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This is an archived document. The links are no longer being updated.

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 health heroes!


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

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