As Tuberculosis (TB) kills more than 1.8 million people worldwide each year (Lantos-Hyde 3). This, combined with the high rate of US immigration from high burden countries there is a need for policies to control the spread of the disease. Funding for prevention and treatment has been increased, however, there are different opinions about the effectiveness of the government’s approach. The below policy analysis is designed to provide an overview of the US laws, policies and guidelines and their potential benefits.
- PROBLEM DEFINITION
There are different obstacles determined by the CDC Report (3) regarding preventing the disease. These are: the high infection rate of foreign-born US citizens, delays in detection, large population of the country and the fact that when statistics are declining the focus of the health care moves to other, urgent issues. However, it is evident from the report published by The Centers for Law and The Public Health (8) that the prevalence of the disease is higher in high risk population. Therefore, the policies should focus on the groups of the society that are the most vulnerable and are most likely to have a latent disease based on statistical data. The current law and health policies, intervention plans treat the population as a homogeneous group, while from the research it is evident that there are some groups that should be targeted more by screening programs than others. The current recommendations of the The Centers for Law and the Public’s Health (9) and interventions are focused on detection, reporting, protection of close relatives, identifying the high risk population and infection-control. The study also talks about the limitations of the government’s powers, due to privacy laws. Also, the State and Local General Communicable Disease Control Law (16) focuses on reporting, testing, screening, vaccination, treatment, therapy, detention and isolation. While it seems like an effective model, it is important to note that there is no reality in identifying high risk population members and testing them for TB separately without facing legal challenges related to discrimination and being labeled as “racist” or “exclusive”.
The five-year plan of the US Government Tuberculosis strategy and program have different goals between 2009 and 2014 (Lantos-Hyde 4):
a, To reduce the number of TB deaths by 50 percent from 1990 records
b, Increasing the detection rate for over 70 percent
c, Successful treatment of at least 85 percent of cases in countries where TB is a known epidemic concern
d, Multilateral approach to treatment and detection, treatment of minimum 57,200 new MDR-TB cases by 2014
While it is important to increase detection and treatment rates, prevention within the Lantos-Hyde policy is only restricted to detecting cases and multilateral approach. It is almost impossible to reach out to countries and gain collaboration in health programs. Corruption and different political structures are in the way of development. While the Lantos-Hyde project is designed to “Encourage country ownership and invest in country-led plans” (5), the project’s success is not guaranteed and the investment in health awareness and monitoring programs abroad might not return. On the other hand, the The Centers for Law and the Public’s Health report (9) mentions that there are several multi drug-resistant and extensively drug-resistant cases. As mentioned above, there are different groups of the society that are at an elevated risk of getting infected. While it is important to maintain equal protection of residents, procedural due process and substantive due process (Fifth and Fourteenth Amendment), it is also important to protect the non-infected and high risk population from the disease. (CDC 14)
While today the policies focus on detection and treatment, prevention is not highlighted in any of the policies examined at a rate that it would provide adequate protection for the population of the United States. As the Lantos-Hyde document has confirmed, there are some groups that are more at risk of carrying the disease and getting in contact with the virus. Prevention of the epidemic, even when the number of cases decline could be easily set up by focusing on this population. Introducing tests for immigrants who come from a high risk country would not affect their individual rights, but protect the rest of the population. It would also be in line with the government’s goals to increase early detection rates. While this screening would possibly be considered selective, it would reduce the cost of the preventive programs, increase detection rate and protect residents of the country. Likewise, those at high risk, such as HIV infected individuals living in the United States, medical and nursing staff getting in contact with the disease would also be screened. For this program, there would be a need for determining high risk groups, population and different risk factors. Research might be concluded on the demographic features of those living with TB, in order to justify selective screening programs. This way the policies constructed would not be based on random selection but backed up by the results of scientific research.
Setting measures for measuring the new approach’s success rate is a challenge. Looking at the original goals and objectives of the original US policies for TB prevention and reduction would be a good starting point. Measuring early detection rate, number of infections, successful treatment rate would be useful. However, there is another measure that is not included in the original policy, and this is developing treatments; second-line drugs and those that work on the treatment plan of drug-resistant cases. According to the The Centers for Law and the Public’s Health report (4),
“an estimated 9.6–14.9 million persons residing in the United States have LTBI (39). This pool of persons with latent infection is continually supplemented by immigration /from areas of the world with a high incidence of TB and by ongoing person-to-person transmission among certain populations at high risk.”
