Public Health Then and Now

New York City's TuberculosisControl Efforts: The HistoricalLimitations of the "War on

Consumption"Barron H. Lemer, MD, MA

Tuberculosis, the "captain of the menof death," was the leading killer in NewYork in 1900, but its prevalence declinedduring most of the 20th century.' Today, itsresurgence-including outbreaks of drug-resistant strains-has provoked intenseconcern among health officials. The situa-tion is particularlysevere inNewYork City,largely due to the high prevalence ofhumaninmunodeficiency virus (HIV) disease andhomelessness. In response to rising rates ofthe disease, city officials have recently in-troduced three control measures: intensivescreening among populations at risk, suchas the poor and the homeless; improvementof staff and facilities to ensure that patientscomplete therapy; and detention of individ-uals who do not take their medications.2-5

Such tactics, in fact, are quite old.New York has relied on the same threestrategies since it began this country's firstantituberculosis campaign in the 1890s. Inboth the preantibiotic era (1893 to 1945)and the antibiotic era (post-1945), how-ever, this approach has had two major lim-itations: (1) antituberculosis efforts, whileappropriately targeting the poor, havebeen inconsistent and poorly coordinated;and (2) control measures have dealt withindividual health habits rather than ad-dressing the underlying poverty that pre-disposes individuals to tuberculosis.6

The difficulties encountered by NewYork's antituberculosis campaign high-light two questions that have continuallyconfronted public health officials: (1)What criteria should be used to prioritizeamong the various preventive health pro-grams? (2) Should public health work onlytarget individual diseases or also advocatelarger social reform? New York and othercities designing new strategies to controltuberculosis must address these questionsbecause a temporary revival of traditional

measures alone will likely have only lim-ited success.

The O,igins of TuberclosisControl

Robert Koch's 1882 discovery of thebacterium responsible for tuberculosis (orconsumption) convinced many doctors ofthe infectious nature ofthe disease. Koch'swork indicated that the major avenue oftuberculosis transmission was respiratorysecretions between persons. HermannBiggs of the New York City Health De-partment became the first official to "trans-late the new bacteriology into practicaluse."6 His 1893 report convinced the de-partment to make tuberculosis reportableand to track down the contacts of infectedpersons. Other programs included the pro-mulgation of an antiexpectoration ordi-nance and the establishment of city dispen-saries, hospitals, and sanatoriums for thecare of the tuberculous. In 1897 the citychanged the reporting oftuberculosis casesfrom voluntary to mandatory.7-9

Despite these new policies, tubercu-losis remained hard to control and, in anera before the widespread use of x-rays,was often difficult to diagnose. In addition,Biggs' rules generated much opposition."Anticontagionists," for example, deniedthat consumption was spread between in-

Barron H. Lerner is with the Robert WoodJohnson Clinical Scholars Program at the Uni-versity of Washington in Seattle.

Requests for reprints should be sent toBarron H. Lerner, MD, MA, Robert WoodJohnson Clinical Scholars Program, Universityof Washington, 3747 15th Ave NE, HQ-18, Se-attle, WA 98105.

The views expressed here are those of theauthor and do not necessarily reflect those ofthe Robert Wood Johnson Foundation.

Editor's Note. See related editorial byReichman (p 639) in this issue.

May 1993, Vol. 83, No. 5

Public Health Then and Now

dividuals. Rather, they claimed the dis-ease was acquired when persons of a cer-tain genetic predisposition came intocontact with "miasmas" emanating fromdecaying garbage. Further, many privatedoctors objected strongly to mandatoryreporting, believing that the policy vio-lated physician-patient confidentiality; in1903, Biggs claimed that more than half ofthe active cases of tuberculosis were stillunreported.8,10

The number of reported cases grad-ually increased,7 however, and NewYork's program would serve as the modelfor a nationwide "War on Consumption."Private voluntary groups joined the fight.Most notable among these was the Na-tional Tuberculosis Association, foundedin 1904.1" Its local affiliate was the NewYork Tuberculosis and Health Associa-tion. The association educated the publicabout preventing the spread ofdisease andalso participated in the organization ofclinics.

