Summary
Iraq has historically faced a high burden of tuberculosis (TB), though significant progress has been made in recent years. However, deep-rooted stigma, limited public understanding of latent TB infection (LTBI), and challenges in healthcare access both in Iraq and among Iraqi immigrants in the U.S. remain major barriers. Respondents from the Iraqi community emphasized the emotional and social burden of TB, associating it with fear, isolation, and secrecy. Barriers to care in the U.S. include confusion about testing eligibility, inadequate TB education for patients and providers, and concern regarding stigma, especially its potential impact on employment.
Recommendations
- TB screening for individuals from Iraq using blood tests (e.g., IGRA, QuantiFERON) rather than skin testing (e.g. tuberculin skin testing, Mantoux)
- Education with a focus on the difference between TB disease and LTBI
- Address stigma directly in public health messaging and within care interactions
- Close follow-up in clinic to ensure treatment completion and adherence
- Culturally tailored TB education that incorporates family support and addresses fear of isolation and death
Methods
The following sections are based on interviews with eight Iraqi community members who were identified by an Iraqi community navigator contracted with Public Health – Seattle & King County. Interviews were conducted either in English or Arabic with an Iraqi community navigator providing interpretation. A supplemental literature review was also performed.
Burden of Disease
2024 World Health Organization (WHO) TB statistics of Iraq1
Total tuberculosis (TB) incidence (number): 9,800
Total TB incidence (rate per 100,000 per year): 21 per 100,000
HIV-positive TB incidence (number): 0
HIV-positive TB incidence (rate per 100,000): 0
Total Population (2023): 46 million
Languages Spoken
Arabic is the predominant language in Iraq, with Kurdish being the second most common. The term used for tuberculosis in Arabic is “Al-Sull” (السُل) or “Al-Daran” (الدرن). “Al-Sull”, in Arabic literature, means “unsheathing a sword” as in battle,2 which evokes fear and fatality, and carries a strong emotional and cultural weight. Respondents noted that simply hearing the term can be anxiety-inducing, reflecting how deeply the disease is associated with death and stigma in the collective memory.
Bacillus Calmette-Guérin (BCG) Vaccination
The BCG vaccine has been administered in Iraq since the early 2000s and has become part of routine childhood vaccinations.3 According to the WHO, BCG coverage in Iraq has consistently been around 95% over the past 20 years.4
Despite general acceptance of the BCG vaccine, respondents reported limited understanding of its efficacy or duration of protection. Several expressed frustrations that they received little to no information about the vaccine when it was administered in Iraq. Other respondents voiced concerns about being asked to receive additional vaccinations upon immigrating to the U.S. and expressed uncertainty about which diseases they were intended to prevent. There was general confusion among respondents about whether routine immunizations required before arriving in the U.S. included the BCG vaccine. This confusion was compounded by the common belief that BCG provides lifelong immunity to TB, which could lead to individuals delaying screening or treatment for LTBI.
Diagnosis and Clinical Features (Recognized by Community)
Respondents were familiar with active TB disease and its classic symptoms: chronic cough, fever, weight loss, night sweats, and loss of appetite. However, most were unaware of LTBI and the risk of reactivation. This knowledge gap contributes to low motivation for screening or preventive treatment, particularly when individuals are asymptomatic.
TB disease is perceived as highly dangerous and life-threatening, and those who are diagnosed often face emotional distress and fear of social rejection. No awareness of extrapulmonary TB was reported among respondents.
Testing of TB Disease and LTBI in Iraq
Respondents described TB screening in Iraq historically being minimal and that diagnosis relied heavily on the identification of clinical symptoms. Recently, awareness campaigns and screening programs have been introduced, often in response to WHO-led efforts and health reforms post-2003.
Testing primarily includes sputum microscopy and chest radiographs for symptomatic individuals. There is limited infrastructure for symptomatic or routine LTBI screening.5 However, awareness is slowly improving, and people are increasingly open to testing, especially in urban centers.6
TB Treatment in Iraq
Treatment for TB in Iraq typically involves standard first-line therapy and is reported to be physically and emotionally demanding. Respondents described the treatment process as exhausting for both patients and their families. Dealing with isolation and long courses of medications was noted to be particularly challenging. However, respondents mentioned that people are generally cooperative and adherent to the treatment plan. They are aware that side effects exist and that patients respond differently to treatment. They also emphasized the importance of family and community support for successful completion of treatment.
Social Factors and Care Delivery in Iraq
Stigma was described as the most distressing aspect of TB. Respondents shared that a diagnosis of TB is similar to a diagnosis of mental illness, inspiring secrecy and shame in the patient and their family. Most respondents said they would hide the diagnosis from extended family or neighbors because of fear of judgment, social exclusion, or being viewed as contagious or weak.
“If you share . . . everybody will talk about it within the family or within the community. So, people don’t want to share even if they seek treatment”
“It’s true you don’t want to say it, it’s like it’s shameful to share it”.
