Multiple problems at the D.C. Health Department's Tuberculosis Control Bureau have led city officials and some in the medical community to question its ability to adequately serve low-income residents and protect public health.
Doctors who refer patients to the bureau for screening and long-term follow-up care say the staff has been mishandling treatment of many infected patients and turning away people seeking TB screening.
The bureau's chest X-ray machine, which provides evidence of TB in the lungs, is 16 years old and breaks down often; at other times, staff members report, they have run out of X-ray film or chemicals, which forces the office to close. Located in a run-down building on the campus of the shuttered D.C. General Hospital, the bureau has unreliable water, air-conditioning and heating systems, city officials say.
In recent months, the agency stopped filing regular TB reports with the Centers for Disease Control and Prevention in Atlanta, and local doctors say that leaves them unable to tell whether TB incidence in the District is rising or falling this year.
Doctors also say the city has no designated facility to house homeless TB patients where health officials can observe them taking daily medications for up to a year -- the only reliable way to contain an infectious disease diagnosed in 79 District residents last year. Instead, many TB patients roam the streets and move from shelter to shelter without sticking with the therapy.
Victor Freeman, president-elect of the D.C. Medical Society, said, "The issue for the medical society was that if we're not managing the most basic public health function, then we have concerns about the ability to manage more complex issues -- especially in the nation's capital, which is a potential target for chemical and biological events."
The District TB rate in 2003 was 13.8 per 100,000 residents, compared with 5.1 for the nation, and immigrants and African Americans are at greatest risk, according to experts. Those who pick up the infection could develop the active disease at any time if their immune system is immature or weak.
Last week Herbert R. Tillery, the Health Department's interim director, said the bureau will get a new X-ray machine, begin renovating the office and resume reporting TB figures to the CDC. The bureau will move to temporary space in the hospital building, he said.
The CDC funds $870,000 of the bureau's $1 million budget and the director of the CDC's Tuberculosis Elimination Division, Ken Castro, said in an interview that the District agency is meeting national standards despite difficulty filling job vacancies and purchasing supplies. In 2002, he said, 92 percent of District TB patients who could be treated for less than 12 months completed their therapy. Last year, the agency's 17 workers saw 3,259 patients.
"What they are reporting to us certainly indicates that, at least when people make it to the program, things are going well," said Castro, who oversees $100 million in such grants each year. "What happens between a provider's diagnosis and the referral to the program is not captured in those benchmarks."
But private physicians and social workers whose patients are at highest risk of TB infection say that the city has often broken promises such as those Tillery made and that care at the bureau continues to be substandard.
Diana Lapp, medical director of the Walker-Jones Health Center in Northwest Washington, said that when she sent a 5-year-old immigrant to the bureau for therapy, a doctor incorrectly told the family that no care was needed and to return when the child was 11. "It is frustrating," she said. "It's not doing the job."
Abdi Naficy, a doctor whose program at the National Institute of Allergy and Infectious Diseases assigned him to work with homeless patients at a downtown shelter clinic, said the bureau makes serious medical errors, especially with patients who have multidrug-resistant TB strains and are HIV-positive. Drug-resistant TB is extremely difficult to treat for people with HIV or AIDS.
"Physicians at the Bureau of TB Control have decided on their own accord and without consultation with the patient's primary physician to make medical diagnoses and prescribe therapy," Naficy wrote in an e-mail to the bureau last year. "At times this action could be best described as malpractice. . . . I personally have no confidence whatsoever in referring patients under my care to the bureau."
Patients share such frustrations. Darius Hawkins, 41, of Southeast Washington, was referred to the bureau for a chest X-ray after a TB skin test was positive this year. "I called before I went, but when I went there they were closed," he said. "The sign said they wasn't open that day. I was very frustrated."
Floyd Simpkins, 73, a retired mover from Northwest Washington, said he went to the bureau for a screening several months ago. "I never did get in," he said. "They stopped us right at the door and said they didn't do X-rays anymore." Both were later found not to have active tuberculosis.
Janelle Goetcheus, medical director of more than a dozen charity clinics in the city run by Unity Health Care, said the federal inaction is unconscionable. "CDC has always been aware of inadequacies of TB control in the District, and they've never moved," Goetcheus said. "They know how bad it is."
The city has no place to house homeless TB patients for "directly observed therapy," in which a worker watches to make sure a patient swallows antibiotics every day. The therapy lasts more than six months, and patients who interrupt treatment are more likely to suffer a serious relapse and to spread drug-resistant strains of TB, experts say.
Goetcheus and others are particularly upset about one HIV-positive woman with multidrug-resistant TB who has chronically neglected to take her four drugs a day. She was missing for a week in June, Goetcheus said.
In the past year, the woman has been hospitalized for several 30-day stays in an isolation room at George Washington University Hospital at a cost of about $250,000 to her Medicaid health maintenance organization, Health Right. But the woman did not always stay in her room and walked the halls or stood in front of the hospital without a surgical mask, according to Goetcheus and others familiar with the case.
Last month the woman landed in the D.C. jail, and Goetcheus was incensed to learn that the woman was not segregated from other inmates and did not receive all of her drugs while there, potentially exposing people to multidrug-resistant TB. Finally, concerned officials at Health Right notified the city's Child and Family Services Agency of the problem, and it took her children for screening.
Walter Faggett, the Health Department's acting chief medical officer, dismissed such concerns, saying that the woman has not been contagious since April. "She did miss a couple doses of intravenous medication, but clinically we are very comfortable that she has recovered and has been treated adequately," he said.
Faggett said that the city has identified places in Maryland where homeless patients can be sent for directly observed therapy but that facilities once used by the city are no longer available.
The city should invest in providing monitored therapy settings, said Peter Hotez, chairman of microbiology and tropical medicine at George Washington University.
"New York City was practically brought to its knees [in the late 1980s] because of lapses in directly observed therapy for TB," he wrote in an e-mail. "It was only because the city recognized the critical importance of surveillance and expanded use of directly observed therapy in institutional settings that the problem was brought under control. If it is really true that the District has become complacent with this therapy, especially among HIV-infected patients with TB, then they are potentially creating a timebomb."
Freeman, the Medical Society official, said Tillery should be given a chance to fix the problems.
"Attacking Herb Tillery and Walter Faggett isn't the answer," Freeman said. "We need to give them support, and if that fails, we need to go up the line to talk about what the problem is. Mr. Mayor?"