Immigrant and Refugee Health—Domestic Policy Implications,

Unmet Needs and Future Trends

Jennifer Edman MD

April, 2002

 

Objectives: 

After completing this chapter, readers should be able to:

  1. Define 6 general categories of immigrant status.
  2. Understand the basic provisions and implications of US federal immigration and welfare reform legislation enacted in the 1990s.
  3. Demonstrate familiarity with the health benefit programs available to all non-citizens regardless of immigration status.
  4. Discuss the legal mandate for and relevance of cultural competency and the application of a “Cultural Assessment Framework” to health care planning and service delivery for immigrants.
  5. Describe how effective screening and treatment of Tuberculosis (TB) in the refugee and immigrant population is an integral component of US TB control strategy.  Discuss the barriers that must be addressed with future programmatic changes.

 

Introduction:

According to the year 2000 US Census data, eleven percent of the US population is foreign-born and currently one in five children are either immigrants or have at least one immigrant parent.[1]  Recent figures reported by the Century Foundation indicate that if immigration rates remain constant over the next 25 to 50 years, two-thirds of the population growth in the US will be contributed by immigrants.[2]  Whether one’s interest in the health status of immigrants stems from altruism and compassion or merely a pragmatic interest in prevention of infectious disease and preservation of the public health, the fact that the percentage of foreign-born individuals residing in the US continues to increase renders the organization and provision of services to this group a key public health and public policy issue.

 

A Historical Overview of US Immigration Policy, 1875-1986:

Immigration to the United States was largely unrestricted by the federal government until passage of the Act of March 3, 1875 (US Statutes at Large) which excluded groups of criminals and prostitutes from entrance and established the foundation for the federal government’s role in the regulation of immigration.[3]  This was followed by the 1879 “Act to Prevent the Introduction of Contagious or Infectious Diseases into the United States” which authorized the National Board of Health to station medical officers at foreign ports to inspect ships and their crew for infectious diseases of specific concern.[4]  Health-related exclusion grounds for immigrants reflect the federal government’s traditional concern with the prevention and control of infectious disease in the immigrant population and date back to 1891 when individuals with “a loathsome or dangerous contagious disease” were excluded.  Discrimination based on race or ethnic group identity also has a long history in US immigration policy.  In 1882, the Chinese Exclusion Act prohibited entry to Chinese laborers for a ten year time period.  This act of overt discrimination was progressively extended to include all Chinese and remained in effect until 1943.  The “Chinese Exclusion Case” or US Supreme Court case Chae Chang Ping v. United States upheld the constitutionality of Congressional action designed to exclude immigrants on the basis of race.[5] 

 

Despite increasing qualitative restrictions on immigration and the institution of medical examinations at US points of entry, the largest wave of immigration in U.S. history occurred in the early 1900s, peaking in 1910, when foreign-born residents and their children constituted 35% of the population.  Immigration then declined during the next two decades as additional restrictions were added, reaching a low point during the Great Depression (1929–1939).  In 1921, the Quota Law added the first numerical restrictions on those attempting to enter the US.  1924 saw further restriction with the elimination of any immigration from races barred from citizenship.[6]  This extension of the quota system endured until 1965 legislation replaced the national-origins quota system with a quota system based instead on hemisphere of origin.  Discrimination based on race or gender was explicitly prohibited by this act.[7]  Since the late 1960s, immigration rates have gradually increased again to a second peak in 1986 when passage of the Immigration Reform and Control Act enabled 2.8 million individuals illegally residing in the US to legalize their status.  Despite initial success, this act meant to discourage illegal entrants has been largely unable to stem the tide of illegal immigration.  1996 INS estimates indicate 5 million undocumented individuals currently reside in the US and that number increase annually by approximately 275,000.[8]

 

Simple Demographics and An Overview of Recent Trends in Immigration:

According to year 2000 US census data, foreign-born residents and their children constitute 20 percent of the US population or 56 million individuals, the largest absolute number at any time in our nation’s history.  The declining birth rates of native citizens ensure that immigration plays an increasingly expanding role in population growth—currently accounting for 37% of growth.[9]  70.4% of the foreign-born population is heavily concentrated in six states:  California, New York, Florida, Texas, New Jersey, and Illinois.  25.9% of California residents are foreign-born as are 19% of residents of New York.  Upon arrival in the US, approximately one quarter of new immigrants indicate intentions to reside in Los Angeles or New York City.[10]  Despite equal likelihood of participation in the workforce as US-born residents, the foreign-born report lower median incomes and significantly lower rates of health insurance coverage.  According to the Kaiser Commission on Medicaid and the Uninsured, lack of health insurance is the key issue facing immigrant populations.  In the year 2000, low-income immigrants were twice as likely to be uninsured than low-income citizens.[11]    

 

Census data reflect increasing diversity present among the foreign-born population.  Currently the largest number of immigrants in the US originate from Mexico.  Other countries with large numbers of immigrants arriving yearly include China, India, the Philippines, the Dominican Republic, Vietnam, and Cuba.  In 1998, Bosnia and Herzegovina, the former Soviet Union, Vietnam, Somalia, Iraq and Cuba contributed the largest numbers of refugees approved for travel.[12]  World region of origin is the key predictor of immigrant social and economic well-being.  Census data from 1997 reveal that individuals from Latin America constitute one half of the foreign-born population but fare far worse than other immigrant groups in terms of percentage of adults with a high school education, percent of workers with employment based health insurance coverage, poverty rate, median household income, and rates of participation in noncash, means-tested entitlement programs.[13]

 

Definitions and Terminology:

All individuals born in the US (including Puerto Rico and other US territories) are granted citizenship at birth.  According to the US Constitution, the designation of citizenship occurs regardless of the immigration status of the parents.  Legal permanent residents and military veterans may later become eligible for citizenship under the naturalization process.  In the most general sense, an immigrant is defined as an individual born outside of the US who enters the country with the intention to remain indefinitely.[14]  For clarification, a non-immigrant is defined as an individual permitted to enter the US for a specifically defined and temporary purpose such as tourism, education, or business interests. 

