AIDS TREATMENT NEWS Issue #208, October 7, 1994
Tadd Tobias and John S. James

Despite antibiotics, the modern world is inherently susceptible to epidemics because of its unprecedentedly large population and massive, rapid travel. Besides known dangers like AIDS, tuberculosis, and plague, there are many thousands of unknown viruses, some of which have caused deadly local epidemics of new diseases with no known treatment -- leading to fear among experts that a pandemic could potentially get out of control and quickly spread throughout the world.

The public health system is our main protection against epidemics. But this system works quietly, through disease surveillance and prevention measures, and can easily be ignored until something goes wrong. In the U.S., the public health system has been seriously weakened in recent years by defunding and neglect. Because it is low profile, it is politically vulnerable; the public can take foolish risks without realizing that anything is being lost.

One concern about Proposition 187 is that it will make people afraid to seek help when they should. In one recent case, an 87-year-old Korean woman died in Pinole, California after being burned in a bathtub accident, when relatives did not call emergency help because of fear that some family members could be deported; the local police chief said she would not have died otherwise. ("Immigrants' Fear of Seeking Help Proves Deadly; Woman Dies After Family with Illegals Hesitates to Get Medical Assistance," San Francisco Examiner, September 6, 1994, page A4). Health experts fear that such cases will become more common if Proposition 187 passes. In this case there was no danger to "the general public"; but if health workers cannot diagnose and treat contagious diseases, everyone's risk is increased.

Last week AIDS Treatment News asked Bob Prentice, Ph.D., Deputy Director for Community and Public Health Programs, San Francisco Department of Health, about the potential impact of Proposition 187 on his organization's work. He made the following points:

* "It would be a tremendous setback to public health efforts because it would mean losing access to people who may be either vulnerable to exposure or in fact have some communicable disease and putting others at risk. Communicable diseases don't know anything about insurance or immigration status. There are aspects of this legislation which would handcuff our efforts to reduce communicable diseases."

* "(Having to check immigration status and report people) is such a philosophical contradiction to everything that all of the staff that work in our programs are committed to. They are working to protect the public health. The physicians in our community health centers have gone on record unanimously opposing Proposition 187 because that's not why they are doctors... I think it is going to cause a tremendous burden on them if they try to decide how they are going to handle something that is completely inconsistent with the basis of their training, the basis of their current practice."

We asked Dr. Prentice if Proposition 187 would save California money by reducing the demand for services.

* "The basic principle of public health is that prevention is the best and least costly approach. For example, if we are precluded from carrying out the relatively simple and inexpensive screening for tuberculosis, and treating people early if there is some indications they are developing active disease, then all the interventions appropriate for that earlier stage will be missed. As a result, people could develop active disease and expose others.

"Another example is if a woman is pregnant and does not get regular prenatal care. It certainly increases the risk during the pregnancy and the risk of having a complicated birth. Those become tremendous expenses. Those are things we could monitor during prenatal care, to anticipate that there may be a high-risk pregnancy, and manage it successfully so it doesn't become costly."

Other Medical Officials

* Sandra Hernandez, M.D. Director of Health, San Francisco Department of Public Health:

"Passage of Proposition 187 will: 1) increase the risk of contagious diseases; 2) increase the administrative burden on our employees, while diverting precious resources away from direct care services; 3) seriously threaten federal funding; and 4) contradict our state mandate to provide medical services to the poor and indigent... Clearly, the health and public safety of all residents will suffer with the passage of this initiative. Finally, the combination of these austere requirements challenges the ethical and legal obligations of our county public health system."

* Findings of fact from San Francisco Health Commission resolution urging the Board of Supervisors and the Mayor to oppose Proposition 187:

- "Proposition 187's requirement that publicly-funded health care facilities verify the immigration status of person suspected to be undocumented will increase the likelihood that immigrants will delay seeking timely medical attention for fear of harassment or deportation.

- "This situation may result in a significant increase in the number of persons treated in San Francisco General Hospital's emergency room whose conditions might have been treated less expensively in an outpatient facility.

- "Studies have consistently shown that prenatal care services, for which undocumented women are eligible under current law, significantly improve a woman's ability to deliver a healthy baby and minimizes utilization of costly neonatal care.

-"Denying undocumented children access to immunization through publicly-funded facilities would reduce the already low percentage (49%) of San Francisco two-year olds who are fully immunized, and increase the risk of contagious disease outbreaks among children.

- "California led the nation in AIDS deaths in 1992 and had the second highest number of deaths from tuberculosis, and failure to provide undocumented persons preventative and treatment services for these and other contagious diseases would hinder efforts to control the spread of these diseases among the population as a whole.

- "Proposition 187 proposes to deny undocumented persons incarcerated in the San Francisco County Jail and other correctional facilities in California access to non-emergency health care services and, thus, exacerbate the difficulty of controlling the spread of contagious diseases among inmates, employees and the population at large upon their release."

* Dr. Thomas Peters, Chairman, Association of Bay Area Health Officials:

"The initiative would have us turn patients away from clinics treating tuberculosis, HIV/AIDS, sexually-transmitted diseases and other communicable diseases. Such a protocol does not make the diseases disappear -- it leaves them undiagnosed, untreated and unfettered. In one fell swoop, the carefully crafted disease-control system in California would be destroyed. Disease prevention cannot be done selectively..."

"It is not just someone else's health that would be threatened, it is yours."

Comment

This is just the beginning of a look at the medical and public health consequences of Proposition 187; other areas include childhood immunization, HIV confidentiality, and even street-outreach disease prevention programs.

So far the media has failed to adequately inform the public about the medical consequences of Proposition 187. If it passes, these problems cannot be fixed by the legislature; a new state-wide vote would be required. And even if some of the provisions are permanently or temporarily blocked by court decisions, much of the damage will be done anyway, because many people will not know the technicalities, and will avoid medical care due to fear.

It is the duty of the press and electronic media to let the public know the consequences of its actions -- before, not after, they are irrevocable. Reporters need only call medical professionals involved in public health, and ask how their work, and how the public, would be affected.

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