Low-incidence Nebraska struggles to cope
Roger Murray, MA, coordinator of the TB control program in Nebraska, is having a bad day. No, make that a terrible day. Sitting in his office in Lincoln with his staff of exactly one public health nurse, Murray has been grinding away for the past month at his federal funding continuation grant. At the same time, he’s been grappling with cultural issues he struggles to understand, and fretting over case contacts who don’t stay still long enough to finish preventive treatment.
"The feds tell us every state’s got lots of foreign-born people these days," he fumes, "so why should we get any special treatment?"
Murray’s dilemma may not differ from that faced by other low-incidence states with pockets of foreign-born residents, but it seems a bit more unusual than most. Not only is Nebraska home to the biggest concentration of Sudanese refugees in the country (5,000 have settled in Omaha, where they’ve presented varied public health challenges), it’s also the principal host to the nation’s meat-packing industry, with more meat-packing houses than any other state.
As in poultry-processing plants, which also are notoriously difficult places to do TB control, the business of processing cattle employs 150,000 workers nationwide. They are unskilled, often illiterate, and often illegal, and they come from Mexico and other countries where TB rates are high. The work is poorly paid as well as dangerous. The industry has the highest injury rates of any occupation in the nation. Because tasks are less automated than in chicken-processing plants (since cows come in all shapes and sizes), most jobs still are accomplished with sharp knives. Cuts, amputations, and musculoskeletal disorders are common, says a union official in a Kansas local with the United Food and Commercial Workers International Union.
Brutal for man and beast alike
The plants process animals at blistering speeds, and for the past several years, unions and consumer safety advocates have campaigned to slow line speed, charging that excessive speed results in more worker injuries and E. coli contamination. It also results in many inadequately stunned animals being dismembered while still fully conscious, according to a hair-raising story that ran in The Washington Post last April. Though some 60% of workers in meat-packing are unionized, the unions are quick to admit they wield little power. As the Kansas union official (who asked not to be identified by name) puts it, "We’re just a fly on the elephant."
Collectively, the brutal conditions conspire to make for the highest turnover rate of any industry, with rates approaching 100% in some plants. "How can I count these people? A lot of them weren’t even here at the start of the year," Murray asks bitterly. "They work for a month, get some money in their pockets, and move on."
Federal guidelines, he adds, tell him he ought to be doing directly observed therapy, directly observed preventive therapy, and even targeted testing, all the while learning about foreign cultures and providing translators. Instead, Murray says he struggles to get 26% of case contacts to complete preventive therapy. "We could put $20,000 into meds, and they’d still take their INH for a month, quit, and then move on to the next plant," he says disgustedly.
Since federal money can’t be used to buy drugs, medication costs are a special sore point. "Pharma-cies call us every week saying they’ve got a prescription for TB meds, but the person doesn’t have a social security number," says Murray. "I always say the same thing — go ahead and fill it, and bill us."
Murray makes no bones about his resentment of the fact that many workers are illegal. "Immigra-tion is bankrupting the states," he says. "Now the CDC comes in with their mandates about targeted testing. What am I supposed to do that with — a smile?" Between drug costs and money spent on DOPT, his program is broke, he reports; he’s preparing to plead for more money from state legislators.
In Kansas, a focus on education
Next door in Kansas, TB controllers cope with a smaller-scale version of what Murray faces, but apparently with less stress and happier results. Though state TB controllers say meat-packing plants are a headache, the approach varies by county. In Ford County, home of Dodge City and the site of one huge operation, TB controllers confine their work mostly to educational efforts, the TB nurse says.
In Finny County in southwest Kansas, the work is more ambitious. First, there is school-based testing, often using direct observation to make sure children finish preventive treatment. Because of the high turnover, many kids move in and out of the county. The problem is that they must be re-tested each time they re-enter the schools, says Paula Fields, RN, TB coordinator in Garden City.
Once in the past, Fields says, TB controllers in the county partnered with a plant and did baseline skin testing on everyone. But the high turnover rates scotched any hopes of getting preventive treatment into reactors, and that approach has been abandoned. Instead, Fields and her staff head for the slaughterhouse each Wednesday, when new hires undergo orientation. They talk about signs and symptoms of TB, and let workers know what the public health clinic offers, and where to go for treatment. A Hispanic employee in the program helps with Spanish translation, and an Asian ministry in town supplies a Vietnamese interpreter.
Federal TB experts say they’re sympathetic with the plight of TB controllers in low-incidence states coping with influxes of foreign-born residents. The trick, they say, is figuring out how to parcel out another year’s worth of level funding in ways that don’t accidentally break one thing while trying to fix another.
"We’re listening to people who struggle with these types of issues, and we’re trying to figure out how we can redistribute money to some of these areas that need a boost," says Joe Scavatto, deputy chief of the Field Services Branch of the Division of TB Elimination at the Centers for Disease Control and Prevention in Atlanta. "The trouble is that there aren’t many mechanisms for doing that — if we take money away from one area, it means we have to reduce our expectations for that area. Sometimes we feel like banging our heads against the wall."
Back in Nebraska, Murray would probably say he knows the feeling.
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