Tuberculosis mortality in New Yorkand elsewhere had begun to decline priorto the start of these public health efforts.Although pulmonary tuberculosis alonecaused roughly 425 deaths per 100 000population in New York in the 1850s, thenumber had fallen to 237 deaths per100 000 by 1900. Mortality from all formsof the disease continued to decline, reach-ing 126 deaths per 100 000 in 1920. By1945, just before the first antituberculosisdrug was introduced, mortality haddropped to 11% of the level in the 1850s:46 deaths per 100 000 population.12

The P ibiotic EmNew York's antituberculosis cam-

paign waxed and waned between 1893 and1945. For example, tuberculosis control"lost its momentum" in the 1920s but re-vived in the 1930swhen the Health Depart-ment established a separate TuberculosisBureau and improved clinic facilities.10 Al-though antituberculosis efforts varied con-siderably during this era, the city basicallyrelied on three strategies: the screening ofat-risk populations, supervised therapy,and the forced detention of infectious pa-tients.

The earliest form of screening, whichbegan in the 1890s,was the examination ofsputum from contacts of infected individ-uals. In the 1920s, officials began usingtuberculin skin testing to screen appar-ently healthy schoolchildren for evidenceof the disease. "Rapid paper" x-ray sur-veying of asymptomatic persons began in1933.13-15

The predilection of tuberculosis tostrike poorer neighborhoods had beenknown for hundreds ofyears.'6 City statis-tics repeatedly revealed that tuberculosismortality in overcrowded Black, PuertoRican, and other inunigrant neighborhoodscould be as much as six times that in Whiteneighborhoods. In 1930, for example, theoverall tuberculosis death rate among

Blacks in New York was 293 per 100 000population, as opposed to 62 per 100 000for Whites; among homeless persons andtransients living in the Bowery district, therate approached 350 per 10 000.1,12,17-20

Speculating that thousands of poor

persons with the disease were probablyundiagnosed or unreported, the HealthDepartment, in conjunction with the Mil-bank Memorial Fund and the federalWorks Project Administration, focusedx-ray screening on these populations.'4.21Such studies, not surprisingly, yieldedbetter results than the screening of popu-lations such as schoolteachers. Out of4716 homeless men screened in the late1930s, 250 (5.3%) had active tuberculosis;1919 (2.9%) of 65 459 Harlem relief recip-ients had active disease.22

The second element of New York'scampaign against consumptionwas the es-

tablishment of inpatient and clinic facili-ties to care for the tuberculous. Althoughnumbers varied, between 15 and 25 san-

atoriums and hospitals both within andoutside the city admitted patients with ac-

tive disease. Treatment at this time con-

sisted only ofbed rest and nutritional sup-

port, with occasional surgery; however,recovery rates for persons with early dis-ease were relatively good.1"'20 Sanatori-ums, moreover, served an important pub-lic health function: they isolated infectiouspersons from the community for monthsto years. Yet existing facilities couldhouse only a small percentage of patients.In 1919, for example, only 4556 (14%) ofthe city's 32 048 registered cases were in-stitutionalized.'0

As with screening measures, treat-ment strategies also stressed the specialneeds of the poor. In 1922, the Tubercu-losis and Health Association and the localUrban League formed the Harlem Tuber-culosis and Health Committee, which as-

sisted with the sanatorium placement ofHarlem residents.17 The Health Depart-ment sponsored similar programs. In1922, for example, it began a campaign totrack down homeless persons with tuber-culosis. In the 1930s, having divided thecity into 30 health districts, the depart-mentrevampedclinicsforBlacksandPuer-to Ricans in Harlem, and hired Spanish-speaking staff.'8'23

NewYork also addressed the issue ofnoncompliant tuberculosis patients.These persons, termed "rounders,"drifted in and out of hospitals.7 Noncom-pliant patients came from all socialclasses, but most were homeless men andalcoholics. Although tuberculosis was of-ten ultimately fatal, patients could oftenremain alive-and highly contagious-foryears. Rounders could thus transmit the

American Journal of Public Health 759

Sanatorium patients receiving bed rest and fresh air treatment, circa 1920. Reprintedwith permission of the American Lung Association, New York, NY.

May 1993, Vol. 83, No. 5

Pubic Heal Then and Now

disease to many others. State quarantinelaws permitted the Health Department todetain infected patients who were be-lieved to be health hazards. In 1903 thecity opened the Riverside Sanatorium for"wilfully careless consumptives underforcible detention."12424 Such individualsreceived little sympathy.2526 "Homeless,friendless, dependent, dissipated and vi-cious consumptives," Biggs wrote, "arelikely to be most dangerous to thecommunity."27(pl7)