   

Six generally accepted categories of immigrant status include:  legal immigrants, refugees, asylees, legalized aliens, parolees, and unauthorized immigrants.[15]

  1. Legal Immigrant:  (syn. legal permanent resident)  A foreign-born individual permanently admitted to the US for family unification purposes or desirable technical skills.  Other methods to obtain legal permanent resident status include:  designation of refugee or asylee status for one year, lottery-based visa allocation, amnesty due to long documented duration of residence, or determination by an immigrant judge on the basis of hardship.
  2. Refugee:  An individual fleeing his or her own county of origin for reason of persecution or fear of persecution based on race, religion, nationality, political opinion, or membership in a social group.   This legal immigration status is granted while still outside of the US.  After residing in the US for one year, status may be modified to that of a legal permanent resident.
  3. Asylee:  An individual residing in the US at the time application is made for protected status because persecution or feared persecution in their country of origin.  Asylees are eligible for the same benefits as refugees. 
  4. Legalized Alien:  A legalized alien is an unauthorized or undocumented immigrant who because of residence since 1982 or proof of special agricultural worker status was granted legal status under the Immigration Reform and Control Act of 1986
  5. Parolees:  Individuals permitted to temporarily reside in the US for emergency humanitarian, legal, or medical reasons.  When the annual number of legally permitted refugees is exceeded, an individual fearing persecution may be paroled into the US.
  6. Unauthorized Immigrants:  (syn. undocumented or illegal aliens)  Individuals who cross the border illegally or overstay their visa or other immigration documents constitute the group known as unauthorized immigrants.  Currently the majority of individuals in this group come from Mexico or other areas in Latin America.

 

Two other important designations of legal status for foreign-born individuals include Withholding of Deportation Status (Cancellation of Removal) and Temporary Protected Status.  Withholding of Deportation is a special designation that acknowledges a non-citizen who would be persecuted upon return to their country of origin.  Unlike refugee or asylee, this status does not lead to permanent residence.  Temporary Protected Status refers to individuals living in the US but hailing from a country of origin where personal safety would be compromised upon return.  Individuals residing under this status are given work authorization.  Recent countries designated under this program include Somalia, Sierra Leon, Bosnia, Kosovo, and the Sudan among others.[16]

 

Loue asserts that immigrant may be defined in three distinct manners:  by a social science definition or by one of two distinct legal definitions (immigration law vs. public benefit law) subject to modification as laws are enacted and changed.  Her argument is based on the premise that there is a need to improve both design and methodology of studies involving immigrants by enhancing the precision of the definition of immigrant status used to characterize the population under study.  Researchers must select the most appropriate definition to employ based on study objectives and target population.  Of particular importance is the need to consider changes in definitions over time when evaluating trends in health care utilization or costs.[17]  Duration of time in the US, language, country of origin, and self-defined ethnicity are additional components of immigrant identity that must be examined and are often unavailable when using vital statistics and medical records as data sources.

 

Immigration Status and Health Coverage—The Current Situation in the US:

The longstanding debate over whether undocumented aliens should be entitled to health care intensified in the 1980’s and resulted in the passage of the 1986 Immigration Reform and Control Act.  This concern with illegal immigration has been largely replaced by a question with even larger ramifications for the overall health and economic well-being of the US population—whether legal immigrants as full participants in US social and economic life qualify for federally funded social programs including health insurance.   

 

Recent Federal policy changes have dramatically impacted legal immigrant eligibility for public benefits including Medicaid.  Prior to the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, legal immigrants and legal permanent residents were entitled to the same panel of public benefits as US citizens, including Medicaid when meeting standard income eligibility requirements.  Traditionally, Medicaid has played a pivotal role in providing health insurance coverage for immigrants because of high rates of poverty accompanied by comparatively low rates of workplace sponsored insurance coverage.[18]  The passage of PRWORA fundamentally challenged the nation’s traditional approach to benefits for immigrants, changing the ability of legal immigrants to receive cash assistance and Medicaid.  Interestingly, the average immigrant family contributes $80,000 USD more in taxes than they receive in lifetime benefits.[19]  A comprehensive explanation detailing the intricacy of recent immigration and welfare law change is beyond the scope of this chapter, therefore a brief overview of major immigration and welfare law changes enacted in the 1990s follows.

 

California and Proposition 187:

Passed in 1994, Proposition 187—a state of California initiative—was designed to restrict undocumented immigrants from government-funded health and social services, including public education.  In addition, under the provisions of the law, educators, health care workers, and social service providers were required to verify the legal residency of individuals prior to providing services and report to the INS anyone failing to provide documentation.[20]  The constitutionality of the policy was immediately challenged and it was overturned in the courts.  In 1999, Governor Davis acknowledged that the statute would never be implemented.  It is widely believed that the anti-immigrant sentiment associated with Proposition 187 limited the access to health care of documented and undocumented individuals because of fear regarding backlash, discrimination, or enforcement of the proposal’s provisions.  Spetz et. al. reported a significant but small decrease in prenatal care use not accompanied by poor birth outcomes in foreign-born women with limited education residing in California after the proposition was approved.[21]  Even though it was never enacted, ramifications of the act reverberated around the country and set the stage for the dramatic federal policy changes of 1996.  

 

 

 

Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA):

A broad new system of classification of foreign-born individuals was instituted under PRWORA.  Qualified immigrants were now defined as individuals meeting Medicaid financial eligibility requirements and belonging to one of nine explicitly specified categories:[22]

1.      Legal Permanent Residents.

2.      Refugees.

3.      Asylees.

4.      Immigrants granted a “deportation withheld” status.

5.      Immigrant granted parole status for minimum duration of at least one year.

6.      Immigrants granted conditional entry based upon marriage.

7.      Battered immigrants and her dependent children, under the provisions of the Violence Against Women Act.

8.      Immigrants born in Canada with 50% or more blood of the American Indian race.

9.      Immigrants of Haitian or Cuban origin accepted under the provisions of the Refugee Assistance Act of 1980.

Under PRWORA provisions, qualified immigrant status does not imply automatic eligibility for benefits.

