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TB Notes 1, 2000
Introduction
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
 
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

Seize the Moment - Personal Reflections

by Carl Schieffelbein
Deputy Director for Special Projects, DTBE

We all have opportunities during our careers to stand at critical decision points. Sometimes it is clear that these are major events; at other times they appear routine, but subsequently it is seen that they had (or could have had) major impact. During the past 33 years I've had the opportunity to stand at many decision points and now can look back to see where more could have been done, if the opportunities had really been fully utilized. I will outline a few decision points in which I participated and try to share what went well and what I believe could have been done better. I will also outline some of the decisions we will all face in 2000.

Decision point: late 1960s

Closing of the TB sanatoria. Due to advances in treatment, long-term sanatorium care was no longer needed. CDC supported efforts to close TB sanatoriums and move toward an outpatient system. We succeeded in reducing the need for long-term sanatorium care and more rapidly got patients back to their families and communities. The costs of maintaining sanatoria were reduced. However, we did not do well in diverting the funds available as a result of the closings to the support of strong TB outpatient care systems. As cases went down, political will to support TB programs also diminished in the early 1970s. We found that many existing TB control systems were unable to effectively survive when federal categorical appropriations for TB were eliminated in 1972.

Decision point: 1989

The Strategic Plan for the Elimination of Tuberculosis in the United States. The plan articulated the goal of defined elimination of TB by 2010. It caught the attention of some advocates and spelled out in broad strokes (still relevant today) the three critical steps needed. However, we later realized that we talked about the plan only within the "TB family" and with our peers. We were not successful enough in getting influential leaders and policy and opinion makers to commit their organizations to full shared ownership and thus, the necessary advocacy to fully implement the Strategic Plan at federal, state, and local levels.

Decision point: November 1991

The rise in TB cases, and the emergence of multidrug-resistant TB (MDR TB). A small group of us met with Dr. Roper (then CDC Director) to discuss a plan of action. It was decided a federal TB Task Force would be created to bring together all HHS/PHS agencies (and a few others) to develop a coordinated response to the MDR TB outbreaks. The Task Force was created and moved quickly, and in January 1992 brought together more than 400 experts to develop the National Action Plan to Combat Multidrug-Resistant Tuberculosis (published in April 1992). The Action Plan called for a total federal TB budget of $610,280,000, of which CDC's need was $484,000,000. Along with many of our partners, we were successful in getting federal appropriations increased. We were successful in getting enough resources to meet our immediate needs, but not enough to allow the success of our 1989-stated mission of elimination. We had reached out to some new partners in the Task Force and through the National Coalition to Eliminate TB, but again, after the crisis was over, we had not built enough effective community partnerships or new and long-lasting coalitions to help achieve the level of resources needed. Also, while we were in the process of obtaining increased federal funding, we saw many state or local areas reduce the amount of local resources going into TB control efforts. In 1990 the Public Health Foundation reported that 13% of TB funds at the state and local levels were federal dollars. In 1998, however, the National TB Controllers Association reported that 42% of budgets were now composed of federal dollars. We succeeded in making state and local programs too dependent upon federal dollars; this is a concern known all too well by those of us who remember the overnight elimination of categorical federal TB funds in 1972.

Decision point: March 1998

I had the opportunity to participate in an ad hoc committee of the Global Tuberculosis Programme of WHO, convened in London, to evaluate TB control in the 22 countries that represent 80% of the global TB burden. The committee concurred that most of these 22 countries would not meet their Year 2000 goals. The committee also outlined what was believed to be shared constraints to progress. These included
  1. weak political will and commitment towards TB control efforts;
  2. lack of adequate funding;
  3. inability to hire and keep trained staff;
  4. organizational and management issues, such as health sector reform, public and private sector interactions (or lack thereof), and integration and decentralization issues;
  5. an inadequate supply of quality TB drugs; and
  6. lack of adequate understanding of the magnitude of the problem and of the possibility of successful interventions.
I believe all but item number 5 are also continuing threats to our national, state, and local TB programs.

You and I stand at some unique moments of decision in 2000. If each of us does not act effectively, we will have missed some opportunities to move the fight against TB into the final rounds. Some of the decision moments at hand:

  • The National Academy of Science's Institute of Medicine (IOM) will issue a report on TB control in the United States. How will you and I use the results to evaluate and strengthen our programs? How will you use the IOM report and local data to secure adequate political will at your state or local level to secure necessary resources?
  • The HIV/AIDS and TB epidemics continue to work together to create unnecessary devastation, both domestically and especially in some international communities. Yet we tend to still work mainly within our "TB family." How will we work better with our colleagues in HIV to develop effective collaborations to help those at risk of TB and HIV/AIDS?
  • There is growing interest and concern about TB both at the federal level and in many state and local areas. How will you and I create new partnerships and opportunities to build on the existing interest to ensure a firm base for operations and programs?
  • The Surgeon General has appointed a Blue Ribbon Committee to look into the development of a TB vaccine. How will you and your TB advisory committees work to support such an effort?
  • There are areas of social mobilization and community empowerment that have not been adequately addressed by the TB community. How will we work with not only lung associations, but other partners as well, to mobilize against TB?
  • WHO is hosting a "STOP TB" partnership to create a new global campaign against TB. How will you and I support these critically needed global activities and still ensure strong domestic programs?

I am aware there are many, many other decision points that we all will face. Many of these opportunities last for very brief moments of time. I urge each of us to seize those moments, and if necessary move outside our areas of comfort, in order to be able to truly eliminate TB in the United States and see TB control in the world early in this century.

Image 1: Picture of Carl Schieffelbein, in his first TB control assignment (1967) adjusting x-ray equipment.

 


Released October 2008
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