TB or not TB: Another good reason to reduce
By G.Patrick Callahan, prisoner of the drug war
(tuberculosis) poses a unique challenge today in correctional
environments as inmate populations increase and overcrowding
makes an outbreak of TB a serious threat." -Controlling
TB In Correctional Facilities, Center for Disease Control (CDC),
1999 I watched with a sense of outrage and dismay as the test
site turned an angry red. By the next day there was a large knot
on the underside of my forearm. After ten years in prison, dodging
untold microbiological bullets, I was hit; I tested positive
for Mycobacterium tuberculosis: TB. Several of us were infected
because we were jammed in close proximity for four months to
a Vietnamese immigrant who had somehow slipped through the system
and become an active TB carrier. What we thought was only a persistent
smoker's hack was, in fact, a virulent case of infectious TB.
"Poor ventilation and overcrowding in prisons may promote
the transmission of infection from persons with undiagnosed TB
to inmates, staff and visitors. Frequent transfers, both within
and between prisons, also contribute to the spread of TB within
the prison system." From Cohen, F. Durham, JD, Tuberculosis:
A Sourcebook For Nursing Practice, 1995.
State and Federal prisons are bursting at the seams. As of this
writing there are 146,000 men and women in federal custody and
two million people imprisoned overall in the United States. This
is chiefly due to our country's nearly fanatical adherence to
a failed drug war policy - the federal prison system grows at
the rate of one thousand prisoners each month. Every federal
lockup is running over its rated capacity; the federal system
is averaging 146% over rated capacity. (Bureau of Justice research,
In 1990 one in every seven state correctional facilities was
under state or federal court jurisdiction (or consent decree)
for specific conditions relating to overcrowding. To date no
federal judge has had the guts to order any federal prison to
comport to its rated capacity. As we consider infectious disease,
prisoners are, therefore, similar to hapless sitting ducks in
a game of government sponsored Russian roulette.
"Hospitals, correctional facilities and other institutional
settings have been the focus of outbreaks of MDR-TB. The extent
of MDR-TB transmission in the community has not been well studied."
- Problem 2, CDC National Action Plan To Combat Multidrug-Resistant
TB When someone is moved from one prison to another, it is standard
practice to be assigned to a former dayroom turned barracks,
rooms crammed wall to wall with bunks, often poorly ventilated,
always filthy, often filled with immigrants from major high-risk
populations in Latin America, Asia and Africa.
"A group at high risk for TB in the United States is composed
of those persons born in countries with a prevalence of TB. In
the United States, persons from six countries accounted for 63%
of foreign born TB cases. These were China, Haiti, Mexico, the
Philippines, South America and Vietnam." - Jacobs, R.F./Starke,
J.R. "Tuberculosis in Children"
Were it not enough to be infected with M. tuberculosis, those
of us exposed were subsequently told that it was a drug resistant
type, that apparently the strain of TB the carrier had was resistant
to INH, the most commonly used and most efficient medication
for tuberculosis. Sometimes bacteria become resistant to more
than one drug. This is called Multidrug resistant TB, or MDR-TB,
a very serious problem. People with MDR-TB disease must be treated
with special drugs. These drugs are not as good as the usual
drugs for TB, and they may cause more side effects. (Bureau of
Tuberculosis Control, New York City Department of Health, 2000)
The primary medications we take each day are rifampin and pyrazinamide.
Side effects can be numerous, including nausea, vomiting, flushing,
rash, jaundice, liver damage and hepatitis. Flu-like symptoms
are common, as are headaches and malaise. As of now, the benefits
of this medication are hypothetical in nature since the particular
resistance to them is unknown, but assuming their efficaciousness,
they must be taken every day throughout the regimen - it is non-adherence
to the regimen that promotes drug resistant TB. The problems
inherent with detection and monitoring this disease are staggering;
they can and often do overwhelm prison medical staff, and the
situation is becoming worse.
In one analysis, Bloom and Murray (1992) estimate that about
one quarter of the recent rise in tuberculosis incidence in the
United States is due to active transmission in hospitals, homeless
shelters and prisons. (Bloom, B.R. 'Tuberculosis: Pathogenesis,
Protection and Control', ASM 1994)
In every study to date it has been demonstrated that - in
the drug war analysis especially - longer sentences have little
or no deterrent value and have had no impact whatsoever on the
drug trade which thrives on massive noncompliance with unrealistic,
badly considered legislation. Long prison sentences do, however,
contribute to the spread of a variety of diseases, with TB among
the most dangerous.
Recent outbreaks in prisons and an increase in both cases and
resistance rates in many areas of the United States have created
an urgent need for system wide improvement in correctional facilities'
efforts to control tuberculosis. The TB threat calls for innovative
approaches by legislators who can mandate necessary interventions
and provide adequate funding for their implementation. It also
calls for strong support from state and local health departments,
public agencies ultimately responsible for TB control within
their jurisdictions. Indeed, effective TB control in correctional
facilities is necessary for the reduction of TB rates throughout
the country and the eventual elimination of TB disease from the
US drug war policy is a national failure of immense proportion.
The drug war is waged in the name of public health; yet due to
the prohibition on needle exchanges, 25,000 otherwise preventable
cases of HIV occur in intravenous drug users. HIV infection has
become a major source for the spread of tuberculosis.
"Poverty and drug addictions are not 'gender neutral'. Women
and families comprise an increasing proportion of congregate
living populations, as in shelters or prisons. The United States
has the world's highest known rate of incarceration, with 426
prisoners per 100,000. Women made up about 3% of the U.S. prison
population in 1981; in a little over a decade that proportion
has doubled. One objective of the National Action Plan to Combat
MDR-TB is to analyze the incidence and prevalence of tuberculosis
in HIV infected women because little data is now available. Women
are among the fastest growing group of persons with HIV disease."
- Cohen, F. /Durham, J.D. Tuberculosis: A Sourcebook For Nursing
In any one regimen of TB medication there is a small percentage
of failure wherein the infected individual progresses into the
full blown disease. TB is often called the 'White Death', killing
3 million people worldwide each year. It is still 'tops' among
the most lethal of diseases, even for those patients who have
successfully completed a medicinal regimen. The dormant disease
can break out if they become immune-suppressed. A car accident
or a case of pneumonia can cause recurrence of TB.
TB among the elderly is higher than any other population group,
accounting for 26 percent of TB cases in the U.S. It can always
be there, in other words, waiting to 'take one down'. Was I sentenced
to be infected with TB as part of my punishment? Was anyone?
Is that part of your punishment? I have yet to read this element
anywhere in the U.S. Sentencing Guidelines; yet exposure to TB
and MDR-TB has become common.
The longer the prison term, the greater one's chances of becoming
infected. Any sentence can, therefore, be a potential death sentence.
Legislators can and should intervene and realize that one of
the most effective ways to reduce the incidence of TB infection
is to reduce the prison population: for the public's health.