I wholeheartedly agree with Dr. Evans that the recent California initiative limiting access to health services for undocumented immigrants may increase communicable disease rates. He stated that "in all likelihood, few immigrants would be compelled to leave the state because of the initiative; they would instead potentially spread the disease and remain ignorant of their disease status out of fear of requesting any health care service" [1]. However, he cited no data to support this reasonable conclusion.

Data from a recent study conducted by the University of Southern California and Los Angeles Tuberculosis Control lend credence to this assessment for at least one communicable disease, tuberculosis. We interviewed 248 symptomatic patients with confirmed tuberculosis in late 1993 and asked why they might have delayed seeking care. In that pre-Save Our State era, few (6%) stated that fear of immigration authorities was a factor in their decision to seek medical care. Those that did, however, were much more likely to delay seeking care for more than 2 months [47%] compared with 18%; P = 0.007), a period that has been shown to result in the spread of the disease. This association persisted after adjustments were made for age, the presence of a serious symptom, cavitary lesion, and a positive smear [2]. If the initiative increases the fear of immigration authorities that patients experience when seeking care—a reasonable expectation given the requirement to report suspected undocumented patients to immigration authorities—these data confirm Dr. Evans's own fear that the initiative may exacerbate the tuberculosis epidemic.