On the precipitous rise of Hep C in our prison population, due to dirty needles. Wouldn't a clean needle exchange be in order here, not to mention national treatment guidelines?
August 6, 2001
A Health Danger From a Needle Becomes a
Scourge Behind Bars
By DAVID ROHDE
rison officials say that nearly 10,000
inmates in New York and thousands
more across the country are infected with
hepatitis C, an insidious liver infection that is
difficult to treat, has no definite cure and,
over many years, kills 5 percent of those
who contract it.
Prison and public health officials are
wrestling with how to respond to the
surprisingly high rates of infection, trying to
figure out how to contain its spread, and
how and when to provide expensive
treatment that in most cases does not work.
Some states are treating hundreds of
prisoners infected with hepatitis C, while
others are treating none.
And beyond concerns about how to manage
the problem inside the prisons — guards, for
instance, fear being infected through contact with inmates' blood — health
officials worry that prisoners may spread hepatitis C through intravenous
drug use when they are released.
A study to be submitted to Congress this fall estimates that 18 percent of
state prisoners nationwide — or about 360,000 inmates — are infected with
the virus.
"There are still legitimate scientific questions about who the treatment will
ultimately benefit," said Dr. Robert Greifinger, a senior fellow for the Centers
for Disease Control and Prevention in Atlanta, who conducted the study for
the Justice Department. "On the other hand, the infection rates are very, very
high. I just don't think it's very clear yet how to manage the problem."
Dr. Greifinger based his study on projections from several state studies.
Many states are just starting to survey inmates for the infection.
In New York, a first-ever survey recently estimated that 14 percent of the
state's 69,000 prisoners have hepatitis C. In Pennsylvania, about 17 percent
of the state's 36,500 prisoners are infected. In Connecticut, the rate is
believed to be 15 percent of 17,500 inmates. New Jersey has not broadly
tested for the virus.
The Northeast is hardly alone in grappling with the problem. In California,
officials estimate that 33 percent of the state's 161,000 prisoners have
hepatitis C. In Texas, 28 percent of the state's 157,000 prisoners are
believed to be infected.
"It's simmering and brewing and if it boils over, the medical costs will be
catastrophic," said Dr. Frederick R. Maue, chief of clinical services for
Pennsylvania's Department of Corrections, which is actively treating infected
inmates. "There will be liver transplants, multiple hospitalizations to treat liver
failures, and increased numbers of deaths."
Doctors say the problem is not that large numbers of prisoners are
contracting hepatitis C while incarcerated; most were infected through
intravenous drug use and shared needles years ago. It is that the infection's
breadth and power are only now becoming clear.
New screening tests developed in the early 1990's have found that far more
people are infected than was ever expected, although many people who
contract it suffer few ill effects. But some people who were infected as long
ago as the 1960's are dying today, underscoring the fact that the disease can
prove fatal over the course of 20 to 30 years.
Hepatitis C causes liver disease in 20 percent of its victims, and eventually
kills 5 percent of those infected. Doctors describe the infection as more of a
potential medical time bomb than an immediate public health threat. Roughly
2.7 million people in the United States have the infection, which is
responsible for 8,000 deaths a year.
Hepatitis C is a blood-borne virus that can linger for years without
symptoms. Aside from intravenous drugs users, hundreds of thousands of
other people are thought to have contracted the virus from blood transfusions
before better screening began in the early 1990's.
Vaccines exist for two other hepatitis viruses. Hepatitis A, which can be
transmitted by food, food handlers and water, rarely kills those it infects.
Hepatitis B is a sexually transmitted disease that kills 5,000 people a year.
The infection rate among the general population for hepatitis C is far lower
— 1.8 percent — than in prisons. Doctors believe that the infections are
concentrated among inmates because of their high rate of intravenous drug
use before being jailed.
The infection may also be gradually spreading in prisons. Studies show that 3
percent to 21 percent of inmates say they engage in intravenous drug use
behind bars. Forty- four percent of those who reported drug use said they
shared needles.
The infection's death toll is rising and is expected to grow steadily over the
next 10 to 20 years. In New York prisons last year, where $71 million was
spent to treat roughly 1,400 inmates with AIDS, eight inmates died of that
disease. Nine died of illnesses related to hepatitis C.
The question of how best to treat the infection has provoked debate in
medical circles. Expensive new drug treatments, costing $10,000 to $25,000
per patient annually, show signs of curbing the infection, but are effective in
only 15 percent to 45 percent of cases, and sometimes make patients sicker.