Pymblms with Tub lndsiConbrl

Despite the Health Department's re-newed efforts, it was difficult to maintaininterest in antituberculosis work in the1930s. Not only was the disease insidiousin nature, but it also remained hard tocure. The major factor, however, was itsdeclining incidence. By 1930, tuberculosismortality was roughly one quarter of its1900 level. Both health officials and thepublic grew increasingly interested in theprevention of more prevalent, noncom-municable diseases.2-30 In 1933, for ex-ample, New York's Welfare Council pub-lished a volume on the control ofconditions such as heart disease, cancer,and rheumatism.31

The loss of interest in tuberculosisdid not go unnoticed. In 1930, City HealthEducation Director Charles Bolduan re-minded officials that the disease was still a"major public health problem"15; 7 yearslater, ex-Health Commissioner HavenEmerson termed neglect oftuberculosis inNew York a "disgrace."32 CommissionerofHospitals S. S. Goldwater notedin 1937that no more than 17 000 of the city's30 000 tuberculous patients "[had] achance of reaching one of the ... bedsprovided."'0

Such protests notwithstanding, tuber-culosis control remained inadequate. Clinicservices were isufficient in several parts ofthe city. The numberofinpatientbeds avail-able in 1937-5250-had increased onlyminimallyover20years. Atone point in thatsame year, the 186-bed Believue tuberculo-sis service reported a census of 268 pa-tients.3334 Even when space was available,patients commonly left against medical ad-vice. It was often dfficlt to convince indi-viduals who were receiving little treatmentexcept for bed rest to remain hospialized.The Health Departnent, moreover, de-tained few patients in the 1920s and 1930s.Not only did officials have dfficlty estab-lishing the legal justfication for detention,

but manyviewed the need to resort to man-datory confinement as a "confession of fail-ure."M'3435 Other commentators criticizedvarious aspects of detention, clag thateither it was too costly, it violated personalhiberties, or it engendered fear ofconsump-tives, known as phhisophobia.724

Despite case-finding efforts and theestablishment of special clinics, the situa-tion remained particularly bad for Blacks.Tuberculous Blacks in New York, wrotefamed statistician Louis Dublin in 1937,are "for the most part ... overlooked."3mHarlem physician George Cannon agreed,stating in 1946 that city health authoritiesand the mayorwere "all but oblivious" tothe tuberculosis problem among Blacks.17Cannon criticized not only the lackofbedsbut also the exclusion of Blacks from con-trol efforts, noting that "there is not onepracticing Negro physician on the visitingstaff of a tuberculosis hospital in thecity."''7 Not surprisingly, tuberculosismortality among Blacks in 1945 remainednearly four and one-half times that amongWhites.'2

The situationwas similarforotherpoorNew Yorkers. Given the lack of inpatientbeds, screening of at-risk populations oftendid little more than increase the number ofuntreatedpersonsknw tobe tuberculous.In stressing case finding, moreover, theHealth Departnent in the 1930s increas-ingly left the follow-up and treatment of de-tected cases to clinics run by voluntaryagencies, hospitals, and private physicians.In 1936, only 14% ofnew cases were undersupervision by the Health Department.373Without a strong coordinating agency, poortuberculous patients often fell between thecracks. Thus, not only did city officials inthe preantibiotic era have diffiulty main-taning enthusiasm for tuberculosis control,but efforts targeting the tuberculous poorwere inconsistent and lacked organization.

Tuberculosis control in New Yorkhad another important limitation. In con-trast to 19th-century public health work,which had by definition included the ad-vocacy of social reform, antituberculosisefforts in the 20th century did little to alterthe circumstances of the poor-such ashomelessness and unemployment-thatmade them susceptible to the disease.6,'730A few critics proposed broadening thecampaign. In 1937, for example, BaileyBurritt ofNew York's Association for Im-proving the Condition of the Poor askedthose involved in tuberculosis control to"accept ... the responsibility of insuringadequate attention to the economic andsocial needs of the family. "36 Louis Dub-lin believed that public health officials

should work for better housing for thepoor.38 The small Black public health sec-tor, David McBride notes, saw tubercu-losis work as part of a larger movement toimprove the living conditions of Blacks.'7

Nevertheless, the basic elements ofNew York's antituberculosis campaign-health education, screening to detect dis-ease, and the administration of therapy-remained oriented toward individualpatients. Tuberculosis prevention, PaulStarr states, moved away "from the broadadvocacy of social reform toward morenarrow judgments."6 The conditions thatpredisposed susceptible populations to tu-berculosis persisted.