 

Qualified immigrants arriving in the US on or after August 22, 1996 are no longer eligible for Medicaid or other means-tested federal assistance programs such as AFDC, food stamps, or unemployment insurance until they have lived and worked in the US for 5 years.  Under the law, limited numbers of individuals qualify for Medicaid regardless of date of entry.  These include:  refugees, asylees, Cubans and Haitians, and individuals under withheld deportation status for their first 7 years after designation; Amerasian immigrants (child with an American father conceived in SE Asia during years of US military presence due to conflict in the region) for first five years of residence only; US Military personnel, their spouses, and dependent children; and legal permanent residents once 40 quarters of Social Security coverage are documented (the equivalent of a ten-year US work history).[23]  The same criteria apply for enrollment in the State Children’s Health Insurance Program (SCHIP).  US-born children are eligible regardless of the immigration status of their parents.[24]  Notably, under the provisions of the law, individual states were given the authority to decide whether or not qualified immigrants present in the US prior to law enactment would continue to receive Medicaid coverage.[25]

 

Under the law, “Not  Qualified” immigrants are rendered ineligible for Medicaid and all other federal public benefits regardless of year of entrance into the US.  This category includes all other foreign-born individuals (non-citizens) namely all individuals residing under color of law (PRUCOL), all undocumented immigrants, and all nonimmigrant visitors and students.[26]

 

Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996:

Passed during the same year as welfare reform, the majority of the provisions in this act relate to increased enforcement of immigration control policy.   The law mandates deportation of even minor criminals without consideration of hardship imposed on family members.  It attempts to prevent illegal immigration through the introduction of “expedited removal and summary exclusion measures” accompanied by categorical denial of appeal and barred re-entry for three to ten years.  This act contains a provision requiring an affidavit of support from a sponsor living at 125% of the federal poverty line making it more difficult for families to sponsor relatives.  In addition, this provision requires sponsors to pledge to support immigrants for 10 years or until they become citizens.  During the period of support, sponsors are now obligated to repay certain categories of benefits obtained.  Notably, Emergency Medicaid services were exempted in an amendment to the final bill.  Failure to document vaccination against common “vaccine preventable diseases” as recommended by the Advisory Committee for Immunization Practices was introduced as new grounds for denial of admission.[27]

 

Public Charge Clarification (1999):

Public Charge refers to individuals dependent on public benefits for their livelihood.  Under current immigration law, the federal government may exclude entrance or deny application for permanent residency if an immigrant is determined likely to become a public charge.  Anecdotal evidence indicates that immigrants with intact eligibility were not accessing health care services out of fear of obtaining a public charge status.  The Public Charge Clarification of 1999 issued by the Justice Department was meant to dispel widespread confusion over the effect of social service program participation on Public Charge status.[28]  Medicaid (with the exception of long-term care) and CHIP were declared to not be subject to repayment by sponsors and independent of public charge status.  In addition, participation in food programs such as Food Stamps and WIC, or other programs not providing direct cash assistance like public housing, energy assistance programs, Head Start, or job training and counseling services were determined to be non-contributory to the assignment of a public charge status.  Cash welfare benefits including TANF and SSI in addition to long-term care provided at governmental expense will be considered in public charge determination.[29]      

 

Immigrant Children’s Health Improvement Act of 2000 and 2001:

Multiple sources indicate that federal welfare law enacted in 1996 and the resulting loss of publicly-funded insurance is eroding the health care coverage of low-income immigrant children and citizen children in immigrant families, threatening access to health care for this vulnerable group. [30] [31] [32] [33] [34] The Immigrant Children’s Health Improvement Act, twice proposed but not yet enacted, is a bipartisan initiative designed to enable states to access federal funds to remove the 5-year ban on Medicaid and SCHIP benefits for immigrant children and pregnant women arriving in the US after the enactment of PRWORA on August 22, 1996.[35] 

 

Limited Health Benefits Remain Intact Regardless of Immigration Status:

The range of publicly funded health benefits remaining available to non-citizens regardless of immigration status or date of entry into the US includes but is not limited to:[36]

  1. Emergency Medicaid:  Emergency Medicaid benefits provide treatment for an emergency medical condition only (including labor and delivery).  In order to qualify, serious bodily harm must be expected to result from the absence of immediate medical attention and the individual must satisfy standard Medicaid financial eligibility criteria.
  2. Emergency Care under the provisions of the 1986 Emergency Medical Treatment and Active Labor Act (EMTAL):  This federal “anti-dumping” law requires every hospital with emergency room services that participates in the Medicare program to provide stabilizing services to any patient regardless of insurance type or ability to pay.
  3. Hill-Burton Act Obligations:  The Uncompensated Care Obligation and the Community Service Obligation mandate that organizations receiving Hill-Burton funds for facility renovation must provide a designated amount of free care without discrimination.
  4. Standard care from Federally Qualified Health Centers.  These programs, mandated under Section 330 of the Public Health Service Act, are funded by the Bureau of Primary Health Care (one agency within the U.S. Public Health Service) and traditionally offer services to all on a sliding-scale or no cost basis.
  5. Medical services provided by Migrant Health Centers receiving federal funds.
  6. Treatment from Rural Health Clinics receiving federal grant assistance.
  7. Emergency Disaster Relief such as shelter, food or clothing.
  8. Essential Public Health Services Not Funded by Medicaid:  These services include immunizations; HIV/AIDS treatment including services mandated by the Ryan White Act; screening for and treatment of both active TB disease and latent TB infection; and diagnosis and treatment of STDs.
  9. Community-Based programs and services designated by the Attorney General as “necessary to protect life and safety.”  Currently seven major categories of services ranging from crisis intervention programs to short-term emergency housing, to police/fire/ambulance/sanitation services are included under this designation.[37]

 

Limited awareness of the eligibility of otherwise non-qualified immigrants for certain programs, discrimination, substandard care, and fear of being labeled as a “public charge” are barriers that prevent immigrants from accessing programs and benefits to which they are entitled.  The cumulative result of recent legislation is to force immigrants to depend even more strongly on the traditional safety-net providers listed above for their primary and emergency health care needs because of increasingly limited access to care within the formal health care system.  There is a need for education and advocacy to ensure that individuals receive the benefits to which they are entitled under law.

