What's in a name: the classification of "key populations"

Commentary by Gill Craig

Tuberculosis in the west affects the most socially and economically marginalised, including those with a history of migration from countries where TB is common.  In the UK, for example, approximately 74% of those diagnosed with TB in 2019 were born outside the country (PHE, 2020).  

Until recently, it was not uncommon to see and hear the term “foreign-born” used to denote this constituency.  Indeed, I remember attending seminars where this terminology was used. I often wondered how this was experienced by those members of the audience who were health care professionals with a history of migration, and their sense of identity and belonging. This example not only points to the need for a “reformed discourse” (Frick, von Delft & Kumar, 2015) when talking about the risk of TB and affected communities, but also cautions us to be mindful of how we classify key populations.

Although the term “migrant” is more generally accepted, this serves to homogenise diverse groups of people who are ethnically, culturally and linguistically distinct, some of whom may be at greater risk of TB than others or who may have a greater need for support, for example, those seeking asylum or refugee status.  In recognition of these differences the somewhat imprecise term “vulnerable migrants” is used, but it tells us little about the kind of vulnerabilities and support needs of individuals. The Platform for International Cooperation on Undocumented Migrants cautions us to avoid the term “illegal migrants” which, it argues, carries connotations of “blame and criminality” and “denies people their humanity” (PICUM, n.d). Undocumented migrants is the preferred usage for those who have no recourse to public funds and with few rights and legal protections. 

Similarly the term “hard-to-reach”, often used to refer to homeless or prison populations, serves to blame those who do not access standard TB services.  They may also be referred to as “complex patients”, but, more accurately, the perceived complexity arises from the need for multi-agency working to provide high-quality, people-centred care. The use of the term “under-served populations” (PHE, 2019) recognises that inadequate service delivery models, rather than people, are the problem. 

Bowker and Star (1999) remind us that categories are social constructs infused with values and that the categorisation of people, places and things can produce (dis)advantage and suffering. How we classify, talk about, and represent those living with and affected by TB is therefore more than a word game or a matter of political correctness, but involves us in an “exercise of power” in terms of who has the power and authority to classify and label others, and has real world consequences. In the context of the hostile environment towards migrants and migration, engendered through political and populist discourse (Griffiths & Yeo, 2021; Grierson, 2018), stigma and discrimination are intensified in the case of an infectious disease such as TB. 

In fact, the risk of TB is not a property of the category of the “[said] key population” per se, but a complex set of interrelated and often systemic social  determinants which place people at risk. For example, migrants may experience differential exposure to risk environments: coming from a country with a high rate of TB,  poor living and working conditions and overcrowded and poorly ventilated settings  are more likely to place people at risk. The experience and risks associated with displacement and settlement in refugee camps will be different to those of documented migrants with rights to cross borders and re-settle for economic reasons.  The risk of TB may differ according to gender, economic status and underlying health conditions. Indeed, the category of migrant likely serves as a proxy for the structural inequalities that give rise to complex layers of risk that some groups of migrants experience, including TB. Problems arise when the policy focus is on treating the classification of people without attending to social difference and the social determinants of health inequalities that create risk and “vulnerability”.

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