Cut wasteful government spending! Balance the budget!

… and let people die. Florida closes its TB hospital in the midst of a deadly TB outbreak.

… and let people die.

The Palm Beach Post has the facts on a TB outbreak in Florida. CDC wrote a report on it in April. But what passes for a state government in Florida still hadn’t heard of it this month. Meanwhile, they shut down the TB hospital to save money.

During the great potato blight, more than one Irish coroner’s jury sitting on the case of a man who had starved to death brought in a verdict of “Wilful murder by Lord John Russell” (the English PM who made sure Irish grain kept being exported throughout the famine). By the same token, these deaths are wilful murders by Rick Scott, John Boehner, Mitch McConnell, Rupert Murdoch, and the Tea Party. They’d rather have TB (not personally, of course) than “socialism.”

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact:

36 thoughts on “Cut wasteful government spending! Balance the budget!”

  1. Well, any public health expert can tell you that the etiology of TB is associated poverty. Our Tea Party friends are just trying to provide appropriate incentives to the poor so that they can lift themselves by their bootstraps. Damned compassionate of them.

    1. And here I was, thinking they were culling the herd. I’ll have to reflect some more on what is happening to our country, clearly.

    1. in the posts and comments after the obamacare decision he said something alomng the lines of see you after the election. he hasn’t commented since.

  2. Mark,

    It’s so unfair of you to mockingly link to situations where Republican’s have stood up to defend freedom from public health without letting your readers know the rest of the story. Republicans really aren’t selfish and uncaring. Where the need is greatest, they’re ready to open their wallets and their hearts to help out those in need. For example, why don’t you tell your readers about a man named Ted Conklin. Ted is a wonderful man. He’s a Republican and a great supporter of Mitt Romney. Above all else, Ted Conklin is a man who truly know what it means to be his brother’s keeper:

    “Ted Conklin, who owns the American Hotel in Sag Harbor, told the New York Times that Obama is a ‘socialist.’

    ‘His idea is find a problem that doesn’t exist and get government to intervene,’ Conklin added, his wife, Carol Simmons, nodding beside him in their gold Mercedes.

    Ms. Simmons paused to highlight what she said was her husband’s generous spirit: ‘Tell them who’s on your yacht this weekend! Tell him!’

    Over Mr. Conklin’s objections, Ms. Simmons disclosed that a major executive from Miramax, the movie company, was on the 75-foot yacht, because, she said, there were no rooms left at the hotel.”,0,4909639.story?track=rss&

    This is the Republican Party at its best—people who are willing to give their all to help out those unfortunate souls who are without a roof over their heads.

      1. Thank you. But since it was I who inspired you, might I ask that you share that perhaps share that donation with some good, liberal Democrats like Darcy Burner or Elizabeth Warren?

        1. Warren, yes. But at some point I hope for someone to help me understand the enthusiasm for the perennially hapless – indeed, perennially useless – Darcy Burner, who lost an eminently winnable seat in 2006 and absolutely cratered in the same seat in 2008, running fifteen points behind the head of the ticket. She gets positively ludicrous amounts of love, attention, and money from the organized left (especially online) despite a resume absolutely devoid of accomplishment (in politics) and a pronounced habit of soaking in their love, attention, and money to no useful purpose whatsoever. She is now running for the third time, and while I don’t know whether any of her primary contenders are any better there’s no conceivable reason to think she’ll improve on her prior dismal results, despite once again captivating an utterly absurd level of national love, attention, and money from the left.

          1. Quite. I used to live in her district, and she is very charming and the women love her. And the results! The results…the res…well. ahem.

          2. I used to live just outside her district, and I donated to her 2006 campaign; possibly also her 2008 campaign, I can’t recall. But at some point she really needs to do something; she’s been unemployed for six years or more, a full-time candidate for Congress, paid by various liberal organizations infatuated with her to “serve on their boards”. She’s never run for a lower office, she’s never led any organization or movement in any memorable way (beyond being somewhat more outspoken than most on Iraq in 2006), and she gets this fervent adulation from parts of the political sphere who really ought to be finding rising stars to back, instead of muddling proven nonentities.

  3. The hospital closed was one of four dedicated TB hospitals in the entire US. Each year there are tens of thousands of TB hospitalizations in the US – distributed throughout the country. “By golly how can that be if there are only 4 TB hospitals in the country” you might say? Because TB can be treated safely and effectively in normal hospitals. 46 states seem to survive without dedicated TB hospitals – and I think if you check you’ll find that they are not all controlled by the eeeeevil Republicans. Indeed, following the closure of the Florida hospital the only highly populous state that will still rely on a dedicated infectious disease hospital to treat its most challenging TB patients will be Texas. Tea Party enclaves like California, NY and Illinois closed their dedicated TB hospitals many many years ago. But I suppose they’re not as compassionate as Texas.

