The challenge of treating illegal African migrants

3rd Opinion: Last week, 6 children with measles were hospitalized. We have not seen a comparable outbreak in years.

By GABI BARBASH, MD MPH
Smallpox vaccine 311 (photo credit: REUTERS)
Smallpox vaccine 311
(photo credit: REUTERS)
“Do not oppress the stranger among us. You know how it feels to be strangers, for you, too, were strangers in Egypt.” – Exodus 23:9
Last week, six children with measles were hospitalized at the Dana-Dwek Children’s Hospital of the Tel Aviv Sourasky Medical Center. This was an exceptional occurrence, the likes of which we have not seen in years. We have treated 12 patients with measles in Tel Aviv since the beginning of this year, in contrast to only two patients hospitalized with the disease throughout all of 2011.
Domestic measles had been wiped out by 2000 in the United States, but imported cases continued to feed small outbreaks, and 90 percent of the cases reported in 2011 originated from abroad.
The situation is similar in Israel. The children admitted to our hospital due to measles are the offspring of African illegal migrants who infiltrated Israel through the poorly secured border with Egypt.
The target of these immigrants is Tel Aviv, where they hope to find work and eke out a living. The community of illegal migrant workers has become a sizable portion of the population in south Tel Aviv over recent years. These people are mainly from Eritrea and Sudan. Tel Aviv, Israel’s metropolis, is a natural magnet for them since there are greater opportunities to find the menial labor which, in desperation, they are more than willing to accept for as long as they can extend their stays in the city.
At the beginning of 2012, this population reached almost 100,000 people living in the most harsh conditions. They are all indigent illegal migrants, and they have no medical insurance. Their illegal status precludes their obtaining regular employment with insurance benefits.
Therefore, they have neither primary care nor preventive treatment and, lacking alternatives, they turn directly to our emergency room for help. Ours is Tel Aviv’s main municipal medical center and, as such, it is at the forefront of treating migrants with no legal status in the country.
This impoverished patient population brings with it a mix of especially difficult medical problems with special therapeutic needs. The number of women who came from Eritrea and Sudan and gave birth in our medical center doubled within one year and reached more than 400 births annually. Among them were multiple and premature deliveries, as well as twice as many emergency cesarean sections than the rate in the general Israeli population. These babies were hospitalized three times more often in the neonatal intensive care unit, and dramatically increased our infant mortality rate (by almost 1 percentage point).
The Africans come from countries in which malaria, tuberculosis and AIDS are endemic. They carry with them a number of serious diseases that are rampant in the areas from which they come.
In 2010, for example, the vast majority (84%) of the 45 cases of malaria diagnosed in our hospital were Africans, and most of them (85%) involved the vivax malaria strain that requires highly specialized treatment to remove the parasite from the liver.
These migrants also have a relatively high rate of active tuberculosis, and the number of cases diagnosed among them by our physicians doubled in 2011. A patient even suspected of a pulmonary tubercular infection needs to be hospitalized in a special isolation room. Many of these refugees also suffer from extrapulmonary tuberculosis (in the spine, or central nervous system) that requires special interventional diagnostic procedures and biopsies performed under general anesthesia in an operating room.
The reported rate of carriers of HIV ranges from 0.5% to 5% in the countries from which these migrants originate.
Indeed, one-third of the new HIV carriers that we diagnosed in recent years (some 50 to 60 new carriers every year) are Africans. The treatment for HIV carriers from Africa is more complex and difficult than that for Israeli carriers. Because they do not have health insurance, only pregnant women and newborns who are HIVpositive are entitled to antiretroviral therapy. Moreover, the HIV carriers are characteristically diagnosed with advanced AIDS-associated illnesses requiring prolonged hospitalization, extensive and repeated laboratory tests and treatment with expensive drugs.
It is indisputable that the massive infiltration of illegal workers and their families into Israel over the past few years has added a considerable workload to the Tel Aviv Sourasky Medical Center, which treats most of the ones who suffer from serious infectious diseases that require hospitalization and complex, expensive medical treatment. The government should bear the responsibility for their healthcare. It does not.
Indeed, government agencies could have arranged for health insurance, or they could have directly funded their treatment, but government officials have failed to take charge. Our government had the option not to do anything.
Our physicians do not have that option. The expenses of our hospital for treating illegal migrants amounted to NIS 7 million for both 2009 and 2010, soaring to NIS 27m. in 2011 ($7.5m.).
This expenditure is not funded by any government agency: it is paid for with the hospital resources that were earmarked to benefit the citizens of Israel who are often treated side-by-side with the migrant patients. Nevertheless, the message conveyed to the medical team by hospital management is clear and unambiguous and based on inflexible medical ethics: treatment of this population must be in every way identical to the treatment given to Israeli citizens, and no financial considerations can be allowed to enter into the medical decision- making process.
Unlike others, the medical community cannot compromise its commitment to “not oppress the stranger among us.”
The writer is CEO of the Tel Aviv Sourasky Medical Center.