 

The Move to Individual State Supported Funding: 

The restrictions placed on federal programs under the welfare reform legislation shift the burden of responsibility for health care costs for immigrants from the federal to the state and local levels.  States with large immigrant populations and states in border areas such as New York and California are disproportionately burdened by this shift.  Under PRWORA, states are given the authority to bar non-citizens from their own assistance programs and the obligation to independently determine state-specific eligibility rules.  States were granted the authority to determine whether to provide TANF and Medicaid to pre-enactment immigrants; whether to substitute state-funded benefits for unqualified immigrants rendered ineligible; and whether to implement further state-specific eligibility restrictions.  State policies are still evolving.  Zimmerman and Tumlin assert that the “devolution” of authority over immigrant policy from the federal to state government not only widens the division between the federally determined immigration policy and state-controlled immigrant policy but is creating an exclusionary, patchworked approach to the provision of benefits with vulnerable groups, particularly the elderly increasingly excluded.[38]

 

Welfare Reform, Medicaid Eligibility, and Citizenship Status—Implications for the Health of Immigrant Populations:

Reforms may have unintended but direct harmful effects on the public’s health and financial well-being.  Without system-wide integration of immigrants and refugees into a comprehensive health care delivery system, it will be difficult to prevent and control the spread of TB and other infectious diseases.  Lack of entitlement to health care benefits and perceived lack of access to services impacts health care utilization patterns, discouraging immigrants from accessing preventive care and forcing individuals to defer health care needs until problems are advanced, acute and ultimately more costly to treat.  Lack of access to preventive and primary health care services results in increased rates of hospitalizations for preventable conditions.  Higher health care expenditures may result as less expensive routine preventive health services are rendered inaccessible and are replaced by acute care services whose larger costs will burden society as a whole.     

 

It is difficult to assess the impact of immigration and welfare reform on health status.  Evidence-based research is needed to document changes in health care utilization, costs, and health care outcomes associated with the recent policy changes.  According to figures reported by the Kaiser Family Foundation, 20% of the 44 million uninsured individuals in the US are immigrants.  Low-income non-citizens are twice as likely to be uninsured than low-income citizens.  Over 58% of low-income non-citizens were uninsured in 1998 with 15% qualifying for Medicaid.  30% of low-income citizens were uninsured in 1998 and a full 30% received Medicaid.[39]

 

Conflicting evidence exists regarding the impact of the new welfare reform on immigrants and access to health care.  Focus groups conducted by the Kaiser Family Foundation indicate confusion and misinformation regarding eligibility and public charge determination exist among foreign-born individuals.[40]  Many anecdotal reports suggest adverse outcomes including deaths stemming from the enactment of the new legislation.  Several studies conducted to determine the impact of welfare and immigration reform report decreased use of publicly funded health benefits among individuals remaining eligible.[41]  Berk and Schur concluded from in-person surveys of undocumented Latinos in California and Texas that 39% of adult undocumented immigrants were fearful of accessing the health care system because of immigration status.  The reported fear translated into statistically significant decreased ability to access common medical and dental services.[42]  In contrast, the recent study conducted by Joyce et. al. found little evidence of impact of PRWORA on perinatal health outcomes or health care utilization patterns of foreign-born Latinas in California, Texas, and New York City.  The study also reported minimal change in the percentage of uninsured foreign-born women in California and NYC.[43] 

 

There is a need for accurate documentation of the impact on health status and access to preventive health care services of restrictive public policy initiatives targeting immigrants in order to further national debate on policy.  The indicators of appropriate access to health care selected by the Institute of Medicine in 1993 should be adopted as standard outcome measures in future studies.

 

Access to Health Care—Barriers to Provision of Services:

Reasons for migration often include religious persecution, political conflict, war, environmental disasters, depletion of natural resources, and economic hardship—all of which can have devastating effects on health status rendering immigrants a vulnerable population often with acute health care needs immediately upon arrival.  Even those arriving in good health face disproportionate risks upon arrival including poor access to health care, adoption of poor health habits during the process of acculturation, and exposure to environmental risk and high injury work environments.[44]

 

In addition to the newly implemented restrictive federal policies, immigrants face multiple barriers that prevent access to health care including:  language, culture, lack of familiarity with the administration and delivery of health care services in the US, and economic hardship.  These barriers contribute to documented racial and ethnic disparities in health outcomes.

 

Language Barriers and Title VI:

Language barriers involve every level of the health care delivery system from filling out application forms for benefits, to explaining symptoms and concerns in the context of the physician-patient encounter, to understanding the instructions on a prescription bottle.  Language barriers may prevent individuals from seeking out a health care provider and contribute to medical error once care is provided.  Although rarely enforced in today’s health care arena, federal law mandates the provision of linguistically appropriate health care.  Title VI of the Civil Rights Act of 1964 states:  “No person in the United States shall, on grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”  Title VI guarantees access to health care regardless of language spoken and ensures that interpretation services and translated materials be provided to patients free of charge.  As some degree of federal funding supports virtually every health care provider in the US, the provisions of the act also apply.[45]  Acknowledging rare compliance with the Title VI mandate, the Office for Civil Rights issued its Limited English Proficiency (LEP) Guidance August 30, 2000 which provides four explicit strategies for health care organizations to ensure adherence to the law.[46]  In conjunction with the LEP Guidance, The Department of Health and Human Services Office of Minority Health issued National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care December 22, 2000.  The fourteen standards emphasize the link between linguistic and cultural competence and need for outcomes-based research and quality improvement efforts within health care delivery organizations.[47]

       

The Importance of the Delivery of Culturally Competent Health Care:

