Since October 2014, when the first severe case was discovered, the town of Marion, Alabama, has been struggling with an historic outbreak of tuberculosis.
Harper's June issue focuses attention on this little-noticed public health crisis. With 34 active cases in a town with a population of 3500, the rate of infection in Marion is almost 100 times the national average, and is higher than the rates in India, Kenya, and Haiti. Nearly 200 more people in Marion are infected but not yet showing symptoms.
Chronic shortages of physicians and other health care services left Perry County vulnerable to an outbreak of a disease all but eradicated in most of the United States. County health rankings consistently place Perry County and its neighbors in Alabama's Black Belt as the least healthy counties in Alabama. With only two ambulances and an underresourced hospital 20 minutes away, Perry County residents' life expectancy is seven years lower than the national average; the percentage of obese adults is almost a third higher than average; and more than a quarter of births are without adequate prenatal care.
Alabama's Black Belt — named for the dark, fertile soil in which enslaved black people grew cotton for white landowners — is home to some of the poorest counties in the United States. Alabama is the fourth poorest state in the country, and Perry is its poorest county: 47 percent of residents live below the poverty line.
The legacy of our nation's history of racial injustice is readily seen today. The poverty rate in Perry County is three times higher for black people than for whites. As Harper's put it, "Jim Crow is gone, yet segregation lingers, along with its associated injustices." The struggle for voting rights in Marion, where the fatal shooting of activist Jimmie Lee Jackson by a white state trooper during a peaceful march in February 1965 was a catalyst for the Selma to Montgomery march, continues. In 1984, Marion activist Spencer Hogue was one of three people prosecuted for voter fraud by Jeff Sessions, then U.S. Attorney for Southern Alabama; Mr. Hogue died last year from other health problems after being diagnosed with latent tuberculosis. And just last year, Alabama enacted a voter-identification law and then closed DMV offices in the Black Belt in what was recognized as a deliberate effort to block black people from voting.
Testing Marion residents for TB got off to a rocky start, as state health workers failed to acknowledge why some residents might be wary of outside medical intervention. In 1932, just two hours away, scientists enrolled black sharecroppers in the Tuskegee Study of Untreated Syphilis in the Negro Male and denied them treatment. Many suffered severe complications of syphilis and infected their partners and children.
In the 1920s, many states authorized forced sterilization of thousands of “undesirable citizens” – people with disabilities, prisoners, and racial minorities. Thousands of poor, Southern black women were sterilized without their knowledge or consent. Most states abandoned eugenics programs after World War II, but sterilization increased in Virginia, Georgia, North Carolina, and South Carolina, coinciding with growing black political power, mandatory integration, and the civil rights movement. Some states continued to sterilize into the 1970s.
The TB outbreak underscores the persistence of racial inequality in Perry County, where the average income is just under $15,000 and 20 percent of residents are uninsured. In 2010, Alabama's governor (a doctor) refused federal money to expand Medicaid, which would have extended health insurance coverage to anyone earning less than $16,394 a year.
Researchers have found that adding one doctor per 10,000 people could save up to 160,000 lives per year. Studies show that the availability of primary care significantly reduces health disparities that result from income inequality. But Harper's reports, "[o]f the few physicians who pass through the Black Belt, most stay for only a few years, to do their good deed or satisfy recruitment packages that forgive school loans in exchange for working in an underserved area."