Most people don’t consider the US to be a country affected by tuberculosis (TB), especially since 95 percent of TB cases occur in developing countries. But what if you heard that a town in the rural US had a TB rate as high as Ethiopia, Somalia, or Haiti? That’s exactly what’s happening in Marion, Alabama, where the scale of a recent TB outbreak has resulted in a public health epidemic.

TB is an infectious disease spread by airborne bacteria and mainly affects the lungs. Some TB infections don’t show any symptoms, known as latent TB, but can potentially progress to active TB and cause death if left untreated.

"Marion, Alabama is experiencing a TB outbreak that is worse than in many developing countries,” said Eric P. Goosby, the UN Special Envoy on Tuberculosis, in a statement issued last week.

The current TB outbreak in Marion has infected 73 people within the county and so far 3 have died.

In Marion, the TB incidence rate is 253 per 100,000 people, which is 100 times greater than the state's rate. In comparison, the US has an overall incidence rate of just 3 per 100,000.

Why rural Alabama?

Marion is a rural town in Alabama’s poorest county, where the population is predominantly black and 47 percent live in poverty.

While poverty and limited healthcare access play important parts, another reason why TB has spread in this community has to do with residents’ widespread distrust of health officials and the medical industry.

If a TB diagnosis is made in the US, people are required to register with local public health authorities and notify anyone they have come in contact with. But patients in Marion have actively avoided seeking care and cooperating with health officials to trace down contacts.

People often avoid going to the doctor until they are really sick. Public health officials’ efforts to reach out to patients have been largely unsuccessful. They’ve even been hit with beer bottles in the process.

This lack of trust may have a basis in the region’s dark medical past. The nearby city of Tuskegee is known for an infamous medical experiment that violated medical ethics and basic human rights.

In 1932, the US government funded a clinical study on syphilis in a group of over 600 black men. The men agreed to enroll in the study in exchange for free penicillin treatment. Over a period of 40 years, researchers deceived the participants by secretly studying the progression of untreated syphilis instead of giving the participants the treatment they were promised. At the end of the study, 28 men had died from untreated syphilis and 100 died from related complications. This doesn’t include the family members who were also infected in the process.

Even outside of Alabama, studies have shown that a lack of trust keeps many black patients from participating in beneficial clinical trials.

The experiment's legacy has justifiably caused mistrust of government and medical professionals that has been passed down from generations.

What’s being done?

Alabama is paying people in Marion to go to the doctor.

With grant funding from the Center for Disease Control (CDC), the local health department decided to use monetary incentives to tackle the outbreak. Anyone who comes in for a blood test receives US $20 dollars, as well as an additional $20 for every step in the diagnosis process. A TB patient can also receive $100 for completing the treatment. The plan has been successful since it targets the poorest residents, who also happen to be the people affected by TB in this case.

Since disbursing funds, more than 1000 people in Marion have gotten tested for TB. While the tests show the outbreak is spreading, there is hope that more people will be willing to seek treatment.

TB is the world’s leading infectious disease killer. And with the rise of drug resistant TB, it may be even harder to contain outbreaks in the future.

While it’s mostly been eliminated in the US, reports show that almost 10,000 new TB infections are diagnosed each year. Minorities and the poor continue to be especially vulnerable to TB.

The outbreak in Marion indirectly highlights a persistent racial and economic gap in health care.

While cash incentives are a temporary solution to controlling the outbreak, reducing poverty and expanding education and healthcare access are even more important.

From Alabama to India, TB is a global disease that affects the poorest regions. Eliminating poverty goes hand in hand with eradicating TB.

TopicsCurrent eventsHealthExplainerUnited StatesTBTuberculosisDisease

Explainer

Defeat Poverty

How a town in Alabama has a TB rate that’s worse than many developing nations

By Megha Cherian