Published: 10/09/2023

By Maria Isabel Barros Guinle, Stanford medical student

Cover image caption: Art mural at a women’s prison in Brazil, courtesy of Dr. Jason Andrews.

A new publication led by third-year Stanford medical student Aditya Narayan and Stanford Medicine researcher, Jason Andrews, MD, associate professor of medicine – infectious diseases – is calling for incarcerated individuals to be prioritized for life-saving preventive tuberculosis (TB) treatment.

Globally, the prison population has tuberculosis rates that far exceed the general population. This means that if you were to find yourself in prison, your chance of contracting tuberculosis would be 4 to 26 times greater than if you were not incarcerated. And despite efforts from international health organizations to decrease TB cases globally, individuals within the carceral system have remained overlooked.

In their new publication, Narayan and Andrews, alongside an international group of experts, advocate for incarcerated individuals to be prioritized in global efforts to reduce TB. They highlight that the most recent WHO guidelines for TB preventive treatment (TPT) expansion to high-risk groups failed to include incarcerated individuals. This omission, they argue, impacts policymakers’ ability to allocate resources to carceral facilities.

Jason Andrews, MD

Andrews, who has been researching TB in prisons for more than a decade, recounts that his work has been largely inspired by his experience working with incarcerated individuals during his residency at UCSF, where he first witnessed the stark deficits in the health care they received. “In the medical system, and, certainly, in the correctional system, there was continued neglect of the health needs of that population” he stated. Andrews went on to add that “one of the diseases that disproportionately affects incarcerated individuals is TB and yet there is very little work being done to find solutions for that.”

One of the diseases that disproportionately affects incarcerated individuals is TB and yet there is very little work being done to find solutions for that

Jason Andrews, MD

Aditya Narayan, 3rd year medical student

Narayan similarly recounted that his interest in this project was influenced by his prior experience establishing a mutual aid harm reduction program for people who used drugs in Central Virginia. “Given the structural violence enacted against these populations, many frequently faced incarceration,” he stated. Narayan added that, once at Stanford, he approached Andrews with an interest in working with incarcerated individuals and was “incredibly grateful to Dr. Andrews for accommodating these interests in infectious diseases, health disparities, and structural health to conceptualize this piece.”

In their call-to-action, Narayan and Andrews address potential challenges, proposed recommendations, and research needs surrounding the implementation of TPT in carceral facilities globally. These efforts, they assert in their paper, are integral to reducing disparities and advancing health equity in incarcerated populations.

Narayan and Andrews recently discussed their recommendations and addressed why it is crucial that we prioritize incarcerated individuals when developing global TB prevention efforts.

Why is it so important to prioritize incarcerated individuals in the overall efforts to combat TB?

AN: Every individual has a right to health and a life of dignity – incarceration should not preclude that.

Incarcerated individuals often come from marginalized and vulnerable populations. The disproportionate burden of TB they face reflects broader social inequities that are established through public policy. Governments and prison authorities therefore have a duty of care towards incarcerated individuals.

In effect, prioritizing TB control in incarcerated populations is a convergence of public health efficacy, human rights, and ethical duty. It reflects a holistic and humane approach to healthcare that recognizes the interconnectedness of all community members and the inherent dignity and rights of every individual, regardless of their circumstances.

Every individual has a right to health and a life of dignity – incarceration should not preclude that.

Aditya Narayan, Stanford Medical Student

Throughout your paper, you refer to incarcerated individuals as “persons deprived of liberty.” Could you elaborate on your choice to use this term?

JA: The choice to use this term comes from talking to Shaka Senghor, an advocate for incarcerated individuals, who told me something that stuck with me: “Nobody should be defined by the worst deeds in their life,” which I agree with. It is also an effort to use people-first language, and it is a term that is very much incorporated into the everyday language of people in other countries, such as Brazil.

Incarcerated individuals have historically suffered from medical mistreatment, which may contribute to a mistrust of the medical system. What strategies may help balance respect for patient autonomy with the need to reduce rates of tuberculosis disease?

AN: Addressing the issue of TB treatment in incarcerated settings necessitates an appreciation for the nuance between respecting patient autonomy and reducing TB disease rates, particularly given the high rate of comorbidities and past instances of medical mistreatment leading to mistrust in the healthcare system among prisoners.

A foundational step towards this balance is the provision of clear, transparent, and culturally sensitive education about TB, its risks, and treatment benefits, fostering informed consent and shared decision-making between healthcare providers and patients.

On a programmatic level, structured transitional care programs can be instrumental in ensuring continuity of care for individuals transitioning out of prison, supporting both their autonomy and long-term health. Lastly, cultural competency training for healthcare providers can enhance understanding and respect for the diverse backgrounds and experiences of incarcerated individuals, creating a more inclusive and respectful healthcare environment.

What would you like your readers to take away from our conversation and from reading your publication?

AN: The crucial takeaway is the pressing need for updated international guidelines and national policies to prioritize TB preventive treatment in carceral settings. The benefits extend beyond prison walls, impacting broader community health and advancing toward global TB control targets. By addressing the unique challenges faced by incarcerated individuals, we can significantly reduce TB incidence, promote health equity, and protect vulnerable populations.