Ten-month-old Adrienne Morgan has just learned to sit up -- for the second time in her short life.
With a tube inside her brain, she has returned to her Northeast Washington home after a three-month stay in Children's Hospital, where she nearly died of tuberculosis.
If Washington's health department were doing its job, the child never should have developed TB, said Dr. Hazel Swann, who just took over as head of the TB control program.
Adrienne Morgan's is but one of the cases that has made TB what doctors call a runaway condition in the District of Columbia. The city had the third highest rate among American cities last year -- 314 new cases and a rate four times the national average. And new cases are turning up at the same rate this year.
Tuberculosis has been essentially curable since the early 1950s, but controlling it on a citywide basis has been more difficult.
Since 1973, Washington has consistently been among the top four cities with populations of over 250,000 for incidence of tuberculosis. And in 1972, the city had a $1.18 million budget for tuberculosis control -- with the help of a $700,000 federal grant specifically for that purpose.
But by 1978, the TB control budget was cut in half to $662,500 -- or to one-third if inflation is figured in. The federal government had folded its TB control grant into a lump sum for the city's Department of Human Resources. And the department decided it had better things to do with its money than control TB.
The staff of 115 people working to control the disease in 1972 have been reduced to 34 today. As a result:
It takes up to eight weeks for overworked public health nurses to find and test those exposed to each TB patient -- long enough for new cases of TB to take hold.
Private doctors and hospitals sometimes fail to report the cases they treat -- in violation of a city law that is not enforced.
Doctors in the city clinics have at times ignored established policies, choosing not to prescribe medicines to some patients with early evidence of TB.
The city health department laboratory has accidently contaminated solutions used to test for TB -- a situation that may have lasted from weeks to months.
The laboratory has been using cumbersome and outmoded procedures, failing to keep up with its workload and, at times, producing unrealiable results.
Patients' records have lacked the lab test results vital to treatment, and sometimes city clinic nurses did not even note patient's weights and temperatures.
And until last summer, the city didn't even bother to fill the job of TB control director for three years after the former director was promoted.
"In the Department of Human Resources," says Dr. Hazel Swann, who took over the program three months ago, "health is no different from -- well . . . the dog pound."
Along with the rates of venereal disease and infant mortality, a city's incidence of tuberculosis is considered to be a measure of the effectiveness of its health department because all three problems are controllable.
The District has had high rates for all three, but its tuberculosis control program has been particularly lax.
Tuberculosis is a contagious disease that thrives in large families and crowded housing. It settles in a person's lungs, where it can either live for years without a problem of flare up into an active case, with a cough that can spread the disease to others and an infection that can attack other organs. A person with active TB has a fever, loses weight and feels rundown.
The disease strikes a higher proportion of blacks than whites. Black men in Washington face a far higher risk of TB than any other group -- more than 90 new cases a year per 100,000 population -- and D.C. blacks of both sexes develop TB five times as often as whites. The disease is found in all age groups, but those between 45 and 65 are stricken most frequently.
Wards 1 and 2 in the city have a disproportionately high rate of TB, particularly the area bounded by 16th Street on the west, North Capitol Street on the east, Spring Road on the north and Massachusetts Avenue on the south. In the last two years, the TB rate there has been five to seven times as high as in Montgomery County.
However, TB knows no boundaries. Last year there were 12 new cases in the city's affluent and predominantly white Cleveland Park and Glover Park neighborhoods.
And the extent to which the disease has spread reflects the city health department's failure to control it.
TB can only be reined in by tracking down infected persons and those they've come into contact with, testing them accurately and keeping infected persons on medication.
By standards set by the federal Center for Disease Control, the local program fails on many of these counts.
According to the center, 95 percent of patients in an effective TB control program should produce a normal TB sputum test after six months of treatment. In the District, only about 50 percent of patients produce one after that time.
Nationally, 85 percent of TB patients take their medication for a full year -- a necessary first step for controlling the disease. In D.C., only 51 percent of patients who began treatment early in 1978 stayed on their medicine that long.
The city's public health nurses are hard-pressed to track down persons exposed to TB because they have to make house calls for other disease prevention programs. Nine years ago, when the program had its own federal grant, a separate staff of eight nurses worked on TB investigation.
"Now, they (the nurse) go to a house and if there is a lock on the door they have no time to look for somebody," Swann said. "So theyy leave a note and walk away."
The nurses cannot cross state lines -- or even health department jurisdictional boundaries. Thus, if a nurse investigates the family of a TB patient in one neighborhood and learns that there are exposed relatives and co-workers elsewhere in the city, those contacts must be checked by other nurses, only adding to the delay.
One particularly dramatic case last year involved a woman who worked in a beauty salon. Her doctor said he later learned that a case of TB had been reported from the same salon three months earlier, but that a nurse had never been out to check it, risking the possible infection of all of the salon's customers.
