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Controlling Tuberculosis at the Border: Profile of Miguel Escobedo, MD, MPH

Miguel Escobedo MD, MPH
When you’re an immigrant ... being a physician has special significance because you feel you are able to ... help people directly.
Controlling Tuberculosis at the Border: Profile of Miguel Escobedo, MD, MPH

Miguel Escobedo, MD, MPH, is the Medical Officer for the US-Mexico Unit of the Division of Global Migration and Quarantine, a program of the Centers for Disease Control and Prevention (CDC). He’s also an immigrant. Dr. Escobedo immigrated with his family from central Mexico to the Mesilla Valley, north of El Paso, Texas, when he was eight years old. He has lived at the southern New Mexico and Texas border ever since. His father, a seasonal farmworker, worked in the local fields and orchards throughout the year: cotton, chili, alfalfa, pecans. His mother worked in the garment industry in El Paso. During the summers, “the children who had the means would go out and swim and go camping. My version of camping was going out and picking onions or hoeing cotton,” said Dr. Escobedo. His earnings from summer farmwork would go towards new clothes, shoes, a bicycle – things his parents couldn’t afford. The experience was “part of my education,” he explained.

EARLY YEARS IN TEXAS

His early interests in biology, coupled with the encouragement of high school and university mentors, brought him on the path to medical school. He believes his upbringing encouraged him to find a profession that would serve the farmworker community: “I think being a physician has special significance because you feel you are able to … help people directly. I can gain knowledge, and I can apply it, and I can cure people.”  As a child, his family would cross the border to the Mexican border town Ciudad Juárez any time health care was needed. “When I needed emergency surgery, we went across the border because care wasn’t [accessible] here. It was [so]routine that we didn’t even think about it – we just went to Juárez,” he said. When he grew up, he recognized that affordable and accessible care was still needed in his hometown. “People need help,” he said. “What better way to [help than to] be a physician and to help people in a very direct manner?”

A PUBLIC HEALTH CAREER: STRONG COLLABORATION WITH MEXICO

After his residency, he worked for a year at local community health centers. He soon found an interest in serving immigrants through the public health sector.  He joined the El Paso City/County Health Department as the Tuberculosis Control Officer and Communicable Diseases Director, where he started a clinic for homeless patients, oversaw a clinic for sexually transmitted diseases, and provided HIV care at the beginning of the epidemic in the 1980s through an early HIV treatment clinic.  

“At that time it became very obvious to me that it did no good to try to treat patients without having a system to communicate closely with Mexico,” Dr. Escobedo said.  He began his first binational project focused on TB when he collaborated with Mexican colleagues on a binational TB project called Juntos.   

He also at that time began working with Karen Mountain, MCN’s CEO, and Del Garcia, MCN’s Director of International Research and Development, to conceive the first version of TBNet, MCN’s tuberculosis patient tracking and referral program designed to keep mobile underserved populations in care.

His collaboration with Mexico continues in his current job. Dr. Escobedo began work for the Centers for Disease Control and Prevention in 2005, before becoming the US-Mexico Unit Medical Officer for the CDC’s Division of Global Migration and Quarantine.  His first task was to set up the El Paso quarantine station, one of 19 stations which respond to public health crises like Avian influenza and SARS. The El Paso unit teamed up with San Diego’s quarantine unit to become the US-Mexico unit, where he works closely with Mexican colleagues to “prevent the introjection and transmission of infectious and communicable diseases from other countries into the US, which primarily focuses on Mexico,” he said.

“We don’t just rely on doing our work on the US side, but we also set up surveillance systems trainings and special projects with Mexico.”  The team provides guidance to local customs officials in regards to illnesses of public health concern, assisting in the proper isolation and treatment of illnesses, and their active surveillance systems with Mexico ensure strong data sharing and collaboration even before diseases are detected, which assures public health preparedness in the case of emergencies: “We don’t wait until diseases come to the border... Whenever we have public health emergencies, like H1N1, and now Ebola, we work closely with Mexico to set up mechanisms to exchange information, notification, community prevention strategies,” Dr. Escobedo noted.  

