Epidemiology
From the Seattle-King County Annual Tuberculosis Report 2004:
“The number of foreign-born TB cases increased to 97 in 2004. The highest case numbers came from Vietnam, Ethiopia, the Philippines, Somalia and Sudan. The increase in numbers among East African countries can largely be traced to a TB outbreak among mostly young males of East African origin. 12 cases were diagnosed with TB matching the outbreak strain. This group was generally involved in drug selling and use, and had a history of incarceration and hospitalizations due to gun or knife injuries. Patients were mostly male, East African immigrants in their 20s, of Amhara, Eritrean, Ethiopian, Oromo, Somali, or Tigrinyan ancestry. Most had a combination of social risk factors such as drug use, incarceration history, and unemployment. All had pulmonary disease, and one was infected with HIV. Cases generally showed a very rapid progression to disease and overt TB symptoms, including cough and weight loss. All cases were either genotypically linked with a matching strain type, or had an epidemiologic link to a patient with an isolate matching the outbreak pattern.”
From Morbidity and Mortality Weekly, Thursday, October 3, 2002 (51(39); 882-883):
“The proportion of tuberculosis (TB) cases among foreign-born persons in the United States has increased steadily, accounting for half of reported cases in 2001 for which country-of-origin information was available. During 1998 — 2001, the annual number of TB cases among African immigrants and refugees in Seattle and all of King County increased approximately threefold to that during 1993 — 1997. Findings indicate that in Seattle-King County, persons at risk for TB who have arrived recently in the United States were primarily from the African-Horn countries of Eritrea, Ethiopia, and Somalia.During 1993 — 1997, fewer than 10 cases of TB in African immigrants were reported each year (5% — 10% of the annual total). The number of cases began increasing in 1998…In 2001, of 139 TB cases reported in Seattle-King County, 28 (20%) were among African immigrants. During 1998 — 2001, of Seattle-King County’s 486 TB cases, 79 (16%) were among African immigrants, 67 (85%) of whom were from Eritrea, Ethiopia, and Somalia.
“The World Health Organization estimates that the TB rate is 260 per 100,000 population for Ethiopia and 229 for all of Africa ( 3 ), rates almost identical to those observed in Seattle-King County. Increases in African immigration and TB are occurring elsewhere; in the United States, the number of refugees from Africa increased from 6,662 in 1998 to an estimated 18,979 in 2001.”
References
Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Global burden of TB: estimated incidence, prevalence, and mortality by country. JAMA 1999;282:677 — 86.
Adair R, Nwaneri O. Communicable disease in African immigrants in Minneapolis. Arch Intern Med 1999;159:83 — 5.
U.S. Committee for Refugees. Regional refugee ceilings and admissions to the United States, FY 1989 — 2002. Refugee Reports 2002;12:9.
Methods
TB is one of the medical problems most commonly seen in newly arriving refugees from the African-Horn countries of Eritrea, Ethiopia and Somalia. Managing illness cross-culturally depends on communication, but communication depends on understanding the socially and culturally determined references and performances associated with a diagnosis and its treatment (Jackson C., 1996). To investigate Oromo community members’ knowledge and understanding of TB, two semi-structured focus group discussions were held at an Oromo mutual assistance association / community center. A staff person at the community center recruited 19 participants who had grown to adulthood in Ethiopia and who speak Oromo as their primary language. All participants reported that they speak Oromo at home; Eleven women and seven men participated with ages ranging from 20 to 62. Fifteen participants grew up in rural environments, and four were raised in urban areas. Their arrivals in the US happened between 1990 and 2002.
The discussions were interpreted in Oromo and English by an interpreter/project coordinator recommended by the community organization. A research coordinator from Harborview facilitated the discussion using questions prepared by a public health TB nurse and reviewed by several Ethiopian interpreters, to guide/prompt the group conversation. A medical doctor from Harborview was present in the discussions. He asked several questions of the group and answered participants’ health-related questions at the end of the meeting. The discussions were recorded, the English portions of the tapes were transcribed, and research coordinator, medical doctor, and interpreter/project coordinator analyzed the transcripts for themes, outlined below.
Characteristics of Good Health and Disease
Good health is recognized as a state of being free of disease; keeping disease away through nutritious foods such as meat and milk; avoiding certain foods (“junk foods”); and maintaining tidiness in what is worn and eaten, and where people sleep. Hygiene is recognized as important to maintaining health, especially for some illnesses like asthma, though in the Ethiopian countryside hygienic conditions were not always readily attained.
Translation or Language Equivalents
The Oromo word qakke (sounds like cockay) refers to TB disease. Qakke directly translated is the word for lung. The English “TB” is also understood.
