If Tuberculosis Spreads ...
By
POLLY J. PRICE in the New York Times
ATLANTA
— DRUG-RESISTANT tuberculosis is on the rise. The World Health Organization
reports around 500,000 new drug-resistant cases each year. Fewer than half of
patients with extensively drug-resistant tuberculosis will be cured, even with
the best medical care. The disease in all its forms is second only to AIDS as
an infectious killer worldwide.
The
United States has given more than $5 billion to the Global Fund to Fight AIDS,
Tuberculosis and Malaria. But drug-resistant tuberculosis isn’t a problem only
in the developing world; we must turn our attention to the fight against it
here at home.
Tuberculosis
rates have declined in the United States in the last decade. In 2012, there
were around 10,000 cases, and of those, only 83 were resistant to all of the
most commonly used tuberculosis drugs — 44 fewer than in 2011. So far we have
been lucky. The low numbers hide the precarious nature of the nation’s public
health defense, and how vulnerable we would be to an epidemic.
The
problem is that responsibility for tuberculosis control is divided among 2,684
state, local and tribal health departments. That infrastructure is politically
and legally fragmented, underfunded and disproportionately strained in many
poor communities.
Patients
with infectious tuberculosis, caused by bacteria that usually attack the lungs,
need medication regularly administered over many months. Local public health
workers provide the medication and observe that it is taken by the patient,
requiring as many as five visits each week. If treatment is interrupted, or if
the drugs are not working, patients have a much higher chance of developing
(and spreading) drug-resistant tuberculosis. At the same time, health workers
must track down and test anyone who had come in close contact with patients
before the disease was diagnosed, to be certain no one else has been infected.
All
this is made much more difficult by the patchwork of jurisdictions and the lack
of coordination among health departments, which can easily lose track of
patients who travel or relocate to another county or state.
Tuberculosis
is also most common in communities with the least stability. Among people born
in the United States, the greatest disparity is between blacks and whites;
blacks contract it at a rate more than seven times higher than whites, often
because of poverty and crowded living conditions. But foreign-born individuals
account for two-thirds of new cases. We have no reliable method to identify
tuberculosis in migrant populations or foreign visitors. Even if screening at
borders were logistically possible, it could take several days to obtain test
results. By that time, it would be difficult to locate travelers who were
unknowingly carrying the disease. And health departments near the southern
border are already overwhelmed, especially by a recent influx of migrant
children from Latin America, where tuberculosis is more common.
Perhaps
most critical is the high rate of tuberculosis among the two million people
incarcerated in America. Prisoners are routinely screened and treated, but that
treatment ends when they are released, even if they are not yet cured. Former
prisoners are also among the least compliant of all patients, possibly because
the strict medication regimen, which requires repeated contact with government
health care personnel, feels like an extension of their prison term. There is
no legal mechanism to determine which local health department “owns” a
tuberculosis patient after he is released from federal or state custody.
Besides
the logistical problems, there are issues with funding on the local level.
Extensively drug-resistant tuberculosis requires 18 to 24 months of treatment
and can cost more than $500,000. A local health department’s entire budget can
be depleted with just one case.
Recent
Comments
Eric
Benton
4
days ago
Back
in the days of shipping as a form of movement from one place to another boats
and hopefully their passengers were required to get a...
Brodston
4
days ago
We
have ignored this problem with the classic head in the sand denial mode for
which this country is so tragically famous. Now we are paying...
Dennis
Mueller
4
days ago
Sadly,
it is pretty simple science that says under-treating TB will increase
drug-resistance strains and those strains will spread. It is...
·
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These
decisions are too important to leave to the vagaries of local politics. In
Jackson County, Ohio, voters last year were asked to approve a tax to continue
to fund the county’s tuberculosis prevention and treatment program. In an
effort to ensure approval, tax commissioners reduced the levy, leaving just
enough to keep the program going. Voters still rejected it, 3,363 to 3,195. As
a result, the health department had to cut the program’s public health nurse
and a clerical assistant.
We
need a better system for tuberculosis treatment, funded at the national level.
The Division of Tuberculosis Elimination at the Centers for Disease Control and
Prevention routinely works with local public health departments to monitor
tuberculosis outbreaks and to provide expert guidance. But it does not have the
funding to help them pay for tuberculosis treatment, even where local resources
are clearly inadequate.
That
must change. Congress should appropriate additional funds to the C.D.C. to
cover costs of tuberculosis treatment that are now borne by local health
departments. The C.D.C. should also take on the responsibility of locating and
monitoring tuberculosis patients who move from one jurisdiction to another,
including newly released prisoners, since many local health departments do not
have the ability to do so.
It
will be costly: Over the next 10 years, one estimate shows that we will need to
spend $1.3 billion on tuberculosis treatment — and that’s if infection rates
remain the same. But tuberculosis’s greatest lesson is that the health problems
of poor people in poor areas are everyone’s problem. Continuing our present
failing system would prove to be far more expensive in the end, because
drug-resistant tuberculosis will not obey political or economic boundaries.
Polly
J. Price
is a law professor at Emory University.
A
version of this op-ed appears in print on July 9, 2014, on page A25 of the New
York edition with the headline: If Tuberculosis Spreads ....
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