Saturday, February 12, 2005

Special Report

Contagious diseases are entering the United States because of immigrants, illegal aliens, refugees and travelers, and World Health Organization officials say the worst could be yet to come.

In addition to a list of imported diseases that includes tuberculosis, sickle cell anemia, hepatitis B, measles and the potentially deadly parasitic disease Chagas, officials fear what could happen if the avian flu, which is flourishing among poultry in Southeast Asia, mutates so that it is capable of human-to-human transmission through casual contact.

The bird flu has killed at least eight Asians since early January. Several of those deaths — in Vietnam and Thailand — were believed to have been caused when the virus passed between people who had sustained contact. If the avian flu mutates so that it can be transmitted with only casual contact, WHO authorities predict at least 7 million and as many as 100 million would die in a worldwide pandemic.

Another concern with Asian immigrants in this country is the link between Asians and hepatitis B, said Jordan Su, program manager for the Asian Liver Center at Stanford University. She said the link is alarming enough to warrant action on its own.

Hepatitis B is a “very common epidemic in Asia” and more than half of the 1.3 million cases in this country are among Asians, who make up only 4 percent of the U.S. population, she said.

“We hope the government will pass a bill that requires every immigrant to be tested for hepatitis B,” Ms. Su said.

“People, in general, bring in diseases from their home countries. But I don’t want to say all immigrants are carrying diseases,” said Dr. Walter Tsou, president of the American Public Health Association.

Dr. Kenneth Castro, director of the Division of TB Elimination at the Centers for Disease Control and Prevention in Atlanta, said the job of preventing these diseases must extend beyond the United States.

“Many diseases know no borders, but all policies to prevent the importation of disease need to be reasonable and implementable, and our efforts to improve disease control cannot be restricted to our borders,” he said.

Concerns about imported disease prompted the State Department on Jan. 21 to temporarily suspend travel to this country by Hmong refugees from the Wat Tham Krabok camp in Thailand. The order came after federal health officials learned of at least 25 confirmed cases of TB among refugees from that camp who had resettled in California, Wisconsin and Minnesota.

Enhanced medical screening and treatment of the refugees are under way both in Thailand and this country, and State Department officials say it could be six months before the travel ban is lifted.

TB a growing threat

According to international health officials, about a third of the world’s population is infected with the bacteria that cause tuberculosis. TB that is resistant to multiple drugs is rampant in many parts of the world, including Peru, Russia, the Baltic nations, Hunan province in China, the Dominican Republic and parts of South Africa, according to Dr. Castro. Some of the cases of TB diagnosed among Hmong refugees resettled in this country are drug-resistant, which makes them far more difficult and costly to treat.

Personnel with the CDC’s Division of TB Elimination have said in various reports that “immigration is a major force that sustains the incidence of tuberculosis” in the United States and other developed countries.

“TB cases among foreign-born individuals remain disproportionately high, at nearly nine times the rate of U.S.-born persons,” researchers said in a 2004 report in the CDC’s Morbidity and Mortality Weekly Report.

The report found that people from outside the United States accounted for 53.3 percent of all new tuberculosis cases in this country in 2003. That was up from fewer than 30 percent in 1993. In 2003, nearly 26 percent of foreign-born TB patients in the United States were from Mexico. Another third of the foreign-born cases were among those from the Philippines, Vietnam, India and China, the CDC report said.

But Dr. Tsou says TB data are “misleading.” He points out that an immigrant might be in this country for years with “inactive” tuberculosis. “But now, after being here for a long time, that person’s immunity wanes,” and he or she develops active TB, which can become contagious, he said.

The fear of imported disease has led to a push by Rep. Tom Tancredo, Colorado Republican, for a moratorium on immigration.

In a recent statement, Mr. Tancredo, chairman of the House Immigration Reform Caucus, cited the “serious consequences” associated with the “smuggling” of illegals into the United States without proper medical screening.

“Among them are the possibilities of the spread of diseases for which we have few, if any, antidotes,” he said.