Disease Recognition
People are aware of TB as a serious disease, while considering it treatable and curable. It is thought possible that a person can get TB repeatedly. People recognize the disease by symptoms of dry coughing, loss of weight, and loss of appetite. Spitting blood is known as a symptom that occurs later in the illness, when the dry cough is mixed with blood in the saliva. People wouldn’t recognize TB without the cough present as a symptom. In the countryside, there are no diagnostic tests available and only coughing will tell that someone has TB. People describe other coughs (not TB) as coughing that isn’t dry and produces a substance (phlegm) that is coughed out.
People recognize the difference between TB and other cough in the first 2 weeks of symptoms. TB is known as a disease in the lungs, though some people also know of TB in the neck. US Immigration performs X-ray tests in the countryside in Kenya and other refugee resettlement locations. People understand the X-rays test people for TB. If the test is positive, the person receives medicine. People are not sure of a means to prevent TB, other than isolating sick people and maintaining good nutrition. In Ethiopia, BCG vaccine is given to infants just after delivery in the hospital and to children in school. Most people are unable to distinguish BCG from the other shots and medicines given for routine prevention, and are generally unaware that the BCG vaccine is used for preventing some types of TB in young children.
Causes
People reported various causes of TB:
- Exposure to cold temperature
- Wind
- Contact with the sick person’s food, spoon/utensils, clothes, breath/air
- Focus group participants emphasized that Oromos do not commonly consider TB to be a test from God, a punishment from God, or as a curse. People generally accept a physical, biological cause of disease. This may root in rural Oromo practice and knowledge of caring for livestock/animal husbandry.
Treatment
People report that doctors in the United States try to explain how they are trying to limit the spread of TB by giving medicine before people are sick. People are told that the medicine makes the disease stay inactive inside them, preventing them from getting sick and spreading the disease to others, keeping everyone healthy.
People generally don’t like to take pills. They are not accustomed to pills. The sick person will usually take medicine when his doctor says it is for health purposes. However, if there isn’t “force” enough to make him take it, he might “forget”. For instance, if he feels the force of pain, he will take the medicine. On the other hand, if he feels pain by taking the medicine, he might stop. It is possible that people might not take the medicine as prescribed. People who refuse to take medicine wouldn’t necessarily tell others about it. Other people may act “don’t know, don’t tell” and accept that it’s up to the individual to take or not take the medicine. People might take the medicine because they think it allows them continued access to doctors and health services.
In Ethiopia, traditional medicine is used in the absence of medical doctors, in the countryside especially. People may prefer medical doctors but have no access to them. Before visiting a traditional village doctor, a family member would give traditional kinds of medicinal nutrition such as honey mixed with herbs as a first treatment. If this treatment does not cure the ailment, then they go to the village doctor to seek help. The doctors are specialists who know the various trees and herbs and treatments for particular conditions. “Carisma”, “Oromaio”, “Karama” are words describing a person who comes from a good stock/family, who has special fortune, good strength and God-given abilities/gifts to treat people’s illnesses.
TB has been treated traditionally with special nutrition. A mixture of aged butter and honey is said to be especially curative of TB transferred by cold temperatures. The butter and honey are melted and the sick person drinks it. Some traditional medicines are not available in the US, such as 10-20 year old wild honey. Practicing herbal medicine is perceived as restricted here in the U.S.
Egg yolks are also taken to cure TB. Early in the morning, a sick person wakes up to drink the egg yoke that is prepared by a family member. This egg-yolk treatment is taken daily for 2 months. Milk and butter are sometimes added to the egg yolk. People perceive it is important to begin this treatment right away when a person becomes sick for best results and recovery. A reason for a delay might be the failure to recognize if coughing is from a cold or TB.
TB of the neck is treated with milk, honey, meat and herbs – these are swallowed and the TB is treated.
Isolation and Stigma
TB is thought to transfer within a short time of living, eating and drinking with the sick person. Isolating the sick is known to prevent TB passing between persons, and the isolation is considered very important. It normally includes not sharing a bed, cup or fork with the sick person. The sick person might stay in the same house with the rest of the family, only in a separate area or room. When parents are sick they may be isolated from each other and their children, and others in the family or community will care for the babies. One person is usually assigned as a caregiver to the person who has TB.
Reportedly, Oromo do “friendly isolation”. The sick person is separated while they are ill, but are not stigmatized or ostracized by the community or family. People may even eat together as long as the utensils are isolated. A married couple might continue to sleep with each other, but usually they sleep separately. The friendly isolation is in no way a rejection, even though the separation can be hard. It’s said, “we will love her, but not date her” to convey there is care taken to isolate (“not date” i.e. not sleep with ) even while there is strong commitment to keep the person part of the family and community (“we will love her”).
