Editor's note: Before COVID-19 ravaged the world, TB claimed far more lives worldwide than any other infectious disease. Painful treatment options and a lack of effective testing have made it difficult to eradicate the epidemic; but what is even more disappointing is that TB disproportionately affects low-income people and non-white people; but for many people, TB has become a "forgotten epidemic". In Brazil, as the number of inmates increases each year, so do the number of infections in prisons, and after the release of prisoners, they may also transmit TB to others in the community in various situations. Poor sanitation, a diet lacking nutrition, scarce testing equipment and treatment have all contributed to the TB outbreak in Brazilian prisons. Timely and effective treatment and prevention of tuberculosis has become an important task for the Brazilian government. Originally published in the Boston Review of Books, the author Katharine S. Walter is a postdoctoral fellow in infectious diseases at Stanford University School of Medicine.
On August 26, 2014, at the Judicial Court of Rio de Janeiro, people fought for the freedom of Phil Braga Vieira.
Nine years ago, Rafael Braga was stopped and arrested by police when he picked up cans for money near a political demonstration in Rio de Janeiro, Brazil. Braga, a 25-year-old black man, was homeless at the time, with two bottles of detergent in his pocket, while police claimed he was carrying explosives.
The judge believed it. Braga was convicted of possessing incendiary bombs and sentenced to five years in Rio's Bangu Prison, a prison of the highest level of security. He was the only person to be jailed during the 2013 national Revolta do Vinagre (i.e. vinegar protests). Protesters were arrested for carrying vinegar to mitigate the injuries caused by the use of tear gas by police, which shocked the entire country. Braga was released in 2015 with an ankle monitor, but was soon re-arrested and charged with drug trafficking after police found him carrying less than a gram of marijuana. Two years later, his lawyer announced that although Braga had been sentenced to 11 years in prison, the sentence had actually been increased as a result of his further charges of human trafficking. On the other hand, Braga, like more than 10,000 other Brazilians imprisoned in 2015, was diagnosed with tuberculosis (TB).
Braga's story highlights the negative role that prisons play in fueling another devastating pandemic. Most people in the Global North have almost forgotten that TB took more lives worldwide than any other infectious disease before COVID-19 began to spread. In 2019 alone, 1.4 million people died from TB, more than twice as many as from HIV/AIDS. About 10 million people are sick at the same time, all of whom are subjected to painful 6-month antibiotic regimens that are often accompanied by strong side effects. This has been exacerbated by COVID-19, which saw the global tb deaths increase for the first time in 2020 since 2005, due to widespread disruptions to access to essential health services, leaving millions of people undiagnosed and untreated.
Despite the incredible damage, Americans have almost never heard of so many people being the victims of this "forgotten epidemic." The New York Times did not produce a map of the TB world, nor did it have mass media to monitor the number of cases and deaths globally on a daily basis. That said, there is no mechanism to stir up public outrage, and many people don't even realize that there are so many unnecessary and preventable deaths. As with many global health crises, from extreme weather that accompanies climate change to the rapid spread of drug-resistant bacteria, the impact of TB falls largely on the poor and non-whites. As Braga's case demonstrates, to liquidate its burden today requires confronting the fact of how the disease is perpetuated by institutionalized racism, global capitalism and mass incarceration.
When I started studying TB four years ago, more than one friend expressed surprise. Hasn't the disease been eradicated? This question embodies the "historical amnesia" of the West when it comes to infectious diseases. The roots of tuberculosis are ancient. More than two thousand years ago, when modern science identified bacteria as culprits, Hippocrates described the horrors of tuberculosis, a disease once called "wasting." Until the mid-19th century, tuberculosis was the leading cause of death in industrialized countries, and popular theory is to describe it as an old disease of European bohemians and elites. Novelist George Sand wrote that "Chopin coughed with infinite grace", and her lover probably died of the disease.
In the twentieth century, important treatment and control measures were developed, from vaccines to antibiotics, but these resources were never equitably distributed. "The emergence of effective therapies only seems to further solidify the significant differences between the distribution and outcome of this disease," wrote the late physician and anthropologist Paul Farmer. The disease continues to devastate the world's population and mutate into dangerously antibiotic-resistant forms. Tom Scriba, director of the South African Tuberculosis Vaccine Initiative, reminded the audience in a recent speech: "The speed of death from TB is unimaginable. ”
Why does this ancient disease persist? One reason is that the tools we have to prevent and treat disease are outdated and grossly unevenly distributed. First, racial segregation of vaccines prevailed. In the case of COVID-19 vaccines, rich countries have stockpiled vaccines. And for TB, a reliable vaccine doesn't even exist: the only commonly used vaccine is the Calmette-Guérin bacillus (BCG) vaccine, which has been around for more than a century and is often ineffective in preventing the most common adult diseases. The torturous treatment regimen has remained largely unchanged for decades. On the other hand, developing a new TB vaccine or antibiotic is not a lucrative move for pharmaceutical companies. Moreover, public health programs, including tuberculosis control, are chronically underfunded, meaning that existing treatments are very expensive. And in many countries, a TB diagnosis for a loved one remains a "catastrophic expense". Millions of TB patients are simply not diagnosed.
