Health Worker Makes House Calls to Help Stop Spread of Disease
By Karin Brulliard
Washington Post Staff Writer
Sunday, May 8, 2005
In the sunny living room of an Ashburn apartment, a little girl with pigtails held a banana and watched cartoons. Nearby, her mother, wearing a white surgical mask, reached to the top of a china hutch and pulled down a plastic pill box marked with the days of the week. It was the size of a textbook.
The woman sat at the dining room table and placed the box and two glasses of water in front of her. Then she pulled down the mask, picked out a dozen tablets and capsules, and slowly gulped them down one by one.
"I hate pills," the woman, who immigrated with her husband and two children to the United States from Peru a year ago, said in Spanish. Until last month, she said, she had taken only an occasional over-the-counter pain reliever for headaches.
Now she must take many pills daily to kill the disease inside her: tuberculosis. And although she said she knows she might forget to take the pills or put off the chore, she does not -- because Erly Janoscrat, the smiling, curly-haired woman sitting to her left, makes sure of it.
As the tuberculosis outreach worker for the Loudoun County Health Department, Janoscrat visits a handful of TB patients each day, watching as they take their pills and offering encouraging words. Most are immigrants, and many are Spanish speakers.
With her visits, Janoscrat, 28 -- who grew up in Honduras and is bilingual -- helps stem the spread of TB and provides comfort to people recovering from a disease that, although shrinking to record lows nationally, has been rising in Loudoun as the county's population has boomed. In 2004, the county had 14 cases of TB, an infectious disease that usually occurs in the lungs and can be fatal if not treated. There were four cases in 2000.
Loudoun health officials say about 90 percent of new patients are immigrants. The same is true elsewhere in Northern Virginia, where growth in TB cases has been more modest. Nationally, immigrants represent more than 50 percent of reported cases -- up from about 30 percent 15 years ago, according to the Centers for Disease Control and Prevention in Atlanta.
"Loudoun County is one of the most rapidly growing and rapidly changing counties in the whole country, and so you've been stressed in the last several years by huge numbers of newcomers," said Margaret Tipple, director of the TB control division at the Virginia Department of Health.
Most immigrant patients, Virginia health officials say, come from Latin America, Asia and Africa, where poverty, poor health care and crowded living conditions keep TB common. People can carry the TB bacteria, which are transmitted through the air, for years before becoming ill.
Here, health officials say, cases in immigrants often go undetected for too long because patients do not recognize the symptoms, which include coughing, chest pain, fever and chills. Immigrants sometimes do not seek help because, depending on the image of TB in the countries they came from, they might consider the disease an embarrassment, a spell that has been cast on them or simply a "death sentence," Tipple said.
"It really is a frightening disease for people who are not informed," said Gloria Collins, assistant director for community health services in Loudoun. "In Third World countries, people are continuing to die from it."
In Loudoun, most TB patients are Hispanic, and that is where Janoscrat comes in -- she speaks their language and relates to them. A former receptionist at the county's health clinic, she is now studying to enter nursing school. In addition to Hispanics, Janoscrat visits immigrant patients from countries that span the globe -- Pakistan, Nepal and Somalia among them.
Her house calls are a form of "directly observed therapy" -- a technique that health officials say is the best way to make sure patients stick to their medications, which most must take for about nine months. The state subsidizes treatment, which can run into the thousands of dollars, on a sliding scale.
Janoscrat said she knew little about TB growing up, other than that her uncle had it. She and other relatives figured he got it because he slept on a blanket on the floor, or perhaps because he showered at night.
Now that she knows better, Janoscrat tries to dispel such myths with her patients while she escorts them through what can be a long, trying recovery. Infectious patients must be isolated for about two weeks, which can cause work problems. Janoscrat has advised the Peruvian woman in Ashburn, who is infectious, to avoid holding her children.
Those things can feel like punishment, Janoscrat said. "People say, 'But I have been a good person. Nobody in my family has TB.' "
As she makes her rounds in her gray minivan, returning day after day, Janoscrat also becomes a friend. On a recent morning, Janoscrat stopped by to see a Somali refugee who lives with her eight children in a Sterling apartment. Inside a dark living room furnished with an ornate red and gold sofa, Janoscrat watched as the woman took her four pills.
"School -- you going to school today?" Janoscrat asked the woman, who wore a vibrantly colored gown.
"Yeah," the woman said, nodding.
On most days, Janoscrat stays to help the woman with her English homework, armed with a Somali-English dictionary she bought for the woman and her own Spanish-English dictionary. She sometimes arranges rides for other patients.
With those kinds of interactions, Janoscrat said she forms bonds and that the patients feel comfortable enough to tell her if they are experiencing side effects from the medications or are having other problems.
"You get their trust, then you're good," Janoscrat said. "Then they can take their medicine."
Earlier in the morning, Janoscrat sat at a kitchen table in a Leesburg townhouse. A Turkish woman cringed as she washed down six pills with water and Diet Coke and spoke of the anguish TB has caused her.
Before they diagnosed TB, doctors performed a biopsy, thinking the woman might have lung cancer. The sickness forced her to cancel a trip to visit family in Turkey, and she said she has been too ashamed to tell anyone, other than her husband and a few family members, that she has TB. Thankfully, she said, she will probably be finished with her treatment in July.
"It's too hard to take medicines. . . . I'm the bad client for her," the woman said, referring to Janoscrat.
"I wasn't going to say anything," Janoscrat joked.
But there has been a benefit to having TB, she said.
"We like each other," she said, pointing to Janoscrat. "See? I got one more friend. Only good thing."