Experience with TB and Barriers to Care in the United States
Many Iraqi immigrants reported barriers to TB testing in the U.S., primarily due to perceived lack of provider responsiveness. They noted that clinicians will sometimes decline TB screening requests unless there are known TB contacts, even for individuals born in Iraq, a high-TB burden country.
Some respondents expressed frustration with limited awareness about TB among U.S. healthcare staff. While privacy protections in the U.S. were cited as reducing stigma compared to that faced in Iraq, some feared risks to employment due to a diagnosis of TB. Employees in the fields of childcare and healthcare are particularly wary of the impact of testing on their employment and were more likely to avoid TB screening. Other barriers to screening for LTBI include language and cultural gaps, and limited understanding of LTBI treatment options and their side effects.
Respondents emphasized the need for more accessible information about TB, including methods of prevention, testing, treatment options, and the impacts of prior BCG vaccination on subsequent testing. They identified culturally tailored awareness campaigns as essential for addressing misconceptions and overcoming key barriers to care.
Historical and Structural Factors
A diagnosis of TB disease was historically seen as a death sentence in Iraq. Older generations still equate TB with inevitable death due to its devastating impact before effective treatments became widespread. Some respondents equate TB with cancer, both of which were historically incurable diseases.
Over the past four decades, Iraq has experienced repeated cycles of war, sanctions, and displacement that have shaped the social conditions and infrastructure in which TB spreads. In the 1970s and 1980s, Iraq’s health system was regarded as one of the strongest in the region, with widespread access to public services and robust training of medical professions. War with Iran (1980-1988) redirected government spending away from government services.
The health system continued to worsen after the 1991 Gulf War led by the U.S. which damaged power, water, sanitation, and transportation systems with bombing campaigns targeting industrial infrastructure. Following the Gulf War, the United Nations imposed wide-ranging economic sanctions which lasted more than a decade. These sanctions restricted trade, financial transactions, and imports including medical supplies and equipment.
Sanctions and economic decline in the 1990s were associated with rising poverty and malnutrition. The medical system was weakened by chronic shortages and failing infrastructure.
The 2003 U.S.-led invasion and the overthrow of Saddam Hussein triggered a profound reshaping of the political and social landscape. Hospitals and clinics faced looting, destruction of equipment, and recurrent interruptions in electricity and water supplies. Many experienced clinicians emigrated, eroding clinical expertise. Ongoing insecurity also complicated public health outreach, routine screening, and treatment for TB.
Large-scale internal displacement has been an important feature of recent Iraqi history. Since 2003, successive waves of conflict and sectarian violence have forced millions of Iraqis to flee their homes and move to informal settlements with limited access to health services. 7
These historical forces have contributed to a pattern in which TB is closely intertwined with poverty, displacement, and a fragile health infrastructure. Wartime scarcity, sanctions, and unreliable public services have shaped the expectations of many Iraqis of the healthcare system. This legacy can influence trust in medical providers, their willingness to seek screening tests or disclose past illness, and fears about the social and economic consequences of a TB diagnosis. These are factors that remain highly relevant when Iraqi community members engage with healthcare systems in the United States.
References
- World Health Organization. Tuberculosis country profile: Iraq. Tuberculosis profiles. Global Tuberculosis Programe. Accessed August 19, 2025. https://worldhealthorg.shinyapps.io/tb_profiles/?inputs&tab=%22tables%22&lan=%22EN%22&iso2=%22IQ%22&entity_type=%22country%22
- تعريف و شرح و معنى سل بالعربي في معاجم اللغة العربية معجم المعاني الجامع، المعجم الوسيط ،اللغة العربية المعاصر ،الرائد ،لسان العرب ،القاموس المحيط – معجم عربي عربي صفحة 1. Accessed July 15, 2025. https://www.almaany.com/ar/dict/ar-ar/%D8%B3%D9%84/#google_vignette
- Vaccination Services in Postwar Iraq, May 2003. Accessed July 13, 2025. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a3.htm
- WHO Immunization Data portal – Detail Page. Immunization Data. Accessed July 28, 2025. Bacillus Calmette–Guérin (BCG) vaccination coverage
- Abdulkareem FN, Merza MA, Salih AM. First insight into latent tuberculosis infection among household contacts of tuberculosis patients in Duhok, Iraqi Kurdistan: using tuberculin skin test and QuantiFERON-TB Gold Plus test. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2020;96:97-104. doi:10.1016/j.ijid.2020.03.067
- Al-Obaidy LM, Attash HM, Al-Qazaz HK. Knowledge and perception about tuberculosis among general population attending community pharmacies in Mosul: A cross-sectional study. JPMA J Pak Med Assoc. 2024;74(10 (Supple-8)):S246-S249. doi:10.47391/JPMA-BAGH-16-55
- United Nations High Commissioner for Refugees (UNHCR). (n.d.). Iraq refugee crisis. USA for UNHCR. Retrieved July 17, 2025, from https://www.unrefugees.org/emergencies/iraq/