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Low-Tech Medical Miracle


Organ transplants, laser surgery, antibiotics. There are times when the bright promises of modern medicine tempt us to forget our mortality.

A decade ago, a plague called AIDS put a dent in that armor of confidence. So far, the AIDS virus has resisted attempts to find a cure or a vaccine. That's troubling, but even worse is the resurgence of tuberculosis, a deadly disease that kills more people worldwide than any other infection and that is much more contagious than AIDS.

While AIDS is still a high-suspense, high-stakes scientific mystery, the sad tale of TB's comeback is a study in careless arrogance. In many of this country's major cities, the rise in the incidence of TB cases represents a public-health disaster -- except in Baltimore, a city that stands as a proud exception to a sorry story of neglect.

The story was recounted again last month in the pages of the Journal of the American Medical Association, in a letter describing Baltimore's experience with "directly observed therapy," a fancy name for old-fashioned common sense, a systematic program of using well-trained and highly motivated nurses for the simple but essential task of making sure that TB patients take their medicine.

"Directly observed therapy" is low-tech. It's not glamorous. Compared to laboratory quests for vaccines or cures, many scientists consider it mundane, even boring. But it works.

According to Dr. Richard E. Chaisson, an associate professor of medicine at Johns Hopkins and medical director of the city's TB clinic, Baltimore's tuberculosis success story began in 1978.

For well over a decade -- since 1965 -- the city had consistently ranked in the top three major U.S. cities in the incidence of TB. But in 1978, the city health department initiated a program based in clinics and aimed at TB patients who were considered "manifestly noncompliant" -- in other words, sick people who refused to take their medicine for an infectious and deadly disease.

That's no small task. TB requires steady doses of medicine over the course of several months. (These days, the protocol calls for a complex combination of four different drugs, not an easy task even for a conscientious patient.)

After three years of the direct-observation program, the city had dropped to fifth in the country, a decline from some 48 cases per 100,000 population to fewer than 36. That same year, 1981, the city intensified its program, employing young nurses imbued with the zeal and skill it would take to fight a killer as sinister and persistent as TB. These nurses took the program outside the clinic walls into the neighborhoods, tracking patients around the city, unrelenting in their insistence that they take their medicine.

The results were dramatic.

By 1992, according to the federal Centers for Disease Control, Baltimore ranked 28th among American cities in the incidence of TB, reporting just over 17 cases per 100,000 population -- about 130 in real numbers and less than half the rate reported in 1981.

More dramatic is the virtual absence of a frightening new strain of TB that is resistant to the drugs commonly used to treat the disease. Last year, New York reported 800 cases of multiple-drug-resistant TB. Baltimore had one -- a New Yorker whose disease was diagnosed here.

The Baltimore story has many inspiring angles. There are the nurses whose courage and resourcefulness keep this success story alive. There was also the personal commitment of the late Dr. David Glasser, an assistant health commissioner who suffered from TB himself and put a high priority on the direct-observation program.

Elected officials also deserve some credit for not slashing public-health budgets, as other hard-pressed cities did during the 1980s. Baltimore is fortunate to have world-class medical care and some of the best public-health experts anywhere. The TB story shows the value of listening to them. If you doubt that, look at New York, where a total of 3,500 to 4,000 cases of TB were reported last year.

This saga isn't over, and Baltimore cannot rest on its laurels. Many people worried that the city's recent cancellation of a contract with Union Memorial Hospital would decimate the TB program. Most of the dissatisfaction with changes in employment status seems to have been smoothed over. But the uproar sparked by the episode illustrates that no program, however successful, is immune to upheavals that could threaten its effectiveness.

For now at least, there will be no final victory over tuberculosis. But with patience and persistence, Baltimore can continue to demonstrate the value of the less glamorous miracles medicine can offer.

Sara Engram is editorial-page director of The Evening Sun. Her column appears here each week.

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