TB And MDR-TB Coming
To America - Illegal Immigrants
Spreading Infection
By James R. Edwards
The National Review - Commentary

Franklin County, Ohio, commissioners recently approved nearly $1 million to treat a growing public-health threat in the county: tuberculosis. The almost 70-percent funding increase from the previous year was sparked by the county health clinic's dramatic rise in TB cases. Two-thirds of the clinic's TB patients are foreign-born; immigrants to the Columbus area have caused active TB cases to increase from 21 in 1997 to 41 in 1998 to 57 in 1999 to 79 in 2000.

This Ohio story is a microcosm of a public-health threat cropping up in locations across America. Current annual immigration of roughly one-and-a-quarter million foreigners (legal and illegal), predominantly lacking in health coverage and largely from Third World countries, has consequences for U.S. health care.

Mass immigration not only adds costs to the health-care system, it also exposes Americans to diseases that, until recently, were virtually eradicated in this country. Some of those diseases, such as tuberculosis, are highly contagious.

Immigration law makes being infected with certain diseases grounds for exclusion on the basis of threatening public health. However, the screening process in the home country and at points of entry is not foolproof, and illegal migration across a land border makes it easier for a disease carrier to bypass health inspection. And it doesn't help any that some diseases, such as TB, may be carried in the body for years before becoming highly contagious.

TB may again rise in the United States, and this will stem directly from mass immigration. Worldwide, this disease has made a comeback, accompanied by vaccine-resistant strains. From 1985 to 1991, TB cases rose 20 percent globally. For the first time, the World Health Organization in 1995 declared tuberculosis to be a worldwide emergency. This lung disease is ravaging Africa, Southeast Asia, and Eastern Europe. TB deaths are rising worldwide for the first time in about 40 years.

TB frequently occurs in connection with HIV. In some parts of Africa, 30 percent of TB patients have HIV. The WHO attributes the quadrupling of TB in certain African countries in the past decade to the "deadly synergy between TB and HIV."

Drug-resistant strains of TB and their affinity to HIV spell trouble in an age of globalization and porous borders. The threat is especially great because a third of the world's population is infected with TB; in Asia, it's half the population. A tenth of those with the disease will develop an active case of TB. Since 1988, multidrug-resistant TB cases have been reported in 43 U.S. states and in the District of Columbia.

The fast rise of tuberculosis cases in Western countries portends a threat in the immigration-prone United States. Germany and Denmark saw TB cases increase 50 percent in 1996 " with two-thirds of all cases among immigrants.


So far, America has escaped the public-health crisis that TB could spark. Even with record-high immigration levels, the Centers for Disease Control and Prevention count declining numbers of TB cases reported nationally. Should there be a U.S. increase, it will occur because of Third World natives immigrating via Western Europe or directly from one of the WHO's TB "hot spots," such as parts of China or India, from which the majority of H-1B skilled-worker non-immigrants come.

In the United States, the incidence of TB is prevalent among immigrants. About 41 percent of the 18,361 known tuberculosis cases in 1998 were immigrants; in 1986, 22 percent of new U.S. TB cases were immigrants. The foreign-born incidence of TB in the United States approaches six times that of the native-born. CDC figures show that during the period from 1993 through 1998, the native-born had 5.8 cases of TB per 100,000, while the foreign-born rate was 32.9.

TB is especially prevalent in Mexicans, Filipinos, Vietnamese, Indians, Chinese, Haitians, and Koreans. Mexican immigrants have an infection rate of 35.5 cases per 100,000, far above the native-born rate. Yet, Vietnamese have an infection rate of 137.7; Haitians, 118.5; and Filipinos, 95.9. Immigrants from many Third World countries carry TB, including those from the Dominican Republic and Ecuador, and even Puerto Rico.

Not surprisingly, most TB cases occur in the heaviest immigrant-receiving states: California, New York, Texas, Florida, New Jersey and Illinois. These six states accounted for about three-quarters of the cases reported from 1993-1998. Of TB cases in the Washington, D.C., area, 75 of 78 cases in Montgomery County, Md., in 1999 were immigrants or refugees. In the Virginia suburbs of Washington, 84 percent of new TB cases in 1999 were immigrants. Ninety-two percent of Fairfax County, Va.'s total TB cases in 2000 were foreign-born patients, who caused a 15 percent rise in the county's TB rate over the previous year.

Clearly, the presence of large numbers of immigrants puts a strain on the American health-care system. Not only are current immigrants more likely to carry TB or some other threat to public health, nearly one-third of persons in immigrant households lack health insurance. That is more than twice the uninsured rate among native-born Americans. Immigration accounted for 59 percent of the growth of the uninsured population between 1994 and 1998.

The public-health challenges of such a large, concentrated segment of uninsured persons strain public and private health resources, especially in heavy immigrant-receiving areas. Five of the six top immigrant-destination states " Texas, California, Florida, New York, and New Jersey " have higher rates of uninsured than the national average. In 1998, American hospitals delivered $19 billion, or 6 percent of total expenses, in uncompensated care. The National Association of Public Hospitals and Health Systems reported that, in 1997, 26 percent of its members' in-patient services and 41 percent of out-patient emergency services went to "self pay," i.e., predominantly uninsured, patients. New York City alone spent more than $1 billion over five years in the late 1980s and early 1990s to control rising tuberculosis cases.

To be sure, active TB keeps an individual from immigrating to the United States; however, Third World immigrants infected with TB may not develop the disease for years. Applicants for immigration visas must have chest X-rays; however, this test doesn't always turn up inactive cases of TB. And a thriving black market of clear X-rays allows applicants to misrepresent a purchased set of X-rays as their own. Meanwhile, illegal aliens bypass these tests altogether.


Once here, immigrants may avoid TB screening because of the public stigma. A female African immigrant in Maryland who worked at a Burger King restaurant avoided doctor's visits and refused to take medicine until public-health officials quarantined her in a hospital for two weeks. Immigrants also are likely to discontinue treatment if they move to another area. Obviously, this kind of conduct further threatens public health and complicates efforts to treat patients.


The threat of infection has risen with the employment of immigrants in Americans' homes. For example, an immigrant TB patient secretly being treated by Maryland public-health officers worked as a wealthy family's chauffeur. Another contagious immigrant was a resident nanny. As the New York Times put it, "TB can circle the world at the speed of a passenger jet and be transmitted by a single cough."


To make things worse, many U.S. public-health officials put political correctness before common sense. A Maryland public-health officer told the Washington Post, "My greatest fear is that there will be this terrible xenophobic response to anyone who is a quote-unquote refugee or immigrant." One official told the New York Times, "It may make absolute sense to screen certain subpopulations because you have evidence of rates of TB way out of proportion to what we see elsewhere. But how you do that without contributing to additional stigma is a challenge we're all confronted with."

If officials have evidence that immigrants from certain nations carry TB at a much greater rate, common sense would dictate that immigrants from those places meet strict screening requirements. Certain countries could face tougher standards if they pose a public-health threat through immigration. There's no legitimate reason not to place the health of the American public above the sensibilities of certain countries, groups, or their paid advocates.

Does America have the resolve to safeguard public health first, even at the risk of being politically incorrect? Do American taxpayers willingly accept the additional burden of the costs mass immigration places on the nation's health-care system? Only time will tell. But America must address these questions. In the meantime, places like Franklin County, Ohio, will bear the burden. __

By James R. Edwards is co-author of The Congressional Politics of Immigration Reform, and an adjunct fellow with the Hudson Institute





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