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They can’t legally be forced to stay and be treated
Consider the following circumstances: A resident of another country enters the United States, commits a minor crime, and is sentenced to a few months’ jail time. Perhaps because the county jail where he is serving his sentence has slipshod TB screening procedures, the man’s TB goes undetected.
The man is released from jail, and an immigration judge orders his deportation. At an immigration service processing center, he undergoes a routine health screening. He is found to have multidrug-resistant TB.
Because the man has a criminal record, he cannot be released back into the community to undergo TB treatment. Instead, he must re-enter custody. Physicians at the immigration processing center try their best to convince him to stay and be treated, but he wants out. A few months after he is deported, the man slips back across the border again, exposing American citizens to a potentially fatal disease.
The scenario is not especially frequent. But when it does occur, it causes trouble all out of proportion to its incidence, says Abraham Miranda, MD, a physician who works for Immigration Health Services at the Immigration and Naturalization Service processing center in Port Isabel, TX. Worse, under current immigration law, Miranda says there appears to be no way to prevent it from happening.
"In virtually 100% of these cases, these people demand to go home," Miranda says. The usual arguments for undergoing TB treatment carry almost no weight under such circumstances, he adds.
Criminals prove especially recalcitrant
"As a physician, I’ve figured out over the years which buttons to push," Miranda explains. "I talk about the person’s children, and how they can get infected more often, how they get meningitis more often, how they could die." None of it makes any difference, he says. "These people don’t care — not if their family suffers, not if they suffer. Perhaps it’s part of the criminal mentality."
More often than not, the TB that such people carry is resistant or even multidrug-resistant, Miranda adds. "MDR-TB is almost a marker for this kind of situation," he says. "These people have already been bounced back and forth across borders, they’ve been in the criminal system back home, and they’re noncompliant with their medications. They have a higher risk of homelessness, drug abuse, and criminal behavior, and until they start feeling sick, TB treatment is very low on their list of priorities. It all makes a bad problem doubly problematic."
There are no data on how often such episodes occur, Miranda says. "I’d say they’re relatively rare, but they cause a lot of problems when they do occur," he says.
Recently, Miranda encountered a man with untreated MDR-TB from a country in Central America. He’d been deported once, had slipped back into the states, had been re-apprehended, and was scheduled for deportation a second time.
When Miranda asked him to consider remaining in INS custody for treatment, the man became extremely upset. "He started screaming about human rights and civil rights," Miranda says. "It was only by force of sheer will power that I convinced him to stay. I used some carrots; I used some sticks. It was not easy."
It’s not that the governments who agree to take their citizens back are intentionally irresponsible or negligent, he adds. "A lot of them would probably argue that they care very deeply about providing good TB treatment," he says. "The problem is that whereas we go to great lengths to provide directly observed therapy, they don’t approach treatment in the same way. They’ll tell me, Write up a summary letter and have him stop by the Ministry of Health,’ and that’s it. It’s the discrepancy between the way we approach TB care and the way most other governments do that makes me uncomfortable."
Fortunately, Mexico is an exception to this rule. Thanks to agreements between that country and the United States, a handful of highly successful cross-border TB projects exist that track and treat TB patients who regularly cross the border or who are bound back to Mexico. Unfortunately, the United States has no such agreements or transnational programs in place for any other countries.
Luckily, too, criminal aliens who have served time in a U.S. prison (instead of a jail) have been screened for TB — "almost ad nauseam," notes Miranda. At the time these aliens are due for deportation, they’re not likely to present with active TB.
U.S.-Mexico agreement difficult to replicate
Miranda admits that it’s hard to imagine what it would take to ease the present predicament. "Our recommendation to INS would be simply, don’t deport this person — hold onto him," he says. But that’s easier said than done, he admits. The prospect of negotiating TB agreements with every country in the world like the one between the United States and Mexico is daunting.
For now, Miranda is working with others (including a group at the Advisory Council to Eliminate Tuberculosis and with the Centers for Disease Control and Prevention) to get a sense of the extent of the problem and to see what diplomatic or legal mechanisms might be available.
An INS spokeswoman says she’s surprised to hear about Miranda’s complaint. Why, asks Karen Kraushaar, would a foreign government willingly accept someone with a communicable and potentially fatal illness? Deportation is a lengthy and complex process, she adds. Presumably, there are many steps along the way where the process could be delayed or halted. "It’s not something that happens in the twinkling of an eye," she notes.
For example, the Justice Prisoner Air Transportation System can refuse to carry someone with a communicable disease. Before final orders of removal can be issued, an immigration judge must approve the order, she notes; "and judges, of course, can do whatever they want, within reason," she adds.
Kraushaar cites a recent case in Los Angeles in which the judge ruled against deporting a child enmeshed in a prostitution smuggling scheme, even though the youngster’s grandparents have petitioned for her to be sent home and placed in their care. First, the judge ruled, the child must undergo medical treatment in the United States.
The trouble is that’s not the way it usually works out in practice, Miranda says. Perhaps to save face, foreign governments rarely refuse to take back one of their own, he says. Plus, by the time an immigration service processing center has uncovered a case of TB, orders for deportation have generally already been issued, he adds.