However, the distribution of biomedical interventions alone does not explain the persistence of TB. Historians believe that before antibiotics were widely used, living and working conditions in Europe and North America were more generally improved, nutritional status was improved, and the risk of tuberculosis was greatly reduced. But billions of people are still forced to live and work in places where TB is prevalent.
According to the World Health Organization, about two-thirds of new cases are concentrated in eight countries: including India, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. Other countries with high infection rates include the Democratic Republic of the Congo and Mozambique, two of the poorest countries in the world. In Ukraine, ongoing war and displacement have fuelled the unbridled spread of MDR-TB, and many fear that the ongoing refugee crisis will trigger a wider epidemic across Europe.
Wherever we look, the same pattern emerges: the burden of TB is linked to race, class, and social vulnerability. In the early twentieth century, the disease devastated indigenous populations throughout North America, and globally, indigenous peoples continue to suffer higher rates of tuberculosis than the surrounding populations. By 2019, tb incidence in the United States was the lowest since 1953 was recorded, but progress in the fight against the disease has been uneven. While in the United States, most TB cases occur in people born in other countries; among U.S.-born populations, blacks are almost 7 times more likely to develop TB than whites. In addition, in 2020, 3% of TB in the United States will occur among inmates, four times the rate expected according to demographic expectations (about 0.7% of the population). In 2020, 327 people were diagnosed with TB while in immigration and customs enforcement detention.
Braga's case shows that these models also extend to Brazil. Over the past 20 years, the number of prisoners in Brazil has more than tripled, from 232755 in 2000 to 759518 in 2021. The country now has the third largest incarceration population in the world, with the U.S. incarceration rate peaking in 2008, while Brazil's incarceration rate continues to climb under right-wing President Jale Bolsonaro. "I've been saying this," Bolsonaro tweeted during his 2018 campaign, "I'd rather choose a prison full of criminals than a cemetery full of innocents." If there is a lack of space, we will build more (prisons)!"
Lucas Sada, a lawyer in Braga and a public defender for the Human Rights Defenders Association, told me that the main reason for the surge in incarceration was Brazil's 2006 drug law. Although the Act aims to reduce drug-related penalties, in practice it opens the door to separate punishments for drug users and drug traffickers. In 2005, 9 per cent of the country's population faced drug charges in prison. By 2019, that number had soared to 41 percent.
As in the United States, incarceration in Brazil is disproportionately targeted at people of color and the poor. According to Brazil's National Prisons Department, black and mixed-race Brazilians accounted for 66 percent of the incarcerated population in 2019, but only 53 percent of the national population. In 2016, most people in Brazilian prisons did not complete primary school. From 2007 to 2018, incarceration rates continued to rise; at the same time, TB cases among incarcerated people tripled. Nationally, 11 per cent of Brazilian cases occur among inmates, a group that accounts for less than 1 per cent of the total population, and one-third of cases occur among men aged 18 to 25, the group with the highest rate of prison admissions. Who is sent to prison largely determines who will develop TB.
On a warm september morning in September 2018, I followed Andrea Santos, a nurse and epidemiologist at the Federal University of Grande Dourados, on a dirt road in Campo Grande, Mato Grosso do Sul, in central and western Brazil. Mato Grosso do Sul borders Paraguay and Bolivia. The incarceration rate here has more than doubled in the past 20 years, and most of those incarcerated are serving sentences for drug-related crimes. As we walked, we spotted a long line at the entrance to the Prison of Jair Ferreira de Carvalho, one of the highest levels of security known locally as "Máxima".
A year ago, I joined Santos and a team led by doctors and epidemiologists Julio Croda and Jason Andrews to study Brazil's growing TB outbreak. Andrews told me that while prisons are considered hotbeds of TB, there is a lack of evidence on how tb can actually be reduced within prisons. He and Croda found a way to try to detect cases and treat them early before the infection spreads. In Brazil, they are piloting a large-scale screening method, including routine inspections of entire prisons, but the World Health Organization dismisses it as too expensive "with limited resources" to consider.
