Why is tuberculosis on the rise again? For one thing, Dr. Reichman says, people who have ТВ don’t keep taking their medication as prescribed. He adds that city and state hospitals, lacking money, began to let ТВ patients leave before they were fully cured, with no way to locate them and no follow-up schedules to make sure the patients were taking their medicines.
As it did 100 years ago, ТВ afflicts mostly the poor -especially the chronically ill and children. Also highly susceptible are those with AIDS, a disease not fully recognized until the 1980s.
Charles Hooks, 43, lives in Newark, New Jersey. He is HIV-positive and also has ТВ. Hooks says he is neither gay nor an intravenous drug user -two major routes for HIV infection. When diagnosed with ТВ, he took his four medications for a few weeks and then stopped. He stopped seeing his doctors too.
To provide follow-up care, the clinic in Newark at which Hooks had been treated assigned Ramona Valentin, a directly observed therapy (DOT) worker, to find Hooks and watch him actually take his medications from then on. He moved a lot. She finally found Hooks at his mother’s home.
“At first,” Hooks explains, “I didn’t want to take my medicines. They made me sleepy. I was going to die of AIDS anyway, I felt, so why take drugs? Now I’m taking them. I feel better.” His medications suppress the tuberculosis infection and prevent its spread.
Once Hooks had returned to their care, his doctors took а ТВ sample from his lungs to learn whether the bacteria had become resistant to the medicines while he’d stopped taking them. Luckily, they had not. So the doctors prescribed the same four drugs he’d taken before – isoniazid, rifampin, pyrazinamide, and ethambutol – which are recommended by the Centers for Disease Control in Atlanta for the treatment of ТВ. (Some doctors use streptomycin instead of ethambutol.) Hooks was told to take all four drugs for at least 6 months. It takes about 2 weeks for the drugs to kill enough bacteria so they can’t infect other people. It takes 6 months for a cure. Once cured, patients almost never get tuberculosis again.
“DOT workers like Ramona Valentin are modern – day heroes of public health,” says Dr. Thomas Frieden, director of the Bureau of Tuberculosis Control for the New York City Department of Health. “They look anywhere to find their clients -in crack dens, under bridges, on park benches. Today, New York has 1,200 patients on DOT.
“In 1992, there were 3,811 cases of active ТВ reported in the city. In 1993, there were 3,235. That drop of almost 15 percent is the first significant decline in New York City since 1978.”
Dr. Frieden credits DOT workers with some of that decrease. He says they give food vouchers, a place to sleep, even cash, to the patients who show up for medication. Yes, this costs taxpayers several hundred thousand dollars a year, but Dr. Frieden contends that it’s worth it. “A single case of ТВ can spread rapidly to hundreds of people and cost millions in health care,” he says. “The average bill for each hospitalized ТВ patient is 25,000 dollars.”
Dr. Reichman notes that follow-up care is essential. If the ТВ bacteria become resistant to two of the four drugs prescribed, those particular drugs can’t stop the disease; it continues to sicken the patient, and others can catch it. After the four-drug treatment becomes ineffective, more drastic measures must be pursued. They include drugs that are more toxic and expensive and may take as long as 2 years to work, with surgery as a last resort.
In New York City, tests show, many patients have drug-resistant ТВ. If they refuse treatment, health department workers can detain them under a law that requires hospitalization until the patient is cured. Mark Barnes, an attorney now in private practice, wrote the law when he worked for the city. “Detention is not the first but the last resort,” says Barnes.
Private sources are enlisting in the battle against ТВ. Thanks to a grant of 1.15 million dollars from the Robert Wood Johnson Foundation in alliance with Bellevue Hospital Center, New York City has a program in which outreach workers aggressively track and treat ТВ patients in poor areas. The foundation underwrites similar projects in Atlanta, Baltimore, San Diego, and southern Florida, all with ТВ problems in hard-to-reach communities.
Our rising ТВ statistics give us a grave warning, to be heeded at home and abroad. Globally, tuberculosis kills 2.9 million persons each year. The World Health Organization sees a bleak future if the drug-resistant strains of the disease get a foothold in countries that lack clinics or hospitals. We can control ТВ. In 1992, only 10.5 persons per 100,000 in the United States had this disease, according to the Centers for Disease Control. With care, that figure can be made even smaller. With carelessness, it can mushroom, as it did in the 1800s, afflicting not only the poor but the middle and upper economic classes as well.
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