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CRITICAL CONDITION: U.S Health Care in Crisis Tuberculosis Therapy: Watch and Wait

September 20, 1993

NEW YORK (AP) _ Charles Rhames is getting a dose of his own medicine at last.

Five times a week, a nurse at a Bellevue Hospital clinic scrutinizes Rhames’ wobbling Adam’s apple and keeps count as he chokes down nine sizable pills.

Rhames is among 1,200 New York City patients who are monitored because, without help, they can’t or won’t take the medicine that can cure their tuberculosis and keep others from catching it.

As national health care reform takes center stage, medical providers - especially in urban areas - are struggling to keep tuberculosis in check.

For 30 years, TB declined in the United States. In 1985, rates began to soar, mostly because of AIDS patients’ susceptibility to the disease and an increase in immigrants carrying the infection, according to the U.S. Centers for Disease Control and Prevention.

At least 10 million Americans are infected with TB, though only about 10 percent will develop an active form of the disease.

Last year marked the fourth in a row that TB cases rose nationally, by 1.5 percent. New York City recorded 3,811 newly diagnosed tuberculosis patients, mostly adults, up from 3,673 cases the year before.

Rhames, 39, is part of a program called ″directly observed therapy,″ which means he gets ″help″ taking his medicine. These patients report to clinics, or are visited at home or at work by government health workers.

Complicated payment structures make it difficult to pinpoint the average cost of directly observed therapy. But ″it’s obviously more cost-effective than keeping them locked up in a hospital,″ said Frances Tarleton, a spokeswoman for the state Department of Health.

A hospital bed at Bellevue costs more than $900 a day.

By contrast, Medicaid pays $95 a week for a nurse to watch one patient swallow pills. Rhames sees a doctor once a month; that costs $185. The cost of social services fluctuates greatly.

Tuberculosis strikes the poor, homeless, malnourished, the elderly, substance abusers, those who live or work in cramped quarters, and those already weakened by other diseases, like AIDS.

It particularly affects the frail and destitute - like Rhames.

A cure takes six months to two years. Patients remain contagious for several weeks or months after they begin taking medicine. But some stop taking the medicine because of unpleasant side effects. Others are fooled into thinking they’re cured when their symptoms diminish.

Tuberculosis sufferers who don’t finish their medicine can develop particularly vicious, drug-resistant strains of the disease. If that happens, doctors must experiment until they find the right drug combination.

That’s what happened to Rhames, who contracted tuberculosis in 1989.

He was living in a homeless shelter when the fever and chills, the weakness, the vomiting and the coughing began. Soon, he dropped 40 pounds.

He was hospitalized for 21 days, then returned to a shelter, where, he said, someone kept stealing his medicine. When he went to the pharmacy for more, he was accused of selling it.

Frustrated, he stopped taking the pills. And a few months later, the symptoms returned. ″It got worse and worse and worse,″ he recalls.

Rhames had developed multiple drug resistant tuberculosis. While doctors struggled for a cure, one of his lungs collapsed and had to be removed; he was hospitalized more than a year. He endured side effects from the drugs: vomiting, tremors of the limbs and eyelids. Finally, a successful combination was found.

Rhames entered directly observed therapy when Bellevue began its program last November. A social worker helped him find housing; he gets counseling and attends a support group.

It’s too early to analyze the program’s success, said Dr. Neil Schluger, director of the Bellevue Chest Clinic.

Theoretically, the city can force patients to enroll if they put others at risk of catching TB. But Bellevue stresses a friendlier approach.

In addition to offering medicine, patients receive snacks, carfare and incentives, like subway tokens or fast-food coupons. By finding housing or a drug-treatment program, social workers help solve the problems that can keep TB patients from taking their medicine.

For a long time, Rhames’ life was seemingly one unsurmountable obstacle after another. Now, he allows himself hope.

″I don’t mind,″ he says with a shrug after swallowing more pills. ″Look, this is my life.″