EDITORIAL Third World Hospital de Luxe

Again America has proven unequal to its task, according to The [Lon~ don] Economist. Because New York City allowed a decline in expenditures for tuberculosis surveillance and care, from $40 million in 1968 to $2 million in 1989, since 1991 they have had to bear $50 million annual costs to play catch-up. Serves them b . . . . . right!

Admittedly patients' failure to complete the course of drug therapy "let resistance [to antibiotics] bloom" (Disease, 1995, p. 15), but the implica- tion that an absence of vigilance or sufficient out-patient care accounts for the spread of tuberculosis is unwarranted. Lack of vigilance is not the source of the epidemic. Entry of an infected population is.

Specifically, "In Los Angeles County, which is second to New York City as a center of tuberculosis, most active cases of tuberculosis are in immigrants" (Ziv & Lo, 1995, p. 1096). Further, "The national surveillance data show that the proportion of diagnosed cases of active tuberculosis in which the patient was foreign-born increased from 22 percent in 1986 to almost 30 percent in 1993" (McKenna et al., 1995, p. 1071). Cantwell et al (1994) report that non-US-born individuals accounted for 60% of the in- crease in active tuberculosis cases in the United States between 1985 and 1992. Secondary transmission to vulnerable U.S. populations amplifies the effect (Raviglione et al., 1995, p. 224).

Americans may not be aware of the magnitude of the TB epidemic because here the disease was in decline through 1984. Worldwide, how- ever, 90 million new cases are forecast for the decade 1990 through 1999 (Raviglione et al., 1995, p. 220).

The tuberculosis incidence rates in countries from which most immi- grants come are 10 to 30 times greater than the U.S. rate. By 1993, the incidence of tuberculosis among the foreign-born population in the United States had risen to 33.6 per 100,000; for comparison, the rate in the U.S.-

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born population "remained relatively constant at 8.1 per 100,000" (McKenna et al., 1995, p. 1072).

Over 15 million immigrants have entered the United States since 1980 and the majority are from third world countries where tuberculosis, hepa- titis B, cholera, and leprosy are endemic. The United States' battle against Southeast-Asian-introduced hepatitis B is ongoing, cholera was intercepted in 1992 at the Los Angeles airport and, in another Southeast-Asian connection, "an epidemic of imported leprosy in the United States began in 1978 and ended by 1988" (Mastro, 1992, p. 1129; Gellert, 1993; Scott, 1992).

The recent-rural origin and the crowding of many populations in Asia and Africa add to the risk from viruses, such as HIV, which jump the spe- cies barrier from wild or domesticated animal to humans. Transmission of a disease strain from chimpanzee to human is thought to account for an outbreak of the Ebola virus on the Ivory Coast in November, 1994 (Morell, 1995). Overcrowding favors transmission (Armelagos et al., 1991, p. 13) creatin 8 vulnerability in the United States' inner cities little less than in the third world.

HIV-AIDS, among the most (if not the most) devastatin 8 import to date, appears to have entered the United States through an itinerant airline em- ployee, not an immigrant. Nevertheless, immigrants are a major vector for reinfectin 8 the resident U.S. population with infectious and communicable diseases which once were eradicated or controlled.

The cost of the resultin 8 demand for healthcare is dispersed amon 8 taxpayers, but the disease burden itself is borne primarily by the most vul- nerable Americans--the poor, the elderly, the young and anyone with an impaired immune-response system.

A different order of health and social emergency, the teen-pregnancy boom, is also associated with immigration. Experts point "to a sizeable increase in births amon 8 Hispanic teens, and . . . now say this growing birthrate is largely responsible for the surprisin 8 increase in national fi 8- ures . . . . In California, Hispanic girls accounted for 7,5 percent of the increase in teen births between 1986 and 1989" (Shapiro, 1992, p. 38).

Unfortunately, policies of the federal government probably contribute to the rising rates of Hispanic teen pregnancies in the United States and, thus, to overall teenage health problems. A threshold incentive, debatably, is Aid to Families with Dependent Children (AFDC), which can be no less a factor among the immigrant Hispanic than amon 8 the native-born popu- lation of any ethnic group. But further influencin 8 the illegat immigrant sector is a provision in the Fourteenth Amendment to the Constitution which gives automatic U.S. citizenship to anyone born on U.S. soil. This

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stipulation effectively guards women who give birth in the United States (and then other relatives) from deportation.

Eleven percent of births in the United States are to immigrant women, but standard demographic reckoning counts births to both illegal and legal alien mothers within the category of U.S. fertility. Thus, the 0.8% rate of natural increase in the United States receives a significant push from immi- gration. The annual 1.1 % or higher rate of population growth in the United States is a composite which results after adding natural increase to the net number of actual immigrants, about 1.3 to 1.5 million annually.

Part of the annual immigrant flow is illegal (estimated at 300,000), part is visa overstayers and those whose asylum claims await adjudication (150,000 to 300,000), part is defined by the 1990 Legal Immigration Reform Act (over 800,000), part is recipients of sporadic amnesties (variable and ran- dom), and part is refugees (a number determined by the President which recently has varied around 120,000 to 140,000 per year).

America is shooting itself in the foot with its disorganized and spec- tacularly generous immigration policy, unmatched by any other in the world. Exponentially growing healthcare needs and costs are but one man- ifestation of an out-of-control policy which treats citizens with less than due regard.

Virginia Abernethy

REFERENCES

Armelagos, G.J., Goodman, A.H., & Jacobs, K.H. (1991). The origins of agriculture: Popula- tion growth during a period of declining health. Population and Environment 13 (1), 9-22.

Cantwell, M.F., Snider, D.E., & Cauthen, G.M. (1994). Epidemiology of tuberculosis in the United States, 1985 through 1992. JAA4A 272, 535-439.

Disease Fights Back. (May 20, 1995). The Economist, pp. 15-16. Gellert, J.A. (1993). International migration and control of communicable diseases. Soc. Sci-

ence Med. 37, 1489-1499. Mastro, T.D., Redd, S.C., & Breiman, R.F. (August, 1992). Imported leprosy in the United

States, 1978 through 1988: An epidemic without secondary transmission. Am. J. of Public Health 82 (8), 1127-1130.

McKenna, M.T., McCray, E., & Onorato, I. (April 20, 1995). The epidemiology of tuberculosis among foreign-born persons in the United States, 1986-1993. New Eng. J. of Medicine 332 (16), 1071-1076.

Morell, Virginia (19 May 1995). Chimpanzee outbreak heats up search for Ebola origin. Sci- ence 268, 974-975.

Raviglione, M.C., Snider, D.E., Jr., Kochi, A. (18 Jan. 1995). Global epidemiology of tuber- culosis: Morbidity and mortality of a worldwide epidemic. JAMA 273, 220-226.

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Scott, Gale (Sept. 8, 1992). Hepatitis in infants "ticking time bomb." Nashville Banner, p. 2. Shapiro, J.P. (July 13, 1992). Solving the mystery: The teen pregnancy boom. U.S. News and

World Report, p. 38. Ziv, T.A. & Lo, B. (April 20, 1995). Sounding board: Denial of care to illegal immigrants. New

Eng. J. of Medicine 332 (16), 1095-1099.