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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.
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Sanjay Basu
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