TB or not TB: Another good reason to reduce prison populations

By G.Patrick Callahan, prisoner of the drug war

"TB (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, 1999)

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 United States.

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 Practice, 1993

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.