L.A. Fights to Cure TB One Case at a Time

By Solomon Moore

July 11, 2005 12 AM PT

Times Staff Writer

The horizon is just starting to glow when Henry Murphy begins his morning rounds, delivering medicine to residents of several local diasporas -- Vietnamese, Mexican, Guatemalan and Chinese -- within a few miles of downtown Los Angeles.

Murphy winds his white county health department van through some of the poorest and most crowded neighborhoods in the city.

They are also among the most likely places to find tuberculosis, an infectious and potentially lethal lung disease that most Americans associate with another era.

“Jason started coughing real bad five months ago,” 19-year-old Rosie Osorio says, at one of Murphy’s stops at a tidy East Los Angeles duplex. “I took him to Kaiser a couple times, but they kept telling me he had a cold.”

Jason Montanes, Osorio’s son, actually has an active case of tuberculosis, all the more serious because he is just 9 months old. He probably caught it from his uncle, who had the rattling cough of someone with advanced TB. Like many people from immigrant families, the uncle didn’t seek help until he was really sick. Now, eight of Jason’s close relatives, who live either with him or nearby, are infected, including his mother, his father and his immigrant grandparents. Only Jason and the uncle, however, have active cases. Jason still has a mild cough and is probably still contagious.

In the United States, and especially in California, tuberculosis is largely an immigrants’ affliction. According to a recent report by the state’s Department of Health Services, California led the nation in the number of new TB cases reported last year, with 2,989. Three-quarters of those were among people born outside the United States and nearly a fifth were younger than 16.

Many immigrants, experts say, bring the bacterium from countries, including Mexico, the Philippines, Vietnam and China, where TB is endemic and healthcare systems are relatively weak. The infection may lie dormant and noninfectious for years, flaring when a person gets old or his immune system is frail. The disease usually attacks a person’s lungs, spreading to others through the air when the person coughs, sneezes, laughs or even sings. Family members and others in prolonged contact are most likely to be infected.

Although TB has been declining for more than a decade in the United States, experts worry about how entrenched it remains in some immigrant enclaves. They worry, especially, about a small but stubborn share of cases -- 1% to 2% in this state -- that are resistant to standard antibiotics.

A study last month in the Journal of the American Medical Assn. found that foreign-born residents accounted for eight in 10 cases in California that were resistant to multiple drugs.

It was immediately incorporated into the emotional debate over illegal immigration.

“If anyone needs another reason to oppose illegal immigration,” conservative syndicated columnist Cal Thomas wrote about TB-infected migrants last month, “how about the spread of a deadly communicable disease?”

Health officials urged calm and understanding.

“Just because somebody has TB doesn’t mean they’re a bad person,” said Dr. Alan Kurz, a Los Angeles County Department of Health Services medical director for Hollywood, downtown Los Angeles, Pomona and Monrovia. “People with TB contribute to the workplace and churches and social organizations like everybody else. They are valuable people in our society. And this is an illness that can be treated.”

With its large immigrant population and dense neighborhoods, Los Angeles County is a TB stronghold. It had 930 tuberculosis cases in 2004, more than most states, according to health department figures. At least nine of those are drug-resistant.

Murphy and his colleagues fight this ancient, international scourge every day, one patient at a time.

‘I Just Started Coughing’

It takes Wah Lee Lau, 79, a few minutes to open his front door, descend the few steps and hobble across his yard to the garden fence, where Murphy holds out a packet of antibiotics.

As Lau reaches for the pills, a shallow cough sputters from his lips. Murphy retreats a couple of feet and turns his head away.

“I don’t know how I got it,” says Lau, a lithe man with gray eyebrows, who immigrated to the U.S. in 1976. “Two years ago I just started coughing. I couldn’t stop.”

Murphy has 20 clients, whom he sees five days a week. All but little Jason were born outside the U.S., though some, like Lau, have lived here for years. About a quarter of foreign-born TB sufferers have lived in the United States for more than 20 years, according to state figures.

A gregarious veteran health worker, Murphy, 58, gets on the road at 5 each morning to ensure that the health department officials know where his clients are, how contagious they are and whether they are taking their pills.

If TB patients fail to take their medicine, he will call in public health investigators who have the power to quarantine highly contagious or uncooperative patients.

Most of the time, however, Murphy’s clients are cooperative. He jokes around with them, calls them by their first names and offers them canned nutritional shakes in case the antibiotics upset their stomachs. He always remembers their favorite flavors.

“I want people to look forward to seeing me,” he says.

Most don’t know much English, and he knows no foreign languages, save a few words in Spanish.

But after a few weeks of daily visits, some become so familiar with Murphy that they recognize the sound of his car. A few answer their door in their bedclothes.

“One guy used to tell me a new poem every day,” said Murphy. “Some of them were OK, but mostly....” He shakes his head.

When patients want to complain about side effects or report that they are leaving town for a while or moving away, Murphy calls a county-run interpreter hotline and passes his cell phone back and forth.

Lau speaks Cantonese. Through an interpreter, he said he hasn’t been back to China since 1980 and has only occasionally received guests from Asia. He could have acquired the infection there, and it might have lain dormant all those years, only to surface in his old age.