Census data reveal that the immigrant population residing in the US today is complex, multicultural, and multifaceted.  In order to provide effective health care to this population, cultural competence will be needed on the part of policy makers, administrators, and direct care providers.  As defined by Castro, Cota and Vega, cultural competence is characterized by a high level of understanding of potentially subtle cultural nuances which enables the health care professional to appropriately interpret the patient’s communication within their cultural context and background.  Cultural competency enables the professional to work effectively in cross-cultural situations and must be an integral part of effective health care service delivery at all levels—including needs assessment, planning, policy, communication of risk, diagnosis and treatment.  Implicit to this definition is the need for an understanding of variability within cultural groups.  Examples of this intragroup variability include different levels of acculturation and the diverse national and cultural backgrounds of individuals comprising the Hispanic or Asian populations in the US.[48]  Successful health promotion programs designed to serve any immigrant cultural group must quickly overcome language barriers, integrating specific cultural aspects of interpersonal relations, adjusting services to the levels of acculturation existing within the target population, and ensuring that the initiative is “culturally operative” in the local community.  The promotion of health behavior change in a culturally relevant fashion is best achieved by incorporating self-identified strengths of the culture into the intervention itself.  Ongoing research directed at the clarification of health implications of “culturally specific factors” for different immigrant communities is imperative so that these factors may be targeted as future mediators of healthy behaviors.[49]

 

The “Cultural Assessment Framework” as proposed by Huff and Kline is based on the concept of cultural tailoring “which involves the development of interventions, strategies, messages, and materials that reflect specific cultural characteristics of the population group targeted for intervention.”[50]  The cultural tailoring process enables a direct focus on specific cultural factors that moderate health behavior.  The authors assert that an accurate needs assessment of any multicultural population must include a cultural assessment component.   They propose five essential categories of investigation including:  demographic characteristics including literacy, language and level of acculturation or assimilation; environmental and epidemiologic influences; cultural or ethnic group characteristics; health care beliefs and practices; and finally “Western health care organization and service delivery assessment.”[51]  Utilization of this framework will facilitate a better understanding of how mainstream cultures differs from a specific cultural or ethnic group of interest when planning a health care delivery program.  

 

Case Study:  Tuberculosis Control in Monroe County, Upstate New York

The control of Tuberculosis represents one example of the pressing need to screen and treat immigrants for communicable infectious diseases.  Despite a recently observed decrease in case rates among the foreign-born, the proportion of cases of active TB disease in the US occurring in that population is steadily increasing.  In 2000, 46% of all TB cases in the US occurred in foreign-born individuals.  The case rate of TB in the US remains seven times higher in foreign-born than in US-born individuals.[52]  As the proportion of reported TB cases among foreign-born persons continues to grow, the elimination of TB in the United States will depend increasingly on the elimination of TB among the foreign born.  All immigrants regardless of status are eligible for TB control services as they fall under the category of essential public health services.

 

The majority of cases of TB occurring in the foreign-born are reported from states with the highest percentage of recent immigrants. According to CDC data from 1997, 15% of the national total of TB cases occurred in the state of New York with 51% of the reported cases occurring in foreign-born individuals.  (The largest proportion of those cases was reported in the metropolitan NYC area.)  Currently in the United States, TB screening is required for immigrants and refugees applying for permanent legal status and foreign-born individuals attempting to adjust their status to legal permanent resident after initially entering the country on a nonimmigrant visa.  Regardless of country of origin, increased risk for active TB disease is associated with shorter length of time of residence in the US (under 5 years), older current age and older age at the time of migration to the US.  The majority of TB cases in immigrants result from reactivation of latent TB infection acquired in their country of origin.[53] 

 

The following case study describes the experience of the Monroe County Health Department TB Control Program in 1995, and presents programmatic experience in addition to data collected by retrospective chart review of records for all individuals started on Isoniazid preventive therapy in 1995 for the treatment of latent TB infection (LTBI).[54]  The study was undertaken in order to identify predictors of adherence to therapy for LTBI in order to improve clinic programming.  The case highlights key issues surrounding the provision of medical care to a refugee and immigrant population, including:

  1. The importance of screening for communicable disease in immigrant populations.
  2. Barriers to the provision of services for immigrants.
  3. The need for culturally competent health care delivery services to facilitate adherence to treatment regimens.
  4. The need for collaboration with community based organizations for effective delivery of services.

 

The Monroe County Health Department serves the City of Rochester, New York and the surrounding county.  Rochester is one of the nationally designated refugee relocation centers.  Located in upstate New York, infectious disease morbidity and mortality in Monroe County tends to replicate NYC trends on a smaller scale after a three to five year delay.  During the period 1992 through 1994, 120 individuals were diagnosed with active TB disease in Monroe County with thirty three percent of the cases occurred in foreign-born individuals.  In 1995, 41 individuals in Monroe County were diagnosed with active TB disease.  Consistent with previous years' experience, 22% of these cases occurred in foreign-born individuals.  Due to precipitous increases in the number of individuals immigrating to the Rochester area and the increased number and scope of community screening programs run in cooperation with the TB Clinic, the number of individuals started on INH preventive medication for LTBI rose from 299 in 1991, to 446 in 1994.  A record number of 525 individuals were offered and accepted INH prophylaxis in 1995 and a full 65.1% were foreign-born, the majority of whom were assumed to have acquired LTBI in their respective countries of origin.  The most common countries and regions of origin for clients screened in 1995 included:  Vietnam, Cuba, Bosnia, the Ukraine, the Caribbean, Sudan, Puerto Rico, and Russia.   

 

As mandated by the US Public Health Service, all legal immigrants and refugees must undergo health screening prior to leaving their country of origin or country of first asylum.  CDC guidelines require a history and physical exam including a mental status examination; chest x-ray, VDRL and HIV testing if 15 years of age or older; and documentation of initiation of catch-up on age appropriate immunizations.  The primary intent of the screening exam is to identify individuals with excludable conditions including communicable disease of public health significance (defined as infectious TB, HIV infection, Syphilis or other STD, Hansen’s disease).  Following protocol, the Immigration and Naturalization Service (INS) forwards an Overseas Health Screening Form on each refugee relocated to Monroe County.  Screening within 30 days of arrival is mandatory for individuals with class A conditions (including infectious TB disease).  Other individuals are requested to complete new arrival screening within 3 months.[55] 

 

