Alabama pays town’s residents to undergo TB testingBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i706 (Published 05 February 2016) Cite this as: BMJ 2016;352:i706
The US state of Alabama, struggling to gain control of a tuberculosis epidemic around the small town of Marion, has discovered more than 100 infections after offering money to citizens to undergo testing and treatment.
With a population of under 4000, the town’s active tuberculosis case rate has been around 100 times the state and national average, at 253 per 100 000 population. But efforts by the state’s public health department to trace potential contacts and persuade residents to get tested have met with suspicion and hostility.
“We had a very, very poor turnout,” Pam Barrett, director of the tuberculosis control division, told a local news outlet, AL.com.1 She said that, at one state sponsored health fair last year, “people threw beer bottles at us.”
The pervasive mistrust of government health workers among the area’s predominantly African-American community is founded in hard experience. Marion’s neighbor to the east, Tuskegee, was the site of the United States’ most infamous medical study, the Tuskegee syphilis experiment.
In that study, under the guise of offering free healthcare and burial insurance, federal public health researchers studied the natural progression of untreated syphilis in 600 black sharecroppers. The men were not informed of their disease or given penicillin to cure it. The long running study was halted for ethical reasons only in 1972.
The town’s fraught relationship with the public health system was again highlighted last October, when a visiting circuit judge told defendants awaiting trial and sentencing at Marion’s courthouse that they could pay their fines and avoid jail time by donating blood for reimbursement to a collection van outside the courtroom.
“If you do not have any money and you don’t want to go to jail, consider giving blood today and bring me your receipt back,” said the judge, Marvin Wiggins—“or the sheriff has enough handcuffs for those who do not have money.”
R Allen Perkins, former president of the Alabama Rural Health Association, told the New York Times, “There is a mistrust of government medicine because of Tuskegee. It dates back to that. We haven’t dealt with the damage of Tuskegee in this state at any meaningful level.”2
Barrett told AL.com, “In my 21 years in TB, I’ve never seen anything like this. People just are not willing to give information to our staff.”
Two tuberculosis deaths in Marion late last year prompted the state to redouble its efforts to get the townspeople tested. But uptake was low until mid-January, when health authorities announced cash rewards. Financial incentives for treatment have been offered by US public health authorities before, but never to a whole town.
For the past two weeks any resident of Marion or the surrounding Perry County has been eligible for $20 (£13.80; €17.90) for being tested, $20 more for returning to collect the results, $20 more for attending a chest x ray if referred, and $100 for completing any recommended course of treatment.
The public office where testing is carried out has been full ever since, with patients lining up before opening. When the offer ended at the start of February, the office had tested 1831 people and had found 100 latent tuberculosis infections and one active, contagious case.
Last week Marion’s plight drew the attention of the United Nations’ special envoy on tuberculosis, Eric P Goosby. “While most people think of TB as a disease that does not affect the US, Marion, Alabama is experiencing a TB outbreak that is worse than in many developing countries,” he said in a statement. “Unfortunately, in many areas of the country, funding for community education and outreach on TB by local health departments is scarce or non-existent.”
In October the World Health Organization announced that tuberculosis had become the top infectious disease killer on the planet, surpassing HIV/AIDS. Tuberculosis killed 1.5 million people around the world in 2014, and nearly 500 000 of those cases were estimated to be antibiotic resistant. The strain prevalent in Marion is susceptible to antibiotic treatment.
Cite this as: BMJ 2016;352:i706