    The original vote to close Florida’s TB hospital passed the Florida house by a margin of 86-27 in spring 2008 with substantial Democratic support (I wonder if those Democrats are guilty of wilfull murder – note to self to check) supplementing nearly unanimous Republican support. The final Florida House vote on the closure of the hospital earlier this year had a similar outcome (86-28).

    The Florida TB hospital was built with a 500 bed capacity but it’s daily patient census had dipped to 30-40 in recent years. Given the fact the hospital was running significantly below it’s capacity (c.f. note above about how TB can be treated in a normal hospital) and incurring an annual deficit of millions of dollars that’s not especially surprising that the state decided to close the hospital, and indeed closure has been discussed seriously for over a decade. And the original vote to close the hospital in spring 2008 was before state tax revenues dried up – especially in Florida where the South Florida real estate bubble that had been propping up the tax base and generating thousands of construction jobs popped rather quickly. And before anyone had uttered the phrase “Tea Party” anywhere near modern politics. And of course the bill to close the Florida TB hospital provided funds and resources to re-locate patients to other hospitals where they could receive continuing care under the same state public health program. But the cost per treated patient will be MUCH lower as it will no longer be necessary to support a sub-scale facility and a sub-scale hospital staff. This would be what you might in other contexts call “bending the cost curve.”

    There is I suppose an argument to be made that only a dedicated TB hospital can address the needs of homeless TB patients who rarely comply fully with the directives of outpatient treatment. But how exactly is a TB hospital south of West Palm Beach supposed to provide frontline care for homeless people 300 miles north in Jacksonville? If its the moral responsibility of a decent society to provide dedicated TB hospitals wherever there are homeless people who might be exposed to TB then we better get cracking on building several hundred such facilities – if not several thousand. After all, we wouldn’t want to be guilty of wilful murder.

    1. California and NY don’t need TB hospitals because their public health infrastructure is still capable of handling these cases with social workers and nurses. As usual, cutting costs on social services for the poorest among us is penny wise and pound foolish.

      1. In 2011 CA and NY both had TB incidence rates above the national average. FL and TX did too, as did LA, NM, NV, AK, HI, GA, NJ, MD and DC.

        Again though – how exactly is an under-utilized (30-40 patients on any given day in a facility built to house 500) inpatient dedicated TB hospital in the belt between West Palm Beach and Miami supposed to serve the needs to homeless TB patients in Jacksonville (Or Tampa, or Orlando, etc.). Unless you’re proposing that the state be given broad powers to forcibly hold patients in such a facility against their will. In which case the civil liberties community is likely to have want to have a word with you given the fact that TB is less virulent than a lot of other infectious diseases and responds relatively well to antibiotics administered in short stays and outpatient clinics.

        1. newsouthzach: California and NY don’t need TB hospitals because their public health infrastructure is still capable of handling these cases with social workers and nurses.

          sd: In 2011 CA and NY both had TB incidence rates above the national average.

          And so that proves exactly what? That CA and NY don’t have the infrastructure claimed? If you think so you need to have your logic circuits cleaned.

          sd: Unless you’re proposing that the state be given broad powers to forcibly hold patients in such a facility against their will.

          But that is precisely what happened in Florida. You did read the article didn’t you? You do understand what the costs of having drug resistant TB in the wild will mean, don’t you?

          Of course all this is mere sophistry. The core questions the article should engender are these:

          Would Fl have closed that hospital if there had been greater communication among the various State bodies and personalities involved? And why so much secrecy? And did right wing political ideology engender that secrecy?

          As for the first question. I suspect they wouldn’t close the hospital if the flow of information hadn’t been suppressed somehow.

          1. Only a subset of the patients in the FL hospital were being compelled to receive inpatient treatment. It’s generally very difficult to commit people to an institution against their will. If you’re proposing that we should lock away people with infectious diseases (including diseases which – mind you – can technically be treated in normal hospitals and/or on an outpatient basis) then that’s all well and good. You’ll have an uphill battle against the Supreme Court, but there you go.

            But the manufactured outrage here is something much more specific – that it was specifically wrong to close this particular hospital in the midst of an outbreak and the wrong was perpetrated by Republicans driven by Tea Party ideology.

            That entire line of argument falls apart when you realize that the hospital in question treats very few of Florida’s TB patients, that it is not necessary to treat all of Florida’s TB patients, that under current law it would be largely powerless to compel many more of Florida’s TB patients to receive treatment, that Florida is one of very few states that even had a dedicated TB hospital left to close, and that the initial (overwhelming) vote to close down the hospital passed over four years ago at a time when Florida had a different governor and when the “Tea Party” didn’t exist as such. The recent outbreak is a complete coincidence with the closure of the hospital and in all likelihood unrelated to Florida’s public health system overall.

