McCain and Congress should lead fight against drug-resistant TB

Just below the media radar in early April, Sen. John McCain (R-Ariz.) pressed Department of Homeland Security Secretary Jeh Johnson to prevent the release from Immigration and Customs Enforcement (ICE) custody of an immigration detainee diagnosed with drug-resistant tuberculosis. McCain did so on behalf of Pinal County, Ariz., which faced staggering medical costs to treat the patient and to prevent further spread of a dreaded and difficult to treat disease.

{mosads}Now, ICE has capitulated. The man will not be released; the federal government will continue to pay for his care while he is in ICE detention. The Pinal County director of public health was right to be concerned: Drug-resistant tuberculosis can require 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.

The one-off solution was a win for Pinal County, and it was likely in the best interest of the detainee. We don’t know the man’s immigration status or why he is in detention. We do know his case is not an isolated event but is likely to recur. At some point, detention ends. A sick detainee who wins his or her appeal is cast upon the nation’s fragmented public health system, often disproportionately based upon the location of the holding facility. When those persons are released, the federal government provides no follow-up care, even for those who present serious public health threats.

But the question of who pays is a much larger problem than the relatively low number of persons with tuberculosis held in ICE facilities. Local health departments face the same costs when prisoners are released, when residents of one state or county relocate to another, and in homeless and other vulnerable populations. For any number of reasons, a local health department might enlist its congressional delegation to find federal money for persons it does not believe it should support.

Tuberculosis is 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. Although foreign-born individuals account for two-thirds of new cases in the U.S., we are wrong to worry only about the undocumented. School children and health workers are more likely to contract the disease from a U.S. citizen than from a non-citizen.

Medical professionals are deeply concerned about the potential for epidemic, drug-resistant tuberculosis in the U.S. While tuberculosis rates have declined in the United States in the last decade, a worrisome number of drug-resistant cases have emerged. 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.

To make matters worse, those without legal status (an estimated 11 million persons) are excluded from ObamaCare, even if they could afford to pay for it. Access to basic healthcare protects everyone’s health, yet we intentionally exclude non-citizens from the social safety net.

McCain and Congress have an opportunity to broaden the fight against drug-resistant tuberculosis to include all vulnerable populations in the U.S. This requires federal money. We rely on local public health departments and their workers to control outbreaks. Many health departments are seriously underfunded and will require a substantial increase in local tax revenue to fight tuberculosis.

In 1988, the Institute of Medicine concluded that the U.S. public health system was “in disarray.” Since that time, improvement has been minimal. Funding for each of these is dependent upon the local political process. Many health departments are seriously underfunded and will require a substantial increase in local tax revenue to fight tuberculosis.

The need for federal coordination to control tuberculosis is not a new idea. A 2008 Government Accountability Office (GAO) report highlighted the need for greater cooperation between the U.S. Department of Health and Human Services (which directs the U.S. Public Health Service) and the Department of Homeland Security whenever a traveler with drug-resistant tuberculosis crosses into the United States. The GAO concluded that federal resources were insufficient.

Congress should appropriate additional funds to cover the costs of tuberculosis treatment that are now borne by local health departments. The Centers for Disease Control and Prevention also need more money to take on the responsibility of locating and monitoring tuberculosis patients who move from one jurisdiction to another, since many local health departments do not have the ability to do so. Drug-resistant tuberculosis may be the least of our public health challenges. Antibiotic drug resistance of all kinds struggles for national attention.

At least for drug-resistant tuberculosis, we know that without adequate funding, the potential spread of tuberculosis at epidemic levels is all but certain. Sen. McCain is right that costs of treatment and prevention should be a federal obligation, but not simply as a one-off solution to an isolated case. This problem is too costly to ignore.

This piece has been revised.

Price is professor of law at Emory University School of Law, where she is affiliated with the Emory Antibiotic Resistance Center.