Correspondence
Legal Action to Ensure Treatment of Tuberculosis
N Engl J Med 1999; 341:130-131July 8, 1999
- Article
To the Editor:
The study by Gasner et al. (Feb. 4 issue)1 of the detention of patients with tuberculosis in New York City — like recent evaluations of detention in other areas2,3 — was conducted exclusively by officials running the program. One of us began an independent evaluation of the New York program in 1996. This preliminary review confirmed the results of Gasner et al.: health officials diligently attempted to respect the civil liberties of detainees and used forcible confinement only as a last resort.4
Nevertheless, other findings aroused concern. Comportment in the hospital was one criterion for determining length of confinement, even though the violation of institutional rules may have no bearing on future nonadherence to medical treatment (which, after all, is the only justification for detention). Furthermore, local patients'-rights groups, which had expressed numerous concerns during the drafting of detention regulations in 1992, initiated little or no contact with patients once the locked ward began operation in 1993.4
History has consistently revealed that self-policing custodial institutions, however well intentioned, may respond unsatisfactorily to legitimate inmate-generated grievances.5 Health departments that detain nonadherent patients for treatment should supplement their own reviews and institutional routines with periodic outside evaluations.
5 ReferencesBarron H. Lerner, M.D., Ph.D.
David J. Rothman, Ph.D.
Columbia University College of Physicians and Surgeons, New York, NY 100321
Gasner MR ,Maw KL ,Feldman GE ,Fujiwara PI ,Frieden TR . The use of legal action in New York City to ensure treatment of tuberculosis. N Engl J Med 1999;340:359-366
Full Text | Web of Science | Medline2
Burman WJ ,Cohn DL ,Rietmeijer CA ,Judson FN ,Sbarbaro JA ,Reves RR . Short-term incarceration for the management of noncompliance with tuberculosis treatment. Chest 1997;112:57-62
CrossRef | Web of Science | Medline3
Singleton L ,Turner M ,Haskal R ,Etkind S ,Tricarico M ,Nardell E . Long-term hospitalization for tuberculosis control: experience with a medical-psychosocial inpatient unit. JAMA 1997;278:838-842
CrossRef | Web of Science | Medline4
Lerner BH . Catching patients: tuberculosis and detention in the 1990s. Chest 1999;115:236-241
CrossRef | Web of Science | Medline5
Rothman DJ. Conscience and convenience: the asylum and its alternatives in progressive America. Boston: Little, Brown, 1980.
To the Editor:
Notably absent from the list of social problems mentioned by Gasner et al. is mental illness. What occurred when patients had mental illness as well as tuberculosis? Please comment on the ethical responsibilities in bringing legal action against a person who may not be capable of comprehending the concept of tuberculosis, much less the legal code of the city and state.
Mark J. Tracy, M.D., M.P.H.
2081 Truesdell Ln., Carlsbad, CA 92008Author/Editor Response
The authors reply:
To the Editor: Tracy raises important issues regarding mental illness. In some cases, mental illness was the reason a patient was unable or unwilling to complete treatment for tuberculosis as an outpatient. As in all cases, the Department of Health ensured that detention was the least restrictive environment in which treatment could be completed. Social workers provided referrals and access to psychiatric care, and when necessary and appropriate, patients were referred for inpatient psychiatric treatment. For patients who were deemed not competent as a result of psychiatric illness, the relevant mental health statutes took precedence. Psychiatric treatment was provided at both detention facilities; patients had to be psychiatrically stable in order to meet the admission criteria for the long-term detention facility.
We agree with Lerner and Rothman that independent reviews of regulatory programs are important to supplement internal review procedures. Of course, full respect for patients' confidentiality must be ensured. Any review must justify access to patient records, which are subject to the stringent confidentiality statutes of public health reporting.
With regard to patient comportment, we reasoned that if patients were unwilling or unable to walk 20 feet to a nursing station to receive medications, they were unlikely to adhere to a program of directly observed therapy in a clinic or in their home. The violation of other institutional rules was never the sole or primary basis for continued detention. Lastly, we would welcome renewed interest and involvement by patients'-rights groups.
M. Rose Gasner, J.D.
Thomas R. Frieden, M.D., M.P.H.
Paula I. Fujiwara, M.D., M.P.H.
New York City Department of Health, New York, NY 10013
