Immigrants from Mexico are no longer embraced with open arms and closed eyes. At an estimated 12 million, our latest demographic shift has entered the American conscious center stage. These new arrivals were at the top of the domestic agenda for the 2006 congressional elections. This political issue will raise its head again.
       The controversy gravitates about 2 main issues. How to better secure the border and what to do with undocumented workers already here. The debate rages across the country. The proposed solutions are wide and varied; Give them amnesty, deport them,
provide temporary work permits, construct a border fence, etc. The atmosphere is charged and stoked by the feverish drumbeat of coming elections. In reality, I wonder if anything will actually change.
       My community health center is a haven for Latino immigrants. These immigrants are mostly from Mexico, with a minority from Central America. Almost all these patients are employed. They bolster the local economy in jobs such as food service, house cleaning, custodial work and construction. They sacrifice the backs, knees, and shoulders that drive the relentless American economy. Many would say they take these menial physical jobs because people with citizenship refuse to do so. They have a strong desire to be here, born from a hostile sometimes life threatening border crossing, the motivation to improve their lives, and the willingness to stand on a street corner waiting to be picked up for an opportunity. It is not Ellis Island, it is not legal, and it is fraught with imperfections.
       Our undocumented immigrant situation has been growing for decades. American companies have hired immigrants at reduced wages to maximize margins in businesses that rely heavily on manual labor. NAFTA, globalization, and shareholders demanding better profit margins have ripened and expanded these job opportunities. In deference to powerful business interests, governments have turned a blind eye to company practices that hire undocumented workers. These employment opportunities have driven a population shift from the south that has infiltrated most areas of the United States. Who hasn’t seen a Latino immigrant standing on a street corner waiting to be propositioned for work?
       The weight of this ongoing migration has made a significant impact on local Governments. Some of the usual victims are health care and education. Over several years these institutions have felt an accelerating population impact. The community health center is forced to deal with an array of immigrant medical problems. From the “cultural norm” of young teenage pregnant mothers to the octogenarians without medical insurance OR a social security number, this group offers unique circumstances that would challenge the resources of the most generously endowed organizations. Most are employed in very physical labor. The result is repetitive motion injuries, back pain, early osteoarthritis, and fatigue but to name a few. Schools are forced to modify their curriculum to accommodate Spanish only students. Many of the Latino immigrants who experienced minimal education for themselves, have no greater expectation for their
young children now living in the US. Because so many live on the edge of survival it is challenging to make education a priority.
     Certain features of this population make them more vulnerable to the vindictive slurs and actions of others. Primarily, without a green card or citizenship, the undocumented have no recourse but to remain invisible in our society until called upon to perform manual labor. This relative isolation is compounded by language differences, unique cultural traits, and under education. As a result, undocumented Latino immigrants maintain a degree of separation that may  evoke suspicion on the part of American culture. It offers an opportunity for political attack while being compensated with wages. One hand giveth while the other attempts to taketh away.
     It is against this bipolar backdrop of poorly defined policies and economics that our story emerges. Here in the safe zone of the community health center the immigrants gather in the lobby. The old, the young, newborn babies with their tired young mothers, proud fathers, women in all stages of pregnancy sporting their abdomens sit and stand waiting in this undersized place. Young children dart about the halls yelling, playing and sometimes making mischief. At over capacity now, our population is growing at 10-12% a year making it nearly impossible to create a physical space that is adequate for any meaningful period of time. The atmosphere is claustrophobic but friendly. For many of the patients have been coming here for years recognize this place as a chaotic sanctuary that offers the opportunity to heal.
     This day among other days I enter the exam room to speak with a neatly dressed man in his mid-twenties. He is a Spanish-speaking only male from Chihuahua, Mexico. Most of our patients come from this city. It is about 3 hours south from the border town of Juarez. Other than its proximity to Santa Fe, I have no explanation as to why most of our Mexican immigrants originate from Chihuahua. The man whom we’ll call Mr. Blancos normally sees a colleague of mine who is on vacation.  Just prior to his initial visit he had a witnessed seizure. He lost consciousness, had tonic-clonic movement, and experienced a post-ictal phase, which is a period of fatigue and grogginess  following a grand mal seizure. Mr. Blancos had no prior history of seizure activity, nor did he have any history of alcohol use, head injury, or recent illness. He was not on any medications at the time of his seizure. He had no history of chronic disease and no family medical history of seizure activity.
      Mr. Blancos neurologic exam was normal. His new onset seizure activity  was a concern. I’m certain my colleague was considering tumor, vascular pathology, and infection among other possibilities when he ordered the MRI of the brain. The study revealed neurocysticercosis.
      Cysticercosis is a parasitic infection that results from ingestion of the adult tapeworm Taenia Solium. It is transferred by eating contaminated under-cooked pork.  Tapeworm is activated in the gastric acid of the stomach. Here the eggs lose their protective capsule exposing oncospheres  which are absorbed from the gastrointestinal tract into the vascular compartment of the body. From the blood these larval cysts can migrate to the brain, muscle, eyes and other structures.