            Florida made a perfectly sensible decision to close down an inefficient sub-scale hospital – a decision in line with the practices of almost every other state. The decision received broad, bipartisan support. If you think that the legislature of Florida was somehow uniquely evil for doing what it did then I suppose just about every state is evil for not having dedicated TB hospitals anymore.

        2. Treating TB requires strict adhearence to proper dosage of antibiotics. Completing treatment turns out to be a problem for homeless people. The result of incomplete treatment can turn an easily treatable strain into a drug resistant strain.
          Supervised treatment of homless TB victims seems a rational strategy to control what is becoming a serious public health problem.

        3. In which case the civil liberties community is likely to have want to have a word with you given the fact that TB is less virulent than a lot of other infectious diseases and responds relatively well to antibiotics administered in short stays and outpatient clinics.

          Life must be nice on Fantasy Island, SD. How are Ricardo and Herve, by the way?

          New onset TB treatment is six months of antibiotics, usually with a cocktail of four antibiotics for two months and two (or three for isoniazid-resistant strains) for an additional six months. If that doesn’t clear the disease, treatment requires determining which antibiotics are effective against the patient’s strain followed by 18 to 24 months of antibiotic treatment.

          In my book, six months is not a short stay. A disease that acquires resistance to first line drugs easily when the protocol is not followed to the letter does not respond “relatively well.”

          These are the reasons that the World Health Organization urges directly observed therapy (DOT) for all TB cases.

          1. But the question is whether or not society can legally compel infected TB patients to be held against their will in a hospital during treatment. The Supreme Court has set a very high bar for such actions, and given the fact that TB is generally treated on an outpatient basis.

            If the state cannot compel patients to be held for treatment then the presence of a dedicated TB hospital in south Florida is not going to be especially relevant for the treatment of TB patients hundreds of miles north who refuse to be admitted to a general-purpose hospital there or to show up at clinics for regular administration of anti-biotics.

            Again – if you think the law should be re-written to allow for much easier forcible detainment of infectious disease patients then that’s all well and good. You’ll face an uphill legal battle in general and will have a hard time explaining why the state should have the power to hold homeless TB patients against their will without applying the same standard to, say, a schoolteacher who randomly gets infected but is perfectly willing and able to submit to outpatient treatment. But in the absence of such laws the TB hospital in question here is almost completely irrelevant to the issue of responding to a TB outbreak. And even in the presence of such laws you’d need to explain why a dedicated TB hospital is essential when the vast majority of US TB hospitalizations occur in normal hospitals.

          2. You are ignoring the critical difference between your hypothetical school teacher and homeless person. They are similar in at least two ways: both are persons and both are infected with tuberculosis. And both pose a social risk of spreading their infection. But they differ on a crucial dimension: we know where to find the teacher, but we don’t know where to find the homeless person.

            Now, why should the State have the authority to hold homeless people infected with TB against their will? (1) Because they pose a clear danger to the rest of society. TB is an airborne disease — I can be infected by simply sharing a bus seat with someone who has an active TB infection. If their strain is a multiple drug resistant strain, I am in for a long, expensive and relatively unpleasant treatment period with uncertain results.
            (2) Because they pose a clear danger to themselves. Properly treated, simple non-resistant TB has a very high cure rate. Untreated, it eventually kills the patient. We know how to cure this disease: if their circumstances are such that the patient cannot comply with the treatment regimen, we owe it to the patient to place them in a setting where they can comply with the regimen.

            Now, why a sanitarium rather than a general purpose hospital? It’s a simple matter of costs. Although TB is debilitating in its end stages, it isn’t in its early stages. These patients by and large need a place with three hots, a cot, and someone to provide their medications on schedule. They do not need the services of general hospital. Sanitaria are going to be making a comeback once totally resistant TB strains (and there is at least one out there now) become widespread.

          3. But legally you have no basis of distinguishing a priori the schoolteacher and the homeless person (both citizens with civil rights), any more than you have a basis a priori of saying that young urban black males should submit to monitoring by the police because a relatively high % of them eventually commit crimes or that males of middle eastern background should be subject to extra security at airports because a relatively high % of them are involved in terrorist activities. Behavior, not demographic markers are the normal and proper standard for interference in liberty. The court cases of the late 1960s on the forced institutionalization of the mentally ill set the precedent that persons cannot be held against their will unless they have committed crimes or are of unsound mind and are a demonstrable risk to others. A homeless guy who says “yeah – I’ll be back next month for another round of anti-biotics” to avoid being held in a hospital has to be taken at his word.

            As the the “cost effectiveness” of dedicated TB hospitals – the state of Florida was spending $10M a year on a facility that housed, on an average night, 37 patients. Hospitals are a largely fixed cost enterprise. Some hypothetical world in which drug-resistant TB is widespread isn’t the world we live in. In the world we live in the state of Florida has a depressed tax base (due to the recession and the collapse of a real estate bubble that had hit the state very hard) and a fiscal crisis. It made a prudent decision to close an enormously expensive facility that served a very small population that could have been served at much lower costs in general hospitals. How in the world is that some sort of moral outrage?