MORE COLLABORATION FOR MORE INFORMATION SHARING

Dr. Escobedo has recently partnered with MCN and others in Project ECHO, an innovative hub-and-spoke model of knowledge sharing through video conferencing, which Dr. Escobedo plans to utilize to enhance binational TB control efforts.  Currently, his unit is setting up consultation services for complicated multi-drug-resistant tuberculosis (MDR-TB) cases using video conferencing technology, he said.  The program is in line with the unit’s goals: “We don’t wait until people show up at the border with infectious TB, we actually set up programs in both countries to maximize collaboration [and] enhance surveillance,” to help get people into treatment before more people are exposed.  

PUBLIC HEALTH CONCERNS AT THE BORDER

Tuberculosis continues to be a huge issue, in addition to illnesses of public concern like pertussis, measles, and even Dengue fever, which has recently been detected at the border.

Dr. Escobedo finds tuberculosis a “fascinating disease.” “We can have great effectiveness if we can educate people, [and] if we can use the limited resources wisely, to prevent a lot of disease and suffering for people,” he said.  “You add the binational component and it makes it even more interesting.”

Currently, between 75,000 and 80,000 new legal permanent residents immigrate from Mexico to the US per year (the number is down from the 100,000 of recent years, he said).  “Of those, four to five percent have TB conditions that require follow-up,” Dr. Escobedo said, whether those conditions are an abnormal X-ray, a positive TB test, or TB exposure that requires follow-up. “We make sure that all of those medical records are forwarded to the local health departments so the immigrants get the follow-up that they need,” he said.  His unit uses a number of tools to assure infectious TB patients at the border are identified and given treatment.  One tool is Do not Board/Border Look Out, which focuses on TB patients who are lost to follow-up, or who left the country before follow-up could be arranged, and focuses on travel restrictions. Dr. Escobedo passes some cases on to Ricardo Garay, MCN’s Health Network Manager, to follow patients who are crossing the border who need to continue care when they return to their country of origin.  Garay then links those patients with care as they travel; for example, facilitating a “meet and greet” at the US-Mexico border, a coordination effort between MCN, the CDC, and the binational TB staff from the border state’s health services department. In such a “meet and greet,” Garay and his US colleagues work with Mexican health workers to ready for an incoming patient needing care, so that Mexican health workers can arrange to assist that person once he or she has crossed the border.

Dr. Escobedo assists in a wide range of TB cases. A recent example is a teen who started treatment for MDR-TB in Houston, Texas, and then suddenly disappeared; it became apparent that the teen had travelled to Ciudad Juárez for his appointment to secure his permanent residency card, an appointment that includes a medical examination.  “I quickly reached out to the panel physician,” one of the physicians tasked with providing medical examinations to new immigrants, in Ciudad Juárez.  “We worked with the binational TB control … and MCN. We facilitated the exchange of information and managed to get him treated in Juárez,” Dr. Escobedo said.  They also paid for laboratory support and second-line drugs that weren’t available in Mexico. “As a result of our quick intervention and collaboration, linking all the parties, the young man got treated, he was rendered non-infectious, and eventually got his green card.” They also managed to secure him a waiver to enter sooner than expected upon completion of treatment, Dr. Escobedo said.

CONTINUED STRUGGLES

Dr. Escobedo’s main concern is “keeping up with new public health challenges,” he said. Despite the strong focus on collaboration, crises at the border can cripple fast action, as was the case with the thousands of unaccompanied children who arrived at the border in the summer of 2014.  Politics in Washington, as well as “mindsets that are hostile to immigrants,” slowed down the movement of resources.  Normally untenable ideas not based on science, like that of quarantining the children for two months, began to be raised frequently in policy dialogue. But resources began flowing and the children began to be admitted. “Eventually, it got done, and it got done well, but it took a long time,” Dr. Escobedo admitted.

“Ebola,” despite no reported cases along the border, “is consuming a lot of resources,” Dr. Escobedo said, noting that several colleagues have been deployed to Africa to assist in readiness and exit screening. But the ongoing issue of note at the border is the decline in funding.

“I think we have been pretty successful” managing diseases of public health significance at the border, he said, “but the lack of support is sad to see. I think sometimes federal government priorities change. We could use more support, both financially and staffing-wise." Dr. Escobedo observed that the level of government support, compared to just ten years ago, has waned significantly. “I think we’re falling into complacency,” he warned.  “Even though we’ve been effective, TB could come back and haunt us.”

30 CLINICIANS MAKING A DIFFERENCE is a project celebrating Migrant Clinicians Network's 30th anniversary through the life stories of 30 clinicians making a difference in migrant health. Learn more about Migrant Clinicians Network.

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