Matt Evans: We Need To Talk Openly About Potential Health Risks From Refugees

The protests and news drama about refugees being a TB risk has died down. So why am I bringing it back up?

I don’t think we’re having a perfectly honest conversation about refugee TB concerns.

What did the Forum say about VNL’s story about the risk of TB from refugees?

“Dr. John Baird, health officer at Fargo-Cass Public Health, watched the story and said it was wrong. He said refugees do not pose a public health risk with tuberculosis. He said the bacterial disease is “not a major problem for our community.”

Asked if living in a refugee neighborhood would pose a health risk, North Dakota Department of Health tuberculosis expert Dee Pritschet said, “I don’t know why it would be.”

However, Doug Schulz, an official with a Minnesota health department said: To get infected “requires prolonged, close contact. Just being in the proximity of someone with tuberculosis, you’re considered a low risk.”

So is it low risk, or no risk?

The answer, of course, is “low risk”.

Schulz is correct. Baird and Pritschet are incorrect. While the risk is low, it is not zero.

What is the actual risk?

Here is what the CDC had to say about a year worth of refugee and immigrant data:

“In the United States, the incidence of tuberculosis is 12 times greater among foreign-born persons than among U.S.-born persons”

In fact, the CDC report of 2009 shows that North Dakota received 34 people with TB classifications.

People with active, communicable TB infections are denied entry into the US. So, the CDC TB classifications are for what is called “Latent” TB, or LTBI. This means that the pathogens that cause TB are in the body, but have currently not overcome the body’s defense mechanisms. Someone with LTBI is not sick with TB, and cannot infect anyone else – unless their latent infection becomes an active infection.

As it turns out, 5-10% of latent TB cases become active TB infections.

Let’s recap: Refugees coming to the USA are twelve times as likely to carry TB as the rest of America. About 27% of the refugees who come here carry latent TB, and about 5-10% of latent TB cases become active, communicable TB.

Now, the CDC tracks where refugees come from if they have latent TB. The top refugee source countries where the CDC sees latent TB infections are Bhutan, Burma, and Iraq. If we look at the LSS resettlement report for FY2015, we see that Bhutan and Iraq make up about 60% of the refugees that LSS settled in Fargo.

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#ffffff” txt_color=”#000000″]It seems inappropriate for a public health official to suggest that the risk is zero.[/mks_pullquote]

So, the hottest places for refugees with latent TB are exactly the places we get most of our refugees from.

One could do some quick math: number of refugees coming into Fargo, times the refugee infection rate, times the latent TB activation rate.

This should predict the number, per year, of refugees coming into Fargo that develop Active, communicable TB.

That number for 2015 should be 328 refugees brought into the Fargo area, times 27 percent LTBI rate, times 5 percent activation rate.

That equals about 4 active TB cases from 2015 refugee activity in the Fargo area. That works out to an effective rate of a bit more than one percent. Mathematically, about 1% of the refugees LSS brings into Fargo should develop active, communicable TB.

The prevalence of TB in Americans is so low that we’re not vaccinated for it.

According to The Forum, the actual number of active TB cases in all of ND for 2015 was 9; 8 of them were not native-born Americans. One of the nine died.

Dr. Baird states that TB is not a major health problem in our community. Based on 9 sick people statewide, I agree with that part of his assessment.

However, I think Dr. Baird would agree that we all share a desire to prevent TB from becoming a major problem in our community. Also, I’d like to know more about the 9 infected people. Were there any transmissions from person to person, or were all the infected people activations of latent TB? If there were transmissions, what were the circumstances?

The CDC has confirmed that TB is increasing in the US. The CDC has indicated that refugees bring TB into the country at a significant rate.

The Forum has disclosed that the overwhelming majority of TB cases in ND are caused by refugees.

It seems inappropriate for a public health official to suggest that the risk is zero. It seems strange for another public health official to insinuate that there was no difference between the TB risk in refugee and non-refugee communities. That is simply false. The data absolutely and completely discredits that point of view.

