Anger and suspicion fuel big tuberculosis outbreak in rural Alabama

MARION, Ala. — Over the coming weeks, state public health workers will fan out across this rural community to begin delivering a weekly regimen of up to four drugs to scores of residents. Then they’ll stand there, watching, until the pills are swallowed.

If they cooperate throughout the treatment, residents will earn $100.

It’s part of an extraordinary effort to control a frightening tuberculosis epidemic centered in this struggling town of 3,600.

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The state has tested about 2,200 people in and around Marion for tuberculosis since mid-January. Health officials have identified 27 patients with active tuberculosis and another 100 with latent TB, which is not contagious but can bloom into full-fledged cases of the lung infection. There have been three deaths from the disease in Marion so far.

“Because our community is so small, to have this many people testing positive or dying of tuberculosis is alarming,” said Frances Ford, a registered nurse and health care coordinator for Perry County, which includes Marion.

State officials and outreach workers say the outbreak has proved hard to control, in part, because local residents have been wary of outsiders and unwilling to cooperate with important tasks such as tracing each infected patient’s contacts throughout the community.

“To have this many people testing positive or dying of tuberculosis is alarming.”

Frances Ford, registered nurse

But Ford and other locals blame the state for allowing tuberculosis to take root and spread, unnoticed, for several years. (The disease can cause coughing, weight loss, and fever if the infection is active, but when it’s latent, there are no symptoms.)

The state used to offer a free TB skin test for residents who needed health clearance to work or volunteer in certain settings, including schools, nursing homes, and prisons. It stopped in 2011 because federal health authorities said there was no need to test low-risk people in the general population, said Pam Barrett, director of Alabama’s Division of Tuberculosis Control.

Caleb Chancey for STATPam Barrett, director of Alabama’s Division of Tuberculosis Control.

Ford said she suspects that if the program had continued, the jump in TB cases here would have been caught earlier. “I think that it would have made a difference,” she said.

To get a handle on the outbreak in Marion, state officials took the unusual step of paying local residents $20 each to come in for tuberculosis testing and another $20 to come back to hear the results. If they’re infected, the state will pay them $100 to take all prescribed antibiotics.

In a county where 25 percent of people live in poverty, that’s powerful incentive.

On a recent morning, the last day payments were being offered, the waiting room at the Perry County Health Department was packed, with every chair taken and people lining the walls, some wearing surgical masks. “Most of them have been lined up since 6 o’clock this morning,” said Barrett. “The clinic opens at 8.”

In some ways, though, the promise of cash for testing has backfired. Barrett said the clinic has been jammed with people who don’t live in Marion and don’t really need to be tested.

And some residents said they were reluctant to wait in the crowded clinic — and risk infection — to get tested for a disease they were pretty confident they didn’t have. 

Caleb Chancey for STATInez Woods, 33, and her son, 2, residents of Marion, Ala.

“I don’t want to be down at the clinic with all them people, no way,” said Inez Woods, 33, a mother of two.

Others declined to cooperate in part because they resented the way outsiders from the state government swooped in and urged the mostly African-American population here to come in for testing.

“People feel like they’re being targeted,” said Jocelyn Tubbs-Turner, a Marion city council member. “They say, ‘Naw, I don’t need that. You’re trying to say that we’re diseased or something?'”

State officials did reach out to local civic leaders at the start of their work in Marion but didn’t involve them in the outreach effort, Barrett said. “We didn’t need to,” she said. “People were already aware of the outbreak.”

“People feel like they’re being targeted.”

Jocelyn Tubbs-Turner, Marion city council member

But without local residents at their side, state officials were bound to run into resistance, Ford said.

“It’s the way you approach people,” Ford said. “You can’t just show up. There is a history of racial tension here. To have white people come in from outside and asking questions … I know they’re just doing their job. But people start thinking, ‘Who are they looking for?'”

Barrett recalled one state-sponsored health fair last year that got an even stronger reaction. “People threw beer bottles at us,” she said.

The distrust is of particular concern as the state’s response enters a new phase: Making sure people with latent or active TB take all their medication. The drugs can improve symptoms in a matter of weeks but if patients stop treatment at that point, the disease can flare up again. Even worse, from a public health perspective, bacteria remaining in the body can become resistant to conventional antibiotics.

“That’s why we’re doing directly observed therapy,” said Barrett. “Making sure that they take the complete course of treatment.”

Suspicion of outsiders runs especially high in the public housing neighborhood known as “The Hill,” a cluster of townhouses and bungalows amid trash-strewn lots. Residents washing cars and playing with kids give hard stares when strangers approach. They don’t like to talk about the TB outbreak.

“No, no, no,” said one woman, who declined to give her name. “If you talk to the news, people think you got it. We stick to ourselves. We don’t deal with people we don’t know.”

Caleb Chancey for STATMelvin and Tynarmia Miller owners of Melvin Miller funeral home in Marion, Ala.

In downtown Marion, storefront after storefront sits empty: The law office, the beauty salon, a clothing shop. Among the few surviving businesses is the Melvin Miller Funeral Service.

Owner Melvin Miller, a tall, broad-shouldered man with a no-nonsense demeanor, was exposed to TB decades ago, while in the military, but said a recent chest X-ray confirmed that he’s fine now. When he and his wife, Tynarmia, handle deceased clients with tuberculosis, they keep it discreet.

“A lot of people are scared,” Miller said.

Ford hopes the state will draw a lesson from this scare: “We have to reach out to our communities before these things happen, and not after,” she said. “I’m hoping they will look at this and realize that being reactive, instead of proactive, is costly.”

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