Tubercle, Lond., (1961), 42, 227

OCCASIONAL SURVEY

TUBERCULOSIS AND IMMIGRATION*

By CLEVE SCHOUfrom the Mission in Austria of the Intergovernomental Committee fa" European Migration, Salzburg

It has been proved over and over again that refugees, previously classified as handicapped, cancommonly undertake normal work and become integrated into their new community. AccordinglyI should like to raise this question: Are the strict health requirements for immigration outdated?I shall concentrate on a physical handicap-namely, pulmonary tuberculosis-which leads torejection by all countries of persons who apply for admission under the normal immigrationlegislation.

With this disease it is, I believe, especially important that the immigration doctor should reach asound decision. AU of us who have to make decisions on the basis of physical examination andx-rays know that there are many borderline cases in which we cannot say whether the disease is'active' or 'inactive' or whether it has been 'active' within the past two years. Moreover, how manyimmigration doctors are specialists in tuberculosis? If applicants could be further investigated at arecognised centre in the prospective country of immigration the matter would be simple. As it is,we have to make up our minds on the available evidence, and, the immigration laws being strict, wecannot give an applicant the benefit of the doubt.

The decision is often difficult and not uncommonly erroneous. This is clear enough from theexperience of people who are rejected under normal migration schemes on the ground that they have'active' tuberculosis, and are later rejected under migration schemes for the tuberculous on theground that they have no 'active' disease. Thus the prospective migrant may suffer needless hard-ship, and the prospective immigration country may be needlessly deprived of a good worker merelybecause he, his wife, or one of his children has questionable signs of tuberculosis. Such cases areoften deferred for some months or a year, in order to give the migrant another chance; but much canhappen in this short time, and, by having to wait in uncertainty, a person may lose for ever hischance of a better future.

What risks does a country run by accepting such cases? This question is not easily answered, butI would like to cite some figures which may throw some light on it.

AUSTRIA

In the revolution of 1956 some 180,000 Hungarians fled to Austria. Fortunately most of themcould be moved out of the country very quickly. The remainder were submitted to an x-ray survey,which was begun in July, 1957, and was completed at the end of May, 1958. We used two mobilex-ray units taking 70 X 70 mm. :films. Our figures give no indication of the prevalence of tuberculosisamong the Hungarian refugees as a whole, as the majority of the healthy refugees had already leftAustria, whereas all rejected for mass emigration schemes remained.

Altogether 16,226 refugees were x-rayed. Of these, 385 (23'7 per 1000) were found to havepossibly 'active' tuberculosis and 388 (23'9 per 1000) were found to have a 'post-tuberculous' state.

The possible 'active' cases comprised: group I, hospital cases, with clear 'activity'; group II,'activity' strongly suspected; group III, 'activity' not excluded by one film.

>I< Based on an address to the International Conference of Medical Immigration Officers, held in Munich on Dec. 5and 6, 1960.

228 TUBERCLE

The 'post-tuberculous' cases were of inactive disease, with evidenceof fibrosis and calcification.Most of the possibly 'active' cases we found came under groups II and III, and most of the

group III cases and some of the group II cases would certainly turn out to be 'post-tuberculous'on further investigation, which unfortunately we could not undertake.

There is little doubt but that all the possibly 'active' and the majority of the 'post-tuberculous'cases would be rejected by a strict immigration doctor for mass migration to any overseas country.Yet, having personally seen all x-rays of cases of tuberculosis or 'post-tuberculosis', I would saythat very few of these patients were in such a state that they could not, in a reasonably short time,be restored to a normal working life through treatment and rehabilitation. The majority of therefugeeswere in the prime of their working life, with many on the rather young side.

We reported both the tuberculous and the 'post-tuberculous' cases to the Austrian healthauthorities, who 'undertook further investigation. The results showed that the majority had'inactive' disease and were fit for work. We were not given the exact figures resulting from theseinvestigations.Sanatorium Treatment

As so many of those included left the country during or shortly after the survey, a completefollow-up has not been feasible. But nearly all patients needing treatment were transferred toThalham Sanatorium, reports from which show that altogether 84 Hungarian refugees were admit-ted for treatment between October, 1957, and the end of July, 1958.

