April 25, 2004
Anatomy Of An Outbreak
News-Press Senior Writer An ailing Santa Maria farmworker who triggered one of the worst outbreaks of tuberculosis in recent county history is cooling his heels in County Jail under a rarely used provision of the public health code, after evading treatment for nearly a year.
Feliciano Morelos, a 19-year-old Mixtec Indian from Oaxaca nicknamed "El Diablo," is charged with a misdemeanor, suspicion of disobeying an isolation order from a Santa Barbara County public health officer and endangering public safety, according to court records.
After allegedly escaping twice from quarantine last year, he was arrested by the Delano Police Department on March 28 for a routine traffic violation and transferred here on an outstanding warrant, police said.
Mr. Morelos' case is the first of its kind in Santa Barbara County. In the past, the county has filed civil charges, but never criminal charges, to force someone to complete medical treatment.
"It is a measure of absolute last resort, used only in situations where there is no other option to protect the public safety," said Paige Batson, the county's disease control and prevention manager. "Having the disease is not a crime. Our slant is never to take the harshest approach. But this guy was spreading his disease over, you name it. He was really posing a very serious public health risk."
Mr. Morelos is now in isolation in a "negative pressure" cell, a room equipped with air filters so that the other inmates will not breathe in the same air. He is awaiting a court hearing on Monday. Bail has been set at $20,000, but no one is likely to come up with the money, prosecutors said.
Mr. Morelos' case highlights both the dangers of tuberculosis and the extraordinary efforts of public health officials to combat it. In 2003, 3,230 cases of active tuberculosis were reported in California, more than in any other state, according to the Centers for Disease Control and Prevention. Seventy-five percent of California's cases were among the foreign-born.
Tuberculosis, it turns out, is a disease of poverty on both sides of the border -- so much so that public health officials in California are lobbying to reopen sanitariums here.
In interviews this month, county public health officials declined to identify Mr. Morelos by name, saying they were required to observe medical confidentiality rules, but agreed to discuss his case.
In all, they said, he has infected 56 people, mostly family members in Santa Maria. Other infected relatives were tracked to San Luis Obispo and Kern counties and Skagit County in the state of Washington.
Nine of the 56 people contracted active tuberculosis, which makes this one of the worst outbreaks of tuberculosis in Santa Barbara County history, officials said. All 56 required treatment for the disease, at a cost of thousands of dollars per patient. No one knows how many people Mr. Morelos might have infected since he was last placed in isolation 10 months ago.
Speaking by phone from jail last week, Mr. Morelos, who cannot read and has never attended school, told a reporter that one of his uncles, an older man with several years in the United States, had tricked him into escaping from quarantine. The uncle, he said, told him nothing would happen to him, urging, "Let's go! What are you doing in there?"
Now, Mr. Morelos said, he has learned his lesson and will complete his treatment, if only he could be released, maybe to a hospital where at least he wouldn't be hungry all the time. He repeatedly asked how long he would be in jail, not seeming to understand that it would be up to a judge to decide.
"I'm young, only 17 years old," Mr. Morelos said, subtracting two years from his age. "I didn't understand the laws here. I won't escape again, I will respect the law. I understand how things are now. Six months is too long. Help me, please."
In a March 31 letter to the county District Attorney's Office obtained by the News-Press, Deputy County Health Officer Dr. Frank Alvarez requested that Mr. Morelos be sentenced to six months in jail -- or longer, if he is not cured by then. It takes between six and nine months to kill the bacteria that cause tuberculosis, a potentially fatal lung disease.
"The only place that Mr. Morelos can be maintained at this point without (our) fearing his imminent flight is in the Santa Barbara County jail," Dr. Alvarez stated.
FAMILY INFECTED
Mr. Morelos first came to the attention of the county Public Health Department in May 2003, when he was arrested in Santa Maria on suspicion of drunken driving and driving without a license. In jail, he was given a routine screening for tuberculosis and found to be highly contagious.
A department investigation discovered between 20 and 30 members of Mr. Morelos' large extended family -- impoverished Mixtec farmworkers from a small town in Oaxaca -- living in one small apartment in Santa Maria with their children.
Among nine people who were sick with tuberculosis were Mr. Morelos' mother and five children under 12. The other 47 people had been infected by Mr. Morelos but did not have the disease.
Tracking the outbreak was especially difficult, county officials said, because the family's apartment was a kind of receiving station for new arrivals from Oaxaca. Family members migrated around California and Washington to follow the crops, often moving in the middle of the night and leaving no trace. Delays and interruptions in their treatment ensued, as health officials in San Luis Obispo and Kern counties and in Washington state scrambled to find them and administer antibiotics.
