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Somali man needs three years of follow-up
Mohamed Hashi, a 29-year-old Somali man suffering from multidrug-resistant TB, has spent the last two years trying to get to the United States. Now, TB experts in Florida are afraid that once he finishes treatment he will have to go home — to a war-torn land where it will be virtually impossible for him to get the follow-up care he needs.
"We’re on a slippery slope here," says David Ashkin, MD, medical director of the state TB control program and Hashi’s physician for the past year. "Legally, there is an obligation to return him to the Immigration and Naturalization Service. From a humanitarian and public-health standpoint, it’s another matter."
The case in some ways resembles others that immigration health experts say are troubling — cases in which untreated or undertreated patients with TB ping-pong back and forth across borders, subject to laws that don’t fully account for the vagaries of life as a refugee or immigrant. (See related article, p. 57.) If Hashi is deported once his treatment is technically completed, Ashkin is convinced he risks death by staying in Somalia. If, on the other hand, he manages once more to return to the United States, he will expose Americans to a strain of TB known to be resistant to seven drugs.
In Somalia, "many people have TB," says Hashi, speaking through an interpreter; but there are no public clinics or TB sanitariums in his anarchy-ridden homeland. "If you have money, you can go to the pharmacy to buy medications, and perhaps you can cure yourself," he says.
No money, no family, and no TB care
Born in Mogadishu, Hashi and his family fled fighting in the capitol when he was young, he says. Then came more fighting, and Hashi’s family members scattered. Now, he says, he no longer knows where most of them are.
He fled north to the United Arab Emirates, where he sought the help of friends and relatives. For two years, he wound his way through northern Africa, traveling from one Arab country to another; eventually, he obtained a tourist visa to America. By that time, Hashi knew he had TB. He has no idea where or when he got it.
By Ashkin’s account, the young man spent the plane trip to the United States wracked with violent coughs, his coat pulled over his head. By the time the aircraft touched down in Miami International Airport, he was so weak he had to be carried off the plane. He was taken into custody by the Immigration and Naturalization Services (INS). At Krome Detention Center in Miami, physicians took chest X-rays and told him he had TB. In INS custody, he was sent to a local hospital for treatment.
But the disease had progressed too far for the hospital to be able to treat it. Hashi’s left lung was almost entirely obliterated by a cavity and infiltrate. He was emaciated and unable to eat, and he suffered from severe hemoptysis. In addition, he was resistant to seven anti-TB drugs.
The decision was made to release him from INS detention, place him in the custody of the state, and admit him to A.G. Holley Hospital, the TB sanitarium in Lantana, FL. At Holley, once doctors succeeded in getting Hashi culture-negative, they removed his left lung, says Ashkin.
The harsh anti-TB medications were unpleasant at first, Hashi recalls. "When I started treatment, I had many hard problems," he says. "I was vomiting and unable to eat. Afterward, though, when my body got into synch with the drugs, I felt better." Now he has gained weight and is responding well to therapy, which should be completed after another eight months. Once therapy ends, he will need three years of careful follow-up.
Who picks up the $400,000 tab?
Ashkin admits he worries not only about Hashi’s fate but about who should take responsibility for cases such as this one. "There’s the difficult issue of who should pay for his treatment," he says, noting that total costs for curing Hashi’s TB will eventually come to over $400,000.
Hashi says he has no wish to return to Somalia and hopes he can find a job here — although with one lung missing, he says he knows he is too weak to do physical labor. He passes the time studying English, Ashkin says, and his facility with the language is rapidly improving. "He’s very bright and very enthusiastic," the physician adds. "It would have been such a shame to have lost all that potential."