Only patients above the age of 14were admitted to this sanatorium, I do recall, however, that wedid not find serious tuberculous lesions in children-all those affected had minor lesions whichcould be readily cured.

The majority of patients admitted to the sanatorium were young people, with the 25-30-yearage-group most strongly represented.

32 of the 84 patients left the sanatorium before their treatment was completed: 20 of these wereaccepted under special schemes for emigration of the tuberculous; 11 were discharged for disciplin-ary reasons or discharged themselves against medical advice; and I (aged 72) died.

More than half the remaining patients (over 59 %) needed less than six months of hospital treat-ment. Nearly all (over 94%) were discharged within a year, and none needed hospital treatment forlonger than two and a half years.Present Situation

Of the tuberculous and the 'post-tuberculous', taken together, more than half had left the countryby the end of November, 1960. Table I shows that more of those with possibly 'active' disease thanof those with 'post-tuberculosis' had left the country-probably because we have had specialschemes only for those with 'active' disease. This finding shows once again that the 'post-tubercu-lous' fall between two stools: they are rejected for mass emigration because the immigration doctorsdo not regard their disease as definitely 'arrested', and they are rejected for special schemes for thetuberculous because they are classified by the selection doctor as 'post-tuberculous'. No wonderthese people are often in utter despair and ask what is to become of them, as they are regarded astoo ill by the one and too healthy by the other.

TABLE I.-SITUATION IN NOVEMBER, 1960, OF CASES DETECTED IN THE 1957-58SURVEY IN AUSTRIA

No. of Left Still inFindings ill 1957-58 cases Austria Austria

Possibly 'active' tuberculosis 385 244 141'Post-tuberculosis' 388 176 212

Total 773 420 353._------~-_._--

TUBERCULOSIS AND IMMIGRATION

TABLE H.-STATUS IN NOVEMBER, 1960, OF 353 TUBERCULOUS AND 'POST-TuBERCULOUS' CASES REMAINING IN AUSTRIA

No. of Desiring IntegratedFindings in 1957-58 cases emigration In Austria

Possible active tuberculosis 141 17 124'Post-tuberculosis' 212 35 177

Total 353 52 I 301

229

Inquiry among the 353 shown in the 1957-58 survey to have 'active' tuberculosis or 'post-tubercu-losis' revealed that 52 still wished to emigrate, while the remaining 301 were integrated in thecommunity (Table II).

The present health of those integrated in Austria has not been determined as they are no longerinterested in migration. I believe, however, that nearly all can now be regarded as 'post-tuberculous'cases. The last of those admitted to hospital was discharged about two years ago.

Of the 52 still wishing to emigrate, only 3 are, to my knowledge, still in hospital. Four have beenplaced in group II and 6 in group III, while 39 are 'post-tuberculous'.

As Table I shows, 420 with possibly 'active' tuberculosis or with 'post-tuberculosis' have left thecountry. The majority were accepted by Denmark, Norway, or Sweden.

DENMARK

In 1957Denmark accepted 50 Hungarian refugees with tuberculosis, the purpose being to choosethose especially suitable for chemotherapy. Of these 50, 49 were in hospital for less than a year andonly I for more than a year; 48 were at work and were self-supporting within eighteen monthsof arriving in the country.

NORWAY

I have received no detailed report from Norway. Such a report would be interesting because theNorwegians have accepted cases of active tuberculosis, regardless of severity. The NorwegianRefugee Council informs me, however, that about 95%of all refugees of working age have becomeself-supporting. This figure is especially impressive because Norway has in the main selectedseverely handicapped refugees, including quite a number of totally blind.

SWEDEN

In the ten years from 1950 to 1959 Sweden accepted 1011 refugees with tuberculosis-mostlyYugoslav and Hungarian. These cases have been studied in detail by Dr. Torsten Bruce, medicalsuperintendent of Soderby Sanatorium. All the following data on Sweden are derived from apersonal communication by Dr. Bruce and from his report in Svenska NationalforeningensKvartalsskrift (Nov. 2, 1960).