Lau has been ill since at least 2003, he says, but he started treatment just two months ago. He thought he just had a cold until he started to cough up blood. Many people infected with TB don’t have medical insurance and don’t get regular checkups.

Eventually, Lau had a skin test at a public health clinic. The test involves an injection in the arm of a substance called tuberculin. The resulting skin bump indicated a positive response for TB exposure. Doctors then confirmed Lau had active TB by X-raying his lungs.

Often, TB patients react with shame, which makes Murphy’s job harder.

When a reporter riding along with Murphy approached one of his clients, she refused to talk, saying, “No, this is an embarrassing disease.”

Murphy is unfazed, and he is always flexible.

“There was one lady who always wanted me to meet her around the corner from her home,” Murphy says, and another who arranged for a clandestine appointment at a coffee shop.

Neither wanted the neighbors to know.

Globally a Major Killer

Though tuberculosis has become increasingly rare in the United States -- there were about 15,000 reported cases in 2003, according to the Centers for Disease Control and Prevention -- it remains a major killer globally.

TB killed 1.7 million people in 2003, a third of whom lived in Southeast Asia, according to the World Health Organization.

In the U.S., many TB victims “are coming here from resource-poor countries where the public health infrastructure is underfunded,” said Dr. Annette Nitta of the Los Angeles County Department of Health Services.

As a result, TB may be left untreated or treated inappropriately.

When “other countries don’t know what kind of strain of TB they have ... they will prescribe medication that doesn’t kill the tuberculosis,” said Nitta.

Sometimes patients, for whatever reason, do not follow through with the six months or more of drug therapy required to kill the bug.

That practice may destroy just the weakest TB strains, leaving hardier bacteria to persist, reproduce and eventually become super-bugs resistant to all but the strongest drugs.

In the U.S., inadequate screening of new immigrants means many come here infected but undetected, public health officials say.

“Foreign students and workers and visitors are not screened for TB when they come to this country; nor are undocumented people,” said Sarah Royce, chief of the Tuberculosis Control Branch of the California health department. “Only refugees are screened, and there are some gaps in that system too.”

Royce described a recent tuberculosis outbreak involving 27 infected Hmong refugees from a Thai camp who have settled in Northern California since last year. Four of them had drug-resistant strains, Royce said.

Although the refugees were screened by U.S.-contracted medical officials in Thailand, the illness was not discovered until they arrived in the U.S.

Some conditions within the United States make TB more likely to spread among immigrants and their families.

Many share crowded living quarters where the bacterium can be passed more easily.

Many work inordinately long hours or have other stresses that suppress their immune systems. And many visit, or are visited by, people from their native countries who may be infected.

Immigrants’ relatively high mobility also conspires against their health, say medical experts, as people on the move are less likely to complete the lengthy treatment for TB.

This peripatetic existence and, among illegal immigrants, the effort to live below the radar, make sick people harder to find and track.

In addition, the drugs can have side effects, including nausea and dizziness, making them unpalatable.

Meanwhile, the foreign origins of many TB cases draw the ire of some advocates for tougher immigration laws.

“Americans should be told that diseases long eradicated in this country -- tuberculosis, leprosy, polio, for example -- and other extremely contagious diseases have been linked directly to” illegal immigrants, Rep. J.D. Hayworth (R-Ariz.) told the Business Journal of Phoenix last month.

Nitta downplayed the likelihood of contracting the disease from strangers, however, saying that most people get TB from family members or others sharing the same home. She cited studies indicating that TB transmission often takes at least eight hours of sustained exposure, although it is possible to catch the disease in far less time.

Nitta also explained that people with strong immune systems -- including older children -- are less likely to contract the disease.

“In general, it’s not a massive problem for us,” said Karen Maiorca, director of nursing services at the Los Angeles Unified School District.

The district, which enrolls more than 746,800 students, requires TB tests for new students and typically sees about eight new TB cases a year, Maiorca said. Most, she said, are foreign-born teens.

Once a case of tuberculosis is discovered, before community workers like Murphy can get to work, the county department must investigate whether anyone else might be infected.

‘It Just Blows My Mind’

At a Buddhist monastery in Highland Park, an elderly monk greets two county public health nurses. He is wearing a citrus-colored robe that leaves one shoulder bare and has a paper mask over his mouth and nose.

The county learned about the monk’s disease when he sought treatment after several months of coughing.

Now county nurses Priscilla Kwong and Emily Avila are testing his fellow monks and several worshippers at the monastery, a converted motel. All are recent Cambodian immigrants.

Kahn Lue, a volunteer who translates for the nurses, says that the monks often eat light meals only twice a day “so their bodies got weaker and weaker.”

While the nurses attend to the monks in a carport, one ascetic makes a scraping sound in his throat and spits.

“Please don’t do that!” Kwong scolds.

The monk smiles mildly. Kwong shakes her head in disbelief. “It just blows my mind.”

By the end of the week, all the monks had tested positive for TB.

Soon, they will receive a visit from Henry Murphy.

(BEGIN TEXT OF INFOBOX)

Tuberculosis

Most of the new tuberculosis cases reported in California are among immigrants.

Tuberculosis cases diagnosed

2000

3,297

Foreign-born: 72%