgium and work in the Netherlands, you go back and forth; you can be considered a circular migrant. So, migration as a topic is very complex phenomenon. And then they’re talking about antimicrobial resistance. I think listeners to your podcast are already familiar with phenomenon of antimicrobial resistance, where microorganisms develop resistant mechanisms to the available antimicrobials. And then they often focus in discussions specifically on antibiotic resistance, so bacteria and antibiotics.
And the question is how antibiotics are used, because the way they’re used and in the quantities in which they’re used can impact the development of antibiotic resistance. So, the question is how do the two phenomena intersect? When we’re looking at migration, let’s focus for instance, on precarious migration. So, for instance, asylum seekers and refugees. We are talking about people who are forced to leave their home countries, and they usually have to take quite a long period of transition time, usually up to several years before they arrive in the home country where they applied for asylum.
And during this period, people are put in extremely vulnerable conditions to infectious diseases. Their treatment regimens can be disrupted. So, if people have chronic condition and get access to medications, due to forced migration, this treatment gets disrupted, but also dependent on the context where they migrate, in which countries they transition into, or which country they settle in, they have very different types of access to healthcare system.
So, when you’re speaking about antimicrobial resistance and migration, one of the important question is access to antibiotics for migrant communities, because depending on your legal status, depending on the context from where you’re migrating and how you’re migrating, you actually might not have access to this essential medication. And that’s a huge problem. It falls under the big umbrella of access to (the) healthcare system, but antibiotics as essential medicines. And another part is antibiotics due to their, usually, very cheap costs—-sometimes again, depending on the countries can actually be accessed or purchased, for instance, from street pharmacists without the need to go to (the) healthcare system. And depending on the person migrating, people might prefer that option simply because they might not have (a) legal opportunity to go to primary care setting and actually receive healthcare that they need.
So, they prefer to just go and buy (an) antibiotic because it will be the only option for them to receive any type of care, or because they’re afraid that if they go to healthcare system and ask for assistance, that it might impact their migration application, it might delay their migration trajectory. So, they would sometimes prefer to actually use antibiotics as a self-treatment mechanism to keep going or to avoid going to (the) healthcare system.
Maggie Fox 05:27
So, tell us a little bit more then about why it’s not just simply a case of “well, here, are these people they’re traveling, they’re carrying these infections with them, maybe we should restrict travel, and then we restrict the spread of these microorganisms.”
Alena Kamenshchikova 05:43
Yeah, that’s definitely not the case. And I think the whole discussion about people are moving and spreading infectious diseases, I would argue is incorrect. Or at least, it’s very damaging for the people moving and it doesn’t give justice to the complexity of the problem. But the question here is not whether we should stop people. The question is why this is happening, why people are put into a condition where they become vulnerable to infectious diseases. Why people (are) put in a position where they cannot get access to primary care, and of course, to use antibiotics.
And that’s a much more complicated question that requires us to think kind of more systematically require us to think about questions such as access to healthcare services, and not just legal access, which should be there, but also an actual practical access. And what I mean by that, if a person arrived to a country, especially if you’re talking about migrants in precarious conditions, for instance undocumented person meaning a person who doesn’t have documents that are required by the host country to legally be in that country, they often cannot access primary healthcare. They often cannot access GP, only emergency care.
But even if they do have (the) legal right to access healthcare, this legal right very often not translate into the actual availability of care. A very common practice, which we unfortunately see being reported in multiple research, for instance, from the UK, but also from the Netherlands. In the UK, regardless of your documented status, you can have access to primary care.
However, let’s imagine if you are an undocumented person and you enter a GP office, the first person you see is the reception and you ask the reception if you can have an appointment with the GP, the very first thing reception will ask you is (for) your identity card. They actually shouldn’t be asking you that because it doesn’t matter legally, you can have access to the GP regardless of identity card, but in practice, we see that’s how GP registration is done.
