Blaming sick people for system failures is an old problem in public health, particularly when patients are poor or morally suspect. New analysis, though, is turning the microscope around to examine the ways that power structures, rather than individuals, contribute to disease rebound and spread. A recent study by MJ Milloy and colleagues in the journal JAIDS (abstract online), which shows the link between incarceration and the failure of HIV treatment, is an example.
Milloy's analysis showed that incarceration kickstarted viral replication among patients who had previously had their HIV under control. The findings make the study one of a number of must-reads on how prison practices not only impact the health of inmates but communities at large. A 2008 analysis by Stuckler et al of 26 countries in Central Asia and Eastern Europe graphically captured the way that higher rates of inprisonment correlated with higher rates of drug resistant tuberculosis overall (click here to see the graph). Epidemiologist Ernie Drucker's recent book Plague of Prisons looks at incarceration in the U.S. in terms usually used for disease outbreaks. As Drucker points out, there has been an epidemic of mass incarceration in the U.S., with associated destruction of social supports and thousands of productive years lost.
In an editorial in JAIDS, my colleagues and I argue that studies like the one by Milloy force us to look critically at the cost of incarceration and at conventional wisdom about HIV treatment failure. It has been common, for example, to suggest that drug users are less likely to adhere to HIV treatment. But have we been asking the right questions? In Milloy's analysis, not incarcerating patients would have resulted in as much as a 40 percent increase in successful HIV treatment. It was not injection of heroin or bingeing on crack, but the social response to those acts, that determined whether people's HIV infection remained under control.
It's an important reminder to those who think that an iron fist (and steel bars) are the best response to combat drug use. Instead of pointing fingers at individuals, we should take a closer look at the social structures that lead to poor health outcomes.