Tubercle, Lond.

, (1961), 42, 227

OCCASIONAL

SURVEY

TUBERCULOSIS AND IMMIGRATION*

By

CLEVE SCHOU

from the Mission in Austria of the Intergovernomental Committee fa" European Migration, Salzburg

It has been proved over and over again that refugees, previously classified as handicapped, can
commonly undertake normal work and become integrated into their new community. Accordingly
I should like to raise this question: Are the strict health requirements for immigration outdated?
I shall concentrate on a physical handicap-namely, pulmonary tuberculosis-which leads to
rejection by all countries of persons who apply for admission under the normal immigration
legislation.
With this disease it is, I believe, especially important that the immigration doctor should reach a
sound decision. AU of us who have to make decisions on the basis of physical examination and
x-rays know that there are many borderline cases in which we cannot say whether the disease is
'active' or 'inactive' or whether it has been 'active' within the past two years. Moreover, how many
immigration doctors are specialists in tuberculosis? If applicants could be further investigated at a
recognised centre in the prospective country of immigration the matter would be simple. As it is,
we have to make up our minds on the available evidence, and, the immigration laws being strict, we
cannot give an applicant the benefit of the doubt.
The decision is often difficult and not uncommonly erroneous. This is clear enough from the
experience of people who are rejected under normal migration schemes on the ground that they have
'active' tuberculosis, and are later rejected under migration schemes for the tuberculous on the
ground that they have no 'active' disease. Thus the prospective migrant may suffer needless hardship, and the prospective immigration country may be needlessly deprived of a good worker merely
because he, his wife, or one of his children has questionable signs of tuberculosis. Such cases are
often deferred for some months or a year, in order to give the migrant another chance; but much can
happen in this short time, and, by having to wait in uncertainty, a person may lose for ever his
chance of a better future.
What risks does a country run by accepting such cases? This question is not easily answered, but
I would like to cite some figures which may throw some light on it.
AUSTRIA

In the revolution of 1956 some 180,000 Hungarians fled to Austria. Fortunately most of them
could be moved out of the country very quickly. The remainder were submitted to an x-ray survey,
which was begun in July, 1957, and was completed at the end of May, 1958. We used two mobile
x-ray units taking 70 X 70 mm. :films. Our figures give no indication of the prevalence of tuberculosis
among the Hungarian refugees as a whole, as the majority of the healthy refugees had already left
Austria, whereas all rejected for mass emigration schemes remained.
Altogether 16,226 refugees were x-rayed. Of these, 385 (23'7 per 1000) were found to have
possibly 'active' tuberculosis and 388 (23'9 per 1000) were found to have a 'post-tuberculous' state.
The possible 'active' cases comprised: group I, hospital cases, with clear 'activity'; group II,
'activity' strongly suspected; group III, 'activity' not excluded by one film.
>I< Based on an address to the International Conference of Medical Immigration Officers, held in Munich on Dec. 5
and 6, 1960.

