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TB Notes 1, 2000
The Denver TB Program: Opportunity, Creativity,
Persistence, and Luck
by John A. Sbarbaro, MD, MPH, FCCP
Professor of Medicine and Preventive Medicine
University of Colorado Health Sciences Center
Four words — opportunity, creativity, persistence, and luck — summarize
the successes of Denver's TB program.
For decades, Colorado had been a mecca for the victims of TB. However,
along with the demise of the sanatorium era, Denver's TB control
program had progressively deteriorated. As in other large cities,
the insured disappeared into the private sector, while the poor
and those from the street continued to be housed for months upon
months on a forgotten floor of the public hospital.
In 1965, Denver was awarded a CDC TB Branch grant, which included
the assignment of one of the CDC's first six TB medical officers.
The project award was designed to enhance the city's decimated TB
clinic. However, the standard of treatment, 24 months of daily INH
and PAS, presented a daunting obstacle to the ambulatory treatment
of a large population of chronic alcoholics and disadvantaged, socially
isolated inpatients. How to treat effectively yet compassionately
was the question.
A little-noticed report in a foreign journal provided an answer.
In Madras, India, the British Medical Research Council (BMRC) appeared
to have successfully treated patients with high doses of INH and
streptomycin given intermittently over one year. The regimen made
sense scientifically and programmatically. If directly administered
throughout treatment, the opportunity for cure would be maximized
and a concerned public assured that these ambulatory patients did
not place the community at risk because they were receiving adequate
treatment ("chemical isolation"). Fortunately, at that
moment there was no local health department authority to say "no"
and the regimen was implemented, although modified to include a
three-drug intensive phase and an 18-month two-drug continuation
The uniqueness of this treatment approach spawned widespread changes
in Denver's ambulatory TB program. The resultant emergence of one-to-one
relationships between nurses and patients led to a major role expansion,
with nurses encouraged to function more independently, including
reading x-rays and determining which standing treatment orders to
implement. By early 1966, both DOT and the nurse-directed TB clinic
had indeed arrived in the US. And what nurses do, they document
— every action and every outcome — and with that documentation,
Denver's ongoing research program was established. Innovation, when
measured, becomes meaningful clinical research. A long list of skilled
TB nurse specialists such as B.J. Catlin, Jan Tapy, and Maribeth
O'Neill not only provided care to thousands of patients but served
as the cornerstone for Denver's contributions to the scientific
and social understanding of TB control.
However, organizations either continue to grow or they die, and
growth requires change. As new knowledge emerged and new drugs became
available, so did new opportunities. Fortunately, the arrival of
Mike Iseman early in the program and subsequently of Dave Cohn ensured
that no opportunity would pass unnoticed. Program components were
evaluated for cost-effectiveness and community impact. Denver was
amongst the first to eliminate the mobile chest x-ray in favor of
selected population skin testing; to focus on the effect of inducements
and enforcement on patient compliance; and to create a meaningful
role for community outreach workers. New short-course DOT regimens
were developed and tested; screening programs were evaluated; the
effect of TB drugs in infected human macrophages documented; and
"molecular epidemiology" was applied to a long-standing
database and a freezer stored with isolates of mycobacteria.
The emergence of HIV stimulated new questions, new initiatives,
and an opportunity to further build upon 30 years of close working
relationships with, and support from, the CDC. Denver's long history
of integrating federal, state, and private grants into a single
local program encouraged its early inclusion in multicenter national
studies sponsored by CDC and the National Institutes of Health (NIH).
Strong academic ties with the University of Colorado's Health Sciences
Center, collaborative teaching at the National Jewish Medical and
Research Center, consultation with the IUATLD and WHO, and membership
on ACET provided expanded opportunities to share the "Denver
experience" and to learn from colleagues throughout the world.
During these years, the recruitment of Denver's retired TB "greats"
such as Gen. Carl Temple and Drs. Roger Mitchell and Jack Durrance
to work regular hours each week in the clinic ensured that the knowledge
of the past would not be forgotten in the excitement of the future.
Unhappily, their days of contribution have passed, but the camaraderie
established between physicians, nurses, and clinic staff produced
an environment in which professional creativity continues to flourish.
Challenging existing beliefs and methods has become standard operating
behavior. The entrance of Randall Reeves and later of Bill Burman
ensures that it will continue, highlighted by their scientific leadership
in the TB Trials Consortium.
The underlying philosophy driving the Denver TB Clinic is perhaps
best summarized in two quotes from a 1970 publication, "The
Public Health Tuberculosis Clinic, Its Place in Comprehensive Health
Care" (Am Rev Respir Dis 1970;101:463-465):
In the private sector, "even with the best intentions of
the physicians and staff, the actual responsibility for care rests
with the patient. In TB control, the responsibility for care rests
with the clinic."
the clinic is the best way to husband the meager
resources of personnel and money and the only way to fix responsibility
on the providers of service rather than on the recipients
Denver's TB program was, and is, based upon the principle that
it is responsible for curing the patient. In the long run, the
persistence of that belief is the true foundation of Denver's