Santos was in charge of part of the work, and she wanted to show me her work at Máxima prison to collect sputum from her lungs and screen for tuberculosis, but she was visibly worried as we drove past. She said the entire prison was locked off on some Mondays because guards and inmates clashed over the weekend and even medical staff were not allowed to enter.
A prison in the metropolitan area of the goiás state in central Brazil
That Monday, Máxima Prison was open. The air in the prison is extremely uncirculated. We passed a cell in which dozens of men sat on three-story bunks, one with his ankles hanging over the other's face, laughter and smoke filling the cell. If one of them has TB, the infection can spread rapidly. Like the coronavirus, Mycobacterium tuberculosis is airborne. Once exhaled from someone's mouth, the bacteria can suspend in air for hours, suspended in tiny particles called droplet nuclei. The COVID-19 pandemic has shown very clearly that airborne pathogens are particularly destructive in congregate environments.
In 2013, Juliana Urrego, an architect and epidemiologist on Andrews and Croda's team, investigated the construction risks that exist in the prisons of Matto Grosso do Sul. She found that overcrowding in prisons was widespread. People are locked in a cell packed with 8 people every day for more than 18 hours a day. The average person can only allocate two square meters of space, which is roughly equivalent to the footprint of a standard bathtub, while cement beds are undersupplied. Santos told me that some shared a bunk; others slept on the floor. The scorching sunlight of Mato Grosso do sul seldom penetrates cells, limiting the UV radiation that can inactivate Mycobacterium tuberculosis. Urrego's team installed carbon dioxide monitors in 141 cells to track the outgoing gas flow and the potential risk of TB spread. Unsurprisingly, air is not circulating. Using a model of TB transmission, Urrego found that breathing and respiring the same air carries a huge epidemiological risk: staying with a sick inmate for 6 months results in a 79% risk of TB infection.
Prison practices only further increase the risk of transmission. Everton Lemos, an infectious disease nurse on the team, digitized cell movements in the state's prison register to determine how infection risk spreads within the prison. He found that prison guards move prisoners between cells more than 8 times a year, for a total of more than 60 cell contacts per year, each of which is a new potential contact. Poor quality of food in prisons, combined with an increased risk of contracting HIV or other pathogens, also increases TB susceptibility. At the same time, the absence of doctors or diagnostic tools, including equipment for X-rays and molecular diagnostic tests, means that inmates will continue to stay in their cells for some time until they are detected (if they are lucky enough to be able to do so), increasing the likelihood of infection for others.
Next to the door where Santos and I entered was another entrance to Máxima, which opened several times a day to facilitate the entry and exit of trucks full of supplies and armed prison carts transporting staff, guards and handcuffed men. Santos estimates that hundreds of visitors come in and out of the prison every Sunday alone. The fact that people are frequently in and out of prisons supports a second, more self-interested argument, namely that there is no need to control the epidemic in prisons, but only to ensure that people outside prisons do not become infected with infectious diseases. As Andrews pointed out to me, the New York Times made the same empty argument as early as 1903: "If inmates are not fit as objects of sympathy, perhaps people outside the prison can be regarded as objects of sympathy." ”
In a study led by Tarub Mabud, a medical student in our group, the team tracked tb cases of people who were cycled incarcerated in prisons in the state. When people are first incarcerated, they are infected with TB at about the same rate as the population outside of prison. However, with the annual incarceration, the incidence of tuberculosis rises sharply, rising to 31 times that of the incarcerated population. The mass screening, led by Santos, revealed a more horrific picture than the surveillance captured. By testing every incarcerated person every six months, the team found that tb rates exceed 5 percent in Máxima and other prisons in the state, which Andrews said already ranks among the "highest" reported rates in the world, suggesting that current data may seriously underestimate the true picture of the disease in prisons. Thus, the prison itself determines this disproportionate risk of the disease, rather than the characteristics of the person being sent to prison, as some critics have refuted. And the epidemiological shadow of prisons is long. Seven years after prisoners were released, their risk of developing TB, and the risk of transmitting the disease to their families and communities, continued to far outweigh the rest of the community.
Epidemiologists believe that prisons like Massima are institutional amplifiers, fuel reservoirs that keep epidemics burning. Brazil is not unique. Studies in Brazil and many countries show that one of the biggest risk factors for TB is having been incarcerated or in contact with incarcerated people. At the same time, the spread of TUBERCULO outside prison walls is difficult to measure. Latent infections are often undetected and do not trigger symptoms for months or even years before people develop symptoms, causing people to unknowingly spread the bacteria to others. As a result, with traditional epidemiological tracking methods, it is difficult for professionals to say exactly when and where someone was infected. However, the bacteria themselves have their own records. Since the MYCObacterium replicates itself during infection, the bacteria's replication machines occasionally make mistakes. By sequencing the genome of Mycobacterium tuberculosis and tracking these mutations, we can identify possible chains of infection and reveal the source of infection.
