Private sector comes to the rescue in DC
Care package has drugs, lab, staff
In Washington, DC, a regional public-private partnership has moved to implement a series of resuscitative maneuvers intended to help keep the city’s ailing Bureau of Tuberculosis Control alive and functioning.
Without a functional laboratory, afflicted with chronic staff shortages, its outreach workers’ cars repossessed or in the shop for repairs, and strapped by unreliable supplies of medications and X-ray film, the TB control department in the nation’s capital has been scrambling to stay above water for years.
Wyndham Reed, the technical advisor to the Bureau from the Centers for Disease Control and Prevention, puts it this way: "Your house would fall down too if you never spent any money on it."
Persuading district officials to accept the help was a substantial part of the process. "They had to eat some crow," says Robert Cosby, PhD, Chief of Human Services of the Metropolitan Washington Council of Governments. "They had to admit they couldn’t do it alone, and they had to get someone else to help them." Long-simmering racial acrimony and distrust among special-interest groups had to be brought to heel as well, says Michael S.A. Richardson, MD, the Oxford-educated Jamaican who presides over the District of Columbia Thoracic Society and who’s been a staunch critic of the city’s TB control department since 1987.
Because the same conditions that brought about the current problems not least among them, a lack of money still afflict the Bureau, members of the partnership have been reluctant to publicize their successes, lest they undermine efforts to rebuild Washington’s infrastructure, says Cosby.
Money crunch has bred series of catastrophes
The district’s parsimonious, triage-based habits of holding onto money for as long as possible, then parceling it out in small chunks, one quarter of a fiscal year at a time, has led to one public-sector catastrophe after another, says Reed.
"I can pay salaries, but it’s impossible to do something like buy six cars at one time," he says. "This is a crisis-oriented operation where nothing’s ever done in a timely fashion. It’s impossible for me to get a procurement order signed. If I have a good idea, it’s two years before someone hears about it."
With no money for upkeep or improvement, equipment and data-collection systems have fallen into disrepair, and incompetence has flourished. Morale in the department has plummeted, Reed says. "When employees don’t get even a cost-of-living raise for ten years, you get some attitudinal problems," he adds.
One of the most visible disasters has been the district’s laboratory. There, the wait for a simple sputum smear can take up to 120 days, Richardson says. Except in the case of rifampin and isoniazid, sensitivity testing hasn’t been performed at all. There is only one lab technician competent enough to perform acid-fast bacillus smears, and when that person is out sick or on vacation, TB-related work grinds to a halt. Reed readily agrees that contamination and overgrowth spoil some specimens; others get lost. In the past, money periodically ran out for reagents.
Patients sent to Area C Chest Clinic, the district’s sole public TB clinic, often showed up only to be told there was no medicine available or no film for chest X-rays, says Richardson.
Addressing a gathering of the National Coalition to Eliminate Tuberculosis (NCET) held in January in the nation’s capital, Washington’s Public Health Commissioner Harvey Sloane, MD, candidly put it this way: "Public health services in the district have been chaotic and incoherent. It’s been a discouraging battle."
In the midst of the chaos, what finally spurred formation of the partnership was a hard-hitting report commissioned by the Medical Society of the District of Columbia. The report issued a number of recommendations; strikingly, few of them differed markedly from other recommendations made by other task forces over the years, Richardson says. Yet this time, changes, both small and sweeping, are underway.
Richardson sees three chief reasons why this time, the call to action did not fall on deaf ears.
Why this time, the wheels began to turn
First, he says, there is widespread anxiety about how hard the fiscal axes will fall when the congressionally appointed financial control board swings them. The board has seized control of the district’s finances, freezing up even some money specifically allotted to TB control, as Congress mulls over an expensive rescue package aimed at salvaging services in the nation’s capital. "The board holds the purse strings and has powers that are essentially unchecked," says Richardson. "It’s like children knowing that Daddy’s coming home, and they’d better behave."
The second reason that change is at last underway is because a change in leadership of the district’s TB control program removed "a major stumbling block," Richardson says.
A third reason behind the changes is due to the manner in which an influential regional planning organization put its weight behind the partnership effort, Richardson says. A day-long regional conference on TB staged by the Metropolitan Washington Council of Governments was a bold stroke, one that helped catalyze commitment to cooperation among a number of powerful players, including the state governments of neighboring Maryland and Virginia. With its theme that "TB knows no boundaries," the conference framed TB as everyone’s problem, not just a disease of impoverished minorities who live in the district, Cosby says.
