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TB's insidious return: did we ask for it?

A new penalty is being exacted on America's communities for years of neglected public health budgets, jampacked prisons, dank homeless shelters and the housing and work conditions suffered by our poor and immigrant groups. The penalty can be spelled in two letters: TB.

Tuberculosis is the world's largest cause of death from a single infectious agent. We Americans thought we'd slain the dragon through a combination of improved hygiene, new drugs, hospital care, and better housing. U.S. cases dropped to a modern-day low of 22,201 in 1985.

However, now there's an ominous turnaround. Nearly 30,000 new cases a year are being reported, with projections of 50,000 a year by 2000.

TB can be communicated by airborne droplets when a person with an active case of the disease coughs up the active bacilli or even exhales deeply within someone else's breathing space. Small wonder the disease thrives in such places as cramped cells and crowded homeless shelters. There are repeated instances of prison guards being infected by inmates, social worker by their clients.

Charlotte Carneiro, public health nurse in Arlington County, Va., describes TB as "slow, silent and quiet." The bacteria can remain dormant in a person for years and then strike resistance is low.

"TB," says Carneiro, "is a marker for a poor economy, an indication of poor socioeconomic times. People need shelter and nutrition and a non-stressful life to maintain their immune system. If that's not present and the disease is present, it will proliferate."

AIDS patients are particularly vulnerable to contracting TB. And new drug-resistant TB strains have appeared that are extremely infectious and can cause death in a matter of weeks, says Dr. George Curlin of the National Institute of Allergy and Infectious Diseases.

Standard treatment for TB patients is a regimen of three to five pills daily for nine to 18 months. But since the medications relieve symptoms within the first few weeks, many victims stop taking them. A partially treated person, Dr. Curlin notes, is at risk to develop a drug-resistant strain of TB later.

The sad fact is that so many of the patients are homeless, drifters or drug-dependent that public health officials have to expend a tremendous effort to track them down and to make sure they are taking medications.

There are massive cultural barriers. Arlington County has 31 distinct ethnic or nationality groups. "Eight languages are represented in the clinic staff," said Carneiro. "We need a mini-United Nations."

All this occurs at a time when America's public health system is alarmingly weak. The Reagan and Bush administration repeatedly balked at requests to fund TB prevention efforts.

Indeed, it is almost by conscious neglect that the contagion now threatens poor and middle-class Americans.

In a decade, we have doubled our prison and jail population, often tolerating conditions of gross overcrowding.

We have overlooked and underfunded (and too often even closed) public hospitals, the safety net for many of the poorest citizens and 35 million Americans without health insurance.

We have failed to consider the consequences of permitting 1 million to 2 million immigrants, legal and illegal, to pour into the country each year, many from developing countries where they had been exposed to TB as children.

And city's housing officials can tell horror stories of multiple immigrant families living in a single-unit--sometimes even "hot- bedding" as families take turns using the bedrooms of a single apartment.

If we are serious about containing TB in the years ahead. we'll need dramatically expanded national housing subsidies for Americans new and old alike. We'll need a national health care system that guarantees universal access. And we'll have to abandon our insane policy of incarcerating vast numbers of petty criminals (minor drug offenders, for example) and then packing them sardine-fashion into jails and prisons.

Getting smart on all these fronts would also help suppress a raft of other infectious diseases currently on the rebound, ranging from staphylococcal infections to meningitis to gonorrhea.

Most basically, we need a new social contract, an outreach by society to deal sensitively with our "at-risk" populations--and in turn to expect responsible health behavior from them.

Community health centers, prevention-oriented and responsive to neighborhood needs, are one of the best ways to make the contract work. About 600 such clinics now operate nationwide. Some, like those run by Dallas' Parkland Memorial Hospital, have reached out across income groups and ethnic rainbows to make health care relate to people's full needs. The Dallas clinics have neighborhood advisory councils. They look first and foremost to prevention. They show respect for their patients and work to reconnect them with their neighbors and the society at large.

TB represents, in the end, more than an insidious disease returned. It is a metaphor for the alienation and lack of caring that is tearing American society apart. America's public health system is becoming sick itself. But with the right thought, and care, it is curable.
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Title Annotation:tuberculosis
Author:Peirce, Neal R.
Publication:Nation's Cities Weekly
Date:Sep 28, 1992
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