Of the 1011 patients only 32 remained in hospital on Jan. 1, 1960; of these, 26 had arrived in1958 or 1959. 5 patients had been under treatment since 1955 or 1956, and 2 had been in hospitalcontinuously since 1950.

The inquiry was concentrated on patients with pulmonary tuberculosis, numbering in all 557(428 male and 125female) who were admitted to Swedish hospitals in 1950-56, together with a fewadmitted in 1957. Of these 557 patients 337 were under the age of 30 and 52 under the age of 15.

By the National Tuberculosis Association's classification (excluding 48 cases either of primarytuberculosis or where the diagnosis of tuberculosis could not be verified) the cases were gradedaccording to extent and nature of lesions as follows: minimal 107, moderately advanced 301, faradvanced 101. Excluding the 7 cases where tuberculosis was not verified the cases were graded

230 TUBERCLE

according to 'activity' as follows: primary tuberculosis 41, 'post-primary' tuberculosis 509 ('active'with cavitation 141, 'active' without cavitation 281, 'probably active' 54, 'probable inactive' 31,'inactive' 2).

Thus in most cases the disease was moderately advanced; minimal and far-advanced disease wasabout equally frequent, each accounting for some 20%of the total.

These figures may give a somewhat too bright picture, for many of the patients had been undertreatment before coming to Sweden. Likewise a falsely bright picture is given by the relatively smallnumber of cases (182) in which tubercle bacilli were isolated from the sputum on the patient's entryinto Sweden.

Of the 550 cases of verified tuberculosis the known duration of the disease before arrival inSweden had been as follows: less than one year 108, one to three years 133, three to five years 97,more than :five years 203, unknown 9. Thus in about 20% of the cases tuberculosis had beendiagnosed within the past year, and in over a third it had been diagnosed more than five years previ-ously. In many cases admission to hospital was required owing to renewed activity of previouslytreated disease. This renewed activity was commonly due to poor conditions in the camps in whichthe refugees had lived.

In Sweden the length of hospital stay of the 557 patients was as follows: less than two months 33,two to three months 101, three to six months 104, six months to a year 173, one to two years 97,two to three years 22, three to four years 18, over four years 9. Thus more than 40 %were dischargedwithin six months and more than 70%within a year.

On average, the refugees received hospital care for considerably longer than is usual for patientswith tuberculosis in Sweden, who rarely remain for longer than six months. But the protractedhospital treatment of the refugees was conditioned less by the gravity of their illness than by thedifficulty of obtaining for them suitable living accommodation and occupations once the need forhospital treatment had ended.

TABLE Ill.-TREATMENT OTHER THAN CHEMOTHERAPY BEFORE AND AFTERARRIYAL IN SWEDEN

Before arrival After arrivalPneumothorax (continued): 97 Pneumothorax: 20

Unilateral 82 Unilateral 19Bilateral 15 Bilateral 1

Extrapleural pneumothorax: 22 Extrapleural pneumothorax: 10Unilateral 22 Unilateral 9

Bilateral 1Phrenic crush: 12

Thoracoplasty: 29Thoracoplasty: 34 3-5 ribs unilateral 15

3-5 ribs 15 3-5 ribs bilateral 26-8 ribs 19 6-7 ribs 9

8-10 ribs 3Resection: 12

Segment in one lung .. 5 Resection: 55Segment in both lungs 1 Segment in one lung 19Lobectomy in one lung 3 Segment in both lungs 1Pneumonectomy 3 Lobectomy in one lung 17

Lobectomy in both lungs 1Lobectomy and

segmental resection 5Pneumonectomy 11Pleurectomy 1

Total 177 ' Total 114---.

