How bad is it when 99 people in the US – most of them homeless, drug
addicts or mentally ill – get tuberculosis? It doesn't sound like much. But it
rings alarm bells here at Threatwatch.
An investigative journalist in Palm Beach, Florida, has reported that
in April in Jacksonville, Florida, the US Centers for Disease Control and
Prevention (CDC) investigated what it called the biggest outbreak of TB in the
US since the early 1990s. Yet even as the CDC was writing its report, Florida's legislature voted to slash
jobs and funding in public health, and to close its only TB hospital. It shut on 2 July.
The subsequent ruckus has focused on an alleged cover-up of the
outbreak. The more important message, though, is how easily TB can get out of
control even in the richest country, and how, unless we are very careful,
economic recession could make that much worse.
In June, the CDC reported how this outbreak started: a schizophrenic man
visited psychiatric clinics around Jacksonville over five months in 2008,
complaining of a cough. On the fourth visit he was finally diagnosed with TB.
But he refused to stay on his TB drugs, which you need to take for months
before you are no longer contagious. So he was locked up in the state TB
hospital.
By then, however, he had already
spread the infection. In 2009 CDC found TB infections in an
"extraordinary" 88 per cent of his contacts in the mental health
facility he attended. The normal transmission rate is between 20 and 30 per
cent.
Hard to trace
The CDC could not track all the
cases and treat them, so the spread continued, and last February, Jacksonville
called them in again. The CDC has now traced 99 cases since 2004, mainly in
homeless shelters.
Of 3222 recent contacts of these
cases, the CDC traced only 253. If only the usual third or so of contacts were
infected, that means around 1000 people are still spreading the strain. The
outbreak, CDC concluded, "has yet to show signs of abating".
So why is Florida cutting public
health spending and closing the TB hospital? It is partly due to
small-government ideology and partly to budget worries. But it is also true
that overall TB cases in Florida have been declining – down nearly two-thirds
from a peak in 1994.
However, beneath the overall
decline, these TB bacteria, in this particular human network of contagion, are
booming: there were 10 cases in 2010, 38 in 2011, and six in the first two
months of 2012. The CDC fears this will result in the kind of TB explosion seen
in homeless communities elsewhere.
"As overall incidence
declines, micro-epidemics become more important," as do delays in
diagnosis by doctors who rarely see TB, says Giovanni Migliori, head of the
World Health Organization's TB centre in Tradate, Italy.
Beneath the radar
This tells us two important
things. Firstly, a lot of TB could be spreading under the radar elsewhere in
the US health care system. Florida actually analyses more TB DNA than most
states. Despite efforts
to fix US healthcare, the sluggish economy means 40,000 jobs in US local health departments like the one in
Jacksonville have been lost since 2008, and nearly half expect more cuts. Similar
cuts seem likely outside the US too, as economic woes deepen.
Secondly, TB anywhere is TB
everywhere. Florida officials say they didn't alert the public to the outbreak
as they didn't want to subject homeless people to further stigma. Fair enough,
but this outbreak may not be limited to the homeless: the CDC found
no history of homelessness, jail or drug use in 21 of the 99 cases it found. In
29 cases, the CDC could not trace the source of infection to the homeless
community.
Meanwhile, TB among the homeless
does not remain there. Such outbreaks, as in New York in the 1990s, breed
drug-resistant TB as it is hard to ensure marginalised people stay on their
medication for months. Every new resistant case makes the global epidemic
harder to fight.
It sounds callous and immoral to
imply that we should care about an outbreak among the impoverished because it
eventually affects the non-impoverished – but in New York, says Migliori, there
was little action until it became clear that the more affluent were affected.
So let's be clear: this will happen unless we pay attention now and avoid
making public health cuts that will cost dearly later.
No comments:
Post a Comment