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TB or not TB - what is the question?

At the turn of this century, the United States had 40 tuberculosis sanitaria--hospitals devoted exclusively to treating TB patients. By 1925, with an increased public awareness of the need for hospitalizing such patients, there were more than 500 such institutions. The only known cure for the disease was bed rest and a nutritious diet. Most patients entered the sanitarium voluntarily; others did not. For these individuals, the law permitted health authorities to commit them forcibly to hospital care.

With the advent of streptomycin in the 1950s (and subsequent newer drugs) for treating tuberculosis, the disease declined dramatically, and TB sanitaria are no more. Today, most cases require only out-patient care. Although treatment may go on for years, the patient is usually no longer contagious after the first month of therapy.

In recent years, however, the disease has again reared its ugly head within a segment of the population that does not readily respond to home care. More than 70 percent of today's TB patients are drug or alcohol abusers. Often, these people have no home, or they lack the incentive for curing themselves, or for protecting others from their disease. Although many are treated long enough to become noninfectious, they stop taking their medication and relapse into the infectious stage. The result is a frightening increase in strains of tubercle bacilli that no longer respond to drug treatment.

The question facing ever-increasing numbers of communities is how to deal with the recalcitrant patient. To many concerned citizens, the answer is simple: enforce the laws and force the patient to take treatment. Unfortunately, this is easier said than done. Incarceration can be cruel--and is very expensive. Because there are no longer any special institutions for tuberculous patients, they must be confined in ordinary hospital infectious disease units. In New York City, the cost of confining a patient can be as much as $250,000 for what may be a two-year complete course of treatment--including $2,000 a week for round-the-clock guards. Forced to take outpatient treatment, the patient may simply disappear until apprehended again, in the meantime having worsened his or her own situation, as well as that of contacts.

The city of Denver has employed one solution to the problem by searching out infected persons and offering them cash incentives to take treatment. Many--including health professionals--object to giving patients money to take medicine that will save their lives. Nevertheless, by giving poor patients $20 a day to take their medicine and a bonus of $100 for completing treatment on time, for example, communities could save not only these patients' lives, but the lives of many others.

Whatever the answer to the question, we must all face up to the fact that tuberculosis has become a ticking time bomb.
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Title Annotation:tuberculosis
Publication:Medical Update
Date:Jan 1, 1993
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