"It's been one of the toughest periods we've had," Ms. Batson said. "We're proud of the effort we've made. We were real persistent. And through this whole ordeal, we have developed a tight network with the Oaxacan population."
A county public health nurse checks in regularly on some patients to watch them take their antibiotics, a standard procedure known as "direct observation therapy."
"At first, there was a lot of mistrust," Ms. Batson said. "But we've built a rapport now. The people we started on treatment are working really well to get it completed."
If the young man in jail he had cooperated early on, she said, he'd be well by now.
"We struggled with him," Ms. Batson said. "I can't tell you all the things that were done. We asked him, how can we help you?"
TWO ESCAPES
On his release from the Santa Barbara County jail a year ago, court records show, Mr. Morelos agreed to be placed under quarantine in a "negative pressure" room in a Santa Maria motel.
The room was stocked with things to eat, and nurses delivered magazines, medicine and hot food daily. They took orders from Mr. Morelos for take-out from La Chiquita, a local restaurant and supermarket.
Mr. Morelos was supplied with information on TB in Spanish, a language he speaks, though not well. A Mixtec interpreter was on hand. According to court documents, Mr. Morelos signed a contract with county public health officials, agreeing not to leave the room or let anyone in. The quarantine was expected to last a month or two, until Mr. Morelos was no longer contagious.
But he immediately broke the rules, according to Dr. Alvarez, who described the motel stay in a May 29, 2003, statement to the court. Mr. Morelos, he said, began bothering motel guests, knocking on doors and asking for cigarettes. He went to Vons, showed up in the motel lobby, and was briefly detained by Santa Maria police on suspicion of drunkenness in public. At one point, a nurse discovered a woman hiding in the bathroom.
By the end of 10 days, Mr. Morelos was gone, Dr. Alvarez said. The family alerted officials that he had left for the Tulare County city of Exeter, and a few days later, his cousin tipped off the nurses that he was back in Santa Maria.
"We found that people began to tell us where he was because they were concerned he was exposing others," Ms. Batson said.
On May 17, 2003, Mr. Morelos was arrested and jailed on suspicion of disobeying a county health officer's orders. A Santa Barbara Superior Court judge ordered him to be quarantined for a maximum of 90 days in a rehabilitation center in the high desert community of Lancaster. But the center did not have 24-hour security, and, according to Mr. Alvarez, Mr. Morelos escaped from there within 12 days.
Thus, health officials said, he was missing from June 16, 2003, until his arrest last month, highly contagious the whole time.
Deportation was never an option in Mr. Morelos' case, county health officials said, because he would just return to Santa Maria and still be contagious.
The Binational TB Referral Program, a San Diego County operation that works with health authorities on both sides of the border, got involved, but officials declined to comment on whether they were able to find Mr. Morelos in his hometown of San Jose Yosocanoo in Oaxaca.
Mr. Morelos says he did return to San Jose Yosocanoo last year and said he was taking medicine there. He said he arrived back in California in January and was in Delano pruning grapevines when was stopped by the police.
From Oaxaca, Dr. Ra|0x9c|l Galan Munoz, an epidemiologist with Mexico's Department of Health Services, said health brigade workers are dispatched to remote areas, sometimes on foot or horseback, to find tuberculosis cases and locate the people they have been with. If it is impossible for a nurse to return daily, he said, someone in the family or the municipal government is appointed to make sure the patients take their pills.
Dr. Galan Munoz said tuberculosis was a very serious problem in Oaxaca. "We have all the conditions for it -- above all, poverty," he said.
At the same time, Dr. Galan Munoz said, the Mixtecs appear to be living in even worse conditions in the U.S. It is unfortunate that a patient such as Mr. Morelos must be jailed, he said, but the danger is that he could develop a drug-resistant strain of the disease if he does not take his medicine. There are 46 cases of drug-resistant tuberculosis in Oaxaca, and 41 in California.
Contacted by phone in Santa Maria, Mr. Morelos' grandmother, who gave her name as Juliana, said she was glad that Mr. Morelos was taking his pills. She said she herself had finished her treatment. The grandmother said the family would not be able to visit Mr. Morelos in jail because they didn't have a car.
"Poor boy," she said.
Jes|0x9c|s Estrada, a Santa Maria spokesman for the Binational Indigenous Oaxacan Front, an advocacy group that operates on both sides of the border, said it was a good thing Mr. Morelos was in jail.
"It's for his own good and the good of others," Mr. Estrada said. "We call him 'El Diablo' because he's a rebellious boy who doesn't listen. You can't reason with him."
