Immigration and Tuberculosis: America's New Problem?
Illegal immigration was a huge focus in the 2016 presidential election and remains a flashpoint topic today. In response to the positions on this issue expressed by President-elect Donald Trump, officials in many cities and communities nationwide declared that they will resist any efforts by the federal government to deport illegal immigrants.
What does “resistance” mean? From statements made by some local city officials it suggests that they will “willfully not cooperate with the federal government” while others indicate that “they will just look the other way and not report citizens who are here illegally.” The term attributed to the cities and even small towns that will not actively report illegal immigrants is “sanctuary cities.” As of December 2016, there were about 300 such communities in the U.S.
A fair number of Americans take offense to these pronouncements, seeing them as indications of unacceptable political (and legal) posturing. But the hard fact is that many communities feel a need to connect with their members, including those members living in the U.S. without legal status for all sorts of reasons, large and small.
From a law-enforcement perspective, many police departments want all people to feel free to cooperate with local authorities and to not live in fear of reporting crimes and criminals. (The reality, of course, is that many undocumented immigrants and workers in the U.S. live in gang-affected areas.)
From a public health perspective, meanwhile, I would argue that health care and stopping the spread of disease is another compelling reason to make everyone in every community less afraid of dealing with local boards of health. Tuberculosis in particular requires this relationship of trust.
Tuberculosis is one of the few infectious diseases that can spread from person-to-person through the air. This makes it imperative for local boards of health to stress precautions and measures to help control the reach of the disease, and to make sure that once contacts (individuals who have come in contact with an infected person) are identified that they comply with treatment.
The difficulty with treatment is that it is a lengthy process, taking anywhere from six to 12 months. Those who start treatment and stop in the middle are at risk not only of still being infectious to others but also of getting resistant organisms. New techniques that involve DNA probes make it possible to identify the strain of the organism, which means it’s also possible to follow the trail of the resistant strains of tuberculosis.
Resistant organisms are a serious ongoing problem. They are classified as “multi-drug resistant TB(MDR TB) and a more severe form is called “extensively drug resistant tuberculosis (XDR TB).”
In 2015, there were 10.4 million people around the world who were diagnosed with TB disease and 1.8 million TB-related deaths. In the U.S., there are approximately 10,000 new cases of TB yearly. The highest prevalence of TB is in New York, California, Georgia, and Illinois. Tuberculosis is also a very important consideration when treating HIV-infected individuals and other people who suffer with chronic diseases that lower immunity.
The single most important consideration in the prevalence of this disease is that 66 percent of these cases occur in foreign-born individuals.
The top five countries of origin for people with TB are Mexico, the Philippines, India, Vietnam, and China. Asians are particularly prone to have resistant organisms.
For this reason, the Centers for Disease Control and Prevention (CDC) published recommendations for managing TB in a 1995 report called "Essential Components of a Tuberculosis Prevention and Control Program." It tasked state and local health departments with responsibility for preventing and controlling tuberculosis. It empowers these boards to enforce local healthcare providers to adhere to the measures and the standard of care. It also assigns the power to identify and follow identified contacts and enforce compliance with treatment.
To ensure cooperation and compliance, the program provides these treatments, many of which are expensive, free of charge, regardless of insurance coverage status. In some cases, it adopts “directly observed therapy (DOT),” which means that the patient is not simply given a prescription with the assumption that he will fill it and take the medicines. Instead, under these guidelines, the patient is required to go to the clinic twice a week and take the medications under the direct observation of healthcare officials.
This approach is not unique to the U.S. The World Health Organization (WHO) also has a similar position statement.
My point is that this discussion about immigration is not a “clear” political or legal issue, but rather a situation with a goal that requires protection of existing communities from the spread of communicable diseases. This is a clear example of an issue that demands reaching out to everyone in communities, regardless of immigration status, for the greater good of the community.
My hope is that the new administration will be able to balance the legal considerations with the health needs of an entire nation.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.