          4. You must really like it on Fantasy Island.

            This world we are living is one where MDR TB is widespread. It is not uncommon in the U.S. and it is the rule rather than any sort of exception in Russia and parts of South America. It is going to become the rule rather than the exception here, if we keep shredding our public health programs.

            With DOT, it isn’t a matter of, “I’ll be back next month,” it’s “I’ll be back tomorrow.” So, I could live with a decision system that says miss one and you’re done.

            The fact that Florida hasn’t made use of its facilities isn’t an argument that the facility is unnecessary. Actually, the Jacksonville epidemic is evidence that Florida’s sanitarium is underoccupied rather than unnecessary.

    2. It would be easier to believe that Republicans gave a s**t if so much of their identity and political philosophy didn’t rest on principles that excuse them from giving a s**t. To recap:

      1. The poor are poor because they lack initiative/common sense and thus choose poverty; people “choose” their lot in life.
      2. Taking care of them creates moral hazard that promotes more poverty.
      3. Government is less efficient/more corrupt than private markets, i.e. charity.
      4. Charity should be left to non-profits and families, not the “nanny state”.
      5. The wealthy have earned their wealth by themselves, and thus owe no greater percentage of taxes to anyone.
      6. Taxes are often little better than theft, and thus progressive taxation is tantamount to fascism.
      7. Redistributive policies are driven by envy and class warfare, not practicality, moral concern, or social responsibility/justice.
      8. The problems of the poor aren’t nearly as bad as liberals make them seem.
      9. The liberal media present these one-sided stories unfairly.
      10. Back in the good old days people took care of themselves.
      11. Social programs inevitably lead to serfdom and socialism.
      12. Democrats only offer such programs to earn votes from the poor (who probably shouldn’t be voting anyway).
      13. Liberals have actually created the social dysfunction we see today with all their hippie sex and feminism, so it’s their fault.

      I’m sure I left out plenty. Of course not all Republicans would agree with every item (although Libertarians surely would). But you’d be hard-pressed to find one who didn’t agree with at least half.

      1. No, I think you hit all the major chords in the theme. You missed the dissonant racist notes but it’s got the beat and you can dance to it.

  4. TB is also a disease of relatively close quarters. At what point do the movers and shakers all live in communities that are gated and screened to the point where they (believe that) they don’t have to fear contagion?

    1. I think that Republicans _already_ feel that they won’t get TB. Given that they’re positive that they’re in mortal danger every minute of their lives without a Glock in a shoulder holster and a .38 strapped to their ankle, and that they’re sure they can safely go without health insurance because they won’t get sick or be injured, it becomes clear that they’re very, very, very bad at risk assessment. Sensible people who are GOOD at risk assessment should make every reasonable effort to ensure that people who are bad at it don’t determine public policy.

      1. Sensible people who are GOOD at risk assessment should make every reasonable effort to ensure that people who are bad at it don’t determine public policy.

        Fully agree. Sadly, the sane people s*ck at politics.

    1. The document you link to allows for detention of infected patients only after demonstrated non-compliance with less restrictive treatment measures. Which is, as far as I can tell, the procedure in Florida as a small portion of the patients in the TB hospital marked for closure were forcibly detained. But its a far cry from saying that the state can sometimes compel inpatient treatment for patients who have demonstrated a pattern of avoiding treatment to saying that the state can and should compel inpatient treatment based on demographic or appearance-related factors (i.e. this homeless guy looks unreliable so let’s lock him up in a hospital)

      And again – even if the state can and should detain all or some TB patients for treatment it does not follow that the only way to do so is in a dedicated TB hospital. Such a facility might – might – be better suited to housing such patients, but the fact that almost every city and state in the country gets by without one demonstrates that they are hardly necessary.

      1. Or, perhaps it illustrates that our once adequate (at least outside the South) public health system is going, or has gone, to Hell. Indeed that was one of Mark’s original points.

        Personally, I prefer to avoid have folks who won’t take their drugs from going around infecting others with resistant TB.

      2. I don’t know much about such things but I don’t think quarentining infected individuals, in the interest of public health is an uncommon or controversial response to life treatening contagions. It hardly seems unreasonable to point out that the difference between a regularly employed person with a residence and a person who sleeps under a bridge is not insignifigant in making a judgement as to whether the patient can be relyed on to take their meds on schedule. Folks living under bridges march to a different drummer.

        1. My mech engineer son would say, BOHICA. (Bend Over Here It Comes Again, for the uninitiated.)

          I hope sd saves some space on Fantasy Island.

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