Culture, Fund Problems Face Doctors Aiding Indochinese

The newspaper story caught the eye of Dr. Tony Catanzaro: A young Laotian man had been arrested by San Diego police after he tried to take hostages at a social center, angered over what he said UC San Diego Medical Center physicians were doing to him.

The curious Catanzaro, the physician in charge of the Indochinese health clinic at UCSD, pulled the medical records of the Laotian and found the refugee was being treated for severe headaches and seizures, with apparently little success.

Catanzaro got the patient released for further medical testing and discovered that a lung fluke--a rare parasite found in Asia--had lodged in the man’s brain, causing seizures each time the fluke released a batch of eggs. Because the fluke is so seldom seen by American doctors--and because 90% of the time it lodges in the lungs to do its damage--initial diagnoses had missed it.

The problem was treated. Today, the Laotian holds down a job and has gained respect, however grudging, for Western medicine.

Catanzaro says the experience illustrates the acuity that physicians need in treating Indochinese patients here and in other areas of the United States where they have settled. Many of their diseases are either rare or seldom seen in modern America as a result of decades of antibiotics use and improved sanitation.

Among the unusual diseases: parasites, such as the lung fluke and hookworm; tuberculosis (TB), largely eradicated among native Americans; hepatitis B, which can cause liver damage and eventual death; middle-ear infections among children, and life-threatening rare anemias.

Physicians emphasize that almost all of the diseases can be treated, and that none of them poses public health problems to the non-Indochinese population. Some will disappear with development of a new generation of Indochinese born in the U.S. who are benefiting from improved sanitary conditions. But others will remain to debilitate the nation’s newest immigrants and in certain cases rob them of their potential to fully enter American society.

“All of these things can be contained or cured if properly handled,” Catanzaro, director of the Center for Indochinese Health Education at UCSD, said in an interview. But the ability to treat these diseases is complicated both by lack of government funding--many Indochinese depend on public-supported health clinics--and by different cultural attitudes toward preventative treatment of chronic illnesses, Catanzaro added.

The problems crop up in the fight against tuberculosis (TB). More than half the Indochinese tested in the county--compared to 15% of non-Indochinese--show positive skin tests, meaning that they very likely have been exposed to the TB bacterium and might develop the disease at some point in their lives.

Those patients who test positive, especially children, can be permanently cured of the germ by taking a sophisticated drug in pill form once a day for a year.

“But it’s a major undertaking to make sure that everyone takes the pills for the entire year,” Catanzaro said. While the UCSD clinics and those run by the county Health Department follow up on patients to make certain the medication is taken, other doctors around the county have neither have the time nor the staff to do so.

“As a result, I think the success rate is terrible,” Catanzaro said, citing figures showing that approximately one-third of those given the pills complete the yearlong medication cycle. Consequently, Catanzaro expects to see more active cases among Indochinese in the next decade as stress or puberty triggers active TB cases in young adults.

Even with an increase, there will be no general public health threat, according to health officials. Linda Hill, physician at the county’s Linda Vista clinic, said that TB “is not a disease you’re going to pick up at Safeway,” noting that a person has to be in contact with an infected person for 400 to 800 hours to have a reasonable chance of picking up the bacterium.

“It’s basically a household disease,” she said, adding that fewer Indochinese children born in the United States now test positive than do those born in refugee camps in Southeast Asia. Hill’s clinic is in the heart of the city’s largest concentration of Indochinese residents.

Hill said Indochinese are reluctant to be vaccinated for TB and hepatitis B--both of which are to a large extent preventable by immunization--when they see no outward signs of illness.

Hill is researching the problem of hepatitis B, which she said will probably take more than two generations to disappear as a health threat. The virus is endemic in Southeast Asia, where 60% to 80% of the population either has an active form or had a mild illness at one time and recovered.

“The threat is among the 20% who show signs of carrying the virus but for some reason cannot manufacture the antibody,” Hill said. A certain percentage of these carriers will develop the full-blown disease at some point in their lives, and have the ability to pass the virus on to their sexual partners, their offspring and, in some cases, to household members through crowded living conditions, she said.