TUBERCULOSIS AND IMMIGRATION 231

TreatmentThe treatment consisted in chemotherapy (which in many cases had been initiated before arrival

in Sweden) and, in some cases, additional measures. As Table III shows, 177patients had had somekind of treatment besides chemotherapy before arrival, and 114 were so treated after arrival. Thusat least 50% of the patients received such treatment either before or after arrival. Bearing in mindthat children are not usually treated by means other than chemotherapy, far more than half theadults were so treated. This strengthens the impression that the disease was rather severe in a largeproportion of cases.

103 patients were readmitted to hospital-a low proportion. In Swedish sanatoria, commonlyup to 50%of patients are readmissions. This low incidence of relapse may have been partly due tothe long initial stay in hospital of many of the patients.

Of the 550 patients, 14 died from tuberculosis and a further 6 from other causes.Social Follow-up

At the end of 1959, 53 of the patients included in this survey had left Sweden-includmg 7 whohad left soon after discharge from hospital, owing, presumably, to difficulty in adaptation to lifein a new country. Most of those who left emigrated to the U.S.A.; Australia, South Africa, andIsrael accepted others, and a few went to Germany or Italy. In addition some returned to theircountries.

Where the refugee's trade was one in which there were vacancies in Sweden, employment wasobtained readily enough. On the other hand, for those with some other occupations, work was notso easily found. Many who had worked as labourers and were incapacitated for such work by theirillness were trained for less energetic employment. In all, at least 100 were retrained, usually formechanical occupations.

Of 438 about whom information was available, 149 were at work within six months after arrivingin Sweden; and rather more than half the total (284) were at work within a year. The capacity forwork and the employment of the whole group of 484 are shown in Table IV. Altogether 51 remainedunfit for work-only 10% of the total. This favourable outcome is largely due to energetic rehabili-tation and to occupational training.

TABLE IV.-CAPACITY FOR WORK AND EMPLOYMENT IN 1959 OF 484 REFUGEES WITHTUBERCULOSIS WHO WERE TREATED IN SWEDISH HOSPITALS DURINO 1950-56

Unfit for work owing to tuberculosisUnfit for work owing to other disease ..Fit for work but not wage-earningFit for work and wage-earning ..

Housewives ..Metal workers . . . .Mechanics, electricians, techniciansTextile workers ..Timber and paper-workersShoe workersFarm labourersRestaurant personnelHospital personnelWhite-collar workers

Clerks.. .. .. ..Draughtsmen, designers, builders, etc.Teachers, etc. .. . . . . . .Intellectual professions (university training)

Miscellaneous professional workers

22106

12

381364

36948815437181339

1250

44

Total 484

232 TUBERCLE

CONCLUSION

The duration of hospital treatment of tuberculous refugees in Austria is strikingly similar to thatin the Scandinavian countries. Clearly the great majority of such patients can nowadays return toproductive work after a relatively short time even if (as is often the case) they have previously beenliving in tough conditions and have to settle in new and strange surroundings.

In the civilised world today, treatment of tuberculosis is so effective, and the facilities for applyingit so adequate, that a person who on arrival is known to have active disease need constitute nodanger to the country. Moreover, the cost involved in treating such a person, and of supporting hisfamily during this treatment, will be negligible compared to his value to the country if he is skilled.

In most, if not all, of the cases discussed here the refugee had previously been rejected by one ormore of the overseas countries; and I find it significant that, although the Scandinavian countriesdeliberately selected 'active' cases and extended the duration of hospital treatment, neverthelessmost of the patients were discharged from hospital within a year, and a great many within sixmonths.

It may fairly be concluded that the overseas countries could safely relax their restrictions withregard to tuberculosis, at least to the extent of accepting those with questionable evidence of thedisease.

We are apt to overlook the fact that those with physical handicaps usually have a strong will andare eager to show that they can keep up with the unhandicapped. The modern industrial communityrequires of its workers skill and training rather than muscular strength and bodily perfection.

I wish to thank Dr. K. Tuchler, medical superintendent of Thalham Sanatorium, Austria, Dr. E. Strandgaard,medical superintendent of Nationalforeningens Sanatorium, Skorping, Jutland, for information about tuberculosisrefugees, and Dr. Torsten Bruce for allowing me to cite at length his findings in Swedenand for supplying additionalinformation.