The sick person usually tells others to stay away until he gets cured. For health purpose people know this is important to do. People isolate themselves to protect others and they are honest about it.
The sick family member is isolated until they are better. When a person stops coughing and gains weight, these are seen as signs the person is healthy again.
Though TB is considered a serious disease, the community is not scared away from trying to maintain normal relationships as much as possible with the sick. People are more afraid of leprosy than of TB, in terms of being physically close to the afflicted person.
Other (not TB-specific) Oromo Considerations on Medicine
Medicinal Foods
Honey, butter, garlic, and onion seed are commonly used ingredients in traditional treatments. Meat is recognized as good for curing disease. Participants considered this to be especially true of meat in Africa where food is fresh, not refrigerated. Goat is the preferred meat. The goats are known to naturally eat many medicinal herbs and it is thought that the medicine is transferred to people who consume the goat meat. “The medicine from the plants mixes with the goats’ bodies in their meat. When the goat meat is eaten, we get the good medicine. In the United States, the cow, goat and sheep eat essentially what we humans eat, so the meat is not seen as having the same curing qualities.” If someone has health problems on the skin, cow or goat stomach is placed on the affected area as a treatment.
Herbal Medicine
Practicing herbal medicine is seen as restricted in the U.S. but in Ethiopia people have seen it help conditions like cancer, eczema, and warts. It is said that in the US eczema is a chronic disease but in Ethiopia traditional herbal medicine cures the condition.
Heat Therapy
Traditional healing of some ailments involves the practice of burning an area on the skin or applying heat to the body.
Koobaa (coba) is a method used to treat sore muscles and is mostly applied on the shoulders and back. This name also describes the instrument that is used to practice this method. The instrument is roughly the size of a tall water glass, made out of a horn of an animal such as bull or bison. The instrument is held over steaming water, heating the inside of the horn. Then it is placed on the sore muscle, usually the shoulder or inside of the spine, creating suction, or sucking in, of the flesh. The koobaa is usually applied on several spots during a single treatment.
Vaccinations
Oromo medicine has historical knowledge/practice of vaccinating animals and some experience inoculating humans. In rural Ethiopia, the main source of income is cows and there exists a TB inoculate for cows. The cow with TB is slaughtered and its lungs are removed and placed in an airtight jar to decay for one week. Then, incisions are made in healthy cows and some of the decayed lung is put inside the cuts. After three days the wounds are swollen and the affected, swollen parts are cut out and the wounded area is then burned. These animals stay healthy. A Foot and Mouth vaccination reportedly involves taking the diarrhea or urine of an infected cow and placing it in a container for a time. The substance is then put into incisions made on other, healthy cows. These cows will become infected but not so badly as the first cow.
Reportedly, Oromo healers developed a smallpox vaccination for people long before Western medicine was introduced in Ethiopia. Historically, there was a small pox epidemic in Oromia from 1886 to1887 that reportedly was biological warfare perpetrated on the people by King Minillik II. The smallpox vaccination worked by taking a small amount of pus from a person infected with smallpox, putting the pus inside an arm incision on a well person, and tying the wound cleanly. This practice prevented the well person from becoming very ill with small pox.
Industry
Technologies leading to chemicals and pollution in the environment are perceived to cause disease.
Recommendations for Providers
- Follow HIPPA requirements protecting confidentiality.
- Be extra careful to respect patient privacy and confidentiality.
- Emphasize the treatable nature of tuberculosis.
- Take the time to explain the difference between tuberculosis infection and tuberculosis disease.
- Especially during the first few weeks of treatment for LTBI, solicit feedback on side effects and tailor the regimen to the patient’s needs.
- Encourage the use of a nutritious diet and traditional therapies to better tolerate the side effects of Western medication.
Patient Education Materials
There are a number of sites that have TB patient education materials in other languages including Amharic, Oromo and Tigrinya. See external resources in the Infectious Disease Patient Education section.
References and Further Reading
Seattle-King County Annual Tuberculosis Report 2007 by Tuberculosis Control Program Public Health – Seattle & King County
CDC’s Morbidity and Mortality Weekly Report, October 4, 2002 / Vol. 51 / No. 39 Increase in African Immigrants and Refugees with Tuberculosis — Seattle-King County, Washington, 1998 — 2001
http://www.cdc.gov/mmwr//preview/mmwrhtml/mm5139a4.htm
Linguistic and Cultural Aspects of Tuberculosis Screening and Management for Refugees and Immigrants March 1996, Carey Jackson, MD, MPH, MA, Medical Director International Medicine Clinic, Co-Director Community House Calls, Harborview Medical Center, Seattle, WA
Refugee Health ~ Immigrant Health: Ethiopians & Eritreans, 1999-2005 by Charles Kemp & Lance Rasbridge (website is no longer available)