Marshals take aim at TB with new in-flight policy

Prisoner transports now subject to TB mandate

In the movie "U.S. Marshals," the main character, played by a laconic Tommy Lee Jones, has to contend with an in-flight explosion, a fiery plane crash, and bad guys on the lam — leaving scant time for worrying about the risk of contracting TB.

In real life, risk of TB exposure poses a much bigger problem than fiery plane crashes. In fact, until recently, employees of the U.S. Marshals had no health care oversight at all, despite the fact that the agency is charged with air transport of all aliens bound for deportation or deportation hearings, all those in custody of the U.S. Bureau of Prisons, plus all those charged with crimes and awaiting trial.

That changed in 1996, the year the U.S. Mar shals got its first health care professional, in the person of Captain Marcia Withiam-Wilson, MSN, RN, the chief U.S. Public Health officer for the Marshals. Coming up with a TB policy was her first assignment. By June, 1998, she had formulated and implemented such a policy. "We’re very proud of the new policies," says Withiam-Wilson. "The Marshals have been very receptive, and we feel as if we’ve really been able to make a difference. That’s something you don’t always get to do in government."

In brief, the new policy requires every prisoner or alien scheduled for air transportation to show proper TB clearance — meaning either a negative skin test or negative chest X-ray. Immigration and Naturalization Service (INS) deportees who’ve been held for less than seven days are so far exempted from the policy, but that, too, may change this December, when that part of the policy comes up for review.

Nurses provide in-flight health care

Withiam-Wilson also has added 12 flight nurses who screen boarding passengers for signs of TB, deny boarding rights if necessary, and provide in-flight health care services — everything from helping inmates with their insulin shots to making sure TB meds stay with the patients.

The new TB clearance policy also means that in practice, thousands of inmates in jails across the country are being tested for TB before they can be transported. Most local jails have been fully cooperative with the new policy, Withiam-Wilson says. Plus, the flight nurses, deputies, and marshals who work for the agency also receive routine TB screening.

What prompted the changes included the recognition on the part of the Marshals that both the INS and the U.S. Bureau of Prisons (BOP), which share use of the Justice Department’s Prisoners and Alien Transportation System (JPATS), had health care professionals appointed to serve them. Plus, a series of incidents sparked concern among marshals.

Complicated code sparks procedural change

First, in 1995, a prisoner with infectious TB was found to have traveled in a plane loaded with prisoners bound from Texas to Oklahoma City, which serves as the national hub of Mar shals operations. By the time the case was discovered, prisoners and marshals alike had dispersed from Oklahoma City to all parts of the country, making for a long and complicated contact investigation the Marshals had to carry out.

Then, in 1996, at a federal district courthouse in Miami, 75% of the deputy marshals were found to have converted their skin tests. Investi gators concluded the infections were probably job site-related.

Initially, Withiam-Wilson says, her bid to put together a new TB policy met with skepticism. Deputies, for example, worried that the policy meant they would have to take on the responsibility of diagnosing TB. Officials at the INS protested that many of that agency’s detainees were in and out of custody too quickly for TB screening.

Withiam-Wilson explained that she wasn’t asking deputies to become physicians, only to begin "thinking TB." As for the INS, the seven-day exemption is a compromise she doesn’t like but says she can live with — at least for the time being.

"Many more INS detainees are being tested now than were before the policy went into effect," she says. "You have to show people you’re not trying to force something onto them, and that you’re willing to work with them. It’s a step-by-step process."

200,000 escorts per year

Last year, the Marshals Service escorted more than 200,000 prisoners, says Withiam-Wilson. Of those, 12.3% were noncriminal aliens — that is, aliens whose only crime is having been found entering the country illegally three times. An additional 11.2% were criminal aliens. The rest of the 200,000 consist of inmates charged with a federal crime and still awaiting trial and are in custody of the U.S. Marshals, and their convicted counterparts, whose custody is assumed by the BOP.

JPATS itself is a product of the "reinventing government" workshops conducted by Vice President Al Gore. As such, JPATS functions as an umbrella mechanism replacing the three previously separate air-transport operations run by the INS, the BOP, and the Marshals.

The Marshals use three 727 jets to move their prisoners, who are shackled and bound with weighted handcuffs. Transports take place five days a week, eight hours a day, with flights shuttling in and out of military bases and other secured landing areas.

"It’s a real art and a science all at the same time," explains Withiam-Wilson. "My flight nurses really love this work — all the flying and the excitement. It really is kind of like being in a movie."

Except, of course, for the absence of Tommy Lee Jones. Perhaps having to worry a lot less about TB makes up for it.