Indeed, the quoted Minnesota public health official disagreed with our two quoted North Dakotans. Recall that Mr. Schulz said that the risk was small – but it did exist.

Strikingly, rather than a quantified conversation about the actual risks, and a careful discussion of the CDC information that VNL was highlighting, the majority of the response seems to have been about how evil, xenophobic, or hateful VNL has been by attempting to raise awareness of the public health considerations of refugee resettlement in our area.

[mks_pullquote align=”left” width=”300″ size=”24″ bg_color=”#ffffff” txt_color=”#000000″]Strikingly, rather than a quantified conversation about the actual risks, and a careful discussion of the CDC information that VNL was highlighting, the majority of the response seems to have been about how evil, xenophobic, or hateful VNL has been by attempting to raise awareness of the public health considerations of refugee resettlement in our area.[/mks_pullquote]

I think it is perfectly reasonable and commendable that VNL is referring people to CDC information about the medical impact of the worldwide refugee crisis. Did they put a bit of spin or hyperbole on it? Perhaps. But anytime a news organization points people at CDC findings, they are doing a public service.

On the other hand, what The Forum has done is published excerpts of the opinions of a few different government experts. Two of those expert opinions appear to make statements of an absolute nature that are simply not supported by the CDC data. The third expert disagrees with the first two, and indeed admits that there is some increased risk from refugee populations.

Risk Tolerance is a highly personal decision. I don’t appreciate it when one expert tells me there is no risk, whereas the data, and a different expert, tells me there is actually some risk – however slight. I, and the people of North Dakota, would like to be well informed citizens. We’d like our public servants to be honest and accurate to the point of boringness.

Critically, we want to be able to retain trust in our public servants. We want to be confident that they are acting in accordance with the correct priorities and ethical considerations, and are executing their duties faithfully and without coercion.

No matter what you think about VNLs reporting on refugee health risks, or the broader topics related to refugee resettlement in the area, we all expect our government to be accountable, transparent, responsive, and boringly honest. These are not partisan or divisive qualities – they are basic American expectations.

The Forum and the litany of letters they’ve published have been uncompromising in their claims that VNL has acted with malicious intentions, and has been creating or altering a story for self-serving ends.

However, after observing the news cycle on this controversy, and looking at the data myself, I’m much more concerned that some North Dakota health officials are outright denying the situation. Since presuming nefarious motives is apparently par for the course on this topic, I’m concerned that our health officials are being asked to support a certain pro-refugee political narrative – at any cost. I’m concerned that this pressure is interfering with their ability to provide the most accurate medical and epidemiological information possible.

I am not making the medical information out to be a huge looming disaster. By any reasonable measure, this is currently a tiny problem. But it is a concern. It’s something to watch and observe. I’d have been perfectly happy the tone of the responses was, “It’s something we’re monitoring.”

But that’s not how the Forum chose to flavor the responses from ND health officials. What I took away from the Forum response was: Dismissal. Denial. Ridicule.

That kind of response usually suggests something other than good science is happening.

The way the Forum has chosen to present the responses of public officials to the VNL report is a much larger concern for me than any yellow journalism VNL may have committed.

After all, if we think VNL is putting some spin on things or is being dishonest or misleading, we can just change the channel.

But if our local government is spinning the story, or misleading us when the data is in plain sight, we need to start thinking about changing our local government. Holding government accountable to our standards of accuracy and integrity is considerably more effort than changing the TV channel, but it’s also considerably more important to the future of our community.

I don’t want a politicized health department. I certainly don’t want a health department that dismisses or minimizes public concerns for political purposes.

I’m not losing any sleep over the small fraction of refugees that develop TB – even though they’re a much greater risk to the rest of us than non-refugees.

Instead, I am very worried that refugee resettlement has become so politicized in Fargo that actual discussions are no longer permitted, and instead are drowned out by shouts of racism, xenophobia, and hurt feelings.

Worryingly, the refusal to speak openly and honestly about some of the challenges of bringing refugees into our community has now extended past the usual voices at the Forum, and has apparently spread to some of our public health officials.