Those who live and die behind prison walls don’t usually get much public attention. Incarceration is, after all, meant to remove criminals from society. But contagious and potentially deadly diseases can’t be locked and left in a penitentiary, especially when infected inmates are eventually released.

The problem of prisoners and ex-convicts transmitting diseases to the general population is especially bad in the countries of the former Soviet Union, where rates of tuberculosis and drug-resistant strains of TB are among the world’s highest.

But Stanford researchers have identified solutions that could help curb tuberculosis in Russia, Latvia, Tajikistan and the 12 other countries in the region. Led by Jeremy Goldhaber-Fiebert, an assistant professor of medicine, the team has shown that a genetic TB and drug resistance screening tool called GeneXpert is more cost effective and better at reducing the spread of the disease than other methods currently recommended by the World Health Organization. Their findings were published online Nov. 27 in PLoS Medicine.

“Tuberculosis doesn’t stop at any border or any locked gate,” said Goldhaber-Fiebert, who is also a faculty member at Stanford Health Policy, a research center at the university’s Freeman Spogli Institute for International Studies.

“Drug-resistant TB is rampant in prisons,” he said. “When infected prisoners get out, they are thought to drive the TB epidemic in the general population. We are looking to find better ways to deal with that.”

About 400,000 cases of TB were diagnosed last year in the 15 former Soviet Union states – 40 times the number reported in the United States. Nearly 80,000 of the sick had drug-resistant TB. According to several studies, the prevalence of TB among the region’s prisoners is 10 times greater than that of the general population.

The WHO suggests three ways to screen for TB in prisons: relying on inmates to report symptoms, actively interviewing prisoners about their health, and administering chest X-rays. The organization doesn’t recommend one method over another, and currently, prisoners in the former Soviet Union are screened annually with miniature chest X-rays.

While X-rays can show whether a lung looks healthy, they don’t always catch TB. And when they do, they cannot differentiate between a TB that can be cured with standard medications and its drug-resistant cousins that require more expensive and extensive treatments.

That’s where GeneXpert has an upper hand.

Since it was introduced in 2005, the diagnostic has been hailed as a potentially powerful tool that can help to cut TB and drug-resistance rates by more accurately diagnosing people and getting them treated. With just a small sample of mucous analyzed by a machine, the GeneXpert system can instantly detect TB and its drug-resistant genetic mutations, well suited to mass screening within the prison systems of the former Soviet Union.

But the GeneXpert test is more expensive than alternative screening methods. And while it promises to be more effective, its impact on total costs had not been quantified in the former Soviet Union region until Goldhaber-Fiebert and his colleagues began their work nearly three years ago.

By developing computer models of the former Soviet Union’s prison populations, the team predicted that using GeneXpert can cut the prevalence of TB among inmates by about 20 percent within four years – provided the screening is combined with standard regimens of drug treatment for infected patients and for those with drug-resistant TB.

“For this to make sense, you need to have the right drugs to cure those individuals you identify,” Goldhaber-Fiebert said.

The additional cost of screening with GeneXpert averages to $71 per prisoner compared to the next best alternative approach, he said.

When compared to the decreases in illness and increases in survival, and factoring the financial and societal costs of TB in the broader population, the method makes good economic sense, he said.

“There is a large, direct value to using this technology for screening in prison settings, and there are potentially substantial secondary benefits to the general population of the former Soviet Union and to the world,” Goldhaber-Fiebert said.

Douglas K. Owens, a professor of medicine who is one of the paper’s co-authors and director of Stanford Health Policy, said the findings could give governments and medical experts the evidence they need to change the way they tackle TB.

“This is the kind of work we hope will inform policymaking about TB control,” Owens said. “We’ve shown there’s a more effective approach for trying to catch TB in prisons, and that means a better chance for preventing the disease from spreading.”

Co-authors on the PLoS Medicine paper also include former Stanford medical student Daniel Winetsky and current Stanford doctoral student in Management Science and Engineering, Diana Negoescu.

The researchers collaborated with the AIDS Foundation East-West. Funding for the study came from Äids Fonds, the International Research & Exchanges Board, the Department of Veterans Affairs, the National Institutes of Health, and Stanford.

An American of Indian descent is focused on the economic impasse between New Delhi and Islamabad and a Polish immigrant is fascinated by the Soviet-era biological weapons program. A young woman from Taiwan wonders whether historical memory is fueling nationalism in China, and a Bahraini is investigating the rise of Islamic fundamentalism in his part of the world. Yet another intends to run for public office. 

All this – and they’ve yet to graduate. 

This year’s 12 honors students at the Center for International Security and Cooperation – Stanford seniors drawn to public policy and international affairs – represent the best of what the university offers: diversity, a passion for learning outside the classroom and a determination to make an impact once they venture out into the world. 

Even two weeks in Washington, D.C., did little to dissuade them from potential careers in public policy. They met with dozens of politicians, journalists, military analysts, lobbyists and experts from the leading private organizations and government agencies in the nation’s capital. While congratulated on their ambitions, the students were cautioned that Washington has become a brutal and highly divisive place to work. 

