Some states have dedicated TB liaisons
When TB control programs try to improve health care in city and county jails, they come up against a variety of villains, including budgetary shortfalls, ignorance of public health principles, small-town stubbornness, and plain incompetence. But unlike lawyers who can haul jail administrations into court, public health departments can’t afford to burn bridges, and must rely instead on education and persuasion.
In South Carolina, the state TB control program recently got money from the Centers for Disease Control and Prevention in Atlanta to fund a position solely dedicated to TB control in prisons and jails. "Many of our jails have no medical staff on site, just a physician who comes in for an hour or two every week," says Carol Pozsik, RN, MPH, state TB controller. "That’s the case in many jails across the nation."
Shea Rabley, RN, MS, the newly appointed state TB nurse consultant for prisons and jails, says she’s still feeling her way around as she tries to learn how correctional systems operate. "It’s an entirely different world from that of public health," she says. "For one thing, the jails don’t have to let me in. I certainly don’t want to antagonize them, either, because I want to be able to keep coming back."
So far, Rabley has run up against problems that stem, in some cases, from lack of money, and in others, from lack of knowledge. Occasionally the problem is neither, but instead lack of willingness to do the right thing.
Rabley says she tries to weigh each situation individually, and to be reasonable about what jails can and can’t do. For example, a state law on the books says every jail must have a respiratory isolation room; but for a facility that hasn’t seen a TB case for seven years, the expense is hard to justify, she says. In those cases, her aim is to help the jail develop a TB plan, so if a case does occur, jail staff will know what to do next.
Being reasonable doesn’t always bring about the desired effect. Rabley tells of a certain jail that got hit with a case several years ago and had to conduct an expensive contact investigation. The facility finally did build a respiratory isolation room, but it still doesn’t conduct TB screening, and staff are using the isolation room for disciplinary lockups.
The headaches Rabley encounters seem to pale alongside problems that plague some big-city jails. In Atlanta, no one disputes that health care at the state’s two biggest jails is abysmal, even in the face of years’ worth of court orders to shape up. The DeKalb County jail in the Atlanta area, already plagued with a massive problems (including a former sheriff who was sentenced to life in prison for the murder of his successor), court-appointed monitor Robert Greifinger, MD, says conditions are "a breeding ground for TB, AIDS, and sexually transmitted diseases."
The DeKalb jail’s TB isolation rooms still are not functioning, Greifinger says, nor are staff trained in how to use them. Once, staff delayed placing an inmate found to have active TB into isolation for 45 hours, according to trial testimony. Most medications for HIV-infected patients still are not being delivered on time, Greifinger notes.
In previous hearings, other grim evidence has been presented. Medical requests were stored in trash bags and not read for weeks or months at a time. A presiding judge recently recounted how an inmate with hemophilia, scheduled to take the witness stand for the prosecution the second day in a row, found he’d been assigned to a new cellmate — one armed with a razor, as it turned out. After he was attacked and taken to the hospital for his injuries, the would-be witness missed his appointed day in court.
In the Fulton County facility in Atlanta, conditions have actually improved, Greifinger says. But overcrowding remains a serious issue, which exacerbates problems created by the jail’s nonfunctional ventilation system. "Right now, the sheriff is doing everything she can, but county commissioners need to give her the money and staff she needs," Greifinger adds. In July, a federal judge made a step toward that end by ordering the jail to provide defendants with attorneys within 72 hours instead of letting them languish for weeks before providing counsel.
The Southern Center for Human Rights, the nonprofit agency that has represented HIV-infected inmates in lawsuits against both jail systems, has made a career bringing attention to equally wretched health conditions in jails throughout the South. Steve Bright, the agency’s lead attorney, gave up a well-paying position 20 years ago to work pro bono on behalf of indigent inmates.
Occasionally, Bright has made a misstep — as when his agency decided to go after Mississippi for "forcing" directly observed therapy on inmates with TB. (Bright subsequently relented once he better understood the facts of the matter, say TB experts.) By and large, his center has helped spotlight medieval-style conditions, and often begin to remedy them.
Another target has been a jail in Huntsville, AL, which had been housing inmates in a barracks-style building built to store cars. The former garage had no air conditioning despite the baking-hot Alabama summers; inmates were never allowed outside; and there was virtually no access to medical care, Bright’s group found.
Even when lawyers are willing to work long hours for low pay on behalf of inmate health care, there still are considerable obstacles, Bright contends. The prison Legal Reform Act, signed by President Clinton in 1996 to end so-called frivolous lawsuits, puts a two-year limit on court orders concerning prison conditions and requires the approval of a three federal judges before orders can be imposed that address prison overcrowding. The law also eliminates "poor-person" status for inmates who file cases, requiring that all inmates pay a $120 filing fee.
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