The Antibioi EmAlthough tuberculosis control in

New York lagged during World War II, astrong economy and the discovery of po-tentially curative drugs rejuvenated ef-forts. Doctors began prescibing strepto-mycin in 1946 and isoniazid in 1952.39 Thecity began a large-scale campaign to treatpatients in the outpatient setting. By 1954,the Health Department reported thatnearly all of its roughly 3000 clinic patientswere under drug treatment. Reflecting aspirit ofoptimism, the tuberculosis sectionof the departmnent's 1954 report was enti-tled "Towards Victory."1041

The New York Tuberculosis andHealth Association, however, was morepessimistic. Although fewer than 15 per-sons per 100 000 population died from thedisease in 1953, the association predictedthat tuberculosis would remain a publichealth problem. Noting the high rate ofundetected disease among the poor, mal-nourished, and particularly the homeless,the association's 1954 report invoked abiblical proverb: "It is difficult to wage asystematicwar against 'the pestilence thatwalketh in darkness.' "`0

In 1959, New York City Health Com-missioner Leona Baumgartner divided thehistory of tuberculosis into three stages:generalization, localization, and individu-alization. She noted that the disease wasno longer endemic but remained a prob-lem only in localized areas. Her recom-mendations for reaching such populationswere familiar: x-ray screening, and im-proved clinic and social services.42 As tu-berculosis entered the third stage, that ofisolated individuals or small groups,Baumgartner's advice echoed that ofnoted epidemiologist Wade Frost"3: itwascrucial, she said, to treat the disease"promptly and vigorously." She advo-

May 1993, Vol. 83, No. 5760 American Journal of Public Health

Public Healtih Then and Now

cated early institutional care, "providedby compulsoxy methods, if necessary,"42until patients were noninfectious.

The Health Department had alreadybegun these interventions by the early1950s. In its effort to "findpeoplewho havetuberculosis without knowing it,"4" the de-partment continued skin testing and rec-

ommended that all persons get an x-ray

every other year. Mass x-ray surveying

had been resumed in 1946 and reached a

peak of 1 181 693 fihms for the years 1955and 1956.4546 Once again, officials notedhigh rates ofdisease among Blacks and Pu-erto Ricans47 (see Figure 1). Between 1943and 1950, the rate of new cases in theseexpanding immigrant communities was

three to four times that in White commu-nities, and x-ray screening targeted thesepopulations. In 1954 x-rays of 1944 home-less men revealed 77 cases of active dis-ease. This detection rate of 4% was more

than 15 times that of the general popula-tion. The city tried innovative approachesto encourage participation in x-ray screen-

ing, including free soda, raffles, and ap-

pearances by celebrities.12,41,47-49Health officials did acknowledge the

difficult social circumstances of the tuber-culous, and at times, predisposing factorssuch as poverty and unemployment wereaddressed. For example, health officialssent social workers to Harlem to help pa-

tients with housing and economic prob-lems, and city agencies funded awork pro-

gram for homeless men with inactivetuberculosis at a camp outside thecity.46 5 Yet the vast majority of antitu-berculosis efforts still operated within thedominant public health paradigm: theysought only to detect and treat the diseasein individual patients.

The availability of antibiotics meantthat most tuberculosis patients, followinga short hospitalization, could receive thebulk of their treatment as outpatients.Early results of outpatient treatment ap-

peared promising. In one study, 209 of351patients, most ofwhom had advanced tu-berculosis, had inactive disease after 2years ofdrug therapy. As a result, multipletuberculosis wards and hospitals in NewYork closed in the mid-1950s; by the1970s, all such facilities had disap-peared.lo,39,40

Poblems with Compliance

The simple availability ofcurative an-

tibiotics, however, did not ensure compli-ance with therapy.51 For example, 20% ofroughly 1100 patients requiring hospitaladmission for tuberculosis in early 1953

refused; 6 months later, only one fifth ofthese patients had begun treatment. In ad-dition, ofthe roughly 9000 tuberculosis pa-tients discharged from municipal hospitalsbetween 1950 and 1954, 25% to 35% leftagainst medical advice. In 1960, theHealth Department estimated that 20% ofits 6300 outpatients had active disease;most of these had left the hospital againstadvice.39,52The situation hadworsened by1962, when the department noted that"hospitalization is less readily acceptedand discharges against medical advice are

more frequent."53Compliance with outpatient therapy

was also erratic. "Patients attend clinicsirregularly and relapse of their disease iscommon," the department reported in1962.53 Random urine testing for isoniazidin clinics in 1970 revealed 25% noncom-

pliance. In 1979, only 53% of Health De-partment cases indicated completion ofthe recommended 12-month course of an-

tibiotics.5455Noncompliance generated concern

across the country. Not only did noncom-pliant patients spread tuberculosis, but ir-regular use of antibiotics promoted drugresistance. Estimates of resistance to atleast one medication in persons with new-onset tuberculosis in 1963 ranged from 3%to 11%.56,57 A study conducted in NewYork in the 1970s found evidence of mul-tidrug-resistant organisms and an overallresistance rate to isoniazid of 8% amongnew and previously treated patients.58

