Jessie Banks takes pills from a neatly labeled envelope and puts them in her patient's hand. Her task is to make sure that three brown-and-red capsules and four white tablets are swallowed, not thrown away. She watches carefully as her patient chases them down with orange juice.
Banks is a public health nurse and one of three investigators for the D.C. Bureau of Tuberculosis Control, which operates at D.C. General Hospital's Area C Chest Clinic. Three times a week she goes out in the field, visiting patients who are unable or unwilling to take their medication regularly, and administers pills and injections to prevent tuberculosis from spreading.
Some patients are hostile. Some pretend they are not at home. Others are afraid to admit they have the disease, never mentioning its name, hoping it will go away by itself.
"I don't like to talk about it," a 47-year-old mechanic said. "I try to stay away from my kids as much as possible. I try to forget about it."
Regardless of the reason, if TB patients will not take responsibility for their own treatment, Jessie Banks must find them and treat them, both for their sake and for the safety of the community.
Currently there are 290 reported cases of tuberculosis in the District of Columbia, according to Dr. Hazel M. Swann, chief of the D.C. Bureau of Tuberculosis Control. Although Swann's figures show the TB rate has dropped by 19 percent during the past three years, Washington still ranks in the top five cities of comparable size in the number of cases of tuberculosis, according to the national Centers for Disease Control in Atlanta.
Swann said there are pockets in Washington in which tuberculosis cases have a history of recurring, largely because of poor, overcrowded conditions. They include the 1300 block of Kenyon Street NW, an area known for its high number of tuberculosis cases during the past nine years, according to Swann; the 1300 block of Irving Street NW; the 1200 block of M Street NW; the 1000 block of Maryland Avenue NE, and the 500 block of Brandywine Street SE.
Swann maintains that the disease is under control. While a patient is receiving treatment, most commonly the drugs Rifampin, isoniazid and streptomycin, tuberculosis is not communicable, she said. And although the bacteria are coughed or sneezed into the air, people in good health should have antibodies that naturally immunize them against TB, Swann said.
"It's not a highly contagious disease," said Dr. Laurence Farer, director of the tuberculosis control division at the Centers for Disease Control. "TB is not easily spread compared to flu and other respiratory infections. It requires fairly frequent or prolonged exposure to air that's been contaminated by bacteria by a TB patient who's coughing. The people with the highest chances of getting it are those who share the air with somebody who has undiagnosed TB, who's coughing the bacteria into the air. That's why it's very much related to housing and poverty.
"It's not something that somebody just riding on the bus or walking down the street is in danger of catching," Farer said. "It's not from a brief, casual encounter."
The relatively high incidence of the disease has little to do with a lack of medical knowledge, according to Swann. "TB is a social problem with medical implications," she said. It is symptomatic of overcrowded housing and poverty, often among middle-aged and elderly men, many of whom are often chronic alcoholics and unemployed.
"You rarely see it in people with high-priority health care," Swann said. "You see it in conjunction with social problems."
Community leaders who live in areas noted for the high number of TB cases say they are concerned, but that there is little knowledge among residents that their neighborhoods are areas targeted in the city's efforts to counter the disease.
"Frankly, I'm not aware of it," said Louis Perkins, ANC chairman for Ward 2C, which includes the 1200 block of M Street NW. But Perkins said he has received calls about the unsanitary conditions at apartment buildings on the block.
"I am aware of TB in Washington and I'm aware that it's on Kenyon Street," said Richard McReynolds, an ANC commissioner for Ward 1A and a member of the ANC Committee on Housing, Community and Economic Development. As for his constituents' knowledge of the problem, he said, "I don't think they really know it's there, which is probably both good and not good. They don't panic about it, but they don't look for or know the symptoms either."
Swann said tuberculosis persists in some city neighborhoods because it is difficult to change the lifestyle that spawns it. "It's a culture," she said, "a sort of support network" among people who reside, drink and socialize with each other.
Banks often penetrates that culture when she goes searching for patients referred by hospitals to make sure they take their medicine. There is a pattern, she said, that repeats itself constantly: Some sort of crisis will occur, which may be followed by heavy drinking, loss of steady income and alienation from old friends and family. Then poor health and nutrition will set in, creating the perfect conditions for tuberculosis to develop. "We don't have an awful lot of people who live with families or someone to take care of them," she said. "Or the ones with good support systems don't have to see us."
"They never say why they don't want to take their medication," Banks said, adding that finding out how they contracted the disease is less important than where, "so we can treat others."
Swann's dedication is apparent in her daily routine. She wakes up at 5:30 each morning ("You just get orange juice, coffee and keep going"), stops at one patient's house on her way to work, and drives others to clinics for X-rays and physicals. In the afternoons she polishes off her paperwork and visits hospitals to track potential TB contacts.
She has developed a savvy for her patients' stories and games. She said she enjoys the process of finding them, of projecting herself into their places and figuring out where they'll be next. "They really think they're pulling the wool over your eyes," she said with a smile.
There is, for example, a 19-year-old woman in Southeast: "When she turned up the glass [of water] she spit the pills into it. I said, 'I see them.' " There are patients who lie about keeping their clinic appointments. But Banks, with her calendar on hand to check if the numbers and days coincide, usually catches them. "You get to the point where you know [for example] that Howard's chest clinic is on Tuesdays and Thursdays, that the Veterans Administration's is on Fridays. . . . The minute they say they'll call and make another appointment you know you got them." And then there are the patients who abandon their previous addresses as soon as they get their public assistance checks, she says. "Oh, Lord, Sunday is the first, isn't it?" she groans.
But she plays along in a manner that combines amusement and respect, exchanging pleasantries with the good-natured ones, mildly scolding the difficult ones -- coaxing them into swallowing their pills, into giving her their backsides for a quick poke of the hypodermic needle -- tracking down the wandering ones from tenements to alleys to liquor stores.
"They say they'd take it if we didn't come, but that's not true," said Banks. "If they'd comply we wouldn't need to do this."
Besides, she said, it is for the community's benefit as well. "You can say 'If I don't take it medication , I'm not hurting anyone but myself,' " Banks said. "But you are."
"Sometimes it's hilarious," she said of her cat-and-mouse efforts to keep the disease from spilling over into the general population. She recalls a man in his mid-30s who lived in Northeast Washington but could always be found on the other side of the city. "He always hung out in a particular park in Northwest. I'd go so often all his friends knew me. I was looking for him three days a week for nine months." First she'd call his home just to make sure he was not there. Then she headed for the park where his friends would direct her to the nearby liquor store.
" 'Oh, you found me,' " Banks recalls him saying, innocently. "Well, yes, I knew where you'd be." And if he was in an agreeable mood, she would drive him to the nearest clinic for a shot of "strep."
Banks, 48, who worked in general health and with venereal disease patients before her tuberculosis work began nine years ago, was born and raised in Northwest Washington. She said she always knew she wanted to be a nurse: "As a kid I remember a lady who was a nurse. Something about her said, 'This is what you want to do.' "
"The fact that you're getting medicine to them now and then is still better than them not getting it at all," she said. "And you hope after a time the medicine will do its job."
It usually does work after nine months to a year of treatment, although tuberculosis can recur, she said. Occasionally, Banks receives gratitude, though it may come in odd ways.
When the man whom Banks found repeatedly in a Northwest park was finally cured, he happily told her: "And I won't see you for a long time."