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TUBERCLE

The 'post-tuberculous' cases were of inactive disease, with evidence of fibrosis and calcification.
Most of the possibly 'active' cases we found came under groups II and III, and most of the
group III cases and some of the group II cases would certainly turn out to be 'post-tuberculous'
on further investigation, which unfortunately we could not undertake.
There is little doubt but that all the possibly 'active' and the majority of the 'post-tuberculous'
cases would be rejected by a strict immigration doctor for mass migration to any overseas country.
Yet, having personally seen all x-rays of cases of tuberculosis or 'post-tuberculosis', I would say
that very few of these patients were in such a state that they could not, in a reasonably short time,
be restored to a normal working life through treatment and rehabilitation. The majority of the
refugeeswere in the prime of their working life, with many on the rather young side.
We reported both the tuberculous and the 'post-tuberculous' cases to the Austrian health
authorities, who 'undertook further investigation. The results showed that the majority had
'inactive' disease and were fit for work. We were not given the exact figures resulting from these
investigations.
Sanatorium Treatment
As so many of those included left the country during or shortly after the survey, a complete
follow-up has not been feasible. But nearly all patients needing treatment were transferred to
Thalham Sanatorium, reports from which show that altogether 84 Hungarian refugees were admitted for treatment between October, 1957, and the end of July, 1958.
Only patients above the age of 14were admitted to this sanatorium, I do recall, however, that we
did not find serious tuberculous lesions in children-all those affected had minor lesions which
could be readily cured.
The majority of patients admitted to the sanatorium were young people, with the 25-30-year
age-group most strongly represented.
32 of the 84 patients left the sanatorium before their treatment was completed: 20 of these were
accepted under special schemes for emigration of the tuberculous; 11 were discharged for disciplinary reasons or discharged themselves against medical advice; and I (aged 72) died.
More than half the remaining patients (over 59 %) needed less than six months of hospital treatment. Nearly all (over 94 %) were discharged within a year, and none needed hospital treatment for
longer than two and a half years.
Present Situation
Of the tuberculous and the 'post-tuberculous', taken together, more than half had left the country
by the end of November, 1960. Table I shows that more of those with possibly 'active' disease than
of those with 'post-tuberculosis' had left the country-probably because we have had special
schemes only for those with 'active' disease. This finding shows once again that the 'post-tuberculous' fall between two stools: they are rejected for mass emigration because the immigration doctors
do not regard their disease as definitely 'arrested', and they are rejected for special schemes for the
tuberculous because they are classified by the selection doctor as 'post-tuberculous'. No wonder
these people are often in utter despair and ask what is to become of them, as they are regarded as
too ill by the one and too healthy by the other.
TABLE I.-SITUATION IN NOVEMBER, 1960, OF CASES DETECTED IN THE
SURVEY IN AUSTRIA

Findings ill 1957-58

Possibly 'active' tuberculosis

'Post-tuberculosis'
Total

1957-58

No. of
cases

Left
Austria

Still in
Austria

385
388

244
176

141
212

773

420

353

._------~-_._--

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TUBERCULOSIS AND IMMIGRATION

TABLE H.-STATUS IN NOVEMBER, 1960, OF 353 TUBERCULOUS AND 'POSTTuBERCULOUS' CASES REMAINING IN AUSTRIA

Findings in 1957-58

Possible active tuberculosis

'Post-tuberculosis'
Total

No. of
cases

Desiring
emigration

141
212

17
35

353

52

Integrated
In Austria

124
177

301

Inquiry among the 353 shown in the 1957-58 survey to have 'active' tuberculosis or 'post-tuberculosis' revealed that 52 still wished to emigrate, while the remaining 301 were integrated in the
community (Table II).
The present health of those integrated in Austria has not been determined as they are no longer
interested in migration. I believe, however, that nearly all can now be regarded as 'post-tuberculous'
cases. The last of those admitted to hospital was discharged about two years ago.
Of the 52 still wishing to emigrate, only 3 are, to my knowledge, still in hospital. Four have been
placed in group II and 6 in group III, while 39 are 'post-tuberculous'.
As Table I shows, 420 with possibly 'active' tuberculosis or with 'post-tuberculosis' have left the
country. The majority were accepted by Denmark, Norway, or Sweden.
DENMARK

In 1957Denmark accepted 50 Hungarian refugees with tuberculosis, the purpose being to choose
those especially suitable for chemotherapy. Of these 50, 49 were in hospital for less than a year and
only I for more than a year; 48 were at work and were self-supporting within eighteen months
of arriving in the country.
NORWAY

I have received no detailed report from Norway. Such a report would be interesting because the
Norwegians have accepted cases of active tuberculosis, regardless of severity. The Norwegian
Refugee Council informs me, however, that about 95 %of all refugees of working age have become
self-supporting. This figure is especially impressive because Norway has in the main selected
severely handicapped refugees, including quite a number of totally blind.
SWEDEN

