Who gets sick and who gets blamed?

Why do some people get sick, or sicker, than others? Explanations throughout history have varied. In the 19th century, those with passionate, creative and melancholic personalities were thought to be more “tuberculosis-prone”, at least among the upper-classes. While it may seem absurd that someone might contract an airborne bacterial infection because they have flair for the dramatic, explanations for health disparities that emphasise individual traits over structural and systemic conditions persist to this day, harming the health and wellbeing of many marginalised people, including migrant and refugee women.

In Australia, First Nations scholars have pointed out how racist stereotypes can operate similarly to the “tuberculosis-prone” character myth in health research. Chelsea Watego, David Singh and Alissa Macoun highlight how merely identifying the gap between Aboriginal and non-Aboriginal people’s health outcomes risks leaving unanswered the question of “what might make race an epidemiological variable that predicts who gets sick or sicker”. In this vacuum, racist explanations that focus on cultural norms, behaviours or even biological inferiority can take root, blaming individuals and their cultures for unequal health outcomes.

We see similar issues in explanations for the health inequity migrant and refugee women face. Colonial portraits of global south women being inferior and needing to be ‘saved’ from their own cultures echo in contemporary explanations for health inequity, with migrant and refugee women framed as lacking agency, intelligence, competence or even an interest in their own health and wellbeing. These portraits provide about as much guidance on how to close the health inequity gap as the creative-personality explanation did for stopping tuberculosis.

Tuberculosis cases went down in wealthier nations, not because those with tuberculosis simply willed themselves to have different personalities, but due to structural changes, especially in the conditions of the working poor. Improvements in general nutrition, sanitation, and improved housing and workplace conditions for industrial workers radically reduced transmission and illness, as did the development of public health institutions and systems that provided free access to testing, treatment, and even social security in the form of a ‘tuberculosis allowance’.

Today, we call structural factors like food security, public sanitation, access to health services, housing, and working conditions, the ‘social determinants of health’. These factors help us explain health disparities far better than racial or gendered stereotyping. In Australia, we have many institutions and systems that are meant to support positive social determinants of health for all, but they are often still unresponsive and inaccessible to many migrant and refugee women. Migrant women are often expected to work in riskier environments with limited workplace protections, lack accessible health information and care in their language, and at times, are excluded from systems like Medicare and Centrelink.

Beyond domestic social services, an often-overlooked social determinant of health is peace and stability. In WWII, as healthcare infrastructure was destroyed, houses were bombed, nutrition suffered, and shelters became crowded, tuberculosis spread, only becoming controlled once the war was over. In Gaza, we see this pattern play out again as its health infrastructure and systems continue to be destroyed and infectious disease spreads.

The health impacts of war are far reaching and have generational consequences. Many migrant and refugee women in Australia who are watching destruction unfold in their homelands carry with them a mental load that is often made more painful by a lack of recognition from both Australia’s health and foreign policy institutions.

Uncovering the ways institutions and systems fail to support migrant and refugee women requires careful, empathetic, and critical investigation, that must begin by listening to the voices of migrant and refugee women. Just as tuberculosis could not be eradicated without understanding of the experiences of the working poor, especially during wartime, health inequity can’t be addressed without listening to migrant and refugee women, who are the true experts on what stands between them and achieving positive health outcomes.