Letters

Patients with tuberculosis can be managed effectively in the community

EDITORCoker observes that the urgency of the response to tuberculosis reflects how society views those on its margins.¹ In contrast, a recent report from New York stated that, despite a reluctance to impose restrictive measures of mandatory directly observed treatment, over 3% of patients with tuberculosis (over 200 patients) between 1993 and 1995 did receive regulatory orders.² These are two diametrically opposed positions to the public health response to the same disease.

In New South Wales, Australia, public health orders can be imposed under the Public Health Act 1991. Yet in over eight years, not a single order has led to a patient with tuberculosis being imprisoned. Notifications of over 500 cases of tuberculosis per year mean that over 4000 cases have been effectively managed in the community. Community based services have been able to manage every case of tuberculosis, using clinic based nurses with minimal involvement of medical staff; standardised treatment according to health department protocols; and directly observed treatment, which has been practised for over 30 years. Thus costs have been contained and levels of drug resistance have remained low.³

Rather than investing in a good public health system and well resourced community based services, the United States seems to be using "deprivation of liberty" to solve not only its social problems⁴ but also its tuberculosis epidemic. This is an abuse of human rights and makes no sense in terms of public health.

Introducing cases of active tuberculosis into the closed environment of a prison is inherently dangerous. High levels of mobility within prisons, and between prisons and the community, facilitate transmission of tuberculosis between the community and prisons (in both directions) and create the situation in which epidemics in prisons occur.⁵

London ought to be looking to effective programmes rather than copying yet another American mistake.

Michael H Levy, director. 
Population Health, Corrections Health Service, PO Box 150 Matraville, NSW 2036, Australia

Garth Alperstein, area community paediatrician. 
Central Sydney Community Health Services, Camperdown, NSW 2050 Australia alpersteing{at}phu.rpa.cs.nsw.gov.au