Several authors-such as Moulding59and Sbarbaro and Johnson60 in Denver-advocated outpatient programs in whichhealth workers directly supervise theadministration of antibiotics to noncom-

pliant persons (now known as directly ob-served therapy). By decreasing the fre-quency of antibiotic dosing to twiceweekly and the duration of treatment to 6or 9 months, and by offering patients var-

ious inducements such as food and even

beer, the Denver group was able to com-plete therapy in more than 90%o of its non-compliant patients.61--63

New York initiated similar pro-

grams. In the 1960s, the city hired "tu-berculosis lay investigators" and publichealth nurses to track down noncompli-ant patients by telephone, home visits,and even occasional "tours" of localbars. Harlem Hospital expanded itstuberculosis clinic in the 1970s andinstituted a supervised therapy pro-

gram.48'64-6 In addition, the New YorkCity Health Department, like othersacross the country, increasingly began todetain patients who failed supervisedtherapy. Noncompliant patients, the de-partment reported, "present a continu-ous challenge to our efforts at publichealth control."53,67-69 Empowered bythe New York City Health Code, the de-partment obtained detention orders for

roughly 80 tuberculosis patients annuallybetween 1968 and 1970.54.70

American Journal of Public Health 761

1.0w~~~~~CD|

WdlbS ft. 0 RU .ST. LEEM {m.s io. RA s S-

I*00( - -i-- ~~~~~~~~~~~~~~~~~~~~~~ 7000 (r

goo- -f- 000I _ A

4000

* * ulcassistance rate= Tuberculosis

Source. Reprinted from Lowell4' with permission of the New York Lung Association.FIGURE 1-overty and tuberculosis In New York City, averaged from thie years 1949

through 1951; rates are per 100 000 popu3tion.

May 1993, Vol. 83, No. 5

Publi Health Then and Now

Control Effodts Wane

By 1960, tuberculosis was no longer

among the top 10 causes of death in New

York. Mortality continued to decline,

reaching a low of 91 deaths in 1985. As a

result, although screening and supervision

continued, it was harder to justify large-

scale spending on tuberculosis. Officials

increasingly devoted funding and atten-

tion to more prevalent conditions such as

heart disease and cancer.10,52,71 Simiflarly,private agencies that were originally ded-

icated to tuberculosis work broadened

their programs to include all respiratory

diseases. Although such groups had re-

sisted expansion,1' the declining rate of

tuberculosis made it logical to inaugurate

campaigns against widespread problems

such as cigarette smoking and air pollu-

tion. The National Tuberculosis Associa-

tion changed its name to the National Tu-

berculosis and Respiratory Disease

Association in 1968, and the New York

Tuberculosis and Health Association be-

came the New York Lung Association in

1972.72

Noting that tuberculosis remained a

major problem among the poor and mi-

norities, commentators again warned that

the disease should not be ignored. "Apa-

thy and indifference to [New York City'31s]tuberculosis problem," Irving Mushlin

and William Kenney stated in 1964, "are

widespread."48They, as well as the New

YorkAcademy of Medicine, urged greater

appropriations to fighit the disease.73 Such

fuinding, however, was not forthcoming.

