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].
But in a tragically ironic example of Cold War competitiveness, only one country rivals Russia in having the largest number of its persons imprisoned and the most eyebrow-raising circumstances leading to such imprisonment. In that rival nation, the most common crimes leading to incarceration are related to drug-selling in the context of urban poverty.
These crimes are entwined with the pursuit of common American dreams—material possessions and all that is advertised, on television and magazine covers, and arrives with them. Pursuing those dreams takes place in the context of the abandoned warehouse shells of cities, where citizens find a means of creating a new, sustainable economy of drug marketing, when the conventional money-makers have abandoned the urban blight for the suburbs. The racial, gender and class dynamics of this phenomenon under which 14 million people have been imprisoned is simply too vast to capture here (although they have been chronicled extensively by others [9, 10]).
Perhaps is it reasonable to characterize the function of American prisons in the words of Nixon's White House Chief of Staff H.R. Haldeman, who during the great rise in numbers of incarcerated young men in the U.S. stated that "you have to face the fact that the whole problem is really the blacks. The key is to devise a system that recognizes this while not appearing to" [9].
In other nations, we find similar forces at work and would argue the same: that the dynamics of class and imprisonment also highlight the concern that treating tuberculosis in this context is a moral issue—a social responsibility, if only in part a reparation for having created the contexts under which the poorest and most marginalized sectors of society would be caged and, later, infected with disease due to our lack of caring. In India, the revolving door of jails that intake and release thousands of the poorest laborers a day serve a vital social function: in the context of massively urban road-working projects, eight-lane highway construction development efforts in cities like Delhi have been designed to support the rise of foreign businesses, and jails have served as a means to prevent union organizing as those negotiating their labor contracts are thrown in and out. Describing such contexts, the former chief British economic advisor to the prime minister recalled that "Rising unemployment was a very desirable way of reducing the strength of the working classes. What was engineered [was] a reserve army of labor, and has allowed high profits ever since" [9].
The fact that tuberculosis rapidly spreads in this context is by no means a radical proposition; indeed, it is one adopted by the U.S. Centers for Disease Control [11]. It is not difficult to imagine that, in countries with increasing capital gains and decreasing equality as such gains are shuttled to a minority, prison sites (as the CDC has highlighted) are often crowded, poorly ventilated, and lack emphasis on medical care—particularly in jails where inmates will be rapidly released back to receiving inadequate care (the cheapest strategy) on the outside. In Russia, the situation has become particularly perverse, as the jails and prisons have become so crowded that mass "asylum" grants are provided by the prison warden, so that huge populations of prisoners can be released out of the system simultaneously, often on a politician's birthday or national holiday. The first prisoners to be granted leave? The most "expensive"—those that require the system to pay for TB therapy [12, 13].
Even the WHO concedes, "Our greatest challenges in controlling tuberculosis is political rather than medical" [14]. However, the problem is not merely at the level of state politics, but deeply entrenched in medical politics as well. While the experts at the CDC may have recognized the situations in which drug-resistant forms of tuberculosis breed [11], many physicians, who are typically not from the same classes as these tuberculosis patients, have been among those propagating the problem. For years, international committees of infectious disease experts declared that MDRTB would be "untreatable"—not because of any technical hurdle, but because of its expense. It was argued that the treatment would simply be too difficult to deliver to sites like Russian prisons, requiring too many resources (while extensive surgeries for the oldest, terminally-ill Americans are considered cost-effective). And it was because they viewed this problem as a purely technical, rather than social, that they did not realize that people from Russia to the United States to South Africa would not simply go home to die. They would find medications, trade drugs amongst each other, and find means of survival when denied care. And in the process, MDRTB would not simply disappear, but rather fester and spread among those most desperate, in situations that were most crowded and least hospitable. Only in 1991, after the disease traveled from Russian prisons to New York, would sentiments change among the medical elite. Such near- sightedness would prove to have public health consequences, in addition to being morally reprehensible.