So, if you’re an undocumented person, you’re asked (for) identity card, you probably turn away and leave without getting the care you’re entitled to. So, self-medication is often the only answer that people have.
Maggie Fox 08:02
You’ve been doing some study on this issue of language, drug resistance, and migration. You’ve mentioned stories like the case of Typhoid Mary, who was an Irish immigrant who spread typhoid to several hospitals … um several households in Chicago. What prompted you to write this paper and what’s going on with language and how people think about this issue?
Alena Kamenshchikova 08:25
If you look historically the way we understand and think about infectious diseases, it’s always associated in our way of thinking, not just a layperson’s way of thinking, but also scientifically, with “the others.” The risk of infection is always come from the outside. It’s never kind of from a neighbor. It’s always from a faraway land, from a stranger, and deceit historically. Indeed, the Typhoid Mary, so she was an Irish – Mary Malone — she was an Irish immigrant into the United States that was blamed for spreading typhoid. –Gaëtan Dugas who was a Canadian flight attendant who was a homosexual blamed for spreading AIDS into the US. We also have this kind of intersection of discrimination, homophobia towards migrant communities. So, this is not a new story. And look at COVID-19 and how kind of the story of COVID-19 has been also developing, where the infectious spread is always coming from the outside, and we need to close the borders. And that’s what will protect us. And now we know that that’s not how it works. And I find this discourse is very dangerous, first of all, for spreading further discrimination towards migrant communities, but also damaging for public health.
And I think it’s kind of this discussion once again, of this kind of identity politics. We all have our identity documents. That’s where you belong. That’s where you come from. If you talk about COVID-19 and (the) European Union, here is a very interesting example. When the pandemic happened and started in 2020, we saw that many countries introduced different border control regulations right to kind of what you also asked him to restrict the movements of people. However, within the European Union, there was very interesting stipulation that the movement of goods and services shouldn’t be interrupted. However, goods and services don’t move by themselves. They’re moved by people.
And in Europe, especially if you look in Germany, in the Netherlands, one of the central economies during COVID-19 were meat factory facilities. And in the Netherlands, (the) majority of workers working in meat factories are labor migrants, mostly from Eastern Europe. So, we are talking about movements of people across the borders, which they had to move to preserve the economy of the European Union and to keep movements of services and goods flowing. However, those were also the one of the biggest clusters of COVID-19 out in Germany and in the Netherlands.
So, people that were put at much higher risk of contracting infection, by the fact that they had to be moving and then we saw a lot of again discriminatory and blaming language, that while migrants are spreading diseases. However, they were forced to move in order to keep the economy running.
Maggie Fox 11:13
So, it sounds to me like what you’re saying is people’s discriminatory practices and the way they think about the way that germs move are actually harmful. And the solution would be equitable provision of healthcare. And that’s probably more complicated than it sounds on the surface, right? Because some of the first lines of healthcare is providing antibiotics. But giving people antibiotics isn’t necessarily always the answer.
Alena Kamenshchikova 11:39
No. And I think it’s not about giving people antibiotics. It’s again asking why people often need to take antibiotics at first place. And here we are talking about access to non-pharmaceutical forms of care. So do people have access to primary care and other forms of treatment rather than antibiotics. And we see when you prohibit people access to primary care services, antibiotics often become the only solutions that’s left.
I think, when we are speaking about migration and antimicrobial resistance or migration and infectious diseases in general, I think we should be very careful. We, I mean as scientists, as public health professionals, but also (the) general public, how we communicate our research to the media, for instance, or to policymakers to make sure we are not creating the narratives of kind of stranger danger migration, infectious diseases, migrants use antibiotics.
We should be very cautious about it because it doesn’t translate the complexity of the problem. It doesn’t transmit this answer to the question of why people are forced to use antibiotics. What are the alternatives people have? So, in 2016, I’ve done my research with people in the Netherlands, this people who were fleeing Syria, and I’ve done ethnography in the refugee center. And I was talking to multiple people there and trying to understand their practices of self-care in terms of access to healthcare, especially during their movement when they left Syria before they arrived at the Netherlands and why I highlighted it is so important how we, as a scientist, communicate this type of knowledge to the media, because if you open media and people also migrating read media, this connection migrants are coming and bringing infectious diseases—people internalize it.