Due to the increasing numbers of immigrants and refugees relocating to Rochester, the TB Clinic assigns an Outreach Worker and a Community Health Nurse to serve as refugee coordinators and has also established special screening programs targeting the refugee and immigrant community.  Often the proper forms are not received or individuals assigned to Rochester leave for more desirable locations before they can be contacted.  Because of the MCHD TB Control program’s mission, the assigned Outreach Worker and CHN attempt to contact every newly arrived individual (regardless of class) arranging an appointment at the clinic for initial screening within thirty days of arrival in Monroe County.  First priority is given to individuals with class A (active infectious TB) or classes B1 (active non-infectious TB) and B2 (inactive TB).[56]  In order to locate all individuals and facilitate transportation to the clinic and the provision of interpreting services, the TB control program relies heavily on the cooperation and participation of three local refugee resettlement organizations.  In addition, TB screening is available at the Bullshead Plaza Outreach Center, conveniently located blocks away from the Adult Learning Center (ALC), a local adult day school which provides English as a Second Language (ESL) and other basic courses and community supports for newly arrived refugees.  Monthly Medication Refill Clinics staffed by the TB Clinic CHN serving as refugee coordinator are held on site at the Adult Learning Center in order to facilitate completion of therapy for LTBI in the newly arrived refugee and immigrant population.

 

Overcoming language barriers to appropriate care is a difficult task and unfortunately all too often in Monroe County family or other community members are relied upon for interpretive services.  Formal interpretive services provided to clients included use of TB Clinic staff (one bilingual CHN—Spanish language), interpreters sent with a patient to the TB Clinic by a Refugee Resettlement Organization, and frequent use of AT&T Interpretive Services provided by trained telephone operators.  In order to improve understanding of latent TB infection, the importance of treatment, and facilitate communication of risks and benefits associated with medications the TB clinic has a library of patient information handouts translated into a variety of languages including Spanish, Vietnamese, and Laotian.  TB Clinic personnel also assist refugee families with referrals to the Monroe County Immunization Program and STD Clinic for confidential HIV testing as warranted. 

 

One potential barrier to acceptance of the need for preventive therapy among immigrants and other foreign-born individuals is the use of the BCG vaccine.  CDC and American Thoracic Society (ATS) guidelines acknowledge that the BCG may prevent dissemination of TB among infected children but maintain that this vaccine loses efficacy within 5 years of administration.  Because of the low prevalence of active TB disease in the US today, the BCG administration is not recommended. Keeping with these guidelines, the MCHD does not consider BCG an effective preventive measure.  However, world wide, the BCG is commonly believed to provide lifelong protection to immunized individuals from the acquisition of TB disease.  Many individuals receiving the vaccine in their country of origin believe that the vaccine causes a lifelong false positive result on a PPD skin test.  Following CDC and ATS guidelines, positive skin tests in any individual who has received the BCG are considered secondary to TB infection, and not a vaccine conferred delayed type hypersensitivity immune response.  Therefore MCHD TB Clinic policy is to regard individuals with a history of BCG administration and a significant Mantoux PPD Skin Test as any other individual with a significant skin test and latent TB infection.  This policy frequently causes confusion among immunization recipients who attribute a positive skin test at the time of screening to a presumed effective BCG vaccine received in their country of origin.

 

Results from the 1995 study directly applicable to the provision of services to an immigrant population include:

 

It is difficult to adhere to a preventive medication for six to nine months when there are no tangible symptoms to treat and when there is no sign of improvement related to taking the medication as is the case with the treatment of LTBI.  This appears to be an even more difficult endeavor for immigrants and refugees relocated to the greater Rochester area.  This study could not analyze the impact of socio-cultural factors on adherence as it was conducted retrospectively and by chart review.  It is easy to attribute irregular clinic attendance and poor adherence to medication among immigrants to low levels of formal education, language barriers, the difficult costs of transportation in the city of Rochester, the lack of personal funds available for individuals to access health care and the consequences of lost income secondary to lost labor during clinic visits.  Despite a cultural or religious disinclination toward medication, a recently arrived refugee may acquiesce under physician pressure and agree to begin INH therapy only to discontinue after returning home and facing community pressure or re-examining his personal beliefs.  This study does not elicit these factors and cannot determine for which socio-demographic groups or cultures they were important.  Further investigation is necessary to elucidate how individuals from different cultural groups use their knowledge to assess and interpret symptoms at the time they seek medical attention and how their decision to access the health care system is influenced by other considerations or experiences.

 

The limitations of the described study combined with the great potential for programmatic improvements indicate the need for further evaluation of the effectiveness of health care delivery programs involving the immigrant population on a local, state, and national level.  For example, some of the efforts of the MCHD TB Control program may be misguided, revealing the need to start with the basic building blocks of cultural competency—a cultural assessment of the current clinic population.  Use of interpreters in individuals with language barriers did not improve adherence to therapy.  This may be the result of study methodology but more likely reflects the need for a larger number of independent interpreters and more frequent use of the ATT interpretation service as mandated under the provisions of Title VI. 

 

In order to effectively address the prevention and elimination of TB on a national basis, the CDC must address the increasing proportion of active disease and burden of latent TB infection within the US immigrant community.  According to the CDC’s 1998 Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons, successful control and eventual elimination of TB in the US will require intensive collaboration between the CDC, state and local health departments, and other national and international public health organizations.  Essential programmatic goals must include:  improvement of overseas screening for TB and development of an evaluation tool to assess the effectiveness of the overseas screening process; computerization or other improvement of the system used to alert local health departments of foreign-born individuals with suspected TB requiring immediate evaluation and possible treatment; coordination of TB control activities at the Mexican border to ensure individuals crossing adhere to a full course of treatment; and implementation of an aggressive national system to universally test immigrants from high-incidence countries for latent TB infection and ensure adherence to appropriate therapeutic regimen.[57]

 

Conclusions:

The health of immigrants impacts the health status of the national and international community.  As the ease of transportation facilitates migration and renders national borders more and more obsolete, surveillance systems and health interventions will be increasingly necessary to reduce the public health risk to the international community from the travel related spread of infectious disease.  Goals for future public health planning must address the need for sound health care policy decisions to be based on a thorough analysis of public health considerations.

