Emory Law: More Than Practice: Polly J. Price
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Emory University School of Law
by PJ Price - 2000 - Cited by 2 - Related articles
Polly J. Price joined the Emory Law faculty in 1995. An honors graduate of Harvard Law School, Professor Price clerked for Judge Richard S. Arnold of the 8th ...
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.
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.
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