TB control is a long-distance haul
Public health nurses are the town heroes
Out West, tuberculosis control is often a long-distance affair. With more square miles and fewer people to fill them than even the most sparsely populated of the eastern states, Western TB control programs don’t always get the respect they deserve, say the people who run them. People back East tend to underestimate the impact of the West’s wide-open spaces, says Denise Ingman, TB program manager in Montana.
"Sometimes those guys laugh off our small number of cases, but in reality, that small number can be a lot harder to manage than their larger numbers," she says.
To cope with the dilemmas peculiar to their environments, program chiefs out West have developed their own survival strategies. Among them are stamina, creativity, and, in some cases, the ability to loosen up a little and trust the locals. In fact, some TB program heads are convinced that the one sure way not to succeed is to issue iron-clad protocols and edicts from afar and then expect anyone to pay attention.
The sheer distances involved make a tight rein and a sharp spur unfeasible, some Western TB controllers say.
In New Mexico, when he drives to a clinic to make rounds, there are often stretches of road so lonely and remote that for hours at a time, his pager goes silent, his cell phone can’t receive or transmit calls, and the only sound on the car radio is static, says Gary Simpson, MD, MPH, PhD, the state’s medical director for infectious diseases. "You can’t imagine the vastness of the landscape," he says, his voice edged with wonder.
Giving up the illusion of total control
In New Mexico, a trip to the "local" clinic can mean an eight-hour round-trip drive, with the speedometer at eighty all the way. Directly observed therapy, or DOT, when it happens at all in rural areas, is rarely the conventional kind; rather, it might consist of the receptionist at the local clinic stopping by the patient’s house for coffee on her way to work twice a week, every week, for nine months.
The enormous distances also mean that when a patient has a problem, Simpson won’t be the person standing watch at the bedside. "Most of the people who take care of TB patients in New Mexico are public health nurses and clinicians," he says. "I’ve come to define my success by how well I can help these people provide the services they do."
When he first came to the job, Simpson says he found giving up the illusion of control a hard but essential first step. "It was scary at first," he admits. As an academician trained as a molecular biologist and a specialist trained in infectious diseases, he was used to micromanaging every variable involved in a patient’s care. But that approach proved all wrong in his new situation, he discovered.
"There are probably a thousand people right now running around the state with medicine bottles with my name on it, and I may never see any of them," he says. "Five hundred miles away, I can never be in as good a position to make the right decision as the public health nurse on the scene."
Simpson started by junking the detail-oriented protocol manual a former TB controller had developed. In its place, he implemented a quality-control movement in the state’s public health department. Now, in each of the 54 public health clinics throughout the state, there is at least one nurse or clinician who has been personally trained by Simpson.
In addition, Simpson says he tries to encourage his colleagues to exercise their prerogatives, a goal he accomplishes by engaging them in dialogues, instead of issuing fiats. "You have to be willing to take the time to say, Well, what do you think about this problem?’ Or, This is the way I’m thinking about it; what do you say?’"
Even the tiniest settlement has a clinic
With private physicians, Simpson nurtures the same spirit of collaboration, and takes every chance available to give doctors the information they need to make the right decisions. "They have to be as current as I am with what’s going on with the patient," he says. "So we send them treatment strategies they can tuck away." Or if problems arise, he dispatches articles on side-effects and complications, always taking pains to make clear that he is there to provide advice, not to make the final decision.
"They’re the primary care physicians; only if they choose, do we take more of an active role," he says.
With 98% of patients completing therapy within 12 months, Simpson credits part of his success to an infrastructure that is a legacy of the state’s history. At the turn of the century, TB sufferers from around the world flocked to New Mexico to take advantage of the climate and the sanitariums that sprang up everywhere. "TB was a big business in the state a big business," says Simpson.
The result is that now, even the tiniest settlement boasts a public health clinic. Adding to the congeniality of the relationship Simpson enjoys with his colleagues is the fact that the public health system itself is a single-layered jurisdiction. "That means if I have a patient who needs his blood drawn, I don’t need to negotiate with three different entities to get a nurse to do that," he says.