 

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Center for Disease Control.  National Center for Infectious Diseases.  Division of Global Migration and Quarantine (formerly the Division of Quarantine).  Medical Examinations.  www.cdc.gov/ncidod/dq/health.htm

 

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Kramer EJ, Ivey SL, Ying YW, Editors.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.

 

Ku L, and Freilich A.  The Urban Institute and The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Caring for Immigrants:  Health Care Safety Nets in Los Angeles, New York, Miami and Houston.  Publication #2227.  February, 2001.  www.kff.org

 

Ku L, Blaney S.  Center on Budget and Policy Priorities.  Health Coverage for Legal Immigrant Children:  New Census Data Highlight Importance of Restoring Medicaid and SCHIP Coverage.  Washington, 2000.  http://www.cbpp.org/10-4-00health.pdf

 

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Nickel, James.  Should Undocumented Aliens be Entitled to Health Care?  Hastings Center Report.  December, 1986:19-23.

 

Perry MJ, Sytark E, Burciaga VR for Kaiser Family Foundation.  Barriers to Medi-Cal Enrollment and Ideas for Improving Enrollment:  Findings from Eight Focus Groups in California with Parents of Potentially Eligible Children. October, 1998.   www.kff.org

 

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Schlosberg, Claudia and Dinah Wiley.  National Health Law Program and National Immigration Law Center.  The Impact of INS Public Charge Determinations on Immigrant Access to Health Care.  May 22, 1998.  www.healthlaw.org/pubs/19980522publiccharge.html

 

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Spetz J, Baker L, Phibbs C, Pederson R, and S Tafoya.  The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prenatal Care by Foreign-Born Mothers in California.  Journal of Immigrant Health  2000;2(4)203-212.

 

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Ziv TA, Lo B.  Denial of Care to Illegal Immigrants:  Proposition 187 in California.  New England Journal of Medicine  1995;332:1095-1098.

 

Recommended Websites:

Access to Resources for Community Health:  an electronic health information and resource center.  www.mgh.harvard.edu/library/arch/immigrant.asp

 

The American International Health Alliance (AIHA) searchable Directory of Translated Materials-health and medical documents--a directory of over 400 health related materials translated into languages of the former Soviet Union and Central and Eastern Europe.

http://www.aiha.com/

 

Asian and Pacific Islander American Health Forum.  www.apiahf.org/

 

Associations of Asian Pacific Community Health Organizations.  http://ahschc.org/defaultothers.htm

 

The Center for Cross Cultural Health.  www.crosshealth.com/

 

CDC—The Office of Global Health.  www.cdc.gov/ogh/issues/refugee.htm

 

The Cross Cultural Health Care Program.  www.hcfa.org/Immigrant.html

 

CulturedMed  The SUNY Institute of Technology Library Resource Center.  www.sunyit.edu/library/html/culturedmed/

 

Church World Service.  http://ncccusa.org/cws/errss.html

 

Department of Health and Human Services, Office of Refugee Resettlement, Administration for Children and Families.  http://www.acf.dhhs.gov/programs/opa/facts/orr.html

 

DiversityRX.  www.diversityrx.org/

 

EthnoMed:  Ethnic Medicine Information from Harborview Medical Center.  Includes link to immigration issues.  http://ethnomed.org

 

Immigration and Refugee Services of America (IRSA).  http://www.irsa-uscr.org

 

InterAction—the nation’s largest coalition of relief, development, and refugee agencies.  http://www.interaction.org/contents.html

 

Massachusetts Office of Refugee and Immigrant Health.  www.state.ma.us/dph/orih/orih.htm

 

Migrant Clinicians Network.  www.migrantclinician.org/

 

National Asian Women’s Health Organization (NAWHO).  www.nawho.org/home.htm

 

National Coalition of Hispanic Health and Human Services Organizations.  www.cossmho.org/

 

National Health Law Program (NheLP):  Immigrant Health. www.healthlaw.org/immigrant.shtml

 

National Immigration Law Center.  www.nilc.org/

 

NYU School of Medicine:  Center for Immigrant Health.  (Formerly the New York Task Force on Immigrant Health)  www.med.nyu.edu/cih

 

Office of Minority Health.  www.omhrc.gov/

 

United Nations High Commissioner for Refugees.  http://www.unhcr.ch

 

US Immigration and Naturalization Service.  http://www.ins.usdoj.gov

 

The Urban Institute.  http://www.urban.org

 

The Welfare Information Network.  http://www.welfareinfo.org/immighealth.htm

 

 


 

[1]The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Key Facts:  Immigrants’ Health Care Coverage and Access.  August, 2000.

[2] Aleinikoff, TA, Century Foundation.  Immigration Reform, The Basics:  A Century Foundation Guide to the Issues.  New York City:  Century Foundation Press, 2000.

[3]Waddell B.  United States Immigration:  A Historical Perspective.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998, p.4.

[4] Waddell B, p. 4, 13-14.

[5] Waddell B, p. 4-5.

[6] Waddell B, p. 7-8.

[7] Waddell B, p. 9.

[8] Waddell B, p. 12-13 and Henry J. Kaiser Family Foundation.  Key Facts:  Immigrants’ Health Care Coverage and Access.

[9] US Census Bureau. The foreign-born population in the United States, March 2000 (US Census Bureau Current Population Reports, P20-534).

[10] Scott, Janny.  Foreign Born in U.S. at Record High.  New York Times.  2/7/02.

[11] The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access, Report #2203.  August, 2000.

[12] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

[13] U.S. Census Bureau.  Census Brief:  Coming to America:  A Profile of the Nation’s Foreign Born.  August 2000.

[14] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

[15] Riedel RL.  Access to Health Care.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998, p. 109.  This citation also encompasses the following 6 definitions. 

[16] Schlosberg C, National Health Law Program.  Immigrant Access to Health Benefits:  A Resource Manual.  Prepared for the Access Project.  Washington, 2001.

[17] Loue S.  Defining the Immigrant.  In Loue S, Editor.  Handbook of Immigrant Health.  New York:  Plenum Press; 1998.  and  Loue S, Bunce A.  The Assessment of Immigration Status in Health Research.  Vital and Health Statistics—Series 2:  Data Evaluation and Methods Research.  127;1999:1-115.

