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The Palm Beach Post exposes a hidden menace

Government cutbacks and the worst TB epidemic in 20 years
July 11, 2012

Reporting on tuberculosis is not most reporters’ idea of a glamor assignment. It’s an ancient disease, drug companies aren’t keen to develop blockbuster medicines, and, anyway, few people get it, right? Wrong. A powerful expose by Stacey Singer, the health reporter for The Palm Beach Post, has revealed a serious outbreak of TB in Jacksonville—the worst the Centers for Disease Control and Prevention has investigated in 20 years. Thirteen deaths and 99 illnesses are linked to the outbreak so far, which Singer reports, “was, and is far from contained.”

Beyond the scary numbers, what makes Singer’s piece so intriguing is that it is a tale for our time. It touches on the current narrative about cutting government spending, which inevitably involves trade-offs between public health and public dollars. And it touches on the trend toward government secrecy at all levels, which made it hard for Singer to do her job.

Over the past two years, 3,000 people may have had close contact with contagious people—residents of Jacksonville’s homeless shelters, jail inmates, and patients at a mental health clinic. “Other health officials throughout the state and nation have reason to be concerned,” the Post said. Only a fraction of the sick people’s contacts had been reached. And a third of those who were reached tested positive for TB.

In April, Gov. Rick Scott, a Republican, signed a bill shrinking the state Department of Health. As it happens, nine days later a federal Centers for Disease Control and Prevention investigator wrote a 25-page report describing the outbreak and what was needed to contain it, a report that, as we’ll see, wasn’t made public until Singer’s relentless push for it was successful last week.

One victim of the state’s budget ax was the A.G. Holley State Hospital, an old-fashioned TB sanitarium that had treated difficult cases of TB for 60 years. The state apparently was in such a hurry to shut down the facility that the health department ordered that the hospital close six months ahead of schedule.

In an interview, Singer told me that the hospital had treated about 70 TB patients each year—all ordered confined by court order because they were a risk—at a cost of about $10 million, half paid for by the federal government and half by the state. She said that after it was ordered closed, the state put out bids for private providers to take care of these patients, but “nobody in the private sector wanted those folks.” Florida Medicaid covers only 45 days of in-patient care and some patients with drug-resistant TB need care for a lot longer. After the Holley facility closed, most of the patients were housed in motels.

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Singer got on to her story via a tipster who advised her to read an article in the American Journal of Psychiatry, which revealed a TB outbreak in Florida in 2008. A single schizophrenic patient had moved from hospital to jail to homeless shelter to an assisted living facility, coughing all the way. Although officials documented his chronic cough, it was not treated until he was sent to the A.G. Holley facility, which subsequently received a $275,000 grant from the CDC to contain the outbreak. Dr. Bob Harmon, who directs the Duval County Health Department, told Singer that after the money ran out, staff members were redeployed.

But last year the number of active cases suddenly increased. “We thought after 2008 that we had it contained, Harmon said, but: “It was not contained.” For 2012, Harmon told the Post, his department needs more resources to contain the current outbreak—at least $300,000 to hire teams of experts to track down people who may not know they are infected. But staff and revenue for his department have been cut. In 2008, when the first TB outbreak hit, Harmon’s staff was 946; now it is 700.

One might argue that the public should know about a disease outbreak of this magnitude, but state and federal officials didn’t see it that way. Singer reported that the public learned nothing about the outbreak until early June, even though the same TB strain had popped up in other parts of the state, including Miami.

State, local, and federal officials apparently did not want the story of the TB outbreak to break out in public, and gave Singer a hard time when she pushed them for records, data, and even the simplest of comments. She had no luck getting the CDC expert who is the main author of the Journal article to talk, or even TB experts at the University of Florida. When it became clear that only two-thirds of active cases of the disease could be traced to places where the homeless and the mentally ill congregated—suggesting that the strain had spread to the general population—the paper asked for a state database showing where every related case has appeared. Singer reported in her piece this past Sunday that the database still “has not been released.”

But she finally got the CDC report last week after interviewing Florida’s newly appointed surgeon general and secretary of health, John H. Armstrong. What shocked her, she said, was that she had not understood— until she finally saw the report—that this was the most active outbreak in the past 20 years.

And “What surprised me most is the CDC’s role in allowing the cover-up to happen,” she said. “They were not willing to inform the public if the local health department decided it was not the right thing to do.” Singer speculated that since Florida depends on tourism, perhaps the state did not want the public to see that Florida is a state with TB. “Maybe the CDC went along with that.”

But because of some old-fashioned muckraking journalism the world now knows Florida is a state that has a TB problem, and has undercut its ability to contend with that problem. The story raises profound questions about the effect of continued government cost-cutting on public health, historically an underfunded stepchild of the healthcare system.

Beyond Florida, will cost cutting in state capitals reach a tipping point at which the public’s health and safety is in jeopardy? Will the public see the link between public health services and the ongoing rhetoric about taxes and spending? Those are questions for the Post to work on, and other outlets too.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.