For anyone who missed the news, Florida has a public health problem of disturbing potential. July 8, the Palm Beach Post broke the news that Florida is in the middle of the worst TB outbreak CDC has seen in 20 years - and it's not contained. Further, the state sat on news of the outbreak, and further compounded the problem by slashing the budget of the state health department and closing the one hospital in the state dedicated to treating tuberculosis.
There has been some mention of the outbreak at Daily Kos already in previous days, but it's worth taking another look as this story develops. It's starting to get a little more attention in the press, but not as much as it should be getting considering that the role of government in health care is supposed to be a big issue in the race for the White House. Florida is a rather painful object lesson on just how wrong conservatives are about this (like so many other things.)
Tuberculosis is an extremely contagious disease that can be fatal. Treatment requires strict adherence to a course of antibiotics over a period of months - and is not alway possible as strains develop that are antibiotic-resistant. It thrives among those with the least access to healthcare, in substandard housing and crowded conditions - but it doesn't stay there.
More below the Orange Omnilepticon.
The Palm Beach Post report broke open a public health crisis that has been simmering since 2008, exacerbated by an official response that kept it under wraps, and further worsened by cuts in public health services. The initial Palm Beach Post report is devastating.
JACKSONVILLE — The CDC officer had a serious warning for Florida health officials in April: A tuberculosis outbreak in Jacksonville was one of the worst his group had investigated in 20 years. Linked to 13 deaths and 99 illnesses, including six children, it would require concerted action to stop.emphasis added
That report had been penned on April 5, exactly nine days after Florida Gov. Rick Scott signed the bill that shrank the Department of Health and required the closure of the A.G. Holley State Hospital in Lantana, where tough tuberculosis cases have been treated for more than 60 years.
The state government has been in damage control mode ever since.
Florida’s Department of Health Tuesday defended its response to the outbreak, saying it immediately called the CDC for assistance when it noticed a “slight” uptick in cases. Further, said Harris in a written statement, the department re-formed a Jacksonville task force on TB, “a clear sign that these actions were conducted with the utmost level of transparency.”The rationale about not being concerned because the initial outbreak was limited to people in homeless shelters, and not the general population does not bear scrutiny.
In an interview with News Service Florida, Harris said the cases did not pose a public health hazard because exposure was largely limited to people in homeless shelters. “That population is very contained, they are not really mixing with the general population, so that’s why we have not felt the need to do widespread notification to the public,” he said.
Treatment for TB can be an ordeal. A person with an uncomplicated active case must take a cocktail of three to four antibiotics – dozens of pills a day – for at least six months. The drugs bring serious side effects – stomach and liver problems among them. But failure to stay on the drugs for the entire treatment often causes drug resistance.emphasis added
The homeless, drug-addicted and mentally ill at the core of Jacksonville’s outbreak are almost impossible to keep on their medications. Last year, Duval County sent 11 court-ordered patients to A.G. Holley, where they were required to stay and be monitored until the bacteria disappears from their systems.
State officials should not be complacent, cautions Dr. Eric Nuermberger, an associate professor of medicine at Johns Hopkins University School of Medicine’s Center for TB Research in Baltimore. That’s partly because the CDC believes roughly 3,000 people were exposed – and TB can lie dormant for years before showing up in statistics.
Forbes Magazine has a scathing editorial about Governor Rick Scott and the policies - Unleashing An Epidemic: Florida Gov Rick Scott Shows The Folly Of Cutting Safety Net Hospital Funding:
Scott’s cavalier approach to public health is dangerous. He’s already proven, through his actions, that health care is less important than the hurt feelings of gun rights extremists, private equity funds’ returns, and manufacturers of pain pills. And now added to that list are the lives of vulnerable TB patients and those who are exposed to their disease.Rick Scott has been emphatic in his opposition to the Affordable Care Act and is refusing to expand Medicaid or set up insurance exchanges. It's all the more telling that as a CEO in the for-profit healthcare industry, Scott had no problem collecting huge payments from Medicare - including payments that were found to be felony fraud.
Across the country, states are contemplating similar decisions. It’s easier to cut a safety net hospital, which has little voice in state capitals, than it is to cut payments to pensioners or teachers that have strong constituencies. But these facilities are still needed. Even with the ObamaCare’s imminent implementation, there will still be 25 million uninsured people (see table 3 in this CBO report), many concentrated in states like Florida and Texas that have large immigrant populations. De-funding these institutions–or forcing them to be sold to private investors, as Scott has recently been advocating–is very short-sighted. And it shouldn’t take tuberculosis epidemic to recognize that fact.
The news out of Florida continues to be less than good. Although state officials have been trying to portray the outbreak as limited, the particular strain of this TB outbreak is turning up across the state.
Although state health officials maintain the outbreak is now mostly contained within the Jacksonville homeless, a state database obtained by The Palm Beach Post on Friday showed sick people with FL 046 have also popped up in 17 other Florida counties. About 23 percent of all FL 046 cases have occurred outside Duval County, analysis suggests, and most of those have been identified in the past two years.emphasis added
Judging by the map at the link above, the state of Georgia had better be doing surveillance of its own.
The ongoing situation in Florida has attracted the attention of the Threatwatch team at New Scientist. They put the outbreak in perspective:
This tells us two important things. Firstly, a lot of TB could be spreading under the radar elsewhere in the US health care system. Florida actually analyses more TB DNA than most states. Despite efforts to fix US healthcare, the sluggish economy means 40,000 jobs in US local health departments like the one in Jacksonville have been lost since 2008, and nearly half expect more cuts. Similar cuts seem likely outside the US too, as economic woes deepen.emphasis added TB anywhere is TB everywhere.
Secondly, TB anywhere is TB everywhere. Florida officials say they didn't alert the public to the outbreak as they didn't want to subject homeless people to further stigma. Fair enough, but this outbreak may not be limited to the homeless: the CDC found no history of homelessness, jail or drug use in 21 of the 99 cases it found. In 29 cases, the CDC could not trace the source of infection to the homeless community.
Meanwhile, TB among the homeless does not remain there. Such outbreaks, as in New York in the 1990s, breed drug-resistant TB as it is hard to ensure marginalised people stay on their medication for months. Every new resistant case makes the global epidemic harder to fight.
If the Palm Beach Post doesn't get a Pulitzer for their coverage of this story, there's no justice in the world. The amount of money 'saved' by budget cuts under Scott are going to be dwarfed by what it is going to cost to bring this outbreak under control. And it could get much worse. If this story continues to develop, look for Florida to take a major hit to its tourism industry, not to mention the toll in lives. Any Democrat afraid to stand up for the Affordable Care Act need only point to Florida to show America the Republican alternative.
Wed Jul 18, 2012 at 4:30 AM PT: UPDATE: The New York Times has an editorial today detailing just how determined Republican governors are when it comes to their War on the Poor. What's happening in Florida may end up just being the prolog to a much larger public health problem. The voting booths of America should come with a mandatory health warning label next to the names of Republican candidates.