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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.
References
1. GlobalHealthReporting.org, XDR-TB Emerges in South African Province, Study Says. 2006, August 16,
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=39212.
2. Farmer, P., Russia: prisoners sentenced to TB. Le Monde diplomatique, 2004. http://mondediplo.com/2004/01/14tb.
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