      Neurocysticercosis occurs when the eggs infect the nervous system. In the brain, the larval cysts may generate a minimal immune response and remain dormant for years. When the cysts initiate an immune response the symptoms typically present as seizures or headache. These predominant symptoms are largely the result of where they reside in the brain. Larval cysts that lodge in the ventricles or cisterns may cause hydrocephalus resulting in headache. Those cysts that are present in the frontal or temporal lobes may cause epilepsy. Cysts that actively degenerate are the most likely to cause seizures. They degenerate more quickly in the first 6 to 12 months after symptoms present. Neurocysticercosis is the leading cause of parasitic infection in the brain. It is a major cause of epilepsy in developing countries such as Latin America.  
       I greet Mr. Blancos. We review his recent history. He’s had no new seizure activity since being placed on valproic acid. He was also started on prednisone to decrease inflammation. Finally he was to begin the anti-parasitic agent albendazole a few days after the prednisone had taken effect.
       He produces the bottles of medication. They are full. Suddenly I’m struck by reality.
       “Por que no se ha tomado la medicina,” I ask.
       “Porque no lo entiendo,” he replies.
       “Huh” I say. My sense of reality heightens. I grab the bottles. The steroid is a taper dose, which means lots of writing on a bottle label. The container is small with a label about an inch and a half squared. The instructions are written in English! The prednisone taper dose is abbreviated in presentation. I feel my face flush as my heartbeat accelerates. He was prescribed this medication two weeks ago.
      As we talk, I cringe at the thought of how much brain tissue this young man may have lost. He has no new complaints. I pull out a piece of paper, carefully and clearly writing his instructions in Spanish. While I’m writing I explain to him why it is critical he take these medicines immediately. “Tomese la medicina  para matar los parasitos,” I say over and over.
      As this injustice has come to pass, I’m angry. I’m suddenly in the middle of it. For a brief moment I ask myself how this situation came about.
      That night I fire off E-mails to the medical director, the CEO, and others. I want to raise awareness and find a solution to this problem.  I site a research article I’ve found on the internet. It was a study done in the Bronx of New York city. Pharmacies were surveyed for prescriptions written in Spanish in Latino neighborhoods. They found about half the pharmacies had the translation software to write labels in Spanish. Surprisingly, the pharmacies found to have Spanish instructions were not the larger chain corporations, but the smaller independent businesses. The article summarizes the importance of providers taking the time to explain instructions in Spanish regardless of what the pharmacy is doing.
       Waves of opinion ripple thru the organization. The pharmacist is called. He calls me. We discuss the matter. He tells me the patient was taken aside and explained in Spanish how to take the medicine. He did not seem to understand the importance of the medication. I state I understand over the phone. But the patient did take the medicine after I carefully explained to him how to use it. Why should it be any different if someone is truly taking the time to explain its use? Furthermore, I say from an operational standpoint this represents a medical error. I’m concerned that we improve on the current system to avoid this situation in the future, that at least the translation software is standard for our largely immigrant  population. He has no direct comment. It is my responsibility to make those about me aware of the issue, I’ll allow the administration to deal with the operational relationship with the pharmacist.
       So many times as in this case, I see what is termed a “medical error” as an organizational error or erosion of resources to effect necessary change. We serve a very large immigrant community and this is our only pharmacy for federally qualified drug pricing. He is a small private pharmacist. I understand from other people in our organization that his computer skills are limited. He was one of a very few to bid on our federally qualified drug pricing program. A program offering discounted medications to the uninsured.  In the brutal world of drug pricing this program is truly a gift. Thus the pharmacist and La Familia are mates in the broken medical system. He apparently needs us and we certainly need him. Ultimately it is difficult to know what he is really doing since he operates outside our organization.
       I could take this issue into the larger arena of public opinion. But I resist doing so, for me to alienate this small world of providers who care for the uninsured could ultimately mean a few less people willing to give their time for immigrant needs. The crisis would deepen and I’m left with even fewer resources to manage my patients.
      I interpret this problem as a bowl of soup. You can spoon out the event that is tragic. But the event simmers in a broth that takes time and effort to prepare. Time is our
historical neglect of the immigration issue. The market forces of globalization are in part responsible for the flood of people over the southern border. Business interests have a resource of inexpensive human labor. Wages are driven down.  Our peculiar medical system has sequestered most uninsured immigrants into organizations like our community health center. They have few resources to gather effective representation when victimized by this system. It is our responsibility to fight for their interests. But who will hear or care when their very presence is an issue of political contention?
         The ability for a relatively small organization to effectively deal with thousands of uninsured immigrants is impaired by their multiple medical needs and our lack of resources to effectively treat them. The flavor of the broth is undesirable because the ingredients are not integrated into a rich flavor. Rather, it is concoction of unrelated tastes that confuse the palate. The bowl of soup sits uneaten. It spoils. Politicians are forced to act. They point fingers. Some want to throw out the soup. Others want to change the flavor to make it more palatable. We’re stymied as the crisis in medical care and immigration policy grows.
       I’m pleased to learn from my colleague that Mr. Blancos is taking his medication. Furthermore, he has not developed any neurological deficits. I took the precious time in the clinic day to explain and write how he should take his medication. It might be termed a noble act in a medical system that gives lip service to compassion for our patients but ultimately respects and rewards productivity. I sleep better that night.