Even the Health Department sounded

frustrated in 1962, stating that the "social

and economic climnate in which tubercu-

losis breeds is not favorable to its cure."153

By the late 1960s, social and political

developments had thrown city health

agencies into disarray.74 Although the pas-

sage of Medicaid and Medicare legislation

in 1965 eased the Health Department's re-

sponsibility for care of the poor, it created

organizational problems by shifting more

care of tuberculous patients to private fa-

cilities. In addition, Medicaid did not

cover admissions to tuberculosis sanato-

riums.3,75 The city's economic problems

culminated with the 1975 fiscal crisis. Cut-

backs affected all city agencies, including

the Health Department, where staffing

was reduced by one quarter.76 Given the

declining mortality rate from tuberculosis,

it is hardly surprising that antituberculosis

efforts were viewed as expendable. By

1979, New York State, which had fi-

nanced half of the city's antituberculosis

program, had withdrawn its funding, and

federal aid for tuberculosis control was cut

by 80%.64

As in the preantibiotic era, the vari-

ous components of the antituberculosis

campaign were maintained at suboptimal

levels. Attempts to track down lost or

noncompliant patients virtually ceased. A

federally sponsored supervised treatment

program that was begun in 1980 never got

beyond the pilot level, funding only five to

six workers. The Health Department also

placed detention on the back burner, forc-

ibly hospitalizing only two patients in

1985.,n

The Time Bomb Explodes

Although New York's antituberculo-

sis campaign waned in the 1970s, there

was ample evidence that a resurgence of

the disease was brewing. In 1970, for ex-ample, the incidence of tuberculosis in thecity (32.8 cases per 100 000 population)was twice the national average. Althoughthe mortality from tuberculosis continuedto decline until 1985, the number of newcases began to increase steadily in 1979.T'he proportion of never-treated patientswith drug-resistant strains between 1975and 1982 was 9.6%, compared with thenational average of 6.%-4,8,

Only after the issuance of a 1987 Cen-ters for Disease Control report on tuber-culosis in New York did officials begin tosee the disease as a "time bomb."80 Con-structed by a 60% rise in poverty between1969 and 1982,81 the bomb was ignited bythe HIV epidemic after 1982. Between1979 and 1986, the incidence of tubercu-losis in the city increased by 83%, a figuremore than triple the national average. By1991, New York reported 3673 new cases,up from 1307 in 1978 (see Figure 2). Morethan 80% of those cases were amongBlacks and Hispanics; 20% to 30% wereamong the homneless.82--84There were alsoreports of increased drug resistance, par-ticularly among HIV-positive patients. Of465 city patients studied in 1991,19% wereresistant to both isoniazid and anotherfirst-line drug, rifampin. By January 1992,four city hospitals had reported outbreaksof multidrug-resistant strains causing 80%1to 90%0MOrtality.82'85'86

Two characteristics of this resur-gence are unique: its prevalence amongimmunosuppressed HIV patients and thepresence of multidrug-resistant strains.Persons with acquired inmmunodeficiencysyndrome (AIDS) are hundreds of timesmore likely to have active tuberculosisthan the general population; at one NewYork tuberculosis clinic, 46% of the pa-tients were HIV seropositive.85-89 Be-cause many of those infected with HIV inNew York are homeless, minorities, andsubstance users, the virus has intensifiedthe incidence of tuberculosis among pop-ulations traditionally most affected by thediseaseY90-92 Increasing drug resistancealso suggests a historical parallel. Strainsresistant to antibiotics may recreate thesituation encountered prior to 1945, whenthere was little effective treatmnent for tu-berculosis, patients remained infectiousfor prolonged periods, and health careworkers were at risk at contracting--anddying from-the disease.

Benefiting from another upsurge in tu-berculosis funding, New York has revivedits three familiar strategies: screening, su-pervised therapy, and detention.2-4'93 In1988 the Health Department conducted

762 American Journal of Public Health

70

60

.150

§40

20

10

Sources. Constructed from Vennema7s(pl 2) and Tuberculosis in New York C40y2M 12) withpermission of the New York City Department of Health.

FIGURE 2-New cases of tuberculosis In New York City, 1960 through 1991.

May 1993, Vol. 83, No. 5

Pubic Healfth Then and Now

x-ray screening of shelter residents, and ithas resumed skin testing of schoolchil-dren.94 95As noted above, however, the de-parmenthasmademultipleattemptsduing

the centulyto screen the poor and homelessin areas such as Harlem and the Bowery,and althogh such programs have at timesyielded good results, they are both expen-sive and time-consuming. In addition, be-cause of the transient nature of such popu-latis, pesons with positive x-rays haveoften been lost to follow-up. And other out-reach strategies, such as intensive nursingand clinic services, have been cut backwhen fuding was needed elsewhere.

The Centers for Disease Control sug-gested another old remedy: opening san-atorium-like facilities for extended care oftuberculosis patients. The city establishedone such shelter in 1988 and may openothers.596 Such facilities, however, alsohave a problematic history. Not only arethey expensive to maintain, especially forpatients receiving little care except oralantibiotics, but patients are often unwill-ing to remain institutionalized, particu-larly ifthey are feelingwell, and high num-bers would likely leave against advice.

