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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].
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Sanjay Basu
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