CDC Logo Tuberculosis Information CD-ROM   Image of people
jump over main navigation bar to content area
TB Guidelines
Surveillance Reports
Slide Sets
TB-Related MMWRs and Reports
Education/Training Materials
Ordering Information


U.S. Department of Health and Human Services

jump over right navigation bar
TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
Return to Table of Contents

This is an archived document. The links are no longer being updated.

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 phase.

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 success.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

Please send comments/suggestions/requests to:, or to
CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333