During my five years as a physician in the Los Angeles County corrections system, I personally saw hundreds of patients with hepatitis C who were untreated for this potentially fatal but curable disease. Although treatment for hepatitis C has gradually improved during my tenure, the system remains woefully incapable of making the kind of concerted efforts that could significantly reduce the toll of infection inside and outside prisons.
Hepatitis C, a viral disease that affects the liver and is transmitted through blood, is very common in prisons. More than a third of the inmates tested tested positive. That suggests the number of people infected with the virus in the country's largest prison system is likely in the thousands.
Hepatitis C is new enough in medical science that it was not officially identified until the 1980s, and was known only as “non-A, non-B hepatitis.” Thanks to the marvels of modern molecular biology, they are now well described, and available drugs cure almost every patient who takes them.
However, untreated hepatitis C still kills about 14,000 Americans each year, a higher toll than that caused by HIV. Because these deaths are preventable, the Centers for Disease Control and Prevention recommends that adults be universally screened for infection.
In this context, one might expect prison medical providers to test widely for the disease and treat it promptly. Infection surveillance and management is important in any correctional medical system, and is routine in our system for other diseases, such as TB and COVID-19.
Unfortunately, this is not what I encountered in practice. All detainees in prison undergo a medical examination. But they are usually superficial and do not include screening for hepatitis C.
When I started treating prisoners in 2018, doctors rarely screened for the disease, in part because known cases were never treated. The protocol was to consider patients only if their disease progressed to advanced cirrhosis.
Moreover, getting the medicine to the patient means arranging a special police escort to make an appointment at the district hospital and then waiting several more weeks for the antiviral pills to be delivered. The whole process took several months and treatment was generally discouraged.
I think the deeper reason behind the reluctance to treat hepatitis C in prisons has to do with inertia and funding. Medicines are under patent and expensive.
However, the cost fell rapidly, and poor states such as Louisiana and Egypt found in their budgets the ability to purchase the drugs and use them on a large scale. Moreover, treatment of the disease is cost-effective due to the resulting reduction in the incidence of cirrhosis, liver cancer, heart disease, kidney disease, arthritis and diabetes. In the long run, reducing the spread of infection will save dollars and lives.
The county jail system has made some important strides in recent years. Patients can now qualify for treatment of hepatitis C without cirrhosis. One of the two medications needed to treat the disease has been added to the list of approved medications in the system, eliminating the need for an external medical appointment.
However, even with these improvements, I have seen the number of patients receiving treatment grow from nearly none to dozens as of last year in a system where the number of hepatitis C cases likely runs into the thousands. Screening is still random, and most working doctors are still not allowed to initiate treatment despite the ease of use of medications.
Meanwhile, illicit intravenous drug use and unsterile tattoos remain ubiquitous among prisoners, helping the virus easily find new hosts. These conditions mean that hepatitis C virus still thrives behind bars, and is more likely to spread in Los Angeles prisons than to be treated there – a shameful situation in 2024.
Once in every generation, a major pathogen finds itself on the cutting edge of history. My parents remember the polio scares of the 1940s and 1950s. Smallpox plagued humanity for thousands of years before it was eradicated in the 1970s. Now it must be Hepatitis C's turn.
Any campaign to eliminate hepatitis C in Los Angeles would be wise to focus on our prisons. A coordinated strategic plan for testing and treatment could quickly reduce infection levels within months, reducing disease inside and outside prisons. Consistent failure to make such an effort is fatal and unreasonable.
Mark Bonin-Bennor is a family physician who worked in the Los Angeles County Jail system from 2018 to 2023.
