Two years ago, federal health experts reviewed the District of Columbia's tuberculosis control program, found it lacking in almost every respect, and provided city officials with nine major recommendations for improving the program.
At that time, the city had the second highest TB rate in the continental United States.
Today, federal officials and officials of the D.C. Lung Association estimate the District still has one of the nation's highest TB rates and they point to the fact that the city has done virtually nothing to implement the federal recommendations.
In addition, these experts say the city's TB rate may really be twice as high as reported, but the District's case follow-up program is so poor it is impossible to know the real extent of the disease here.
Tuberculosis is viewed by many as a disease of the past, associated more with legendary characters like John 'Doc' Holliday and Camille than with modern urban living.
While most forms of TB can now be easily treated with drugs, the disease once known as consumption is still very much with us - in urban and rural settings alike.
Tuberculosis is a chronic bacterial disease of the lungs, transmitted by airborne droplets. It is a disease often associated with poverty and its conditions - overcrowding, poor housing, malnutrition, general lack of hygiene and, some experts say, the stresses of urban life.
In 1977, the last year for which there are figures available, 49.6 of every 100,000 District residents were reported to have TB, a rate second only to Newark's 59.3 cases for every 100,000 residents.
The 1977 study by experts from the federal Center for Disease Control in Atlanta, which was based on a 1976 figure of 45.4 cases per 100,000 city residents, included recommendations that the District health department:
Appoint a full-time director to the TB control program, a position which had then been vacant a year and has now been vacant three years;
Revise and consolidate forms, and develop standard formats for clinic and hospital charts, a project which is now under way two years later;
Develop better communications with laboratories in the city "possibly through a routine visitation program, and develop information feedback programs for private (physicians) and hospitals" - none of which has been done;
Send key city staff people to Atlanta on a regular basis for the TB courses offered by the Center for Disease Control, which federal officials say has not been done.
Part of the District's problem, said Dr. Laurence S. Farer, director of the CDC's TB surveillance program, is the fact that it has "a large black population, a lot of poverty and a lot of immigrants. Washington probably has more TB in people who come from abroad" than other cities.
Studies have shown that tuberculosis is more common among blacks than whites, saif Farer, regardless of their socio-economic status. The reason for the difference is unknown, Farer said.
It used to be believed that TB, or consumption, could be cured by the patient's moving to an area of the country with clean, dry air, such as the Southwest, which is said to explain how "Doc" Holliday ended up with Wyatt Earp in Tombstone, Ariz.
Such theories, said Farer, were "all a myth. All that's needed now is to get the drugs into the patient."
Moving out of the crowded, urban situation may have prevented reinfection, said Farer, but it did nothing to cure TB, which can remain dormant in an individual for decades, making its first active appearance in old age.
District officials, as well as federal TB experts and physicians in private practice here, all say the District's program has been severely hampered by a lack of funding and staff.
In 1972, when the major federal anti-TB funding was cut off, the District had a budget of $1.2 million and 115 employes to combat tuberculosis, said Dr. Vedat O. Oner, the District's chief of disease control.
"As of today, after seven years of inflation, our budget runs about $600,000 and we have 34 employes," said Oner, who acknowledged that the TB control effort is "not one of the most effective programs in Washington, D.C."
Dr. Raymond Standard, chief of public health in the District, recently noted that the TB rate has remained essentially the same during the past decade, despite the cut in funding and personnel.
However, according to Dr. Robert B. W. Smith, president of the medical section of the D.C. Lung Association, "we really don't know" if the situation has remained the same because "the data collection is so terrible that we really don't know where we are."
"It's this groping around in the dark that's worrisome," said Smith. The real concern isn't for the 300 or 400 "cases a year, it's that we aren't getting rid of a reservoir of cases and a treatable disease," said Smith. He added that the District is unable to track down those persons who have had close contact with persons known to be infected with TB because of inadequacies in the control program.