In the ten years from 1950 to 1959 Sweden accepted 1011 refugees with tuberculosis-mostly
Yugoslav and Hungarian. These cases have been studied in detail by Dr. Torsten Bruce, medical
superintendent of Soderby Sanatorium. All the following data on Sweden are derived from a
personal communication by Dr. Bruce and from his report in Svenska Nationalforeningens
Kvartalsskrift (Nov. 2, 1960).
Of the 1011 patients only 32 remained in hospital on Jan. 1, 1960; of these, 26 had arrived in
1958 or 1959. 5 patients had been under treatment since 1955 or 1956, and 2 had been in hospital
continuously since 1950.
The inquiry was concentrated on patients with pulmonary tuberculosis, numbering in all 557
(428 male and 125female) who were admitted to Swedish hospitals in 1950-56, together with a few
admitted in 1957. Of these 557 patients 337 were under the age of 30 and 52 under the age of 15.
By the National Tuberculosis Association's classification (excluding 48 cases either of primary
tuberculosis or where the diagnosis of tuberculosis could not be verified) the cases were graded
according to extent and nature of lesions as follows: minimal 107, moderately advanced 301, far
advanced 101. Excluding the 7 cases where tuberculosis was not verified the cases were graded

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TUBERCLE

according to 'activity' as follows: primary tuberculosis 41, 'post-primary' tuberculosis 509 ('active'
with cavitation 141, 'active' without cavitation 281, 'probably active' 54, 'probable inactive' 31,
'inactive' 2).
Thus in most cases the disease was moderately advanced; minimal and far-advanced disease was
about equally frequent, each accounting for some 20 % of the total.
These figures may give a somewhat too bright picture, for many of the patients had been under
treatment before coming to Sweden. Likewise a falsely bright picture is given by the relatively small
number of cases (182) in which tubercle bacilli were isolated from the sputum on the patient's entry
into Sweden.
Of the 550 cases of verified tuberculosis the known duration of the disease before arrival in
Sweden had been as follows: less than one year 108, one to three years 133, three to five years 97,
more than :five years 203, unknown 9. Thus in about 20% of the cases tuberculosis had been
diagnosed within the past year, and in over a third it had been diagnosed more than five years previously. In many cases admission to hospital was required owing to renewed activity of previously
treated disease. This renewed activity was commonly due to poor conditions in the camps in which
the refugees had lived.
In Sweden the length of hospital stay of the 557 patients was as follows: less than two months 33,
two to three months 101, three to six months 104, six months to a year 173, one to two years 97,
two to three years 22, three to four years 18, over four years 9. Thus more than 40 %were discharged
within six months and more than 70 %within a year.
On average, the refugees received hospital care for considerably longer than is usual for patients
with tuberculosis in Sweden, who rarely remain for longer than six months. But the protracted
hospital treatment of the refugees was conditioned less by the gravity of their illness than by the
difficulty of obtaining for them suitable living accommodation and occupations once the need for
hospital treatment had ended.
TABLE Ill.-TREATMENT OTHER THAN CHEMOTHERAPY BEFORE AND AFTER
ARRIY AL IN SWEDEN

Before arrival

After arrival

Pneumothorax (continued):
Unilateral
Bilateral

82
15

97

Extrapleural pneumothorax:
Unilateral

22

22

Phrenic crush:

12

Thoracoplasty:
3-5 ribs
6-8 ribs

34
15
19

Resection:
Segment in one lung ..
Segment in both lungs
Lobectomy in one lung
Pneumonectomy

---.

Total

12
5
1
3
3

177 '

20

Pneumothorax:
Unilateral
Bilateral

19
1

Extrapleural pneumothorax:
Unilateral
Bilateral
Thoracoplasty:
3-5 ribs unilateral
3-5 ribs bilateral
6-7 ribs
8-10 ribs

10

9
1

29
15
2
9
3

55
Resection:
Segment in one lung
19
Segment in both lungs
1
Lobectomy in one lung 17
Lobectomy in both lungs 1
Lobectomy and
5
segmental resection
11
Pneumonectomy
Pleurectomy
1
Total

114

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TUBERCULOSIS AND IMMIGRATION

