Assistant public defender John Carey meets with one of his clients in the Cook County Jail law library; not for research, but for health reasons.
The library is larger than regular interview areas, and Carey said he believes the air circulation is a little better there, too.
That’s important, because Carey’s client has tuberculosis, a disease that in some stages is contagious. It is caused by airborne bacteria that are spread by coughing and sneezing.
Carey doesn’t believe his client is contagious, but he isn’t taking any chances.
“It can interfere with your ability to represent the guy,” said Carey. “I want to be in an environment where I can comfortably talk to the guy and not be at risk.” Carey said he intends to have a TB test.
Fueled by immune-suppressed lifestyles among drug addicts, alcoholics, people infected with HIV and the homeless, the lung disease once thought to be on its way to eradication is making a comeback-sometimes a fatal one.
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That comeback, though not as severe as in other parts of the nation, has caused concern among Chicago area residents who must work with, treat or legally represent those most likely to contract TB.
Health-care workers are at the highest occupational risk for tuberculosis. But public defenders, corrections officials, people who work with the homeless and drug addicts, social workers and even teachers in some hard-hit areas are also at risk.
These workers’ fears are not unfounded. Corrections officials across the nation became concerned about tuberculosis after 12 inmates and a guard in the New York State prisons died of multi-drug resistant tuberculosis in 1991.
All had depressed immune systems that made them especially vulnerable to TB. The 12 inmates were HIV-positive and the guard had cancer.
A 30-year decline in the number of tuberculosis cases nationwide ended in 1984 and the surge began.
Due to HIV infection, overcrowding, poverty and cutbacks in TB eradication programs, the number of TB cases across the country increased from 22,201 in 1985 to 26,283 in 1991, the latest figures available.
In Chicago, after bottoming out at 649 cases in 1987, the number of new TB cases rose to 793 in 1992, according to the Chicago Department of Health. Cases have also risen in the suburbs.
Even more worrisome, the bacteria that causes tuberculosis has started to mutate into strains that are resistant to the safest and most-effective drugs available. The treatment for these strains is expensive, time-consuming, and doesn’t always work. Fatality rates are high.
TB bacteria become drug resistant when infected patients do not complete the full course of treatment.
The remaining germs can reproduce and cause symptoms to recur, and will not respond to the previous drug used.
Because many of the people now becoming infected are less likely to complete their drug treatment, some medical officials have called for quarantines and even treatment mandated by law.
About 5 percent of the new cases in Chicago are resistant to the most effective drug, isoniazid, and about 2 percent cannot be treated with isoniazid or rifampin, the second most effective drug. The suburbs have also seen a handful of drug-resistant cases.
“We do not have any inmates who have the drug-resistant strains of TB,” said Nic Howell, spokesman for the Illinois Department of Corrections. “But we are very cognizant that TB is on the rise. We test inmates on a regular basis and, as of last year, we test the staff, too.”
Howell said about one inmate in every five will have a positive TB test, which indicates a dormant TB infection.
People have about a 10 percent chance of developing active TB in their lifetime once they are infected.
Dr. Michael Puisis, acting medical director of Cermak Hospital, which treats jail inmates, says about one out of 1,000 Cook County Jail inmates develop active tuberculosis, and the rate appears to be rising.
Puisis said 30 inmates were found to have active TB from February to July 1992, up from 26 for all of 1991.
Since the New York prison deaths, jails have beefed up screening, built isolation rooms and trained guards on how to protect themselves.
In Illinois, for example, all inmates are tested before being incarcerated.
If they are going to Cook County Jail and they have active TB, they are isolated at Cook County Hospital within 24 hours and not returned to the jail until they are no longer contagious, Puisis said.
If they are on their way to a state prison, they are sent to state prison hospitals and quarantined in “sick bay rooms that vent directly to the outside,” until they are no longer infectious, Howell said.
But people who have just been arrested are not tested for TB, and that puts public defenders, judges and other court employees, especially those who work in branch or night courts, at a high risk of unknowingly coming in close contact with active TB.
“We come into contact with the highest risk group in the country,” said Bruce Mosbacher, chairman of the Public Defender Association’s TB Committee.
“The groups we work with have the highest infection rate: poor people, inner city people, drug addicts, alcoholics and persons with AIDS.”
Faced with the possibility of contracting a potentially fatal disease, people at occupational risk of TB are anxious to learn what precautions to take to avoid infection.
It is a balancing act of protecting employees without compromising treatment and service to patients and clients, and of being cautious while not causing unnecessary panic.
“It would be very difficult to have lawyers walking around in face masks,” said Cook County public defender Rita Fry. “I do understand the fear and concern. We are working with the jail to do what we can do to make it safer for inmates as well as ourselves.”
Nationally, unions and employers have been sparring with each other and with the federal government over TB safety precautions for more than a year.
The National Institute for Occupational Safety and Health has recommended health care workers and others at significant risk wear battery-powered respirators, dubbed “Darth Vader” masks by critics.
The federal Centers for Disease Control and Prevention is revising guidelines that were written before TB cases started to increase and drug-resistant strains appeared.
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“Our concern is to make the workplace as safe as possible,” said Jordan Barab, assistant director of health and safety in the department of research of the American Federation of State, County and Municipal Employees.
“The current facilities in most health-care and correctional institutions are not adequate to protect workers, patients, or inmates.”
People are only contagious when they get to the stage of active TB where abscesses form in their lungs and they cough up bacteria-laden sputum.
Although it is thought to take several months of close contact with someone with active TB to become infected, public defenders could build up that much exposure to many different sick clients, experts say.
“It’s always in the back of your mind,” said Jill Goldsmith, an assistant public defender who works in Branch 66, the court docket where defendants charged with murder and other violent crimes enter the criminal court system.
Goldsmith said that while she was stationed in Juvenile Court, one defendant came in for a hearing who had tuberculosis.
The judge had someone call the CDC to determine that the person did not pose a great risk before proceeding with the hearing, she said.
An interpreter, who translated the hearing into Spanish for the defendant, held a napkin over her mouth, Goldsmith said.
Mosbacher said the association’s TB committee is trying to get on-site testing for public defenders who are concerned that they might have been exposed to TB on the job. Such tests were recently made available, but few people showed up. Mosbacher said most had been tested by their own doctors.
He said his group is also trying to get better ventilation for the lockup areas behind the courtrooms.
They also want germicidal ultraviolet lights, which kill TB germs, in the lockups, and simple things such as facial tissues for people to cover their mouths with when they sneeze or cough.
However, the changes Mosbacher’s group wants cost money, especially the ultraviolet lights and proper ventilation. With a tight budget, the county is relying on stopgap measures.
“We have to strive as best we can to minimize the risk until money is available to have the proper equipment in place,” Fry said.
“We have to decide how to arrive at a rational and humane solution to how to handle AIDS and other diseases without additional funding.”