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TB Notes 1, 2000
Not by DOT Alone
by J. Michael Holcombe, MPPA, CPM
Mississippi TB Controller
Mississippi proved directly observed therapy (DOT) to be a great
tool toward TB elimination. However, DOT is not a programmatic cure-all,
a stand-alone solution, or the proverbial yellow-brick road. Not
what you expected to hear from Mississippi, is it?
We know that DOT is the best way to treat TB. It might not always
be the most convenient or the easiest, but with the correct drugs,
dosing, monitoring, and delivery, it is unsurpassed at present.
When it comes to DOT and its impact, we must remember the Chinese
proverb, "Hear and forget; see and remember; do and understand."
With full implementation of universal DOT on a statewide basis
in the mid-1980s, TB program performance indicators began to improve.
Patients' sputum converted faster, reducing the potential period
of infectiousness; a greater percentage of patients completed therapy;
a greater percentage completed therapy in a timely manner; the number
of patients acquiring drug resistance decreased rapidly; the number
of program admissions for inpatient care dropped dramatically; the
average length of an inpatient stay dropped; and the number of new
TB cases began to fall. The reduction in morbidity allowed more
time for contact follow-up, the expansion of targeted testing, and
the implementation of directly observed preventive therapy in select
high-risk populations. This increased the number of patients on
preventive therapy and the percentage of patients completing preventive
To further support the strengthened efforts, laws were modified
to improve our ability to protect the public from patients who fail
to cooperate with treatment or isolation, and rules were changed
to improve reporting. We placed emphasis on outpatient care and
privatized elements of the program best and most efficiently provided
by private providers — radiology services, for example — to expand
availability, improve quality, and ameliorate cost.
Many told us universal DOT could not be done; a few said it should
not be done. But we continue to truly believe DOT is the best service
we can offer our patients and the public. We believe DOT offers
the surest and best chance for a timely cure. Why should we treat
anyone with less than what we believe is the best we can offer?
Their future is our future.
True, Mississippi has made great strides in TB control. But we've
made those strides not by DOT alone.
Each and every one of those great strides was made by everyday
people: nurses, aides, clerks, outreach workers, doctors, disease
intervention specialists, and volunteers — hard working, dedicated,
and passionately devoted individuals who were, and are, determined
to make a difference one patient, one facility, one community at
From the establishment of our sanatorium early in the century through
its demise and the rise and continuing refinement of our outpatient
treatment delivery system, public health nurses have made most of
those great strides possible. Usually, the nurse comforts, educates,
and gives hope to the distressed patient who has been notified of
exposure or disease. The nurse confronts and calms the angry, hostile,
and all-too-often dangerous patient who has given up and no longer
cares about himself or others. The public health nurse persists
through heat or snow, wind or rain, dogs, gangs, or alligators and
finds the patients and persistently guides, cajoles, or bribes them
through treatment. If, along the way, that means baking a few extra
cookies, making an extra trip after work to deliver a home-cooked
meal to a homeless or lonely patient, buying an extra can of soup
or a chicken for an impoverished patient while grocery shopping,
or taking the time to put a grubby little 4-year-old on the lap
and reading a story in hope of making the treatment seem a little
more palatable . . . that's nothing special. That's just the way
DOT happens: good people doing good things. No bells, whistles,
or wreaths of laurel — just another great stride taken in silence
and out of public view.
Public health nurses, of course, don't work in isolation or independently.
Without a doubt, each stride is made easier by the clerk who greets
the patient kindly and patiently, then helps expedite the visit.
Each stride is made easier by the outreach worker who helps ensure
each dose of medication is ingested and each appointment is kept.
Physicians who take time from their busy practice to conduct regular
clinics at the health department also make each stride easier, more
sure, and more purposeful. And the advances in science, the effective
anti-TB drugs available, and the emerging technology for more rapid
and accurate diagnosis have been and are unquestionably essential
to the progress we have made.
Yes, DOT has been a vital tool for ensuring progress and managing
cost. We used it as the fulcrum to move Mississippi from a deepening
rut and to change the direction of TB control. But, DOT was only
part of the plan. Progress cannot be achieved by DOT alone. DOT
requires achievement goals; community support; good legislation;
adequate infrastructure and funding; a dedicated, determined public
health field staff; and the strong support of administration.