As highlighted by TB expert Paul Farmer, "Though there are probably more cases of MDRTB in Tomsk province [Russia], north of Kemerovo, than there were at the height of the TB epidemic that hit New York in 1991, the services that must fight TB in Tomsk are allocated less than 5% of the resources available in New York. 'Costs easily exceed $1bn and many reach several times that amount,' the New England Journal of Medicine reported at the time of the NY scare. But the ideas of cost-effectiveness could be invoked to justify huge expenditure because the money ended the epidemic: 'Despite their cost, efforts to control TB in the US are likely to be highly cost-effective'. During the same period, hundreds of millions of roubles left Russia for accounts in the US, Switzerland and the Caribbean; perhaps this cash flow helps explain why aggressive TB control, which necessarily includes treatment of all the afflicted, is cost-effective in New York but not in Siberia" [2].
A group of medical advocates including Farmer has since rallied around the Russian prison system to improve the use of available technologies and systems of care. They have negotiated with drug companies and lowered the price of second-line TB drugs dramatically, causing the WHO to have little choice but to coordinate the effort to expand access to second-line medications and the resources and technical training to treat MDRTB. MDRTB has now been successfully treated, rather than being ignored and assumed to disappear among the poor, in places as resource-strained as Peru and Haiti [2].
Now, with the specter of XDRTB, the medical community can again make a choice as to whether to view this disease as merely a technical hurdle, a "cost-ineffective" disease to treat, or a symptom of a horrific social circumstance. This is a particularly important choice in the context of HIV, as the rise in tuberculosis in the past few years has been sharply defined by the dynamics of HIV transmission, given the potential for HIV to compromise the immune system and leave vast numbers of persons not only more susceptible to tuberculosis, but also more likely to progress to active and contagious TB [11]. About 30 percent of the 40 million people living with HIV or AIDS currently also have TB [15]. HIV, of course, stems from similar social roots as tuberculosis [16], and so it is no surprise that the diseases travel as a destructive duo. But their mutual co-dependence highlights the need for structural interventions in settings like prisons.
Russian prison wards themselves have improved somewhat as years of advocacy and attention have turned an embarrassing spotlight on the situation in that country. However, much is left to be done, and in vast sectors of the nation, MDRTB is still out of control; only a few carefully-tuned sectors have begun to properly treat the disease in the form of pilot projects. But while so much attention is focused on the crisis in Russia, it is essential to revisit the aforementioned comparison of the Russian circumstance to that of the United States.
As illustrated by physician Robert Greifinger, "U.S. prisons have so much more in common with Russian prisons than we have in contrast" [8]. The U.S. has the greatest incarceration rate in the world at is about 738 people per 100,000 population, versus the Russian rate of 606/100k [17]. Greifinger also notes that "in the case of the U.S., the excess incarceration is not due to more violent crime. Rather, it is due to higher incarceration rates and longer sentences for property crimes and drug offenses. The U.S. and Russia similarly incarcerate young men (predominantly) who are poor and undereducated….the morbidity of inmates in the U.S. and Russia is similar, especially the rates of major mental illness, sexually transmitted disease, viral hepatitis, HIV infection and other chronic illness…some U.S. prisons and jails get similarly crowded to those in Russia. As recently as May 2004, the Fulton County (Georgia) jail housed more than 3,000 inmates in a facility built for half that number; 500 were sleeping on mats on the floor of the day rooms because there were not enough bunks in the cells at the time. In 2003, the Julia Tutwiler Prison for Women in Alabama housed more than 1,000 women in a facility, without air-conditioning, built for 364…[and] both the U. S. and Russia have insufficient valid and reliable data on the health status of inmates, due to inadequate surveillance and research" [8].
