Over the next few months, the call load at the Division of TB Control died down. Aisha continued to work on public outreach programs and to consider ways that the Directly Observed Treatment Short (DOTS) course programs could be expanded. One thing that Aisha really liked about DOTS was the inclusion of community workers and the fact that the drugs were taken to the patient, lessening the burden on the patient. Patients trusted those who were familiar with their needs, culture, language, and challenges, and thus were more likely to comply with the daily dose of antibiotics over a six- to 12-month period. Aisha came across programs that went a step further to provide patients with food, shelter, and money in exchange for the antibiotic treatment. Still, there were challenges.
There was something else troubling Aisha as her internship was coming to a close. The Senate Immigration Bill had jumped over many hurdles and many believed the President would approve it, allowing close to two million illegal immigrants to apply for citizenship in the next two years. Aisha was surprised to see the newspapers neglect the impact such a bill would have on the public health infrastructure and especially TB screening for latent TB infection (LTBI). The most recent drug susceptibility reports indicated that more than half the foreign born disease cases were in persons from Mexico, the Philippines, Vietnam, India, and China, with the largest contribution from Mexico. More disconcerting was that 50% of all foreign born MDR TB patients were from Mexico, that California accounted for 30% of the total MDR TB cases in the U.S., and that immigrants with LTBI converted to active disease within the first few years of entry. “If only we could screen and treat these latent infections before disease developed,” Aisha thought to herself.
By federal law, anyone 15 years or older applying for citizenship in the U.S. must undergo TB screening via X-ray and, if positive, undergo an additional test to clarify the disease status. Test results determine whether the person can enter or needs to follow a course of treatment before entry. Individuals who test positive for latent infection via X-ray are allowed to enter and are not required to be treated. Individuals who test positive for disease via X-ray but negative via sputum are not infectious and allowed to enter without treatment. Individuals who test positive for active disease via X-ray and sputum test are required to undergo treatment before entering the U.S. and the cost of treatment is the responsibility of the patient.
Aisha reviewed the Senate bill carefully. The bill had two provisions that were of interest to her: (1) illegal immigrants who had been in the U.S. between two and five years were required to leave the country and reenter; (2) those who had been in the U.S. longer than five years would stay and apply for citizenship from within the U.S. In both cases, these individuals would be subjected to TB screening. For those required to reenter, anyone diagnosed with active infectious disease would need to undergo treatment before reentry. If they were unable to secure the essential antibiotics in their country of origin, they would be blocked from reentry. For those immigrants applying for citizenship from within the U.S., a diagnosis of active infectious TB disease would require administration of antibiotic treatment and it was unclear who would cover this cost. The cost could be substantial and compliance sketchy. Should anyone be diagnosed with MDR TB disease, the length of treatment could extend to 24 months, and the individual could be asked to stay home until they were no longer infectious. This could be especially problematic for the 1.5 million farm workers who would apply for citizenship under the guest worker provision. Their citizenship would be sponsored by their employers, who would expect them to be working every day.
“How could the media neglect this from the long laundry list of other requirements, which includes learning to speak English, undergoing a criminal background check, paying back taxes, and fines?” Aisha thought to herself. She did a quick literature search and came across an appalling editorial that proposed deportation of all illegal immigrants and no access to healthcare or treatment as the country was unable to support and care for its own. Stunned, Aisha forwarded the editorial to Dr. Sanjari and they spent the afternoon arguing the pros and cons of treating those who might test positive for the disease during the application process for citizenship under the provisions of the bill.
Read the following material and develop both a pro and con argument for instituting a public health infrastructure that can meet the demands of the newly proposed bill. In preparing your statements, reflect on the challenges that Aisha alludes to in the first paragraph.
Originally published at http://www.sciencecases.org/mdr_tb/mdr_tb2.asp
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