Anatomy, physiology of DC’s partnership
Getting players to sit down at the table
The story of tuberculosis control in Washington, DC, is actually two stories: the deterioration of an infrastructure and the rise of a new entity to help carry the load.
"When we’re dealing with public health issues, sometimes we take the infrastructure for granted and move onto discussions of how we need new diagnostic tests, new vaccines, new therapeutic regimens," says Ron Valdiserri, MD, deputy director for the National center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention.
"That’s all very important. But this goes to show you can’t forget about the infrastructure."
Valdisseri is quick to add that in cases where the infrastructure is in trouble, "it’s important for [the CDC] not to micromanage what’s happening in a jurisdiction." What that means, he adds, is that sometimes, the private sector must step in and offer its help.
Between 1992 and 1994, no fewer than four task forces and coalitions issued reports detailing the troubles that afflicted the Bureau of TB Control in Washington, DC, says Michael S.A. Richardson, MD, the president of the District of Columbia Thoracic Society. Distressed by shortcomings, which rivaled or dwarfed situations he’d witnessed in his native Jamaica, Richardson began to speak out about what he was seeing in 1987, he says. To his dismay, the response was often jaded: "They’d say, Oh, we’ve been talking about that kind of thing since back in the sixties.’"
A run-down laboratory and an overworked, demoralized staff were bad enough; but what really troubled Richardson was the numbers, he says.
A big fuss over numbers: What were they?
To begin with, case reporting was lax, with few sanctions applied to those who delayed or neglected to report cases. Just as bad, the Bureau often disputed the cases that were reported, Richardson says. "We’d say, Look, the numbers have gone from 112 to 130.’ And they’d say, No, no, no. It’s only gone from 92 to 97.’" The discrepancies were extremely disturbing, Richardson says. "That is basic information."
By the late 1980s, Richardson says, the CDC had begun to realize that "they would have to begin working creatively through some other agencies." Under the auspices of the local chapter of the American Lung Association (ALA), the CDC initiated an investigation and issued a report. "But the report was shelved," says Richardson. (Several medical epidemiologists involved in the review were contacted at the CDC; all declined to comment.) The Bureau TB controller contended that recommendations contained in the report had already been carried out, Richardson says. As a result, "nothing got done for two years."
Things began looking up when interim caretaker, Kurt Brandt, MD, was appointed TB control officer for the district two years ago, Richardson says.
Next, the Metropolitan Washington Council of Governments (COG), a progressive organization that years earlier had staged the nation’s first regional HIV conference, decided to sponsor a day-long TB conference. The symbolic impact of the conference was significant, Richardson says. "It was the first time there was any official recognition that TB was a regional problem, not just a single-jurisdictional problem," he says.
"We try to give people a neutral forum in which they debate their concerns," says Robert L. Cosby, PhD, Chief of Human Services for COG. The conference imported Lee B. Reichman, MD, MPH, director of the National Tuberculosis Center of the New Jersey Medical School in Newark; and Patricia Simone, MD, MPH, Chief of Field Services Branch of the CDC’s Department of TB Elimination. People began talking; "Synergy and momentum took place," says Cosby.
Meanwhile, Abe Macher, MD, an employee of the federal Public Health Service, began badgering local professional societies of physicians to get involved. The Medical Society of the District of Columbia, or MSDC, decided to commission a task force to report on the situation to its Board of Directors.
Lots of old hands were on deck
Task Force members included some of the same members of the ALA chapter who, years ago, had watched in frustration as the CDC report languished on a shelf, as well as veterans of a thwarted MSDC attempt at formulating a five-year plan for TB control. With some arm-twisting, representatives from the District’s TB control bureau came on board as well. According to Cosby, "they were essentially told that things would proceed without them if they didn’t come."
Notably, task force membership managed to stand the usual racial politics of the District on their collective head. In the past, a black man who’d served as TB controller for the District had routinely accused private sector groups of representing exclusively white interests, and of picking on blacks, Richardson says. Now, the chief spokesman for the private sector, Richardson, is black; and Brandt, the new interim head of TB control, a capable, longtime bureaucrat whom Richardson described as sympathetic to the Bureau’s concerns, is white. Suddenly, it was no longer possible to frame the TB debate as a matter of whites picking on blacks, Richardson says.
The task force began by identifying four forces its members decided were exerting a strong impact on TB control, Richardson says.
First, there was an extraordinarily self-serving system of political patronage in the district, Richardson says. Because district wards are identifiably white or black, he says, "If you say, TB is highest in Ward 8,’ all the representatives in Wards 1 or 3 relax. They figure they don’t have to worry about it because none of those people are voting for them."
Second, there was race. "There are continual misalliances based on race," says Richardson. "If I am black and you are white, even if you are saying something that is true, I must oppose you because of your race. It is tremendously destructive."
Third, was the district’s bureaucracy notoriously top-heavy, turf-minded, and all but immovable. "In terms of money, allocations, and accountability, things did not move at all," says Richardson. "It was a nightmare."
Fourth, there were special-interest groups representing various special-interest groups the HIV-infected, inmates of the District’s huge prison system and especially the homeless, who have found a powerful spokeswoman and advocate in Janell Goetcheus, MD, head of Healthcare for the Homeless.
No pandering, but no scolding, either
"We didn’t pander to any of these groups, but we made sure all of them were represented," says Richardson. "When they spoke, we listened to everything they had to say very carefully." In its eight recommendations, the report took care to incorporate the diversity of perspectives as well, says Richardson. "We didn’t cast blame or set out to embarrass anyone," he says. Most of all, Richardson says, an air of trust was established among the formerly warring factions.
In due time, the report was completed and presented to the MSDC. Public officials were made aware of the report but expressed little interest, Cosby says, until someone leaked the findings to the press. At that point, says Cosby, Harvey Sloane, MD, Commissioner of Public Health, stepped into the picture.
"Sloane began to ask some tough questions," says Cosby. "Like, how well is our lab func-tioning? And the answer was that it wasn’t." Finally, Cosby says, the time seemed ripe to force the district into taking action, now that Sloane had begun to acknowledge problems publicly. At last, the process of recovery could begin.
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