When it’s done right, detention is expensive

Boston unit stresses privileges, outpatient links

Civil detention facilities, done right, aren’t cheap. What prevents every jurisdiction from having its own is the cost of providing all the services the facilities need to offer — typically, security measures, mental-health services, drug rehabilitation, and highly specialized medical care.

"It’s important to keep in mind that for many of these patients, TB is the least of their problems," says David Ashkin, MD, medical director of A. G. Holley State Tuberculosis Hospital in Lantana, FL, and the state’s TB controller. "Things like substance abuse and mental illness, not TB, are what impair these patients’ decision-making abilities. That’s why they don’t take their pills. And that’s why they’re here."

Taxpayers don’t want the patients in acute-care hospitals, and jails aren’t equipped to deal with them, says Linda Singleton, RN, director of policy and community service at the Division of Tuberculosis Prevention and Control for the Massachusetts Department of Public Health in Boston. That leaves places like the Lemuel Shattuck Hospital’s Tuberculosis Treatment Unit (TTU) in Boston. Along with the A.G. Holley Tuberculosis Hospital, the Boston facility is acknowledged as a leader in the new wave of TB sanitoria.

When plans were first implemented to establish the Shattuck’s TTU, back in 1990, "we were lucky," says Singleton. As one of the last remaining public health hospitals in the country, it already had many of the necessary elements. Chief among them, and key to Shattuck’s success, are its use of a therapeutic milieu and its emphasis on maintain-ing close links to outpatient services, Singleton says.

The concept of therapeutic milieu includes a system of graduated privileges and days structured with therapy and community meetings.

As for strong links to outpatient services, the rationale is that DOT workers and public-health nurses "have a valuable point of view to contribute — the street point of view," Singleton says. "So we make them an active part of the treatment plan."

Many patients arrive at the TTU as the result of a court-ordered, 15-day period of observation. Yet few remain against their will, Singleton says. No one discharged from the TTU in 1995 had a long-term court order, records show. "Of course, they know if they don’t agree to a plan, we could make them stay," Singleton notes. "But if they agree themselves, they’re left with some dignity."

TTU doesn’t usually keep its patients until they’ve swallowed their last pill, either. About 75% of patients are discharged before they finish treatment; of that percentage, 97.3% finish therapy successfully outside the hospital, says Singleton.