States are responding differently to the problem. In New Jersey, for instance,
no prisoners are currently being treated, but in Pennsylvania, 417 prisoners
are. New York is treating 95 prisoners at a cost of about $6 million a year.
Inmates in various states, including at least five in New York, are suing
prison systems and claiming that they are being denied treatment. Last year,
a federal judge in Kentucky ordered prison officials to treat an inmate at a
cost of $25,000 a year. Kentucky prison officials had not provided
treatment, saying it was unlikely to be effective.
The case of Edward McKenna, 55, a New York prisoner dying of the
infection, shows the charged debate surrounding hepatitis C. Mr. McKenna,
an inmate at the Woodbourne Correctional Facility in Woodbourne, N.Y., is
suing the state, accusing prison doctors of denying him treatment that could
save his life.
"In a roundabout way, they're telling me I'm going to die and that's the way it
is," said Mr. McKenna, who expects to live only two more years at best.
"They won't treat me."
In 1990, Mr. McKenna shot his younger brother during a backyard
argument in Bay Ridge, Brooklyn. The murder, which he called an accident,
led to a prison sentence of 10 to 20 years.
In July 1999, Mr. McKenna was diagnosed with hepatitis C, something he
believes he contracted while injecting drugs when he was an Army private
stationed in Thailand in the early 1960's.
Mr. McKenna said he asked for treatment in September 1999, but a prison
doctor told him he was not eligible because he had an appearance coming up
before the Parole Board within a year. New York, like other states, follows
guidelines from the National Institutes of Health that say only people who will
be available for a full year of intensive care should be treated. Otherwise, the
treatment is ineffective.
But when Mr. McKenna appeared before
the Parole Board a year later, he, like 80
percent of violent offenders in the state, was
denied parole and given two more years in
prison.
Jack Beck, a lawyer for the Legal Aid
Society who is advising Mr. McKenna, said
that prison doctors used Parole Board
appearances as a pretext for denying them
the costly treatment. In a medical document
provided by prison officials, a doctor wrote
that Mr. McKenna did not qualify for
treatment because his earliest anticipated
release date was his Parole Board
appearance.
But Mr. Beck said the expiration of an
inmate's sentence should be used when deciding on treatment because the
chances of a violent offender being paroled were slim.
"It's definitely a rationing protocol," he said, referring to New York's rules for
deciding whom to treat. "It's very expensive and they clearly don't want to
treat people."
Dr. Lester N. Wright, chief medical officer for the New York Department of
Correctional Services, said the state's procedures met national standards,
and that prison doctors did not use inmates' Parole Board appearances to
deny treatment. "I usually look at the conditional release date," he said,
referring to the expiration of a prisoner's sentence. "We don't know what the
Parole Board will do."
Prison officials produced a document on Thursday from Mr. McKenna's
medical record that quoted him as telling a doctor he did not want treatment
for hepatitis C. Mr. McKenna, they added, also had to be counseled to take
medication for severe emphysema, and was a poor candidate for hepatitis C
treatment.
Mr. McKenna denied both claims and cited 10 documents in his medical
record that he said supported his version of events. When asked to provide
copies of the documents on Friday, prison officials said they did not have
enough time to locate them.
Mr. McKenna's infection has progressed to full-blown liver disease. Most
doctors agree that once the disease reaches that level there is no point in
treating it. Mr. McKenna says he is willing to try anything at this point. He
has lost 50 pounds.
"As long as I'm breathing, there is always hope," he said.
The men and woman guarding Mr. McKenna also fear the infection. Officials
with the state's correction officers' union say that a half-dozen officers have
recently reported being infected by prisoners. They say officers may not
make their infections public for fear of being stigmatized by co-workers.
Prison officials say only one guard has reported being infected, and there
was no evidence that an inmate was the cause.
Glenn S. Goord, New York's commissioner of correctional services, said the
state was addressing the problem aggressively, as it has with other medical
problems. "We're committed to providing the best constitutional and
community standards as we can," he said, referring to treatment. "The
governor has asked me to do whatever is appropriate to protect my inmates
and my staff."
Doctors say that having so many people infected with the virus incarcerated
creates an opportunity for education. Before returning to the community,
inmates must learn how not to infect others.
But the debate over the costly new treatments continues. New national
treatment guidelines are due out this fall.
Dr. Anne S. De Groot, a Connecticut prison doctor and editor of a
newsletter on infectious disease in prisons, said prisoners with identical
illnesses were being treated differently in different states. "If you're in
Pennsylvania you will get treated, but if you're incarcerated in other states in
the Northeast you will not," she said. "It's ridiculous we don't have a
standardized approach." |