Our American system, therefore, has been made almost as vulnerable as that in Russia. A particular case from Alabama illustrates the medical inadequacies of the American prison system in preventing and treating tuberculosis. When Dr. Stephen Tabet, an HIV specialist, investigated the conditions of the Limestone Correctional Facility (Alabama) in August 2003, he was disgusted to observe a health care system in which "patients . . . are treated like they are nuisances." Tabet cited the facility's "number of preventable deaths" as its "most egregious failure." In his report, he gave a clear warning: "Without adequate infection control practices, the possibility of an outbreak of drug resistant tuberculosis and the subsequent deaths is acute." His words went unheeded. When he made a follow-up observational visit less than a year later in March 2004, he was astonished to find that a prisoner who soon died from active tuberculosis had been housed with the entire HIV+ population, exposing all the patients, whose immune systems were severely compromised, to the deadly disease. It was this "broken, severely stressed or often non-existent medical system" that put patients at risk of otherwise preventable illnesses [18, 19].
But the irony is that while medical advocates have slowly improved some of the circumstances for prisoners in the Northeast United States, and some prisons of the South, they have faced a cruel discovery: that the circumstances in the communities of those commonly imprisoned has gotten so bad that improved prison medicine has made some persons "healthier" behind bars that outside it. This has applied to conditions including TB and HIV, in which the regimented style of medication delivery inside prisons is immune from the chaotic circumstances outside that can make it difficult for people to get doctor's office visits, renew prescriptions, and maintain the high levels of adherence that are necessary to avoid drug resistance [20].
A recent study of inmates released before completion of TB therapy indicated that only 43% were able to make it to at least one doctor's appointment after release, secondary to difficulties leaving their place of employment [11]. But the top reasons for the relative safety inside prisons are not even issues of infectious disease, but rather the main reasons why young men die on the outside: accidents, homicide and suicide. The same has been observed in Russia; one health policy report recently declared that "The chances of survival of young men in Russia may actually be improved by being in prison, highlighting the need for policies that reduce the overall level of violence and other external risks" [21]. As Greifinger writes, "incarceration as a type of protective custody for young men in harm's way is neither rational nor legal…There must be other, less coercive, means to keep poor young people out of harm's way" [8].
Indeed, there are. And one of the most intuitive—although least pursued—ways of determining such means is to ask the incarcerated themselves, as well as their friends and families. Many of these persons have created their own programs, typically involving linkage from prisons to their communities, along with social support mechanisms to order the chaos of urban life in America. In regards to medical care, these programs involve administering TB and HIV therapy by flexible means such as roving healthcare vans or by using case-management strategies operated by community healthcare workers.
Such linkage to care has involved programs not only to provide simple prison education courses, but to supplement this with real material benefits: early release to drug rehabilitation programs, connections to outpatient physician and home-based healthcare services, nutritional supplementation and access to the social work resources. This has assisted many in overcoming key employment problems, substance abuse, and safe-shelter challenges of those released from prisons—which if left unconquered can often lead to recidivism [9, 11, 22, 23].
Measures to link releasees to community-based services also reduce the specter of drug-resistant TB, for example, through programs that have allowed mobile nurses to deliver medications and check laboratory values at a patient's workplace. This can assist patients in tenuous social and employment circumstances, who would otherwise have to miss work or childcare to visit a clinic [15]. The same positive results have also been shown for HIV-related care services [20]. These programs even reduce costs that would have to be later borne in greater amounts by the unmotivated prison system, itself notorious for improper medical care [24-26].
But the measures do rely on our own motivation to recognize tuberculosis as a social issue produced by the circumstances created in our prisons. It also requires us to recognize how far the institution of prisons has transformed since its inception. In the 1960s, the Assistant to the Director of the California Department of Corrections stated that "The point of view of the institutional staff is treatment. Actually, the hopes of the prison employees resemble yours for the well-being of your loved-one while he is in prison and for his welfare and happiness later on when paroled." But by 1997, the Democratic Representative from Mississippi was declaring that "We want a prisoner to look like a prisoner, to smell like a prisoner. When you see one of these boogers a-loose, you'll say, 'I didn't know we had zebras in Mississippi'" [9].
How well we treat tuberculosis will derive in no small part from how we begin to look at these two quotations, and where we draw the line regarding the purposes of our prisons. To really tackle TB in prisons is to view this pathology as more than just a mycobacterium, but as a moral responsibility in response to our society's decisions, and the institutions we have created in the shadows of our community's philosophies.
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