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DC cases down; lab still on the wish list
Things are looking up in the TB control division in Washington, DC. The proof? People there are starting to talk — ever so cautiously, of course — about the functioning public health laboratory they hope to have someday.
These days, outreach workers have cars to take them to their patients. There’s new leadership, even a dab of new money. "There have been some bad days," says Margaret Tipple, MD, the district’s new chief of TB control. "I’m cautiously optimistic."
One thing that serves to keep Tipple’s optimism from overflowing is the current debate over the district’s finances for the upcoming year. Recently, President Clinton vetoed Washington’s budget bill, complaining it was too loaded down with riders aimed at keeping the district under the thumb of the Control Board. The result is that for now, TB control and all other municipal functions are running on federal and local dollars provided by a continuing resolution. "That, of course, means nobody can do any long-term planning," Tipple adds.
That’s a mere aggravation compared with what Tipple says is the real threat: that Congress will punish the district with budget cuts. For years, TB control has subsisted on short rations; any more belt-tightening could plunge the program back into the hole it’s just begun to climb out of. "What keeps people here awake at night is the fear that Congress will say, Hey, TB is going away. Let’s cut the money.’ Then we’ll be in the same downhill slide as before, but in an even harder situation."
Meanwhile, good news isn’t altogether absent:
• On the case front, numbers this year appear to be going down, perhaps by a sizeable fraction. For the last few years, they hovered at 100 to 110 per year, making for a formidable case rate — the nation’s highest, in fact — of 20/100,000. Rumor has it that cases for this year may be down as much as 30%. Tipple will say only that it looks as if the total may be down.
• As for completion rates, they stand at more than 90%, and, for whatever reason, the district has seen hardly any multidrug-resistant TB, Tipple adds. Much credit is due to the staff, she says. "Like people in most places, they’re terrifically overworked, but they put in a lot of effort, and they try to be flexible and to chase patients down wherever they are."
There are wrinkles that still need to be ironed out in a program aimed at housing homeless patients who refuse to stay put. In the long run, the district’s biggest trouble may be its grim demographics, which are characterized by a stubborn combination of social ills, addictions, and poverty, all of which make for some truly difficult customers. "The easy cases are going away," notes Tipple. "The residual cases are all in populations with multiple risk factors that are hard to reach."
In days past, poor record keeping plagued the program. Whether that problem has been solved is open to debate; a team from the Centers for Disease Control and Prevention in Atlanta is looking at the accuracy of case reporting.
Tipple says she has no reason to believe there’s a big problem. "On the whole, physicians and laboratories and hospitals are aware of the reporting requirements. In the case of the larger hospitals, at least, they’re good about it. As we get into managed care and private providers, I’m less certain." Still, there’s no evidence that people are failing to report cases, she adds. "A missed case eventually gets into trouble and turns up, and we’re not seeing late badly managed cases."
On the laboratory front, little has changed — not yet, anyway. As Tipple explains, outreach workers without cars still can manage to do outreach, but a laboratory without reagents and functioning equipment can’t improvise. The result is that the run-down lab facility, housed in a government building in the district, still can’t manage so much as a simple smear, and fancier tests are completely out of the question.
"We’ve managed to cobble things together, and a couple of local hospitals have been helping us almost gratis," says Tipple. "But it takes time, and things can fall through the cracks. We spend a lot of time making sure that doesn’t happen."
Ivan Walks, the District’s newly minted health commissioner, is said to be juggling the District’s various needs, including the public health lab. "Call me next month, and I could have good news for you," says Tipple. "Or who knows? They could decide they need more money for immunizations or mental health programs and they have to cut back on TB."
Success has its price
One moral of the story could be that success, even the most hard-fought, has its price. "Now that we’re starting to do better, people who had been holding off are coming out of the woodwork with great ideas, and we’re about to be asked to do a bunch of additional things but without any additional money," says Tipple.
Take targeted screening in high-risk populations, for example. In Ward 1, the Baltimore-based Annie E. Casey Foundation has stepped in with a modest grant aimed at providing outreach to the ward’s mix of Hispanic communities. "The idea is to try to capture some of the harder-to-reach people, some of whom may be fearful even of coming into the clinic if they’re undocumented," says Patrick Chaulk, MD, senior associate for health for the foundation.
His assessment, like Tipple’s, is optimism tempered with the knowledge of remaining obstacles. "They have all these backdrop issues — the politics, the entrenched bureaucracy, the tax base — that make doing anything difficult. Before, it was a Keystone Cops approach to TB control. It’s still going to take a while to make a big dent. But that’s because they’re not just trying to improve this program, they’re trying to resurrect it."