“You gravitate toward public policy and you’re likely to become a leader,” former U.S. Sen. Chuck Robb, D-Virginia, told the students at a meeting in the Beaux Art landmark that has housed the American Red Cross since the presidency of Woodrow Wilson.

 Robb listened to their thesis topics, offered advice and contacts, and took questions about world policy and events. He then joined the chorus of others inside the beltway lamenting the poisonous partisan politics of Capitol Hill. 

“It’s just toxic,” said Robb, who now promotes common ground between Democrats and Republicans as a member of the Bipartisan Policy Center. “You just can’t get anything done. I think we’ll have a lame duck session in Congress and nothing will happen until March. Then, a full-scale depression next spring – and I think the markets will crash.” 

The students had heard likeminded pessimism earlier that day from Walter Pincus, who covers intelligence, security and foreign policy for The Washington Post. He said PR and TV now run Congress because candidates consistently worry about how their comments on camera will be used against them in their next re-election campaign. 

“Politics are totally polarized in a way I’ve never seen before,” said Pincus, who teaches a seminar about government and the media in the Stanford-in-Washington program. Compounding the misery, he said, is the nearly $1 billion spent on political ads trashing opposing candidates in the exhaustive presidential campaign. 

“We go off and tell the rest of the world they ought to have elections, but our elections have become a PR operation,” Pincus said. “So – that’s my happy view of the world.” 

The students laughed nervously. That evening, they chatted in front of the White House about all the negativity they had heard that day. Some seemed spooked. Others made that clarion call of each new generation: It’s our turn to make things right. 

“I believe that each of us has a duty and responsibility to do what is right, what is just, and to move the world – our country and our community – at least one step forward to make each day brighter than the last,” said David Hoyt, an international relations major who aspires to public office. “And I believe that students in CISAC, by coming together and addressing these … pressing issues of our time, are starting that process.” 

The Interschool Honors Program in International Security Studies at CISAC is a competitive program in which 12 seniors are chosen from among all Stanford majors to spend their final year investigating a global security issue. They are mentored and attend seminars and classes taught by CISAC faculty and researchers and present a thesis at the end of the year. They come to think of Encina Hall as a place where their ideas count.

“I always thought of CISAC as my intellectual home at Stanford,” said Jane Esberg, an honors student from the class of 2009 who is now at New York University’s Center on International Cooperation and intends to pursue her Ph.D. in political science. “It was the first place where I felt like everybody thought about things that I really cared about. They never really treated me like a student – they always treated me like a colleague.”

Martha Crenshaw, a Senior Fellow at CISAC and its umbrella, the Freeman Spogli Institute for International Studies, is an expert on political terrorism and has directed the Honors Program for three years. She co-teaches s weekly honors seminar with Joe Felter, a senior research scholar at CISAC and retired U.S. Army colonel and Special Forces officer.  

“It’s a special pleasure to work with a small group of very talented and imaginative students who have such diverse interests,” Crenshaw said. 

The Washington leg of the program, known as Honors College, takes place in the two weeks before the academic year begins. The students also visit national battlefields to reconstruct war policy; a private tour of the National Portrait Gallery allows them to recount U.S. history through the individuals who shaped the great American story. 

The two weeks also helps them bond and unveil their thesis topics. 

“The secret of the honors program is the interaction,” Tom Fingar, the Oksenberg-Rohlen Distinguished Fellow at FSI, told the students on their first night. They had gathered in a hotel conference room for the inaugural hashing out of their theses – some of which would change dramatically after two weeks of feedback in Washington. 

“You are going to be one another's most valuable critics,” said Fingar, an East Asia expert and former chairman of the National Intelligence Council who spent 23 years in the U.S. government. “In the end, this is your product, but your product that is informed by a collaborative process.” 

Fingar has been escorting the students around Washington since the program's inception in 2000. His years in intelligence and at the White House and State Department opened doors to counterterrorism and intelligence officials at State, the National Security Council, Homeland Security and the Department of Defense. The students also met those who strive for public policy toward peace and reconciliation, at the Eurasia Group, Carnegie Endowment for International Peace, Amnesty International and the Stimson Center. 

The students got an earful on how to operate if they gravitate toward capital careers and were encouraged to take time before determining what they wanted to do with their professional lives. 

“I quickly realized that I don’t like doing law,” said Matthew Rojansky, a Stanford Law School grad who is deputy director of the Russia-Eurasia Program at Carnegie, when asked about the benefits of law school. “Don’t jump into it with any uncertainty or reservations. Take time after school. You guys have a lot of options in your lives.” 

The next day, the students met national security and terrorism correspondents at The New York Times. They asked the reporters about the attack on the U.S. consulate in Libya, the covert use drones, and whether cyberwarfare is the next big security challenge. 

“The CISAC honors students are an amazingly talented group that we look forward to meeting every year,” said Eric Schmitt, who covers terrorism and national security for the Times and was a Knight Journalism Fellow at Stanford. “As journalists working in Washington, we’re able to give them insights from the front lines on the policies and politics of their research topics.”