The first dimension should be - to see the immigrant as a person, recognize his fear, and treat him with respect, kindness and compassion. I have worked a lot with TB (including MDR), and seen that a major problem is that health providers (HPs) give information at the wrong time, and then blame the patient for not undrstanding, or not taking action/following advice. Many providers seem to not understand that a person who has been diagnosed with a serious disease will be scared, and that a scared person does not take in cognitive info. The patient is insecure, and needs to feel secure with the provider before he can process information. We have seen (and this is also increasingly recognized  in the literature) that when the provider focuses on building a relationship with the patient and focuses on making him feel safe and cared for, the patient will much sooner be open to info. He will also be more likely to act on the info when it is provided by a person he feels safe with, and can ask questions from.

Obviously, good skills in communicationg clearly and managing the emotions - both the patient's and the HP's - are essential here. Many providers get scared for their own health (understandably so) when faced with an MDR patient. This fear needs to be recognized, and the HP needs to learn how her own fear can influence the communication with the patient (and with colleagues and supervisors), and learn to stop her own automatic reactions, take a step back, and act with compassion: The HP strengthens awareness of her own communication habits, and learns to act with more consciousness.

We have developed a model for training HPs in communication and management of emotions, in collaboration with health personnel, and implemented it in 8 countries. In the first 6 countries, we worked with TB patients (and physicians and nurses treating them). Evaluations show that the approach works.

Management of emotions - especially those the health provider has him/herself - is an under-focussed and under-researched theme in medical research. 

According to Syracusa principles, the society has the priority in order to protect the public health of the community. The immigrant with MDRTB has the right to free access to diagnosis and treatment. Ideally he should be isolated until negative culture is obtained.

For those MDR TB involuntary isolation or those who are immigrant the measures should be according to the legitimate law of the country. But what we have to know is that not by compelling the patient.

Bioethics emerged in the 1960s as an interdisciplinary field of inquiry concerned with the moral, social and religious issues and more recently with the health and treatment. In pluralistic societies, where the flux of immigrant and refugee has grown, interaction between patients  from different ethnic backgrounds and health workers are becoming routine. Tuberculosis (TB) remains a significant public health problem on a global scale. In Canada Few cases of XDR tuberculosis were imported. Screening and treatment of latent tuberculosis was incorporated several years ago.

Xiang case had surely a dormant bacilli in his lung and was not detected upon Visa emission. The cost of MDR TB treatment is more than 50 000 $ and this cost is up to 200K in case of XDR TB. Active and contagious Tb patient must rest and not allowed to leave by air. Positive AFB smear, mainly for MDR or XDR TB, must be isolated in separated and negative pressure room, until smear conversion to avoid transmission of resistant bacilli. In other hand, the hosting country must bear the cost. In ideal scenario, the temporary visitor/worker, like Xiang must suscribe to insurrance protection to cover his outcome loss upon invalidity. More importantly, most of developped contries must integrate a principle-based analytic framework to allow screening and efficient treatment of latent TB. The results of testing should not influence immigration outcome, but be used to mandate medical review and consideration of voluntary preventative treatment.

Thank you for these wonderful responses. Just to let you know, that the Journal of Bioethical Inquiry is accepting responses of 500-800 words for possible inclusion in a special issue on TB and ethics next year. If you would like to write a response to this case study, you might like to copy and paste this link for further information on how to submit:

http://bioethicalinquiry.com/the-ethics-of-isolation-for-patients-with-tuberculosis-in-australia/

Responses need to be received by mid November to fit with the peer-review and publication schedule.