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For the elite corps of TB experts at National Jewish Medical and Research Center in Denver, recent years have brought some tough times.
The hospital’s mycobacterial section, long acknowledged as a court of last resort for TB patients with intractable disease, has been downsized. Collection rates from indigent patients, never substantial, in recent years had dwindled to a trickle — even as the cost of treating multidrug-resistant disease took off into the stratosphere.
In its upper echelons, the hospital’s administration was unflagging in its pledges of support; but starting as long as a decade ago, the focus clearly had begun to shift from the antique-sounding disease toward childhood asthma and cystic fibrosis.
Even so, the prevailing mood here these days is one not of defeat, but instead determination and optimism. "I believe we will not only survive, we will prosper," says Michael Iseman, MD, chief of mycobacterial service in the hospital’s pulmonary section.
For one thing, Iseman says, the new scaled-back arrangement — one in which he voluntarily took a pay cut so the hospital could maintain a strong clinical service — has given Iseman more time to pursue grants and do research. He and other long-timers say they are also thrilled at the recent addition of a new staff member, Mary Ann DeGroote, MD, a Fulbright scholar with impeccable credentials and a high level of enthusiasm.
The mycobacterial section also has begun staking out a new area of expertise: the treatment of disease caused by nontuberculous mycobacteria, also known as atypical mycobacteria. Although there exists no national patient registry for atypical mycobacteria, available evidence suggests infections due to atypicals are on the rise, many TB experts say. "It’s almost as if there is a population of vulnerable people, and when TB recedes, the atypicals come in to take its place," says Iseman.
Along with new energy and focus, revenues are now up, too. Philanthropic giving from families and descendants of patients whose lives were saved here decades ago has risen by 50%. Patient referrals are also beginning to rise, perhaps thanks to a shift in the mindset of HMOs, where gatekeepers who once may have been reluctant to send patients to costly centers of expertise are newly chastened by a string of recent lawsuits that have levied steep penalties against HMOs.
Then there’s research. After years of trying unsuccessfully to build a bridge to the hospital’s highly-regarded T-cell biology research unit, Iseman says he now senses interest there.
Outside National Jewish, however, a sense of bitterness lingers. "Mike Iseman is a national treasure," says Lee Reichman, MD, MPH, director of the National TB Center at the New Jersey Medical School in Newark. "They ought to give the man a chauffeured limousine and a gold-plated desk. Instead, he takes a pay cut and goes on half time. It’s a disgrace."
National Jewish was founded in 1899, nestled in the front range of the Rocky Mountains. The mountains set the stage for the establishment of a host of other TB sanitariums, as well. Most of these sprang up to serve a clientele of well-to-do middle-class denizens of the East Coast, thousands of whom boarded stagecoaches and railroad cars to come west, hoping to find a cure in the pristine mountain air.
Unlike the rest, National Jewish declared its mission was to serve patients who could not otherwise afford to pay. From the day it opened until the mid-60’s — the decade that saw the creation of government-sponsored insurance programs for the poor — the hospital’s dictum was: "None who enter shall pay, and none who can pay shall enter."
The descendants of TB patients who benefited from treatment at the hospital in those early years form the core of an energetic contingent of fundraisers. Though there are individual donors among them, there are also several industry and trade associations based in New York City and Los Angeles that sponsor annual dinners every year, raking in as much as a million dollars a pop. Taken together, gross contributions amount to some thirty percent of the mycobacterial section’s annual budget. Nor has support dwindled as U.S. TB rates have fallen; to the contrary, Iseman says he’s certain that donors take pride in knowing they’re helping combat one of the principal scourges of the developing world.
The tradition of philanthropic giving means the hospital still maintains a "scholarship" fund for patients who can’t pay; the trouble, as any TB controller knows all too well, is that the cost of treating even a single case of multidrug-resistant TB can be staggering, often as much as $250,000. In instances when patients are eligible for Medicaid, the hospital may collect a paltry $0.25 on the dollar; but in many such cases, patents are simply admitted as "self-paid" — a euphemism understood to mean there will be no payment.
With numbers of MDR-TB down nationwide, Iseman is philosophical about what the future holds. "MDR-TB may have been our stock in trade in the past," he says. "But clearly, it’s not the future of the program."
The upshot is that a lot of the TB work that still goes on here is a labor of love and is carried out on a strictly pro bono basis. Until recently, Iseman and his colleague Gwen Huitt, MD, took turns fielding the approximately 2,500 calls that come in every year from patients’ families and physicians. To ease the crushing load, they applied for a small grant to fund two nurses whose job is to screen and organize calls. Now, the two physicians divide about 600 consults between them, but the workload is still enormous, and both physicians lug work home with them at night.
Several years ago, when morale was at a low point, the beleaguered mycobacterial section went looking for a new home at the University of Colorado in Denver. In many ways, the match would have been a good one, because the university houses not only Marvin Pomerantz, MD — chief of thoracic surgery at the university, and the surgeon who performs the lung resections many MDR-TB patients eventually require — but also a cadre of local and state TB experts who often refer patients.
But at the time, the university was beset with troubles of its own, in the shape of an internal squabble over whether to pack up and relocate to a huge parcel of land bequeathed to the institution on the outskirts of town.
To Iseman, the deal began to look "like a first-class berth on the Titanic," he laughs; eventually, talk of moving elsewhere died down.
These days, in any case, Iseman says he is content. "This, not somewhere else, is going to be my last stand," he says. "You know, my mother was Irish," he adds. "I’m not one to give up."