“Because the Indochinese population is so young (more than half under 18), we suspect we could still see a lot of future cases among 20% of the 600,000 Indochinese in the U.S.,” Hill said.

A new vaccine can be given to protect children who show no signs of the virus but whose parents are carriers. The vaccine, given as a series of three shots, is already recommended for the newborns of any mother who is a virus carrier. In this way, transmission of the virus from parents to offspring can be arrested. The vaccine is not effective for people already identified as carriers.

“We do get some resistance from parents, because they already see their kids getting shots for a variety of things--nine shots in 18 months (diptheria, whooping cough, measles, etc.),” Hill said. “What has worked in a lot of cases is legislation; i.e., you tell them their kids can’t go to school without the immunizations.”

But the vaccine is expensive, and there is insufficient funding to identify all the children born overseas whose parents may be carriers. So Hill expects the effects of hepatitis B--which in its most virulent form can bring liver cancer--to last another 50 years or longer.

One type of disease that can be eliminated within a short period is that brought on by parasites. Most are caused by organisms that exist naturally only in Southeast Asia, such as the lung fluke--which inhabits live crabs--and that cannot be transmitted to others. Parasites that can be transmitted through poor sanitation are showing up less frequently in Indochinese children than among their elders because of improved health conditions here.

The key for doctors is to recognize parasitic conditions so they can be treated, Catanzaro said.

“There was great excitement among (UCSD) doctors here when we saw our first case of schistosomiasis (a snail-borne parasite that affects more than 200 million people worldwide from Africa to Asia),” Catanzaro said. “Everyone gathered around the tissue slide.”

Another type of disease found among Indochinese--one that is relatively rare but has serious consequences for offspring--stems from the combination of two genetic anemic conditions not seen in native Americans.

“It’s rare, but when the combination happens, it can be devastating,” said Dr. Faith H. Kung, chief of the child blood cancer unit at UCSD Medical Center. Kung had never seen the combination before the Indochinese migration. “When you get (both anemias), you become totally dependent on blood transfusions.”

There are tests to detect the genetic conditions in parents, Kung said. She said she spends a lot of time trying to convince parents with anemic children that transfusions are vital for the children to live normally. An equal effort involves trying to convince parents who test positive and want a child that their offspring has a 25% chance of being double anemic.

“The risk has not deterred most from having children,” Kung said. “Many Oriental (immigrants) have an ingrained idea that a lot of kids is good because the infant mortality rate (traditionally) has been so high. It’s hard to break the habit.”

Kung recalled one couple where the husband decided the risk was too great, but the wife became pregnant in spite of his concerns. Fortunately, the baby did not have the blood problem, Kung said.

Pediatricians also have substantial difficulty in persuading Indochinese mothers that bottle-feeding is less satisfactory than breast-feeding. “There are problems in that the formula may not be prepared properly, the kids get more diarrhea, etc.,” Hill said.

But the women, she said, believe that breast-feeding will take time away from learning English and job skills necessary to become wage earners. “It’s a matter of economics,” Hill said. “We’ve made little progress in trying to convince them that breast-feeding is not a hindrance in any event.”

Doctors have also noted a higher incidence of middle-ear infections among Indochinese children compared to non-Indochinese, although little research exists on possible reasons for the greater occurrence. Suzanne Dixon, a UCSD pediatrician, speculated that some of the middle-ear infections result from bottle-feeding, in which the infant does not receive antibodies from the mother’s milk that can ward off such infections.

In addition, the crowded nature of many Indochinese homes--where two or more families with many children live together--promotes the spread of such illnesses, Kung noted. In any event, Hill said that she sees more middle-ear infections than any other acute illness at the Linda Vista Clinic.

“And there are problems again with treatment, because the parents can’t see the ear infection, the signs of a problem,” Hill said. “We have difficulty with the patients taking all the antibiotics prescribed--or convincing parents that in some cases a tube should be placed in the ear to prevent hearing impairment--so we may eventually see some speech delays or effects on school performance.”