Initiative Would Hasten Spread of TB, Study Says

A study released today predicts that passage of Proposition 187, the anti-illegal immigrant initiative, will hasten the spread of tuberculosis in California because immigrants will be afraid of contacts with medical authorities.

The research, led by a USC team and based on data gathered in Los Angeles County, already is fueling concerns in the medical community that Proposition 187 will drive illegal immigrants underground because it would require health-care professionals to report undocumented immigrants to the U.S. Immigration and Naturalization Service.

“If we were to try to implement (Proposition 187), we would decimate our clinics,” said Dr. Shirley Fannin, who leads the public health fight against tuberculosis and other infectious diseases as chief of disease control programs for Los Angeles County. “The secret of not having these people become a problem to themselves or others is the early discovery and management of the disease. If you scare people away or make them frightened, they aren’t going to come in early.”

Fannin said she also fears that passage of Proposition 187 could trigger the revival of other diseases, such as long dormant strains of syphilis that haven’t been common in California for 50 years, or lead to a re-emergence of the measles epidemic that peaked in 1990 and killed 41 Californians, 34 of them preschool-aged children.

The new study found that under current law most undocumented immigrants with tuberculosis believe that they are safe from deportation when they seek medical care.

Even so, 6% of those with active tuberculosis who told researchers that they did not have immigration documents said they delayed care because of fear that they would be reported to immigration authorities, said the authors of the study, published today in the Western Journal of Medicine.

If a measure such as Proposition 187 were to pass, that percentage would rise, leading to the spread of the disease, the scientists predicted. The authors said that “any increase in the fear of immigration authorities” by patients “is likely to increase the delay between onset of symptoms and first contact with the medical care system.”

“Because each patient possibly exposes an average of 10 contacts to the disease during the course of delaying care, such an increase would spread tuberculosis beyond those who delay,” the study said.

The study, drafted by a team of USC and UCLA researchers led by Dr. Steven Asch, a faculty member at the USC School of Medicine and an internist at County-USC Medical Center, said that the longer people with active tuberculosis delay treatment, the more likely it is that they will spread the disease.

The publication of the report just a few weeks before the Nov. 8 election landed with a predictable political bang.

Dr. Ralph Ocampo, president of the California Medical Assn., a statewide organization of physicians opposed to Proposition 187, cited the study in once again criticizing the measure for attempting to put physicians in a conflict of interest position with their patients by requiring doctors to report people they even suspect of being illegal immigrants to immigration authorities.

“Using health-care facilities at all as a detection site is immoral and flies in the face of what the medical profession should stand for all over the world, which is that we take care of sick and injured people first,” said Ocampo, a San Diego surgeon. “If there is a question about legal status, let that be handled by the appropriate authorities but not by health-care professionals.”

Gov. Pete Wilson, an active supporter of Proposition 187, said through a spokesperson that if the measure passes, he will continue to provide those services that are necessary to protect the public health.

“This is a problem that exists today and will exist in the future whether or not Proposition 187 passes or fails,” said Leslie Goodman, an assistant chief of staff for Wilson. “We don’t know what the potential consequences might be.”

Goodman, who in the past has criticized opponents of the initiative for using scare tactics, said, “You have to question the motivation of this group in putting out this study.”

The journal is published by the California Medical Assn. and represents a consortium of 10 western states. Paul Moreno, a spokesman for the CMA, said the study was started 2 1/2 years ago, before Proposition 187 got on the ballot.

The report’s authors do not cite Proposition 187 by name, but instead refer in the report to “legislation” and the “immigration initiative.”

Among the questions researchers asked of the people they interviewed who had active tuberculosis was: “Were you afraid going to the doctor might cause trouble with immigration authorities?”

The researchers found that “few patients feared that seeking care would result in difficulties with immigration authorities” and that most seemed aware that health-care professionals did not report information on residency status to the Immigration and Naturalization Service.

Fannin and other health-care professionals say they have spent years cultivating that trust. In the arena of public health, they say the reason for that is to protect society at large as well as the individual.

“Disease does not check on someone’s immigration status and the disease controller had better not,” Fannin said.

The issue is important because the study found that 71% of the 313 patients who agreed to be interviewed reported that physicians discovered their tuberculosis when they sought care for one of the classic TB symptoms: coughing, fatigue, fever, swollen glands or weight loss.

The study examined 526 active cases of tuberculosis reported to the county’s Tuberculosis Control Registry between April and September, 1993.

Researchers said the county was an ideal target for such a study because it “lies at one of the epicenters of the tuberculosis epidemic--second only to New York City.”

They said further that “unlike the nation as a whole, immigrants make up most of the active tuberculosis cases in Los Angeles.”

In its latest update, the Los Angeles County Department of Health Services said that 1,940 active cases of tuberculosis were reported in the county in 1993. That figure is down from 1992, when 2,198 cases were reported, but up dramatically from the 1,190 cases discovered in 1988.

Using phone numbers and addresses from the county’s Tuberculosis Control Registry, the researchers wrote and phoned people with TB. Because many are transients, efforts were made to track them down in soup kitchens, shelters and a special clinic for the homeless.

Ultimately, the researchers got the cooperation of 313 people, 69% of whom were immigrants. One-fifth of the respondents said they were in the country illegally.

“Tuberculosis in Los Angeles County is definitely a disease of immigration,” Asch said.

Whether they came into the country with the disease or picked it up here was unclear, he said.