By contrast, Idaho is divided into seven health departments, each of them consisting of four to seven counties and each district virtually autonomous. Yet for different reasons, a variation of what works well in New Mexico gives good results in Idaho, too.
"In general, we don’t go in and dictate policy," says Jesse Greenblatt, MD, MPH, Idaho’s TB control officer. "We go through what can be a laborious, but ultimately productive, process of building consensus." Like Simpson, Greenblatt leans heavily on education as a means of persuasion and has made good use of that tool in surmounting what he considers his biggest challenge: namely, trying to standardize practice in each of the autonomous seven public health districts.
Taming Idaho’s free-for-all mentality
"Unless someone actively takes it upon themselves to unite these programs, people tend to go in a variety of different directions," Greenblatt says. When he assumed his post in 1994, he found that because of the state’s free-for-all mentality, hardly any patients received DOT, and only about 8% completed a full course of therapy.
When Greenblatt decided to set sail for increased levels of DOT, he found resistance to change was greatest not among district health officers but among the private physicians who ran the local public health clinics. To build his case, he opted for carrots instead of sticks, hitting upon the expedience of using federal funds to send clinic physicians to National Jewish Hospital in Colorado for an all-expenses-paid stint in continuing education. So far, the gambit has worked wonders, he says.
"It’s one thing for these docs to hear me, a 30-year-old TB officer, talk about DOT over the telephone," Greenblatt says. "It’s another for them to hear it in person from Michael Isemann. It’s had the effect of completely turning them around."
The other change Greenblatt has made is to focus TB-control activities in local districts. "When I came on, efforts were very diverse the districts were running big clinics, doing lots of surveillance, and giving prophylaxis." Stop the surveillance, he advised, limit prophylaxis to everyone but members of high-risk populations, and concentrate on DOT. "I met with little resistance," he says, "partly because I packaged it as a money-saver."
Like his counterpart in New Mexico, Greenblatt also relies heavily on public health nurses and for two reasons.
One, says Greenblatt, has to do with the state’s extraordinarily conservative, often anti-government brand of politics. "We do have some individuals who are very opposed to government intervention," he says. "The nice thing about having strong local public-health districts is that when the district nurse comes calling on folks who are difficult to work with, they know these people. I’m not aware of any situation where someone’s pulled out a shotgun and told a public health nurse to get out of the house."
The other reason for his heavy reliance on locals stems from the sheer distances involved.
In Wyoming, TB control’s a one-man job
Despite the fact that most district offices maintain satellite clinics in their constituent counties, many TB patients live 50 miles up a dirt road, far from the nearest health department clinic, says Greenblatt. "That means we have to make some unique arrangements with the local folks who live there," he says.
Out West, such "unique arrangements" turn out to be almost commonplace. Just ask Wyoming’s Alex Bowler, MPH. He not only heads the state TB control division, he is the division. "I mean, no secretary, no data-entry person, no nothing, just me," he says.
In a state where TB poses a measured problem, the state has mounted a measured response, says Bowler. "We’ve got lots and lots of places where the elevation exceeds the population," he adds.
Or ask Montana’s Ingman, who remembers the time a ranch hand with TB drifted over from Washington state. As if it wasn’t enough that the man landed a job sixty miles from the nearest public health clinic, clinicians soon discovered he had multidrug-resistant TB to boot and, thus, required daily ministrations from health care workers.
Patching together a solution in Montana
In the end, Ingman hired and trained a home health aide to deliver meds three times a week; a public health nurse found time to take care of the remaining two days. To pay the tab, Ingman scrounged around in her budget and finally located some emergency funds.
Back in New Mexico, Simpson says he loves the result of trusting well-trained locals to do their jobs right. "I’ve been so rewarded with people going the extra mile," he says. "I’m privileged to be able to work with these people."
Often, the public health nurses are the activists in their communities, says Simpson, the ones who pen weekly health columns for the local paper, start HIV support groups, and are known on a first-name basis by everyone in town. "We are by definition a frontier community, and I think of these people as true warriors," says Simpson. "They’re out there on the front lines. They know I’ll always be there to support them, and they know I’ll always tell them: Use your own best judgement.’
"And they do."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content