Somalia, Minnesota meet as TB rates begin to soar
Plentiful jobs, generous hearts draw newcomers
Mary Tyler Moore probably wouldn’t recognize her old digs in Minneapolis. Here in the Twin Cities area, newcomers from Somalia are the latest in a long line of immigrants and refugees who’ve altered the texture of daily of life in ways the intrepid sitcom heroine could hardly fail to notice.
"We have Somali restaurants. There are Somali shops. You see the women walking about the city," says Deb Sodt, RN, state TB control officer of Minnesota.
One less-than-desirable result is while most of the rest of the country basks in declining case rates, Minnesota TB controllers are looking at rates Sodt terms as "skyrocketing." Most of the state’s cases occur in its burgeoning foreign-born populations; in fact, Minnesota ranks second only to Hawaii in the percentage of TB that occurs among the foreign-born. No longer a stronghold of blond-haired farmers of German and Scan dinavian descent, Minnesota is now a place where one resident in 20 is foreign-born. "A lot of people don’t realize this," says Sodt. "They still think we’re lily-white."
In terms of population shifts, the main reason is that the state has become one of the principal sites in the United States for so-called secondary migration — meaning that many immigrants head here after first landing somewhere else, such as California or Texas.
That trend, in turn, is partly the result of a long-standing history among Minnesotans of reaching out to those in need. During the Kosovo crisis, for example, fully half the calls that went out across the nation to one big donor organization came from Minnesotans, whose stout Lutheran heritage encourages them to open their arms, their houses, and their wallets to those in need.
From a spate of new restaurants serving up exotic fare to plenty of workers for industries with low-paying jobs available, most of the changes the foreign-born bring have been welcome; but TB controllers say they are beginning to feel the pinch.
Over the past decade, Minnesota has seen a jump in TB cases of 77%; by July of this year, reported cases were 48% higher than the same time last year, according to Wendy Mills, MPH, epidemiologist for the state’s TB program. Last year, cases among the foreign-born accounted for 71% of all cases, with Somalis, along with other northern African groups, fueling the lion’s share of the load.
Another big group of foreign-born is made up of Hmong, members of a mountain tribe from Vietnam who, having sided with American troops during the Vietnam War, sought sanctuary in this country after the fall of Saigon. Now 70,000 strong, the Hmong community here is either the largest or the second-largest in the nation, depending on whom you ask. Many other Southeast Asian groups are putting down roots here as well, including Vietnamese and Laotians. Southeast Asians accounted for most of the TB among the state’s foreign-born residents until recently.
Epidemiology in the state’s Somali community helps show how the change in population com position has affected TB rates. With its almost decade-long history of civil strife, Somalia already suffers from a rate of TB the World Health Organi zation estimates at 174/100,000. On top of that, many Somalis have had to endure long waits in crowded refugee camps before winning permission to emigrate.
Since many Somalis arrive in Minnesota only after spending time somewhere else, only about 20% of the state’s foreign-born cases are picked up through the ordinary immigration screening process; that means the majority of cases here result from reactivation of latent infection.
Immigrants are drawn by jobs
Probably the strongest single draw for the immigrants is the promise of jobs. The Twin Cities area boasts only a 1.6% unemployment rate (compared to about 4.6% nationwide), which is far better than any other urban area of comparable size. Many Somalis have found jobs in the meat-packing industry or in the computer-repair shops that dot the surrounding area; industries here are unusually willing to hire non-English-speaking workers and give them training, observers say.In addition, the state’s schools admit students up to age 21, which means young Somalis whose education was interrupted by stays in refugee camps can finish high school. State welfare benefits are relatively generous, too, although few Somalis seem inclined to accept welfare, says Sodt. "You hear they have an incredible work ethic. Many work two and three jobs."
Their admirable qualities notwithstanding, the Somalis pose unusually tough challenges to TB controllers. To begin with, many don’t speak English, which means interpreters are necessary. But the long civil war has done lasting damage to relations among countrymen, and Somalis from opposing clans still regard one another as enemies. Clan members settle in the same areas, go to the same community organizations for help, and generally recreate old rivalries, even after leaving their homeland far behind. Practically speaking, this means an interpreter from one clan will refuse to speak to a patient if he is from another clan, or vice versa.
Somalis resist preventive therapy
To make things worse, TB bears an exceptional stigma among Somalis, who regard the illness as a death sentence or fear they will be torn from their families. Outreach workers must be delicate, inquire only about symptoms, and not mention the disease by name. Contact investigations are especially tough because patients are unwilling to have family members discover their disease. Finally, the concept of preventive medicine — taking isoniazid for a latent TB infection, for example — generally meets with misunderstanding and resistance.
As the Somalis migrate outward from Minn eapolis and its surrounding counties to more rural parts of the state, increasingly fewer resources are available for dealing with tuberculosis, TB controllers say. In rural Minnesota, most health care must be supplied through private practitioners. Physicians who staff public health clinics scattered in rural areas often are not familiar with TB symptoms.
Finally, TB controllers still have their hands full dealing with other refugee groups. Members of a tiny band of Tibetans who arrived earlier this decade are now financially solvent enough to start bringing over family members. Among the original 200 Tibetans, whose passage was specially arranged by the Dalai Lama, TB infection rates stood at about 95%, and drug resistance complicated many of those cases. Recently, TB controllers from Canada called to ask about rates of MDR-TB among Tibetans. That signaled to health authorities here that some Tibetans had begun to trek further north, carrying the seeds of illness with them.
TB controllers expect the rise in rates will continue well into the next century, says Sodt. At least on paper, the solution is simple, she adds: "We need more resources."
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