The horizon is just starting to glow when Henry Murphy begins his morning rounds, delivering medicine to residents of several local diasporas -- Vietnamese, Mexican, Guatemalan and Chinese -- within a few miles of downtown Los Angeles.
Murphy winds his white county health department van through some of the poorest and most crowded neighborhoods in the city.
They are also among the most likely places to find tuberculosis, an infectious and potentially lethal lung disease that most Americans associate with another era.
"Jason started coughing real bad five months ago," 19-year-old Rosie Osorio says, at one of Murphy's stops at a tidy East Los Angeles duplex. "I took him to Kaiser a couple times, but they kept telling me he had a cold."
Jason Montanes, Osorio's son, actually has an active case of tuberculosis, all the more serious because he is just 9 months old. He probably caught it from his uncle, who had the rattling cough of someone with advanced TB. Like many people from immigrant families, the uncle didn't seek help until he was really sick. Now, eight of Jason's close relatives, who live either with him or nearby, are infected, including his mother, his father and his immigrant grandparents. Only Jason and the uncle, however, have active cases. Jason still has a mild cough and is probably still contagious.
In the United States, and especially in California, tuberculosis is largely an immigrants' affliction. According to a recent report by the state's Department of Health Services, California led the nation in the number of new TB cases reported last year, with 2,989. Three-quarters of those were among people born outside the United States and nearly a fifth were younger than 16.
Many immigrants, experts say, bring the bacterium from countries, including Mexico, the Philippines, Vietnam and China, where TB is endemic and healthcare systems are relatively weak. The infection may lie dormant and noninfectious for years, flaring when a person gets old or his immune system is frail. The disease usually attacks a person's lungs, spreading to others through the air when the person coughs, sneezes, laughs or even sings. Family members and others in prolonged contact are most likely to be infected.
Although TB has been declining for more than a decade in the United States, experts worry about how entrenched it remains in some immigrant enclaves. They worry, especially, about a small but stubborn share of cases -- 1% to 2% in this state -- that are resistant to standard antibiotics.
A study last month in the Journal of the American Medical Assn. found that foreign-born residents accounted for eight in 10 cases in California that were resistant to multiple drugs.
It was immediately incorporated into the emotional debate over illegal immigration.
"If anyone needs another reason to oppose illegal immigration," conservative syndicated columnist Cal Thomas wrote about TB-infected migrants last month, "how about the spread of a deadly communicable disease?"
Health officials urged calm and understanding.
"Just because somebody has TB doesn't mean they're a bad person," said Dr. Alan Kurz, a Los Angeles County Department of Health Services medical director for Hollywood, downtown Los Angeles, Pomona and Monrovia. "People with TB contribute to the workplace and churches and social organizations like everybody else. They are valuable people in our society. And this is an illness that can be treated."
With its large immigrant population and dense neighborhoods, Los Angeles County is a TB stronghold. It had 930 tuberculosis cases in 2004, more than most states, according to health department figures. At least nine of those are drug-resistant.
Murphy and his colleagues fight this ancient, international scourge every day, one patient at a time.
'I Just Started Coughing'
It takes Wah Lee Lau, 79, a few minutes to open his front door, descend the few steps and hobble across his yard to the garden fence, where Murphy holds out a packet of antibiotics.
As Lau reaches for the pills, a shallow cough sputters from his lips. Murphy retreats a couple of feet and turns his head away.
"I don't know how I got it," says Lau, a lithe man with gray eyebrows, who immigrated to the U.S. in 1976. "Two years ago I just started coughing. I couldn't stop."
Murphy has 20 clients, whom he sees five days a week. All but little Jason were born outside the U.S., though some, like Lau, have lived here for years. About a quarter of foreign-born TB sufferers have lived in the United States for more than 20 years, according to state figures.
A gregarious veteran health worker, Murphy, 58, gets on the road at 5 each morning to ensure that the health department officials know where his clients are, how contagious they are and whether they are taking their pills.
If TB patients fail to take their medicine, he will call in public health investigators who have the power to quarantine highly contagious or uncooperative patients.