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TB Notes, 2000
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TB's Public Health Heroes
by Dan Ruggiero, Olga Joglar, and Rita Varga
Division of TB Elimination
Tuberculosis is frequently called a "social disease with medical
implications." The populations most affected by TB today are
urban and poor; they are the medically underserved low-income populations
such as high-risk minorities, foreign-born persons, alcoholics,
intravenous drug users, residents in long-term care facilities such
as correctional facilities, and the homeless. Active tuberculosis
with subsequent spread of infection to contacts poses a significant
threat to the community. Practicing physicians, for the most part,
focus on the individual patient, and to some extent on the family;
public health officials focus on patients as a group, on families,
and on the community. So, in controlling TB, who are the real heroes?
Who, on a daily basis, deals with the patients, their families,
and the health care providers? Who does the leg work required to
ensure patients are monitored through completion of treatment, and
that contacts are identified and evaluated? Public health field
workers are the real heroes in the fight against tuberculosis.
Image 1: Picture of a nurse crossing roofs to visit patients.
Historically, in the United States, community outreach workers
have played an important role in waging a successful battle in the
war against tuberculosis. Hermann Biggs, in 1896, called for health
inspectors to visit homes of TB patients and educate their families
on how to deal with those suffering with the disease and how to
prevent future cases. In the 1920s and 1930s visiting nurses were
climbing and jumping over New York City tenement roof tops to visit
TB patients who were being given the "fresh air treatment."
In the 1950s, federal public health advisors were assigned to local
health departments to provide technical assistance and treatment
guidelines and to assist local health departments with TB surveillance
and control activities. In the 1960s New York City hired "lay
tuberculosis investigators" to track down noncompliant patients.
The workers would visit patients' homes, and as needed, track them
to unsavory locations, such as local bars, clubs, and hangouts.
Since then, most state and local health departments have hired and
trained lay persons and nurses to carry out similar functions and
activities. Who are these people that have played an important role
in the fight against tuberculosis and why is it that we hear so
little about them? They are the backbone of the TB control program,
the foot soldiers who are willing to place their lives on the frontline
each day in order to do battle against the common enemy - tuberculosis.
TB control programs have used public health field workers with
different backgrounds and expertise to monitor patients and assist
them in adhering to and completing the recommended course of treatment.
Responsibilities assigned to these workers vary by area and degree
of complexity. Some workers conduct surveillance activities by visiting
hospitals, laboratories, and infection control officials; others
provide services out in the field such as conducting home visits
or providing DOT, which can put them in risky situations. And even
under difficult circumstances, field workers continue doing their
work. Field reports document clients and patients directing violent
threats and hostile incidents to public health workers. Field workers
survive by learning conflict resolution and field safety and by
using precautionary measures when conducting their activities. The
threat of violence that field public health workers experience while
in the line of duty cannot be controlled by detection devices used
in office facilities to provide protection to workers. Although
these workers know of the risks involved, they continue to carry
out their efforts to control TB in their areas.
Many names have been used to describe the job of these dedicated
individuals. Outreach workers, public health advisors, case managers,
DOT workers, and epidemiology technicians are some of the titles
given to the public health field workers. The heroes of TB come
from all backgrounds, education, and ethnic groups. Hiring requirements
vary from state to state, and while many have advanced college degrees,
others may be from the same population group as the patients they
serve and have little or no schooling.
Public health workers have the responsibility of establishing effective
communication with patients. The outreach workers are usually the
first contact the patients have with the health department and TB
programs. The ability of outreach workers to use their interpersonal
and communication skills in dealing with patients will set the stage
for a positive or negative attitude toward the healing process,
and consequently whether the patients will comply with the recommended
regimen. Field workers must be culturally sensitive and must understand
patients' beliefs, cultures, and environment; in many instances
they develop relationships with patients that extend beyond the
duration of treatment. Just like the TB heroes at the turn of the
century, they bring with them a spirit, zeal, vision, and determination
to assist those individuals afflicted with TB disease and infection
and to bring about an end to this disease.
The dramatic decrease in the number of TB cases in the US since
1993 could not have been accomplished without the persistent hard
work of theses individuals. The success we enjoy today came about,
and continues, through the efforts of thousands of outreach workers.
Whether it is a public health advisor purchasing pizza out of his
or her own pocket to ensure DOT compliance, or a nurse driving long
distances to make sure that patients living in rural areas receive
their medication or are transported to a clinic or hospital for
tests, public health field workers do whatever is necessary to achieve
their objective: tuberculosis control.
What do we call these individuals who have been central figures
in the tuberculosis control movement for the past 40 years? Public