Mr. Morelos himself insists he does not feel sick, and wonders how the nurses know he has a disease. But he says he is taking red, orange and white pills for tuberculosis.
Mainly, he talks about how there is no sun in his jail cell, about how he can't sleep because the light is on all night, and how he is all alone, with no television and nothing to do. He says he needs a shower badly and would really like to play basketball or buy a soda.
"Only God knows what I'm going through here," Mr. Morelos said. "I'm hungry all the time. All they give you is ham sandwiches. How can you fill up on that? I like tortillas, beans and rice."
Mr. Morelos asked a reporter to phone his family and tell them to accept the charges when he calls.
"I'm very sad here," he said. "I can't even talk to my mom."
NO SANITARIUMS
Tuberculosis was once the leading cause of death in the United States. With medical advances in the 1940s, the disease began to disappear, until it made a comeback in the late '80s, after funds to control it were cut.
Last year, 14,871 active cases of tuberculosis were reported nationwide, 51 percent of them in foreign-born individuals, according to the Centers for Disease Control and Prevention.
The state of Oaxaca, an area about the size of Indiana, has about 560 active tuberculosis cases yearly. There, as in the U.S., the risk of tuberculosis is highest among people with limited access to medical care, adequate housing or good nutrition.
During the past 10 years, Santa Maria has increasingly become a port of entry for Mixtecs looking for work. Eight Mixtec villages in Oaxaca are now represented in Santa Maria, and their total population here has been estimated at more than 10,000 people.
The Mixtecs here generally live at or below the poverty level, earning between $7,000 and $12,000 per year. They provide the labor for the $143 million-yearly strawberry crop; and they work in grapes, broccoli and lettuce, too.
Officials say that last year's tuberculosis outbreak highlights the importance of building sanitariums in California -- places where people can be cared for and supervised, other than in jail or in a crowded home full of children.
Legal residents to the U.S. are screened for tuberculosis and barred from entry if they are contagious. When they are under treatment and no longer contagious, they are allowed in. But there is no way to screen the million or so undocumented immigrants who find their way into the U.S. every year.
Decades ago, there were sanitariums throughout the U.S.: here on the South Coast, there was one on what is now Camino del Remedio. But last summer, because of budget shortfalls, California shut down its last two facilities -- one in Lancaster and one in Acton.
Dr. Alvarez is working with other public health officials in California, trying to find private and public funding to build new sanitariums.
"We desperately need these," he said. "As long as we live in a global village, we'll continue to see ongoing transmission of TB. We need to maintain a very fortified and vigilant public safety net."
It is not easy, as the Santa Maria experience shows. County nurses had to overcome the mistrust of family members who feared they would be deported. In the beginning, they did not understand the nurses' role or see any need to take pills, said Heather Olgin, the county public health nurse who was the lead investigator.
"They think of shelter and food as the priority," Ms. Olgin said. "Getting medication is not a priority, especially if they don't feel sick. They don't see anything's wrong."
Half the family spoke only Mixteco, requiring a translator during every visit. With a mask over her nose and mouth, Ms. Olgin searched every corner, including closets, in case people were hiding there. Families would move or leave town to pick crops in Kern and Tulare counties and Washington state, disappearing without a trace.
Ms. Olgin said she never showed up in uniform or parked her county vehicle nearby, not wanting to scare people away.
"They've never heard of TB," she said. "All of a sudden, you're making them take 10 pills a day, when they may have never taken one in their life. You tell them they have no choice.
"It's taken months for them to finally not just slam the door in my face."
In January, Ms. Olgin relocated Mr. Morelos' mother in San Luis Obispo, still sick with tuberculosis, accompanied by three children Ms. Olgin had never seen. They were infected but not sick.
The mother, who had been in Washington, may have returned to San Jose Yosocanoo to bring back these children, though no one knows for sure, Ms. Olgin said. Recently, she said, the woman gave birth in Santa Maria to a baby who is under treatment -- just in case.
Ms. Olgin now visits 12 patients in Santa Maria regularly, including the mother, watching them take their pills. Most are used to her now, she said, but there are still a couple of families who will take off without warning.
"We have to directly observe them taking the medication, and they didn't want to comply with that," Ms. Olgin said. "They said, 'Don't come to my work because people are going to be suspicious.' They see it as an intrusion. They don't see that we're trying to do this to save their lives."
Heather Olgin, a county public health nurse, was the lead investigator in last year's outbreak of tuberculosis
among an extended family of Mixtec farmworkers in Santa Maria, where the Mixtec population has swelled
over the past decade. Rafael Maldonado / News-Press Photos