Determining risk factors for infection can be developed using the The Centers for Law and the Public’s Health report’s data. The report lists high-risk groups as follows:
a) foreign-born persons
b) HIV positive individuals
c) at risk children
d) residents of correctional facilities
e) homeless population
Further, exposed persons’ characteristics are also described in the study:
a) homeless shelter workers
c) medical staff
5. OUTCOME PROJECTION
Changing the policies from general screening and prevention to a focused approach plan of action would mean that the cost of controlling and reducing TB in the United States would be reduced. While the Lantos-Hyde report focuses on “going out” to high risk countries and developing strategies to prevent the disease, there is no guarantee that these efforts would have a measurable positive affect on the US population’s TB infection rate. By using the statistical data in the CDC report and the recommendations, the cost of screening, prevention would be only a fraction of the cost of creating multilateral programs. However, the goals of the 5-year plan would be achieved while money could be spent on education of high risk persons, developing second-line drugs and new treatment methods for those with drug-resistant viral infection. Early detection would reduce treatment costs and the burden of the healthcare industry alike.
By implementing the strategy described above, the government could further reduce the number of diagnosed cases by up to 70 percent by 2017, while the selection of people to be screened would be backed up by medical research.
It is, however, important to note that the new policy would trigger some debates in the US regarding individual rights, and privacy law needs to be considered. Amendments in the legal system would be needed to allow the automatic screening of foreign-born nationals entering the country the first time. It is possible that the selective screening of foreign-born people already living in the country would not be possible due to the current Migration and Neutralization Clauses (CDC) While currently “ICE does not invoke this latter power as a matter of policy. Rather, denials of admission or removals of undocumented persons who cannot prove their TB status are based on the lack of documented proof in support of their entrance in or existence within, U.S. Borders”, (19) the legislation is already in place and the power of the policy needs to be revoked. This would not need creating new legislation only strengthening the existing one, therefore, no additional resources are needed for this aspect of the approach.
By focusing on high risk population in the United States, it is possible that the efforts of the multilateral programs would be weakened. The detection rate among non-high risk population would also be reduced, while the overall statistics would improve. Still, it is important to note that while the policies would focus on the social and ethnic groups more prone to getting infected with the virus, this acts as a preventive method for the rest of the population as well. The lower the number of cases in per a hundred thousand people in the United States, the less likely it is that the virus will spread among low-risk population. Overall, the new approach would carry a benefit for the whole of the US population; protecting both high risk and low risk people. Some arguments would be created based on the cost of research determining the high risk population, however, historical data and statistics is already available for analysis.
- CONSIDERATION AND DECISION
While some changes and new partnerships need to be created in the US policy for TB prevention and treatment, it is evident that higher results could be obtained with a lower investment. Decision-makers would face various obstacles; such as the declining rate of new TB infections in the United States, lack of interest from politicians and health care professionals. However, any type of cost-reduction program combined with higher effectiveness, if argued correctly can be impressive in a post-recession country. Money can still be spent on helping other countries detect and eliminate TB epidemics, according to the Lantos-Hyde program, however, the main focus of the government should be the protection of its own residents. While the vulnerable population can easily be determined based on studies and statistics, the prevention of the infection among the rest of the residents will also be provided. Lower overall rate of TB infections carries lower risk for the rest of the population. The strengthening of border forces’ authority, setting up screening upon entering the country might carry a larger than expected expenditure. That is why it is important to review the costs, projected benefits and results before creating a detailed plan.
- RECOMMENDATIONS AND REFLECTION
The US Tuberculosis policies reviewed within this paper seem to answer one question and neglect another one. They answer the question: “What we would like to achieve” but do not provide a clear idea for “How we want to get there”. It would be extremely useful if a discussion forum was developed within the country among Tuberculosis experts in the medical field, professionals who are in day-to-day contact with high risk population, charities, politicians and health care organizations This way research can be concluded with the support of all parties, existing legislation and policies would be taken into consideration and all the issues related to TB would be addressed. A higher detection rate would call for advanced and cost-effective screening instruments that are safe to use. Further research of high risk groups would also help experts determine the right treatment, prevent infection based on the most common ways the virus spreads. Therefore, in order to understand the illness, the most effective treatments, find alternative solutions for drug-resistant cases would also be possible through collaboration between groups affected. Taking the CDC report (The Centers for Law and the Public’s Health) further, inviting the authors for a TB symposium would be the first step of the process and could result in dramatic decrease of new cases by 2017.
Lantos-Hyde United States Government Tuberculosis Strategy. (2010) Web.
CDC. Tuberculosis Control Laws and Policies: A Handbook for Public Health and Legal Practitioners. (2009) Web.
Centers for Disease Control and Prevention. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005;54 (No. RR-12): Print. (CDC1)