Treatment
The treatment consisted in chemotherapy (which in many cases had been initiated before arrival
in Sweden) and, in some cases, additional measures. As Table III shows, 177patients had had some
kind of treatment besides chemotherapy before arrival, and 114 were so treated after arrival. Thus
at least 50 % of the patients received such treatment either before or after arrival. Bearing in mind
that children are not usually treated by means other than chemotherapy, far more than half the
adults were so treated. This strengthens the impression that the disease was rather severe in a large
proportion of cases.
103 patients were readmitted to hospital-a low proportion. In Swedish sanatoria, commonly
up to 50 % of patients are readmissions. This low incidence of relapse may have been partly due to
the long initial stay in hospital of many of the patients.
Of the 550 patients, 14 died from tuberculosis and a further 6 from other causes.
Social Follow-up

At the end of 1959, 53 of the patients included in this survey had left Sweden-includmg 7 who
had left soon after discharge from hospital, owing, presumably, to difficulty in adaptation to life
in a new country. Most of those who left emigrated to the U.S.A.; Australia, South Africa, and
Israel accepted others, and a few went to Germany or Italy. In addition some returned to their
countries.
Where the refugee's trade was one in which there were vacancies in Sweden, employment was
obtained readily enough. On the other hand, for those with some other occupations, work was not
so easily found. Many who had worked as labourers and were incapacitated for such work by their
illness were trained for less energetic employment. In all, at least 100 were retrained, usually for
mechanical occupations.
Of 438 about whom information was available, 149 were at work within six months after arriving
in Sweden; and rather more than half the total (284) were at work within a year. The capacity for
work and the employment of the whole group of 484 are shown in Table IV. Altogether 51 remained
unfit for work-only 10% of the total. This favourable outcome is largely due to energetic rehabilitation and to occupational training.
TABLE IV.-CAPACITY FOR WORK AND EMPLOYMENT IN 1959 OF 484 REFUGEES WITH
TUBERCULOSIS WHO WERE TREATED IN SWEDISH HOSPITALS DURINO 1950-56

Unfit for work owing to tuberculosis

Unfit for work owing to other disease ..
Fit for work but not wage-earning
Fit for work and wage-earning ..
Housewives ..
Metal workers
..
..
Mechanics, electricians, technicians
Textile workers
..
Timber and paper-workers
Shoe workers
Farm labourers
Restaurant personnel
Hospital personnel
White-collar workers
Clerks..
..
..
..
Draughtsmen, designers, builders, etc.
Teachers, etc. ..
..
..
..
Intellectual professions (university training)
Miscellaneous professional workers

38
13
64
369
48
81

54
37
18
13
3

9
12
50
22
10
6
12

44
Total

484

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TUBERCLE
CONCLUSION

The duration of hospital treatment of tuberculous refugees in Austria is strikingly similar to that
in the Scandinavian countries. Clearly the great majority of such patients can nowadays return to
productive work after a relatively short time even if (as is often the case) they have previously been
living in tough conditions and have to settle in new and strange surroundings.
In the civilised world today, treatment of tuberculosis is so effective, and the facilities for applying
it so adequate, that a person who on arrival is known to have active disease need constitute no
danger to the country. Moreover, the cost involved in treating such a person, and of supporting his
family during this treatment, will be negligible compared to his value to the country if he is skilled.
In most, if not all, of the cases discussed here the refugee had previously been rejected by one or
more of the overseas countries; and I find it significant that, although the Scandinavian countries
deliberately selected 'active' cases and extended the duration of hospital treatment, nevertheless
most of the patients were discharged from hospital within a year, and a great many within six
months.
It may fairly be concluded that the overseas countries could safely relax their restrictions with
regard to tuberculosis, at least to the extent of accepting those with questionable evidence of the
disease.
We are apt to overlook the fact that those with physical handicaps usually have a strong will and
are eager to show that they can keep up with the unhandicapped. The modern industrial community
requires of its workers skill and training rather than muscular strength and bodily perfection.
I wish to thank Dr. K. Tuchler, medical superintendent of Thalham Sanatorium, Austria, Dr. E. Strandgaard,
medical superintendent of Nationalforeningens Sanatorium, Skorping, Jutland, for information about tuberculosis
refugees, and Dr. Torsten Bruce for allowing me to cite at length his findings in Sweden and for supplying additional
information.