They are terrified to go and ask from healthcare professionals because they’re afraid it’s going to impact their migration application. So, one of the persons with whom I spoke, it was a woman with a kid. And —— the kid was quite ill when they were moving to the Netherlands. And they asked her when they were transitioning to Italy, whether she went and asked for some healthcare. And she said, no, so she said that she just —— gave him antibiotics.
And they kept moving because, and I quote, “you have to arrive to Europe healthy.” So, it is this also fear that’s been perpetuated by populist politics, by media that people on the move, they’re terrified also to ask for healthcare services, because they’re afraid it will impact their migration application.
Maggie Fox 14:09
And of course, one reason why we have so much migration is people migrate to work, but working conditions actually affect the spread of disease too.
Alena Kamenshchikova 14:19
Especially when you’re talking about labor migration, low-skilled labor migration. People usually are paid per hour. People usually do not have any social insurance. So, if they fell sick and depending on the country where they are, they prefer to just to use antibiotics because it is this quick solution. If I work, for instance, as a construction worker, and I fell sick, my job doesn’t provide me with the sick leave and I have to provide for my family.
Depending on the country where you are, some people actually bring antibiotics with them use them from their home countries, if they can access their prescriptions or if you can buy it on the street from a street pharmacist dependent how it is regulated in the country, they prefer to kind of quickly have antibiotics and keep working. So that’s why when —— we are talking about antimicrobial resistance in general as the problem, unfortunately, it’s very often become narrowed down to this kind of personal behavioral problems that people just don’t know. That’s why they don’t do that. But it’s much more complex than that.
People don’t have social insurance or health insurance to be off work. And when you’re speaking about migration, you also add their fear of deportation, fear of detention. You also add the fact that they might not be able then to return, to return back home without any payment. So, you layer all this down, and then you see that very often the options that they see is antibiotic because it’s cheap and accessible, and it might not help their care at all. Maybe they have viral infection and not bacterial. But it’s also very difficult to say later to stop antibiotics, because again, it will not solve the problem.
The problem is people don’t have social security, especially people in precarious conditions, especially labor migrants. And that’s such an important question to address if you really want to tackle the core of antibiotic use, antimicrobial resistance, but also infectious diseases in general.
Maggie Fox 16:14
Because it might sound a little bit trite to say it, but healthcare for one person is healthcare for everybody.
Alena Kamenshchikova 16:20
Maggie Fox 16:22
Alena, thank you so much for joining us.
Alena Kamenshchikova 16:25
Thank you so much for inviting me. I was really happy to chat with you.
Maggie Fox 16:30
If you liked this podcast, which is brought to you by the One Health Trust, please share it by email or social media. And let us know what else you’d like to hear about at [email protected]. Thanks for listening.
Dr Alena Kamenshchikova is an assistant professor in social studies of infectious diseases at Maastricht University, the Netherlands. She has been researching the tensions between global human mobility, border security, and state-based practices of infectious disease control. She has been interested in how (in)equalities and (in)equities can take place through public health campaigns, such as antimicrobial resistance screening of refugees, as well as through practices and language of science (see her research on metaphors used in antimicrobial resistance research). Alena has been trained as a political philosopher and for the last seven years she has been working alongside infectious disease professionals and microbiologists to develop transdisciplinary approaches to address complex infectious disease topics, such as antimicrobial resistance (call for transdisciplinary research in antimicrobial resistance).
Hosted and written by Maggie Fox
Special guest: Alena Kamenshchikova
Produced and edited by Samantha Serrano
Music composed and sound edited by Raquel Krügel
Transcript edited by Dipyaman Sengupta