The city has reexpanded its directlyobserved therapy program for noncompli-ant patients. Officials are again offering in-centives such as food coupons and sub-way tokens to encourage the homeless toappear for daily therapy. The Health De-partment has also resumed its policy ofdetaining noncompliant persons; it issued40 detention orders in 1991.2 New Yorkhas periodically tried mandated treatmentmeasures in the past, both with roundersin the preantibiotic era and with noncom-pliant patients spreading drug-resistantstrains after 1945. Directly observed ther-apy is extremely labor-intensive, how-ever, and detention requires legal pro-ceedings and locked hospital wards. As aresult, such efforts have never been sus-tained. Detention, moreover, raises a civilhlberties question: Will the courts permitthe detention of patients who are not ac-tively infectious because they have a his-tory of noncompliance?,97,98 Numeroushistorical examples exist of the use of de-tention as a social control measure.99Y100

Familiar problems have hamperedNew York's recent efforts. For example,out of 1408 x-rays performed on shelterresidents in early 1988, only one new caseoftuberculosiswas found.95 This lowyieldmay in part reflect concurrent HIV dis-ease, which may mask evidence of tuber-culosis. Further, as of November 1991,only 8 to 10 caseworkers had been hired tofind and medicate hundreds of homeless

tuberculous persons.83 Brudney andDobkin found that, despite evidence ofthespread of the disease in shelters, the Tu-berculosis Bureau had made this homelessunit a "low priority."64 Thus, cure rates,not surprisingly, remain poor. In a 1990study of 74 patients at one city clinic, 44%were lost to follow-up.64

Conclusion

For more than a century, health of-ficials have known that tuberculosis iscontagious. And while historians have de-bated the value ofcontrol measures,28 it isclear that certain tactics, such as isolationof infected individuals and completion ofdrug therapy, are effective. The antituber-culosis campaign in New York has con-

sistently instituted measures based on

these principles. Yet two problems thatconfront public health programs have con-

tinued to limit the success of such efforts.The firstproblem is how public health

agencies should best allocate limited re-

sources. As Charles V. Chapin admittedin 1917, health officers often "do not feelsure of the relative values of different linesof health work."101 Decisions regardingfunding allocations must be made bothwithin and between various preventionprograms. Factors that may influencefunding between programs include the se-

verity of the diseases in question, theprevalence of such diseases in the com-

munity, and the publicity those diseasesreceive.102 As tuberculosis in New Yorkdeclined, tuberculosis control became a

victim of its own success. Rather than ac-

celerate efforts to eradicate the persistentfoci of the disease among poor popula-tions, public and private groups shiftedfunding to more prevalent problems, suchas smoking and heart disease. Thus,screening, supervision, and detentionmeasures for tuberculosis-all of whichhad been accelerated when funding wasavailable-were cut back.

The second problem is that publichealth campaigns ofthis century have gen-erally not addressed the underlying socialconditions that allow diseases like tuber-culosis to persist.29.30.103 "It is notenough," Charles E.-A. Winslow wrote,"for the health administrator to developthe soundest possible programme for hisown field of social endeavor"; such a planhad to be part ofa "larger total programmeof social reconstruction."104 New Yorkofficials have long recognized the role ofthe "plague of poverty" in the spread oftuberculosis. In 1962 the Tuberculosis Bu-reau conceded the necessityof"a massiveassault ... against [the disease's] realroot, which is poverty."53 Nevertheless,as a result of the structure that publichealth has assumed, tuberculosis controlhas sought to detect and treat disease inindividual persons rather than addresslarger societal ills.

Numerous groups are now calling forfunding increases for antituberculosiswork. One coalition has asked the federalgovernment to increase the Centers forDisease Control's 1993 tuberculosis ap-propriation from $20 million to $325 mil-lion.105 Such funding increases, needed tofinance directly observed therapy and

American Journal of Public Health 763

Mobile x-ray screening at Far Rockaway Beach, Queens, New York, 1948. Reprintedwith permission of the New York City Department of Health.

M--

May 1993, Vol. 83, No. 5

Public Health Then and Now

other basic programs, should be sup-ported. Given the emergence of multi-drug-resistant strains, there is no diseaseas contagious and potentially lethal as tu-berculosis, particularly for HIV-positivepersons. Moreover, as the development oftherapies for multidrug-resistant strainswill probably take several years, inade-quate preventive measures could lead toan epidemic.106

Although increased funding is cru-cial, New York and other cities revivingantituberculosis measures should recallthe limitations of past efforts. Anothertemporary increase of screening, super-vised therapy, and detention is not an ef-fective long-range solution. Rather, offi-cials should evaluate various controlstrategies "on the basis of their clinicaland public health importance and theircost-effectiveness."'107108 If and when tu-berculosis again subsides and a differentcrisis beckons, we should not simply cutback all control strategies to low levels butshould instead continue those strategiesthat have proven effective; otherwise, tu-berculosis will again resurge.

