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At the 16th International AIDS Conference in Toronto last summer, researchers studying in South Africa made a startling announcement: in a study of 536 people with tuberculosis living in the rural town of Tugela Ferry, the researchers discovered a strain of tuberculosis so virulent that it was resistant not only to the most commonly-used "first-line" medications, but also to back-up "second-line" drugs as well. The disease was exceptionally difficult to treat, and all but one patient (including 6 healthcare workers) has died within 25 days of infection [1].
The strain of tuberculosis, known as XDRTB--short for "extensively drug-resistant tuberculosis"--is even more resistant to medications that the well-known problem of "multi-drug resistant tuberculosis" (MDRTB), which still plagues vast sectors of the world and cost over $1 billion to control in the U.S. alone when it hit New York in 1991 [2]. XDRTB has now been reported in countries as distant as South Korea and Iran [3].
An often-asked question, of course, is whether the strain is spreading from one country to another; but all too often, such drug-resistant strains are not found simply because of a Hollywood "outbreak" scenario of sick people traveling on airplane flights. The problem usually starts internally. Especially in the case of tuberculosis, the answers are found in the urban cities, slums, and in particular, prison wards of nations that possess enough resources to control TB, but maintain great inequalities that threaten to undermine such efforts.
Drug-resistant strains of TB have been found in just a handful of common situations. Often they involve locations where doctors are inadequately trained in tuberculosis drug management, resulting in improper combinations or durations of medical treatment, which enhances the potential for the bacterium to evolve mutant versions of itself. Typically, the context of poor drug treatment isn't just a training problem, but also a fundamental misuse of basic technologies that could help identify the strains being treated and assist physicians to choose appropriate drug regimens. And sometimes patients are simply denied care altogether or left with such poor access to services that they seek medications on their own—finding combinations of pills that will inevitably lead down the road of resistance [4].
Particularly in close-knit settings, such as hospitals (in which the South African tuberculosis strain seems to have spread), it only takes a few mismanaged patients to provide the seed for the rapid spread of MDRTB, if not XDRTB. Time and time again, these situations have been found in prisons. In most nations, TB rates in prisons are five to ten times the rates outside of prisons, and often closer to 100 times that amount in the context of outbreaks [2]. The most highly-publicized cases come from Russian jails, but the problem is, frankly, everywhere.
A basic question is asked by those who seek to draw attention to the crisis of tuberculosis in prisons: how do we make people care about criminals? The most common answer has been to highlight the rapid rate at which tuberculosis has spread from beyond the bars. Since the 1991 New York epidemic to recent cases in Russia (where MDRTB was found among 37% of inmates and 20% of civilian TB patients [5]), frighteningly drug-resistant strains have spread from prisons to the "civilian" population. But to make this argument is also to fundamentally de-contextualize the very framework of why people in cages are getting tuberculosis.
What we intend to argue is that tuberculosis treatment in prisons is a moral issue, not merely a risk to the "others" in the community. And while it may not be politically expedient to highlight this fact, it does serve to document and explain the patterns of tuberculosis that we observe both inside and outside prisons today. The issue is not merely one of prisoners who interact in the wrong crowds, get TB, and infect the outsiders. Rather, it is an issue of how so much of Russia became desperately poor under the recommendations of American "development" economists during the 1990s (including Jeffrey Sachs, now head of the Millennium Development Goals project) [4, 6].
In parallel with the financial meltdown, one doctor reported on the collapse of TB treatment infrastructure: "Suddenly, the money stopped. There were no drugs, communication with local hospitals broke down as telephones were cut off over unpaid bills, there were no stamps or envelopes to send letters, doctors could not use a car to see their patients, it was impossible to transport patients to hospitals. The system broke down" [7]. In this context, ordinary Russians, let down by the financial "freedoms" brought to them, ended up in prisons after stealing food, snatching purses to pay the rent, and committing similar crimes of poverty, desperation, depression, and related drug addictions that now form the vast majority of jail admissions in Russia [2]. 60% of these prisoners were unemployed prior to incarceration [8].
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Sanjay Basu
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