Andrews and Croda's team carefully incubated the sputum samples for several weeks, and by sequencing these more than 1,000 bacterial cultures from inside and outside the prison, we reconstructed a partial map of transmission in Mato Grosso do Sul. The bacterial genome forms closely correlated clusters, indicating that the spread is recent. Transmission groups often span prisons and surrounding communities. So-called "spillover events," i.e. spread from prison to outside communities, have occurred in many cities across the state. Frequent movements between prisons and prison cells create a highly connected network of contacts and ample opportunity to spread TB bacteria to new, highly vulnerable populations across the state. In other words, prisons are not only warehouses for disease, but also the power pumps of epidemics, spreading the risk of disease far beyond the confines of prisons.
According to Andrews and Croda's hypothesis, if prisons are the main cause of the continuation of the TB epidemic in Brazil, then public health interventions should be focused there. Mabud used epidemiological models to predict the effectiveness of a specific treatment that combined frequent TB screening with prophylactic treatment with isoniazid to treat patients with detected latent TB. Our team estimates that within a decade, TB incidence will fall by 80% in prisons and 40% outside prisons.
But the most effective interventions certainly go beyond traditional public health approaches. "First, it's very important that we reduce the number of people being incarcerated, detained, and in prison," Chris Baylor, an epidemiologist and human rights scholar at Johns Hopkins University, told me in a 2017 interview. "Prison is a very bad place for anyone."
Another area to focus on is the release of the prison. The release of prisoners has proven to be not a new and unfamiliar epidemiological intervention. In 1999, in the face of the uncontrolled spread of MDR-TB in prisons, a country granted a massive amnesty that allowed thousands of people to return home early. The COVID-19 pandemic has also raised awareness of the public health risks of mass incarceration, not just about incarcerated people, but also for entire communities. In 2020, the National Academy of Sciences, Engineering, and Medicine brought together experts in law, medicine, and public health to propose strategies to reduce the risk of excessive COVID-19 infection in prisons. "Lifting the incarceration is an appropriate and necessary mitigation strategy, and institutions can address the risks of COVID-19 by incorporating correctional facilities," they found. ”
The United States has made some targeted inmate releases in this direction, but it's no surprise that they tend to benefit whites substantially. In a paper uploaded in January to medRxiv, a preprint of research that has not yet been peer-reviewed, a team of researchers at Yale and Northeastern University found that the proportion of blacks and other non-whites incarcerated in 2020 rose sharply as a result of these releases. "One of the most important consequences of prejudice in release is not only about who is released, but also about who is left behind," the authors write. The American Public Health Association advocates "abolishing the incarceration system and replacing it with just, equitable structures that promote public health." ”
Unfortunately, there is little current momentum towards abolishing incarceration as a means of controlling TUBERCULO. In its annual Global TB report, WHO does not list incarceration as a risk factor, although across the Americas, epidemiologists call the "population attribution ratio" of incarceration exceeds the proportion of smoking, alcohol consumption, diabetes and HIV. WHO also does not publish statistics on the number of people incarcerated with TB each year. This "obsession" with individual risk factors masks "the institutions and places that make people sick." As physician and activist Rupa Marya observes, "For most of the diseases we treat medically, social/environmental problems are more predictive than genetics." So why should we ignore them? Because medicine is a colonial entity. By focusing on the individual, we continue to mask the true pathology. ”
Braga's lawyer, Sada, told me that Braga's case is "one of the greatest symbols of class and racist selectivity in the Brazilian criminal justice system over the past decade." Shortly after Braga's arrest in 2013 and until his illness in 2017, an activist group called Pela Liberdade de Rafael Braga Vieira protested and launched a campaign on social media, making his story nationally famous throughout Brazil and internationally reported.
On September 12, 2017, their collective work brought a small victory. Brazil's high court will allow Braga to be transferred to house arrest so that he can recover from tuberculosis. "This is an absurd picture of a violation of fundamental rights," the court wrote.
In cases like Rafael Braga Vieira, which reached a different level, he fits the general characteristics of prisoners in the country: low-income and less educated blacks and young people in prison, suffering from the state's reluctance to provide the lowest quality of public services, which are indispensable even for those deprived of their liberty.
At the same time, the court went on to say that the ruling "does not imply recognition of the right of every sick person incarcerated in the country's prisons to be placed under house arrest". So the ruling has not brought them comfort for thousands of patients whose names have not been disclosed by the media.