Experts have long known that prisons are incubators for disease. Some diseases such as H.I.V. and hepatitis C are by some estimates ten times more common in prison than in the general population [PLN, June 2003, p.10]. Yet the health care of prisoners is typically of little or no concern to the public, many believing that prison health issues don't directly affect anyone but the prisoners. The harsh reality, however, is that prison health issues affect everyone, both inside and outside the walls.
The prevalence of confirmed AIDS cases in prison is three times that of the general population, according to the Bureau of Justice Statistics (BJS). The BJS cites the rate of H.I.V. infection as 1.9%, but that figure is questionable since only 19 states conduct mandatory H.I.V. testing. Most experts believe the rate is much higher. Moreover, in the decades that AIDS has spread, the prison population has also ballooned to more than 2.1 million. Now, with roughly 600,000 prisoners reentering society each year, scientists are beginning to view imprisonment rates and H.I.V. transmission as intertwined epidemics that require combined prevention and treatment strategies.
Many of these studies focus on African-Americans who, according to the BJS, represent 40% of the U.S. prison population. The Centers for Disease Control and Prevention (CDC) says that African-Americans now account for more than 50% of all new H.I.V. infections and that African-American women account for 72% of new cases among women. But this issue is not confined to the African-American community. In states where the majority of prisoners are white, the same scenarios play out.
According to researchers, high rates of imprisonment increase risk behaviors associated with H.I.V. because it worsens economic conditions, skews the ratio of men to women, and increases the social value of men who are not in prison. H.I.V. is an opportunistic disease that thrives on disruptions of social networks," says Dr. David Wohi, an infectious disease specialist at the University of North Carolina. You can hardly get more socially disruptive than removing double-digit percentages of men from communities for extended periods of time.
The problem is exacerbated because the two factors known to increase the risk of H.I.V. transmission--unprotected sex and drug use--are not adequately addressed in prison. Sex between prisoners is not as common as many people believe, but it does happen. And since most prisons ban condoms, any sexual activity is risky. Add to the mix drug addiction, which frequently goes untreated in prison, and the risk increases exponentially, says Robert E. Fullilove, associate dean at the Mailman School of Public Health at Columbia University. The war on drugs took the group that was at greatest risk for H.I.V. infection and made sure that they would be locked up, without ever considering what to do when they got out," said Fullilove.
Hepatitis B is another potential killer lurking in the nation's prisons. In Georgia, for example, a study by the state Department of Human resources conducted between 1999 and 2002 found that 92 prisoners were infected with the disease. On closer examination of 57 of the cases, officials determined that 75% had been infected while in prison. Like H.I.V., the disease can be transmitted through unprotected sex, reused tattoo needles, and shared syringes. Most people fully recover from hepatitis B, but roughly 6% develop a chronic infection that can lead to liver cancer or end-stage liver disease, said Dr. Cindy Weinbaum of the CDC's viral hepatitis prevention branch.
Vaccinations are obviously needed. Not only might infected prisoners spread the virus upon release, but the expense of treating complications associated with the disease is passed on to the public. Thus, the CDC notes that, Implementation of [vaccination] programs in correctional settings nationwide could result in a considerable reduction in the hepatitis B-associated disease burden.
Even so, most states have no program to vaccinate prisoners. Georgia is one example. Prison officials there said they would vaccinate incoming prisoners if the money was available. Absolutely it's a good idea primarily because 350 inmates are released every week from a Georgia prison and come back home," said Brian Owens, executive assistant to Georgia Corrections Commissioner James Donald. But apparently prevention is not a concept Georgia legislators are familiar with. In 2001 they turned down prison officials' request for $1.3 million to vaccinate the 16,000 prisoners arriving annually and to vaccinate existing prisoners over a 3-year period.
Sometimes prison health issues affect the public in unexpected ways. In late June, 2004 five prisoners at the Ironwood State prison in California contracted botulism. Treating them wiped out antitoxin reserves for the entire southwestern United States. The prisoners apparently contracted the illness from a compromised batch of pruno, an alcoholic drink made by fermenting potato peels, fruit scraps, and bread crumbs.
Contracting botulism from food is rare but potentially lethal. However, early administration of botulism antitoxin--which is stored at U.S. Public Health Service quarantine stations at eight international airports, including Los Angeles International--can limit, though not reverse, neurological damage, according to the CDC. The Los Angeles station typically keeps at least 10 doses in stock, but had only 3 when Riverside County health officials called to request the 5 doses needed to treat the prisoners. The rest had to be ordered from the quarantine station at San Francisco International Airport.
Between 1990 and 2000, 263 people in the U.S. contracted food-borne botulism, resulting in 11 deaths, the CDC said. None of the Ironwood prisoners died, though one or two of the sickest had to be transported to the hospital by helicopter. All told, the prisoners' medical care cost more than $352,000, said Ironwood Prison Lt. Dale Dorman.
But at least they received treatment. For prisoners infected with hepatitis C, widely considered the most serious of a family of liver viruses, treatment is typically not available. Most prisons refuse to treat the disease due to the high cost, which typically runs between $25,000-$35,000 per prisoner [see PLN May 2004, p.1].
Fortunately, a vaccine for this often fatal disease may be on the horizon. According to researchers, roughly 20% of people with the virus spontaneously eradicate it from their bodies. One reason may be that their immune systems attack the virus quicker. So-called natural killer cells stand ready in the body to attack invading viruses. But between infections, inhibitory receptors called KIRs keep them in check, ensuring they don't attack healthy tissue. The researchers located a particular gene combination that controls one KIR receptor, then discovered that the molecule attached to it was twice as common in recovered patients than in those still infected. Researchers plan to exploit this gene in the search for a vaccine. Dr. Chloe Thio of John Hopkins University explains that when the body detects a viral infection it must activate the killer cells by turning off inhibiting receptors. This KIR combination appears weak, so it's easier to overcome," she said.
The new research, reported in the journal Science on August 5, 2004, won't benefit patients anytime soon, but It brings us closer to understanding how the virus works," said Thio, who coauthored the study. In the long term, whether we can use this information to modulate the body's immune system to improve therapeutics or vaccine design--that is the ultimate goal," she said.
Hepatitis C results in about 10,000 to 12,000 U.S. deaths annually. Currently, between 3 million and 4.5 million people in the U.S. and about 180 million worldwide remain chronically infected, at risk of eventually developing liver cancer or experiencing liver failure. Of the U.S. total, nearly one-third are prisoners. Most will simply be dumped back into society, untreated and uneducated about the disease, a ticking time bomb inside them. And society will pay the cost--in money, in misery, in lives. Obviously, prison health issues do affect everyone.
Sources: New York Times, Atlanta Journal-Constitution, Press-Enterprise
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