Despite predictions earlier this century that infectious diseases would soon be eliminated as a public health problem (Burnet, 1963), infectious diseases remain a leading cause of illness and death in the United States. The incidence of tuberculosis, which was presumably under control has increased in several urban areas throughout the country. Furthermore, control and prevention of the disease have been undermined by drug resistance as well as lack of federal funding.
The homeless population is of particular concern as they are often immunocompromised, underserved, and disenfranchised from the traditional medical system. As a result, tuberculosis is most prevalent in cities among homeless individuals and has suffered from a twenty percent increase since 1985 (Bloom, 1995). Combined with the HIV epidemic and increased intravenous drug use, tuberculosis has become one of the leading causes of morbidity and mortality among homeless populations as a reemerging killer.
Currently, a combination of five primary drugs are used for chemoprophylaxis, as drug resistant bacteria have made single drug treatments obsolete. However, social and residential instability in homeless persons are a major obstacle in completion of the drug treatment. The most effective plan to ensure administration of medication is the use of Directly Observed Therapy, which calls for health care workers and volunteers to visit patients at shelters to visually confirm administration.
DOT not only prevents the transmission of tuberculosis, but also combats the spread of multi-drug resistant strains of the bacteria. In studies done is several cities, DOT has been shown increase the number of completed regimens by over forty percent (Iseman, 1993). Nonetheless, despite DOT’s success, federal funding for such programs remains grossly inadequate. As a result, there has been widespread change and expansion of health policies in many major cities.
Investigations into the policies of three major U.S. cities (New York, San Francisco, Chicago ) have presented the current state of tuberculosis treatment amongst the homeless. Information about the disease and its epidemiology was first obtained through articles found in the library. The general history of public health policy against the disease was then also researched in published articles found in the library and on the internet. The current programs in each respective city were then researched by accessing the city’s department of public health homepages on the internet and by calling faculty in the departments for specific information.
The results of the research into the policies of the cities is as follows. New York is hardest hit by the reemergence of the disease, and suffers four times as many cases as other major cities. Due to the sheer size of the homeless population, the New York City Department of Health has issued a “Comissioner’s Order for Directly Observed Therapy” (CODOT) to ensure the expansion of the treatment in highly infectious areas such as homeless shelters. As a last resort, patients may even be detained until an adequate course of treatment is completed.
An additional organization has been created: The Education and Training Unit. Conceived by the Bureau of tuberculosis control, health care providers perform “grand rounds”, visiting the many shelters throughout the city to diagnose potential cases and educate the homeless and shelter staff members. The city’s health department may also be noted for its extensive use of formerly homeless volunteers to execute policies.
Although San Francisco’s population is much smaller than other major cities, it has the fifth highest tuberculosis rate in the country. The city’s Health Care for the Homeless program has extended PPD skin testing in homeless shelters and food lines. In addition, to increase patient compliance, patients under the DOT program receive transportation vouchers and food which act as incentives to complete the therapy. In 1992, Health Care for the Homeless instituted a respite program in several shelters where homeless persons with tuberculosis were allowed to rest and recuperate while medications were monitored.
The health policy of Chicago against tuberculosis serves as the paradigm for effective eradication of the disease within a city. The disease has reached an all time low in 1996, due mostly to the city’s aggressive implementation of DOT. Backed by the CDC, DOT was made the standard for all tuberculosis cases encountered in the homeless population in 1993. Officials estimate that it has prevented over 550 cases, saving 7.5 million dollars in hospital costs. The Metropolitan Chicago TB Coalition was also founded to help mobilize public and private resources to control the disease.
The project brought forth an indepth look at the current policies of some major U.S. cities against tuberculosis, and exposed some general trends therein. It is clear that DOT is the only effective way to prevent transmission of the disease as well as the development of multi-drug resistant strains of the bacteria. Moreover, federal funding for these programs seems to be lacking, which has led some cities to create their own funding organizations. Tuberculosis has begun to be recognized as an epidemic among homeless populations, and projects such as this have helped to alert the public health community to this disease.
There a few clearly needed improvements in public health policy against tuberculosis. Firstly, an increase in federal funding is imperative to the extension of DOT therapy. In addition, there is a great need for increased man-power in the homeless areas, and a need for more education amongst the homeless and their providers. Additional projects could explore specific aspects of public health policy such as the acquisition and allocation of funding, or the development of educational programs in the community and their actual effectiveness in preventing the spread of the disease.
Upon completing the project, we have found that the deliverance of health care to the homeless is less about management and planning than logistics. The ability to provide treatment.