Report — From the June 2017 issue

Where Health Care Won’t Go

A tuberculosis crisis in the Black Belt

Download Pdf
Read Online

It was a miserable January morning in Marion, Alabama, last year, with temperatures twenty degrees below average and freezing rain that sliced sideways. But that did not dissuade the people lining up outside the Perry County Health Department. The first appeared at the door when the sun had barely risen, then a couple more arrived, and soon they came by the hundreds. Some brought their children, others showed up with cousins; there were families four generations deep. By nine o’clock, the line had lassoed around the building, with its tail pitching into the parking lot. People held umbrellas in one hand and with the other gripped handkerchiefs or scarves tightly across their mouths. Many were from the same neighborhood, and most were black. All of them had come to collect twenty dollars in exchange for getting tested for tuberculosis.

Shane Lee, Marion’s town doctor for the past quarter-century, pulled his taupe pickup truck into the parking lot. His clinic was kitty-corner to the health department, and he was having trouble finding a spot. It was Lee who had discovered the community’s first severe case of TB, a little more than a year earlier. In October 2014, a nurse practitioner tore into his office with a fresh medical mask over her mouth, frantically waving an X-ray film. The mask, a tight-fitting turquoise respirator, was unusual. And then he looked at the radiography, which showed that the patient’s lungs were nearly completely whited out. It was the worst case of tuberculosis that he had ever seen.

The road from Marion to Greensboro, Alabama, the site of the closest hospital. All photographs by Nina Robinson

Since then, Marion, a town of 3,500 and the seat of Perry County, has been grappling with a historic outbreak of a disease that has vanished from worry in much of the United States. Thirty-four active cases have been found; if that doesn’t seem like a lot, consider that the rate of infection — what the World Health Organization uses to determine severity — is almost a hundred times the national average, and higher than the rates in India, Kenya, and Haiti. Nearly 200 more in Marion were discovered to have latent tuberculosis, meaning that they were infected but had not developed active symptoms — which include bloody coughing, shortness of breath, night sweats, and weight loss.

There is no hospital in town. The nearest one, twenty minutes away in Greensboro, has minimal resources. The road to get there is narrow, unlit at night, and littered with roadkill. Perry County has only two ambulances, one of which is on standby for the local nursing home. Life expectancy here is seven years lower than the U.S. average, and the percentage of obese adults is almost a third higher; by the latest count, more than a quarter of births take place without adequate prenatal care. Lee’s clinic is Marion’s only place for X-rays.

When he saw the image of the infected lungs, he called Pam Barrett, the tuberculosis controller for the state of Alabama, in Montgomery. She conferred with her team, and as Lee alerted them to signs of infection in more patients, they realized that all the cases originated from the same place — an impoverished African-American neighborhood called the Hill. While encounters at the grocery store or the hair salon can, on rare occasions, transmit TB through the air, repeated and extended exposure — living in the same apartment, for instance — puts someone at the greatest risk. This was how the disease was spreading in Marion. “We knew all the cases were coming from the Hill,” Barrett told me recently. “Nobody else needed to be tested unless they were close contacts.”

The case Lee saw in that first X-ray was at an advanced stage, and the patient died. Though the health department’s staff tried to track those who might be vulnerable to infection — they traced the patient’s immediate contacts until they found someone positive, then traced that person’s contacts, working outward — most people declined to speak about others in their midst, even when they came for screenings at Lee’s clinic.

If the team wanted any chance of containing the outbreak, they needed to connect with the Hill’s residents quickly. Barrett came up with an idea: a health fair to test them, an event planned not as “a tuberculosis thing” but as a fun community gathering with free pizza and soda, token giveaways, and raffles for cash. In addition to TB screenings, the fair would offer blood pressure monitoring, finger pricks to check glucose levels, nutrition counseling, and sexual-health education materials. To get local buy-in, her staff partnered with Sowing Seeds of Hope, a Christian community-development organization in Marion, which loaned its logo for flyers and helped post them around town. While location scouting, Barrett personally passed word on to the guys who frequented the Hill’s basketball court.

Early one Saturday morning that November, Barrett and her colleagues drove several hours from Montgomery to the Hill. They convened at the basketball court and began setting up tables and supplies. But shortly after they got started, a group of young men appeared and threw beer bottles at them, which whipped past their heads and crashed near their feet. The health workers ducked for cover. The men shouted expletives, then ran off. Barrett called the police. Soon, two sheriffs stationed their car conspicuously out front. Eventually the testing began, and the health workers kept on until the afternoon. But turnout was low, and no active cases of TB were found.

“I’ve done health fairs all over this community, and I’ve never had that kind of reception,” Frances Ford, a native of Marion and the director of Sowing Seeds of Hope, told me. The health department ran into trouble, she said, by popping in as outsiders and declaring their intention to concentrate solely on this neighborhood. Barrett, unlike the people she was trying to reach, is white, and though some members of her team are black, they didn’t know the town. “They targeted African-American people — they referred to them as ‘the people on the Hill,’ ” Ford explained. “The way things were said, the wording. It was stereotyping. That’s what I heard.”

Over the next year, the outbreak continued to rage. Desperate, Barrett decided to try something that the health department had never done before: a cash reward. Twenty dollars to get tested; twenty more if patients returned to pick up their results. If those results were positive and patients followed up for chest X-rays, another twenty would be disbursed.

On that January morning in 2016, as the financial-incentives program began, Barrett’s team finally made some headway. One by one, people from the line around the health department were let in, and during the next three weeks, the state’s nurses and doctors managed to test more than 2,500 people. All told, the project cost the state of Alabama $235,000.

Shane Lee on his way to a house call

“No public health department has money lying around to pay people to look after their health,” Richard Chaisson, the director of the Johns Hopkins Center for Tuberculosis Research, told me. I asked the health workers why they didn’t consider simply going door-to-door around the Hill instead. It would have been less expensive, more personal, and easier to trace members of a household. One of the nurses, a white woman, replied: “If we wanted to get shot.”

Ford was aware that the Hill had a reputation for being dangerous, but she wanted me to know that she didn’t share this view. “I’ve never seen anything that I feel uncomfortable around,” she said.

Previous PageNext Page
1 of 8

You are currently viewing this article as a guest. If you are a subscriber, please sign in. If you aren't, please subscribe below and get access to the entire Harper's archive for only $23.99/year.

= Subscribers only.
Sign in here.
Subscribe here.

Download Pdf
is a physician and an assistant professor of medicine at Columbia University. Her article “Hashtag Prescription” was published in the June 2016 issue of Harper’s Magazine.

More from Helen Ouyang:

Get access to 168 years of
Harper’s for only $23.99

United States Canada


April 2019

Works of Mercy

= Subscribers only.
Sign in here.
Subscribe here.

view Table Content


You’ve read your free article from Harper’s Magazine this month.

*Click “Unsubscribe” in the Weekly Review to stop receiving emails from Harper’s Magazine.