Even with adequate funding, how-ever, antituberculosis efforts must ad-dress the second historical limitation: thepersistence of poverty. Although publichealth work has helped to control tuber-culosis,28 109 mortality from the diseasebegan to decrease well before such effortsbegan. Historians have attnbuted this de-cline to improvements in housing andnutrition.110-113 Given this fact, it is im-portant to acknowledge the role that im-proved living conditions must play in thefight against tuberculosis.

Public health officials cannot hope torectify social inequality, but recent pro-grams have begun to address this issue.New York, for example, has developed arange ofhousing options and support serv-ices for homeless persons with AIDS(Ellen Alpert, personal communication,September 30, 1992). British groups in-volved in a similar project hope it will bethe first step toward using housing to''prevent disease and promote publichealth.""'14115 Such programs may evenprove cost-effective. A recent study inHaiti showed that tuberculosis patientsgiven economic and nutritional supportdid better than those merely receiving freehealth care."l6 As Rene and Jean Dubosnoted 40 years ago, the fight against tu-berculosis must "increas[e] . .. the resis-tance of man through a proper way oflife."'6 0

764 American Journal of Public Health

AcknowledgmentThe author would like to thank Thomas R.Frieden for his advice on this paper.

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Commentary: Tuberculosis in NewYork City-The Consequences andLessons of FailureSheldon H. Landsnn MD

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The resurgent tuberculosis problemofNewYorkCitydeserves close scrutiny.In his article in this Public Health Thenand Now, Lemerl discusses New YorkCity's three strategies for controlling tu-berculosis throughout the 20th centuly.He suggests that tuberculosis can only becontrolled by a sustained commitment toamelioration of the social conditions thatpromote the trasmission of the disease.A review of the current New York Citytuberculosis problem suggests, in fact,that a sustained commitment to fund anadequate public health infrastructurecould control tuberculosis independent ofthe need for broader social change.

The current epidemic of tuberculosisin New York City has three components.The first is the increase in cases, whichhave risen from 1530 in 1979 to 3673 in1991.2 In large part this absolute increasecanbe attributed to themarked propensityof those individuals dualy infected withtuberculosis and the human immunodefi-ciency virus (HIV) to develop active tu-berculosis.3

The second component is the rise ofmultidrug-resistant tuberculosis; its ori-gins are somewhat different from those ofthe overall rise in tuberculosis cases. InApril 1991, ajointNew York City/Centersfor Disease Control survey documented a19% rate of the multidrug resistant tuber-culosis strains among all confirmed cas-es.4 Our inability or unWifligness to fundthe public health and targeted social-ser-vice programs that will enhance comple-tion of tuberculosis treatment and cure of

disease is at the heart of the multidrug re-sistant tuberculosis problem. Incompleteand inadequate treatment favors the sur-vival of resistant strains. In 1991, approx-imately 55% of patients in New York Citywith tuberculosis completed a full courseof tuberculosis treatment.5 The ability toensure that patients ard treated until curedis complicated by the increase in home-lessness and substance abuse and bydecreasing public health resources. Sub-stance abuse and its associated maladapt-ive behaviors contribute greatly to theproblem of noncompliance.

The third component of the epidemicis contnbutedbythenoomialoutbreaksoftuberculosisdocumented in severalNewYork City hospitals,6-8 and a New YorkState prison.9'10 Transmission of active tu-berculosis in shelters and jafls is also sus-pected but has not yet been docu-mented.11 12These outbreaks are a result ofthe combined first two components of thetuberculosis problem. In these institutions,increasing numbers of patients with tuber-culosis, many infected and infectious withmultidrug-resistant tuberculosis strains,

Sheldon H. Iandesman is Professor of Medi-cine, State University ofNewYorkHealth Sci-ence Center, Division of Infectious Diseases,Brooklyn, NY.

Requests for reprints should be sent toSheldon H. Lanman, MD, SUNY HealthScience Center at Brooklyn, Division of Infec-tious Diseases, 450 Clarkson Ave, Box 122,Brooklyn, NY 11203.

Editor's Note. See related editorial byReichman (p 639) in this issue.

May 1993, Vol. 83, No. 5