With new people in charge and fresh incentives to make changes, the partnership that has emerged weaves together state and regional governments, universities, professional medical societies, the local chapter of the American Lung Association, and special-interest groups representing (among others) the prison population and advocates for the homeless, Richardson says.
The fat lady hasn’t sung yet’
"But the fat lady hasn’t sung yet," he warns; the crisis in the district’s infrastructure continues, diminished but not abated. Even so, fruits borne by the partnership are already in evidence, among them the following:
• The state of Virginia is now providing lab services to Washington at cost.
• The state of Maryland has furnished a nurse coordinator to track patients who travel between Maryland and the district and to track prisoners released from the district’s large prison system;
• District of Columbia General Hospital will ensure an uninterrupted supply of TB drugs, by providing them if shortages occur.
Attempts also are underway to find more cars for the Bureau, says Richardson. (A deal to make available cars impounded by the district’s police department fell through.)
Several other developments give evidence to the greater spirit of cooperation afoot in the region.
For one thing, a representative from the Virginia Department of Health is helping to screen inmates in the District’s prison system for TB and is passing that information back to the District of Columbia Bureau of TB Control, says Cosby. In addition, the University of Georgetown Department of Medicine has been conducting TB Grand Rounds in the auditoriums of several of the district prisons, says Henry Yeager, MD, a pulmonary and critical care physician at the Department of Medicine. The prison system, with its 11,000-plus inmates, is rife with HIV infection, drug abuse, and multi-drug resistant TB, says Yeager; arranging for case-conferences on site improved communication between TB experts and correction officials, he says. (Though the rounds have been temporarily suspended, they’re scheduled to start up again at some point in the future.)
Another important outcome of the partnership is the fact that Commissioner Sloane has publicly embraced the notion of cooperation. "In a time of diminishing resources in the public sector, the importance of the private sector both as watchdog and partner cannot be overstated," Sloane told his audience at the January NCET conference. Sloane added, "All I can say is partnership, partnership, and more partnership." In particular, Sloane has given his imprimatur to the formation of a formal advisory committee on TB to the district. To form such an advisory committee was the first order of business recommended by a report issued by the CDC back in 1994, Richardson points out; yet, like many other reports and recommendations on the subject of TB control issued over the years, it was ignored until now.
As Richardson envisions it, the advisory committee will be separate from the District’s health department, even though it will incorporate department representatives, along with other "interested parties." The job of the committee will be to devise a long-range plan (five or ten years, perhaps, Richardson says) that will be monitored and for the implementation of which the entire committee will be held accountable.
"That way, TB control won’t be done by just one person," says Richardson. "It will not be under the aegis of just one person."
Meanwhile, cases are up from 102 to 139
Meanwhile, large-scale problems persist.
TB cases are up in the district from 102 in 1995 to 139 in 1996, Reed says. As Cosby points out, cases are down in the region as a whole, which argues that the rise in the capital may ot be attributable simply to artifact or to better counting. District shelters, which serve the estimated 5,000 to 15,000 homeless people in the capital, have refused to accept TB patients discharged from hospitals or the local clinic, and the TB unit at DC General has been closed down.
In the Bureau of TB Control, there still are only six caseworkers to provide these cases with directly observed therapy, Reed says, and the cars they drive are still "falling apart."
The district lab is still not functional, Reed says, and money designated by the CDC for the lab is now being shunted to Virginia’s facility.
Despite the rise in immigrants, who in 1995 comprised 14.7% of all cases, the Bureau has not a single interpreter, Reed says. Overall, the staff is nine positions short. Since the resignation of the head of TB control more than a year ago, there has been no permanent replacement appointed to that post.
"I think it would be fantastic if just for once in our lives, we could stumble over each other instead of being chronically short-staffed," Reed says.
Finally, Richardson confesses he doesn’t know where, exactly, the money will come to underwrite the creation of the new TB advisory committee he and Sloane have agreed to create. Nor does he know how the committee will get the teeth it needs to see that its own advice gets taken.
"Sloane is a savvy politician, and he’s displayed a lot of creativity in resolving problems, especially those related to procurement," says the Council of Governments’ Cosby. "But Richardson is in for the long haul." For that reason, Cosby says, he and others in the region remain hopeful.
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