Before nurses can investigate a case, it must be reported. D.C. law requires doctors to report active cases of TB within 24 hours, or risk a $300 fine or 30 days in jail or both. But TB nursing coordinator Sarah Farley said the law has never been enforced. As a result, probably only half the city's TB cases are ever reported, estimates Dr. Heinz J. Lorge, chief medical officer at the city's TB clinic on Upshur Street NW.
"It's a question of not even recognizing the disease when it's there," said Dr. Alfred Munzer, president of the D.C. Lung Associatin. He agreed that even though many TB patients are no longer hospitalized, doctors are unaware of reporting laws and unfamiliar with TB and how to treat it.
TB program staff rely on the cooperation of local hospitals, but infection control nurses at some District hospitals -- notably Sibley Hospital and Greater Southeast Community Hospital -- never call the program to report cases, said Farley, who takes the reports.
Officials at both hospitals said that they did report all cases. A Sibley official said a misunderstanding did arise over a patient from Prince George's County. And a Greater Southeast spokeswoman suggested that some confusion may have arisen since more than half its patients are from that county. In addition, the hospital's nurse-epidemiologist was changed recently, possibly contributing to some confusion.
In Baltimore, which had the second highest incidence of TB for an American city last year, the budget for TB control is nearly twice the size of the District's. Officials there are fighting back by monitoring cases closely. There, nurses interview TB patients before they leave the hospital. City law requires pharmacies to file a report each time they dispense TB drugs and doctors know that they will be prosecuted for failure to report TB cases. As a result, 95 percent of the city's cases are reported by doctors, according to the city's director of TB control, Dr. David Glasser. Baltimore's TB rate is high, partly because so many of the city's TB cases are uncovered, he said.
San Francisco had the highest incidence of TB in the nation last year, largely because of the influx of Asian refugees to that city.
The failure to track down cases here is showing up in the increasing number of children under three -- screened by the city's maternal and child health program -- who are found to have TB infections. These very young children face a higher risk of severe complications from the disease than do adults.
The performance of the city's TB laboratory has also been a problem since the tests are so vital to determining where the disease has spread and whether it has been cured.
Last spring, lab workers accidentally contaminated a solution used to test the sputum of TB patients, and TB germs in the solution itself caused a rash of results that showed TB infections. This may have increased the workload of the TB control staff as it tried to track TB infections that didn't exist.
No one is certain how long the results were invalid: Lorge estimates it was from February to April; the city's chief of preventive services said, "One week or ten days," the microbiologist who heads the TB lab, said, "Maybe about two to three weeks." The source of the contamination is still a mystery.
The contamination incident, Swann said, only heightened the clinic doctors' impression that lab results had been unreliable for about two years. But the clinic staff didn't help the situation -- frequently mishandling specimens before they reached the lab.
Last spring, Swann said, it was common for patients' sputum specimens to sit around for two or three days before being sent downtown to be tested. By the time the sputum was put in a culture, no TB bacteria would grow, so a number of cultures probably were falsely read as being clear of the disease, she said.
Both Swann and Dr. Alston Shields, director of the city's laboratory facilities, agreed that the TB lab has been unable to keep up with the volume of work needed. Besides doing about 275 TB lab tests a month, the lab must do sensitivity testing, in which the germ infecting a particular patient is tested for its susceptibility to different drugs.
Such tests become crucial when a patient is not getting better because the bacteria in his lungs have become resistant to the prescribed medicines. But Shields said that the lab has been able to run sensitivity tests on only eight patients a month, far fewer than the number requested by Swann.
Shields defended the accuracy of the TB lab's results, saying that the lab does well on quality-control specimens sent out every three months by the Center of Disease Control.
But he said that the staff had been doing sensitivity testing according to specifications received in the early 1970s, which required 64 separate test tubes.
It was not until a federal consultant visited the lab in October that the staff learned that the test can now be performed with only eight tubes, saving time and money.
The expert also pointed out that while the technicians were testing the TB germs' susceptibility to seven different drugs, they were not testing one of the three drugs used most often in the city clinics to treat patients.
Alafe O. Adeyemi, the head of the lab, said he thinks that with the time-saving suggestions offered by the consultant, the lab will be able to handle the demand for more sensitivity tests.
Swann said she has spent her first months on the job working on treatment procedures, record-keeping and lab accuracy, before tackling the problem of how to find more cases of TB.
Leafing through files soon after she took the post, she came across a 1977 report from a federal team that had visited the program and recommended changes. None had been implemented.
Swann said she considers herself a "team player" for the city's Department of Human Resources, but she says she never would have taken charge of the TB program if she had realized how troubled it was.
As Farley puts it, "Ten years ago, they said TB was going to go away, that it wouldn't be a problem anymore. All of a sudden, here it is today, as big a problem as it was 10 years ago."