Mr. Tancredo’s worries were prompted, in part, by the rising migration of Hispanics to the United States and a potential increase in the number of cases of Chagas disease, which is spread by insect bites in South America and which can be spread through blood transfusions. It is curable in its early stages, but kills about a third of the people infected if it is not caught in time.

The American Red Cross estimates that nationally, the risk of a blood donor having antibodies to Chagas or being infected with the disease is 1 in 25,000. The risk is 1 in 5,400 in Los Angeles and 1 in 9,000 in Miami. The Red Cross says it will begin screening donors for Chagas, once a suitable test is found.

Blood supply at risk

“An estimated 15 million South Americans [plus Mexicans and Central Americans] are suffering from Chagas,” said Dr. Arthur C. Aufderheide of the University of Minnesota School of Medicine. “I’m amazed” that only five cases have turned up in the U.S. blood supply since 1986.

Federal data suggest that as many as 10 percent of the approximately 1,000 Mexicans who emigrate to the United States daily probably are infected with Chagas, said Dr. Louis V. Kirchhoff, a Chagas specialist and a professor at the University of Iowa’s medical school.

Other researchers say immigration is resulting in population shifts that are contributing to a rise in sickle cell anemia.

While many incorrectly believe the disease is a condition that afflicts only blacks or it has been eradicated, one in every 16 Hispanics — the fastest-growing U.S. immigrant group — also carry the genetic trait that can cause the painful and incurable blood disorder.

The number of Hispanic sickle cell cases in the United States has risen rapidly, and one in every 900 Hispanic infants in this country is born with the disease, said Gil Pena, outreach director for the American Sickle Cell Anemia Association, based at the Cleveland Clinic.

Dr. Samuel L. Katz, one of the world’s foremost authorities on measles and a professor of pediatrics at Duke University, says the childhood illness is another contagious disease linked to immigration. In the 1960s, he was part of a team that developed an effective vaccine against the disease.

“Instead of having millions of measles cases, as we did in the old days, in the last 10 years, there have been less than 100 cases of measles per year in this country,” Dr. Katz said. “We’re able to study the genes of the virus to learn where it came from, and almost all of the measles cases that have been found in the United States [in recent years] were imported from a variety of different countries,” he said.

The pediatrician noted that many of the imported measles cases have come from Japan, Germany and Italy. Those developed nations “have not been as aggressive about measles immunization” as some other countries, he said.

While acknowledging that certain illnesses occur predominantly in foreign-born people, Dr. Alfred DeMaria, director of the Bureau of Communicable Disease Control of the Massachusetts Health Department, said foreign travel, not immigration, is the real culprit.

Dr. DeMaria cited a case in his state last fall in which a Haitian-born woman was diagnosed with diphtheria. The throat infection is common in places such as Haiti and other countries in South and Central America, Asia, Africa, the Middle East, Turkey and Albania, but it is extremely rare in this country because of mass immunization.

Dr. DeMaria said it is believed the 60-year-old woman got diphtheria from her husband, who recently had traveled to Haiti. Although he had no symptoms, health officials found evidence of the infection in his throat.

“If I vacationed in Tanzania, I could bring any number” of tropical diseases back home to this country, as could a globe-trotting businessman, he said. But “there’s very limited risk of transmission in this country,” Dr. DeMaria said, concluding that “refugees and immigrants don’t account for major problems” in terms of public health.

Despite the risks, the CDC’s Dr. Castro said the “facility of movement” between countries must be preserved.

“If everyone is required to have a chest X-ray before getting on a plane, it’s not going to work,” he said.

But immigration opponents contend immigrants are carrying Third World diseases — some of which had been virtually eradicated here — to the United States.

“Mass immigration is a threat to our nation’s health. Diseases nearly eradicated are breaking out again,” the U.S. Immigration Reform Political Action Committee says at its Web site.

The cost of care

Immigrants, particularly illegals, also impose “huge costs” on the U.S. health care system, especially in states bordering Mexico, says Steven A. Camarota, research director for the Center for Immigration Studies (CIS).

According to a survey by the American Hospital Association (AHA), hospitals in 24 Southwest border counties in Arizona, California, Texas and New Mexico reported uncompensated care totaling nearly $832 million in 2000.