[18] Holahan J, Ku L. and Pohl M.  The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation.  Is Immigration Responsible for the Growth in the Number of Uninsured?  Publication #2221.  February 2001.

[19]Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

[20] Mizoguchi N.  Propostition 187:  California’s Anti-Immigrant Statute.  In Kramer EJ, Ivey SL, Ying YW, Editors.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.

[21] Spetz J, Baker L, Phibbs C, Pederson R, and S Tafoya.  The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prenatal Care by Foreign-Born Mothers in California.  Journal of Immigrant Health  2000;2(4)203-212.

[22] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 10-11.  Encompasses 9 listed categories.

[23] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 12.

[24] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 12-13.

[25] Fix M, Zimmerman W.  Urban Institute.  All Under One Roof:  Mixed-Status Families in an Era of Reform.  Washington, 1999. 

[26] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 11.

[27]Fix M, Zimmerman W.  Urban Institute.  All Under One Roof:  Mixed-Status Families in an Era of Reform.  Washington, 1999.  

[28] Schlosberg, Claudia and Dinah Wiley.  National Health Law Program and National Immigration Law Center.  The Impact of INS Public Charge Determinations on Immigrant Access to Health Care.  May 22, 1998. 

[29]U.S. Department of Justice, Immigration and Naturalization Service.  Summary:  A Quick Guide to ‘Public Charge’ and Receipt of Public Benefits.  October 18, 1999.  

[30] Ku L, Blaney S.  Center on Budget and Policy Priorities.  Health Coverage for Legal Immigrant Children:  New Census Data Highlight Importance of Restoring Medicaid and SCHIP Coverage.  Washington, 2000. 

[31]Capps, Randy.  The Urban Institute New Federalism National Survey of America’s Families.  Hardship Among the Children of Immigrants:  Findings from the 1999 National Survey of America’s Families.  Washington 2001Series B, No. B-29, February 2001.

[32]Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Access to Health Insurance and Health Care for Children in Immigrant Families.  Los Angeles, 1999.  

[33]Brown ER, Wyn R, Ojeda V.  UCLA Center for Health Policy Research.  Noncitizen Children’s Rising Uninsured Rates Threaten Access to Health Care.  [Policy Brief]  Los Angeles, 1999.  

[34] Cherlin A, Fomby P, Angel R, Henrici J.  Welfare, Children and Families, A Three City Study.  Public Assistance Receipt Among Native-Born Children of Immigrants.  [Policy Brief 01-3]  Baltimore, 2000. 

[35] National Immigration Law Center.  Background on Immigrant Children’s Health Improvement Act of 2000, H.R. 4707 (Diaz-Balart) – S.1227 (Chafee).  Washington, 2000. 

[36] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 17-26.

[37]Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 17-26.

[38] Zimmerman W, and Tumlin KC, The Urban Institute.  Patchwork Policies:  State Assistance for Immigrants Under Welfare Reform, Occasional Paper Number 24.  Washington, 1999:112 pp.

[39] Kaiser Family Foundation.  Immigrants’ Health Care:  Coverage and Access.

[40] Perry MJ, Sytark E, Burciaga VR for Kaiser Family Foundation.  Barriers to Medi-Cal Enrollment and Ideas for Improving Enrollment:  Findings from Eight Focus Groups in California with Parents of Potentially Eligible Children.   

[41] Spetz et. al.

[42] Berk M and Shur C.  The Effect of Fear on Access to Care Among Undocumented Latino Immigrants.  Journal of Immigrant Health  2001;3(3):151-156.

[43] Joyce T, Bauer T, Minkoff H, Kaestner R.  Welfare Reform and the Perinatal Health and Health Care Use of Latino Women in California, New York City, and Texas.  American Journal of Public Health  2001;91:1857-1864.

[44] Kramer EJ, Ivey SL, Ying YW, Editors.  Demographics, Definitions, and Data Limitations.  Immigrant Women’s Health:  Problems and Solutions.  San Francisco:  Jossey-Bass Publishers, 1999.  Page 11.

[45] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 55-56.

[46] Schlosberg C.  Immigrant Access to Health Benefits:  A Resource Manual, page 57.

[47] Department of Health and Human Services, Office of Minority Health.  National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care.  (65 Fed. Reg. 80865-79)  December 22, 2000.

[48] Castro, Felipe, Cota, Marya and Santos Vega.  Health Promotion in Latino Populations:  A Sociocultural Model for Program Planning, Development, and Evaluation.  In,  Promoting Health in Multicultural Populations:  A Handbook for Practitioners.  1999, Thousand Oaks:  Sage Publications, p. 142-143.

[49] Castro et. al., p. 138.

[50]Huff RM, Kline MV.  The Cultural Assessment Framework.  In,  Promoting Health in Multicultural Populations:  A Handbook for Practitioners.  1999, Thousand Oaks:  Sage Publications, p. 481.

[51] Huff and Kline, p. 481.

[52] Division of Tuberculosis Elimination, Centers for Disease Control.  Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations-United States, 2000.  MMWR  51(05);2002:101-104. 

[53] Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons: Report of the Working Group on Tuberculosis Among Foreign-Born Persons. MMWR  47;1998:1-31.

[54] Edman J, Moss M, Younge M.  Predictors of Adherence to INH Prophylaxis.  American Journal of Respiratory and Critical Care Medicine, Mar 2000;161(3):A.  Presented at ALA-ATS International Conference, Toronto Canada, May 2000.  Manuscript in process of submission.  Contact author for figures and calculations.

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[56]Center for Disease Control.  Instructions to Panel Physicians for Completing New U.S. Department of State MEDICAL EXAMINATION FOR IMMIGRANT OR REFUGEE APPLICANT (DS-2035) and Associated WORKSHEETS (DS-3024, DS-3025, and DS-3026).  

[57] Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Tuberculosis Among Foreign-Born Persons: Report of the Working Group on Tuberculosis Among Foreign-Born Persons. MMWR  47;1998:1-31.