An expensive illusion? The use of isolation as a tuberculosis control strategy in Taiwan.

摘要

This research examines the use of isolation for tuberculosis patients in Taiwan from 2006 to 2008, the first three years of the "Ten-Year Mobilization Plan" aimed at halving the incidence rates of tuberculosis by 2015. Despite the importance of reducing the prevalence of this disease, especially given the emergence of drug-resistant tuberculosis, the use of isolation to treat and contain it invariably poses restrictions on individual liberty. To justify this intrusive public health intervention, it is important to examine how the isolation regulatory scheme is applied and to evaluate whether the regulation protects and promotes public health in a way that would justify infringing upon individual liberty.;This dissertation examines four issues: (1) Why did Taiwan adopt isolation as one of its tuberculosis control strategies? (2) How did Taiwan implement the regulatory scheme for isolating tuberculosis patients? (3) To what extent was the use of isolation warranted in efforts to prevent disease transmission and forestall the development of drug-resistant tuberculosis? (4) What changes will ensure that Taiwan's isolation regulation maximizes public health interests without sacrificing individuals' liberty?;This study adopted a qualitative method to answer these questions. A total of twenty-two semi-structured interviews were conducted with two groups: local health officials and health care workers at designated hospitals. For the first group, eleven interviews were conducted with fifteen Taiwanese officials from ten local health administrations that covered areas where newly registered tuberculosis cases accounted for 62.03% of all cases in 2006. For the second group, eleven interviews were conducted with fourteen health care workers --- including physicians, nurses and TB case managers --- from eight designated hospitals that isolated tuberculosis patients.;The research led to several conclusions. First, treating physicians played an important role in initiating the isolation processes by sending referrals to local health administrations. Second, while physicians' decisions to send Referrals were based mostly on patients' sputum smear-positive test results, there was a strong correlation between these decisions and the intention to receive full reimbursement from the government for isolation-related expenses. Third, almost all physicians' referrals for isolation were approved by local health officials based on positive test results without additional assessment of the necessity of isolation in the review process. Fourth, small number of isolation processes was initiated by public health workers to ensure treatment of allegedly uncooperative or non-compliant patients, usually from socially vulnerable groups. Finally, some allegedly uncooperative or non-compliant patients were not pursued for isolation, while those isolated did not always complete a full course of treatment.;The findings raise the following serious concerns about the application of isolation measures. First, when isolation processes were initiated by treating physicians, they were over-inclusive, incurred substantial economic costs, failed to consider less restrictive alternatives, and unfairly placed the burden of isolation on patients who were willing to be treated. Second, when isolation processes were initiated by public health workers, they were under-inclusive and unfairly burdened vulnerable groups while providing limited corresponding benefits to public health.;Based on these findings and concerns, several recommendations for improving Taiwan's public health regulation in this area can be put forth based on the World Health Organization's guidelines on the use of detention for tuberculosis patients. First, procedural protections, like those provided to mentally ill patients in the newly revised Mental Health Act, are needed: there should be an impartial decision maker, and the patient should have the right to initiate a review procedure and ask for release. Second, there should be specialized hospitals to provide a suitable environment and essential medical services for isolated tuberculosis patients. Third, when seeking an isolation order, health officials should be required to document facts regarding patients' behaviors that might pose a significant risk to others and to demonstrate previous attempts to adopt less-restrictive measures. Fourth, to ensure treatment, mandatory DOTS (directly observed therapy, short course) with a variety of incentives, support arrangements, and social welfare mechanisms should substitute for isolation to reduce burdens on individuals' liberty. Finally, the government should stop using social characteristics as evidence of risk in current rules and practice and acknowledge its responsibility to remove barriers that contribute to the prevalence of tuberculosis and fund more cost-effective alternatives to prevent transmission and facilitate treatment completion.