A subsequent report prepared for the U.S.-Mexico Border Counties Coalition determined that about 25 percent of those nonreimbursed costs resulted from emergency medical treatment provided to undocumented immigrants.

Ray Borane, mayor of Douglas, Ariz., says he knows about those financial burdens firsthand.

“The city of Douglas is the major crossing point for illegals … and there have been some people who have come over here specifically to get dialysis or complicated eye surgery. They’ve established illegal residency in this country in order to thrive off the health care system,” he said, adding, “Illegals and undocumented immigrants don’t have any health insurance. We’ve never been reimbursed for their care, and the federal government has looked the other way, so they are not held responsible.”

However, Mr. Borane, a Democrat, said medical services available for illegals have been “drastically” reduced since Arizona voters enacted Proposition 200 last November, which requires proof of U.S. citizenship for those seeking medical treatment or other public services in that state.

For the most part, however, “hospitals treat first and bill later, and they aren’t required to ask about a person’s citizenship before providing treatment,” said Tiffany Himmelreich, spokeswoman for the Ohio Hospital Association.

She said hospitals in that state treat their share of immigrants, particularly Somalis in Columbus and “many Latin farm workers in the Cleveland and Toledo areas.” She was unable to say how many lack health insurance.

Under new federal Medicare rules that took effect Oct. 1, medical workers are required to “make a good-faith effort to obtain citizenship information” from patients who receive emergency care in hospitals or doctors’ offices. The rules were issued in July after Congress established a $1 billion immigrant health program under the 2003 Medicare law to assist those who provide emergency care to undocumented aliens.

Advocates for illegals fear the new rules will drive those without papers underground, and they will not get the health services they need. They are seeking legislation that would prohibit health care providers from informing immigration officials about people who are in this country illegally.

A report by CIS, using 2004 data, “found that 35 percent of [all] immigrants don’t have health insurance, and an estimated 65 percent of illegals don’t have it,” Mr. Camarota said. In contrast, fewer than 13 percent of U.S. natives and their children lack health insurance, the analysis showed. In 2002, he said, the federal government spent $2.5 billion to provide families of illegal immigrants with Medicaid and another $2.2 billion to provide medical treatment for uninsured illegals.

“State and local governments probably spent another $1.6 billion on top of that providing health insurance for illegal aliens,” said Mr. Camarota, whose group analyzes Census Bureau data.

The health system of Los Angeles County, Calif., has been described as the largest safety net for the uninsured in the nation.

“We have 2.5 million uninsured people in Los Angeles County out of a population of 9.6 million,” said Dr. Brian Johnston, a trustee of the Los Angeles County Medical Association.

California state law requires that counties provide medical care for the uninsured. “But we have the lowest rates of reimbursement for Medicaid of any program in the United States,” he said.

Dr. Johnston said the situation has been bleak for health providers and patients alike.

“In 2002, [emergency rooms] and trauma centers in California provided $520 million worth of medical care for which they received no reimbursement. About $150 million was lost in Los Angeles County alone,” he said. Those losses were 18 percent higher than in 2001, and those in 2001 were 16 percent ahead of 2000. “So this puts the entire system at risk,” Dr. Johnston said.

He noted that Los Angeles County experienced the closings of seven emergency rooms last year and 16 clinics the year before.

Although many of the uninsured people flooding emergency rooms and clinics in Los Angeles are illegal immigrants, Dr. Johnston doesn’t think most are trying to rip off the system.

“Illegals come here to work, and they do work. But they can’t get health insurance,” he said.

Screening at home

Some see stepped-up health screening in immigrants’ home countries or immigration bans as methods to attack imported health crises.

“I’m sympathetic to the plights of many states that are spending lots of resources for services for immigrants. But to deny people health care is counterproductive,” Dr. Tsou said.

He says it’s “necessary to detect these diseases early” in the foreign-born. But this country’s health care system makes that difficult, “since Medicaid is denied to legal immigrants for five years.”

“Pregnant immigrant women are examples of how this health care system is dysfunctional, since they are denied prenatal care. But their babies do receive Medicaid. We should give people medical care, regardless of their citizenship status,” Dr. Tsou said.

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