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New ID chief institutes four-drug prophylaxis
It’s probably a good thing that Carl Brown, MD, doesn’t mind a little heat in the kitchen. "My friends ask me, What on earth are you doing there?’" says the affable chief of the infectious disease (ID) service at the sprawling Rikers Island correctional facility in New York City. The answer hasn’t been as simple or straightforward as Brown expected when he took the job a year and a half ago, he confesses.
Still, since Rikers jumped headlong into managed care almost two years ago, it’s pretty much been business as usual when it comes to TB, he adds. "TB hasn’t really been a big issue because a lot of things put into place [before the changeover] have stayed. The New York City Division of TB Control has a strong presence here, and we have a good relationship with them. Most of the people who were here before are still here now."
As head of the ID service at the Rikers state-of-the-art Communicable Disease Center, you’d think Brown would be dodging bullets full time, either from critics of managed care or from the cost-cutters and gatekeepers at St. Barnabas, the dark-horse contender that grabbed the three-year, $342 million contract to provide health care at the jail away from the venerable Montefiore Medical Center. He’s faced his share of criticism, he says. "Once, I was supposed to be giving a talk on the treatment of HIV in an incarcerated setting, and suddenly I’m batting back questions about whether the women’s prison is a syphilis factory!"
To his mind, most of the problems that attended the St. Barnabas takeover — the fourfold increase in inmate complaints documented in the first year, the scathing articles in the city newspapers — can be attributed to politics and to peoples’ tendency to get antsy when big changes take place.
"My sense is that St. Barnabas came in without its best political hat on," he says. "I don’t think they realized what would happen when you replace an institution that’s been here for 21 years. It was an explosive arena. Once inmates saw the opportunity to complain, and newspapers got involved, everyone got treated as if the complaints were legitimate."
A quality assurance investigation initiated by the head of the city’s Health and Hospital Corpor ation (who has since departed in what an HHC spokesperson describes as a "voluntary separation") suggests that some of the complaints of poor medical care are not without foundation. In addition, the Manhattan district attorney’s office is investigating charges that St. Barnabas allegedly was raking off supplies intended for the jail for its own use.1
Security issues complicate job
Brown also has experienced some difficulties of his own, but as he sees it, the troubles are just business as usual in the provision of health care for the 17,000-plus inmates who make up the country’s largest correctional facility. "This wouldn’t be a difficult job at all if you didn’t have to filter everything through this thing called the Department of Corrections.’ Anything you try to implement, you always have to look at the security part."
Working to educate clinicians and patients and building consensus around issues also take time, he adds. "So much of what I do is public health and preventive medicine," he says. "And that requires some personal touches. It takes someone with the personality for it." Throw in some HIV — "that’s like throwing gasoline on a fire," Brown notes — add a handful of politics — "there, nothing’s ever simple" — and you’ve got a job that’s clearly not for everyone.
Two programmatic changes Brown has enacted since the St. Barnabas takeover include four-drug prophylaxis for suspect cases and a newly inaugurated policy of direct observation for everyone on preventive medicine, with the first change proceeding more smoothly than the second, he adds.
The first change came about as a result of talks with Paula Fujiwara, MD, New York City’s head of TB control. "She convinced me that four-drug prophylaxis would be a better idea for someone with, say, questionable anergy status, than what we were doing when I first arrived, which was single-drug prophylaxis," Brown says. "We have more and more people, is my sense, whose smears are negative, who have minimal if any signs on their chest X-rays, but whose cultures are positive. When their cultures grow out, it’s a good thing we already have them on four-drug therapy."
Complaints about policy changes
The other change under way — finding better ways to provide preventive therapy to latently infected inmates — hasn’t gone as smoothly, Brown says. In that situation, complaints from upstate correctional facilities where many Rikers inmates make their way prompted a change in Rikers Island policy. "People upstate were complaining they couldn’t tell who was on preventive therapy and who wasn’t," Brown recalls. "So the medical director decided we’d just put everyone on [directly observed preventive therapy]."
In theory, it sounded good. Brown made the rounds, selling the idea to skeptics. "I’d tell them, It’s one thing if you’ve got a patient who’s over 35 and they’re out on the street, but it’s something else in an incarcerated setting. Here, we can make sure everyone gets their PPD read.’"
The trouble came with the direct observation part because that requires two trips, not just one, to the pharmacy window, where a staff member now duly records the ingestion of pills. But inmates are balking at standing in line for that second trip, says Brown; so far, about half on INH have dropped out.
Direct observation problems notwithstanding, Brown’s posture suggests that of a man standing calm in the eye of a storm. "Nothing’s simple, but I’m enjoying this job," he says. "I’ve got a good team here."
1. D.A. investigates health care panic at Rikers Island. New York Observer, Sept. 15, 1998: Observer Online.