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Binational cases caught in a tug of war
A wallet-sized pocket card is at the center of
a squabble between groups in Texas and California. The trouble centers around which of two groups — CURE-TB, based in the San Diego department of health, or the Texas organization known as TB NET — gets what might be called referral rights to binational TB cases.
The Centers for Disease Control and Prevention (CDC) in Atlanta, trying gamely to broker a solution between the two camps, has suggested piloting a third, wallet-sized card that will be piloted in Texas, California, and some third inland location.
But what exactly the third card will say or do isn’t yet clear. The hope seems to be that its creation will give everyone in the fight a bit of breathing room, allowing the disputants to step back and try once more to work out their differences.
Both groups consist essentially of data banks and referral services, amounting to, in the case of TB NET, a toll-free number and a pocket-sized written patient record, and in the case of CURE-TB, simply a wallet-sized card that features a toll-free number. Both groups were created to accomplish the same purpose: ensure continuity of treatment among binationals.
There’s nothing especially remarkable about the overlap. After all, tons of competing groups have traditionally proliferated along the U.S./ Mexican border, all jockeying for funds, attention, and space. What lends urgency to the situation is that when active cases among binationals do turn up, the Mexican government (along with other interested parties) needs to know which of the two groups to call.
"The Mexicans don’t know the difference between CURE-TB and TB NET," points out Kayla Laserson, epidemiologist at the Division of TB Elimination at the CDC. "They just know that there needs to be more cross-referral between the two groups. So we’re trying to get them to sit down and come to some formal agreement."
Division of labor could be possible
One tentative solution that seems to be shaping up is a division of labor whereby TB NET handles latent infections and CURE-TB takes charge of active cases. The rationale for that division goes something like this:
Both groups handle tracking and referral for active cases and latent infection. But TB NET, with its flip-out paper record of patient care, was designed to serve the needs of providers who care for migrant workers who are moving from state to state, not back and forth across national borders. So TB NET, it’s reasoned, is best equipped to handle tracking patients who move within the United States.
CURE-TB, with just a toll-free number (and no telltale paper record that might cause problems for someone trying to cross a national border), should by the same logic take charge of keeping track of active cases moving across the U.S./ Mexican border. Because Mexico’s priority is treating active cases, not latent infection, the proposed solution takes it one step further: Why not let CURE-TB take care of active cases, while TB NET looks after latent infections?
On the face of it, that sounds simple. In fact, this is where things begin to get sticky. For one thing, both groups have been tracking both active cases and contacts, and neither is eager to let go of either group, says Charles Wallace, chief of TB control in the state of Texas.
Plus, to TB NET — which originated the idea of a portable pocket-sized record and toll-free number five years ago - CURE-TB feels like an interloper that came along and stole the idea of a pocket card.
"Both programs perform essentially the same functions, even though CURE TB has only recently become interested in tracking contacts as well as cases," Wallace says. "The real difference, as I see it, is that one program, CURE-TB, is part of the existing health department infrastructure. The other, TB NET, operates out of a community-based organization, the Migrant Clinicians’ Network." Like water and oil, the two infrastructures have little affinity for each other, a fact that’s only exacerbated the politics of the dispute, as Wallace sees it.
There are logistical issues as well, says Del Garcia, spokeswoman for the Migrant Clinicians’ Network, which in turn is both the founder of TB NET and the name of the 1,700-member organization of providers who work in migrant health centers. For one thing, Garcia says, the decision to delegate active cases to CURE-TB overlooks the fact that in some far-flung Mexican locations, phones aren’t available, meaning that a paper-free referral system depending solely on a toll-free number simply won’t work.
"You have health units out in the middle of nowhere where they’re functioning with a CB radio, and a phone or fax machine simply aren’t resources that are available," she says. "But I’m not sure everyone [in the dispute] understands that."
Additionally, Garcia says, it makes no sense to ask TB NET to refer all its active cases out of the community-based organization infrastructure into the health department infrastructure. One problem is that in some places the two systems sometimes consist of the same lone physician. "In some places, the doctor who works in the migrant clinic is also the doctor who serves in the health department, so you’re basically asking him to refer from himself to himself," she says.
The other problem is that in many far-flung rural outposts in America, migrants may have no easy access to a health department. "If you’re a migrant worker in Chicago or Los Angeles, that’s one thing; there, of course, we’ll gladly refer active cases to the local health department. But in Arcadia, WI, or Chambersburg, PA, the health department may only be open three days a week. There may be only one nurse who divides her time between diabetes, maternal and infant health, and TB. And that one nurse probably doesn’t speak Spanish."
As Wallace points out, with four or five migrant streams and a 2,000-mile border, there ought to be enough work to keep everyone busy and happy. "There’s enough to go around for everyone," he says. "It would unfortunate if in the end we can’t get these two agencies to sit down and agree."