‘Tough Love’ Lessons From a Deadly Epidemic
Barron H. Lerner, M.D.
New York Times June 27, 2006
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This article focuses on directly observed therapy (DOT), in which healthcare workers monitor the administration of medications, its role in quelling the increase in tuberculosis cases in New York in the 1990s, and its proposed use in the treatment of HIV. It also deals with the conundrum of determining the proper course of action when the rights of the individual clash with the public good, all in all an appropriate topic as we approach this country’s Independence Day.
Public Health & The Treatment Of Tuberculosis in the 1990s
While there were other causative factors, noncompliance was a significant problem in the rise in tuberculosis in the 1990s, especially among patients who used injection drugs or had psychiatric problems. The author notes, “In one often-cited study, 89 percent of tuberculosis patients at Harlem Hospital were lost before completing treatment.”
Not only did those patients fare poorly and possibly infect others, but their incomplete compliance led to the drug-resistant forms of tuberculosis.
With federal financing, New York aggressively expanded the use of DOT, with outreach workers administering anti-tuberculosis medications special clinics, the patients’ homes, or wherever patients could be found.
Further, those who didn’t fare well on DOT were placed under forcible detention, either at Bellevue Hospital or at Goldwater Hospital. According to Dr. Lerner, “More than 250 patients were detained between 1993 and 1998, some for as long as two years.”
From 1992 to 2001, new cases of tuberculosis dropped from 3,811 to 1,261.
HIV Treatment Monitoring
The New York health department has now proposed a similarly aggressive program for treating HIV. Specifically, these regulatory changes would include
- Simplifying consent for H.I.V. testing to encourage clinicians to screen more patients
- Tracking H.I.V. in a manner similar to tuberculosis
- Monitoring patients to ensure that they take their medications properly
Commentary
Dr. Lerner has done a laudable job of illustrating and summarizing the strengths of DOT and its effectiveness in managing tuberculosis within the confines of newspaper column. And, he points out the clinical issue that differentiates tuberculosis from HIV as a public health issue – the tuberculosis, unlike HIV, can be spread through casual contact.
Dr. Lerner’s primary argument is, indeed, primarily clinical in scope: Given that DOT is effective in reducing morbidity and mortality caused by noncompliance, thereby saving lives and decreasing the risk of epidemics to the public, public health officials should be legislatively allowed to use this tool.
If this perspective becomes the exclusive approach, of course, it begs the ethical question of how one determines at what point the danger to the public at large outweighs the rights of the individual to the extent that treatment can be legitimately coerced to the point of imprisonment, whatever nomenclature is used to designate forced detention and however humane the conditions.
It seems intuitively clear to me that at some point, public safety demands, even in a democracy, the restriction of the rights of those who endanger it – even if the individual is innocent of wrong doing and the danger is unintentional. It seems equally clear, however, that government cannot rationalize draconian measures simply because they work.