Correspondence
The Law and Control of Tuberculosis
N Engl J Med 1993; 329:136-138July 8, 1993
- Article
To the Editor:
In his discussion of the law and tuberculosis control (Feb. 25 issue),1 Annas concludes that interventions short of confinement are preferred and that it is “appropriate to use monetary and other inducements to encourage compliance with outpatient therapy.” Although we agree that confinement should be a last resort, we recommend against direct payments to drug abusers (who are at high risk for drug-resistant tuberculosis) because there may be a substantial risk of relapse or overdose when cash is given directly to addicts. Physicians who treat substance abusers are familiar with the detrimental effects of cash on their patients' compliance with treatment.
We recommend that officials responsible for tuberculosis control review the definitions of disability prepared by the Social Security Administration to apply to drug abusers2. When a patient is addicted to alcohol or illicit drugs, current law requires that there be a third-party payee for social security disability payments, to disburse the funds for the benefit of the addict. We suggest that the local tuberculosis program seek to act as the payee for adults with tuberculosis. This would enable the program to provide housing, food, and other needed services, as well as tuberculosis treatment. In addition, a determination of disability by the Social Security Administration almost always ensures eligibility for Medicaid.
Social Security officials have stated that their goal is to “assure that every drug addict and alcoholic who needs treatment will be identified and encouraged to file for disability benefits”3. They stated further that “Currently, about 24,000 persons are receiving benefits because of a disability based on addiction. The number of people who should be receiving benefits is surely 10 times that many, possibly 20 times as many”3.
3 ReferencesAlan I. Trachtenberg, M.D., M.P.H.
Lura Oravec, M.S.
National Institute on Drug Abuse, Rockville, MD 208571
Annas GJ . Control of tuberculosis -- the law and the public's health. N Engl J Med 1993;328:585-588
Full Text | Web of Science | Medline2
Social Security Administration. Disability evaluation under Social Security. Washington, D.C.: Department of Health and Human Services, 1986.
3
Office for Treatment Improvement (OTI). Supplemental security income for individuals disabled by alcohol and other drug abuse: workshop report (ADM 270-90-001). Rockville, Md.: Alcohol, Drug Abuse and Mental Health Administration, 1990.
To the Editor:
Annas is appropriately concerned about the rights of the disempowered and homeless. It is this same group, however, that will be harmed by an inadequate tuberculosis policy. When a homeless patient with tuberculosis goes untreated, it is not the rich and privileged who suffer, but the other residents of the shelter. Striving to protect the rights of one innocent person with a communicable disease may rob many other innocent people of their health and safety.
I share in feeling outrage that society has chosen to ignore the health needs of the homeless, the addicted, and the HIV-infected. Unfortunately, there is currently neither public desire nor political will to address these needs meaningfully. Therefore, we must deal with the situation that exists.
By the time patients have demonstrated inability or unwillingness to comply with tuberculosis therapy, they have in all likelihood infected others. Requiring “clear and convincing” evidence of noncooperation before treatment is enforced is a prescription for exponential disaster. The fact that it is primarily the indigent and disempowered who would have their civil liberties curtailed should not obscure the fact that it is primarily the (as yet uninfected) indigent and disempowered whom mandatory treatment would protect.
It is not appropriate to compare patients with multidrug-resistant tuberculosis with psychotic patients who are of doubtful danger to society; instead, they should be compared with patients with smallpox. If we knew of patients with smallpox, would we accept their promise to stay at home as adequate protection for society? The risk of transmission of tuberculosis is proved, the consequences are often lethal,1,2 and the fact of infection should itself be considered clear and convincing evidence of risk to the public health. Every patient should receive mandatory treatment, whether it is provided under direct observation, in confinement, or in confinement alone for those who refuse treatment. Infected people should bear the burden of proof of compliance before they are switched to voluntary treatment.
2 ReferencesDavid W. Roberson, M.D.
University of Washington, Seattle, WA 981951
Frieden TR ,Sterling T ,Pablos-Mendez A ,Kilburn JO ,Cauthen GM ,Dooley SW . The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993;328:521-526
Full Text | Web of Science | Medline2
Goble M ,Iseman MD ,Madsen LA ,Waite D ,Ackerson L ,Horsburgh CR Jr . Treatment of 171 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. N Engl J Med 1993;328:527-532
Full Text | Web of Science | Medline
To the Editor:
Annas suggests that in tuberculosis control there is
an understandable egalitarian desire to try to treat everyone in the same way by subjecting everyone to directly observed therapy. There is, however, insufficient justification for requiring this annoying, inconvenient method of treatment for patients who are virtually certain to take their antituberculosis medications. . . .
How is Annas going to predict just who these patients might be? Perhaps he will exclude all African Americans, homeless people, injection-drug users, or the socially disaffiliated. Perhaps he will include all physicians, lawyers, and whites.
Medical science knows that 33 percent to 100 percent of people do not take their medication properly1,2. Unfortunately, medical science has no way to predict who these people are. There is no correlation of age, race, sex, or socioeconomic status with compliance with a medical regimen3,4. This problem has led to our disastrous tuberculosis epidemic.
Physicians who treat tuberculosis have patients who are lawyers and physicians who are terrible at compliance, just as we have injection-drug users and alcoholics who are excellent at compliance. That is why the statement on tuberculosis treatment by the Advisory Council for the Elimination of Tuberculosis and the joint statement by the American Thoracic Society and the Centers for Disease Control and Prevention emphasize “strong consideration” of directly observed therapy for everyone, until compliance with medication has been demonstrated.
4 ReferencesLee B. Reichman, M.D., M.P.H.
Bonita T. Mangura, M.D.
New Jersey Medical School, National Tuberculosis Center, Newark, NJ 071031
Brenner E, Poszik C. Case holding. In: Reichman LB, Hershfield E, eds. Tuberculosis: a comprehensive international approach. New York: Marcel Dekker, 1993:185-285.
2
Rudd P . In search of the gold standard for compliance measurement. Arch Intern Med 1979;139:627-628
CrossRef | Web of Science | Medline3
Roth HP ,Caron HS ,Hsi BP . Estimating a patient's cooperation with his regimen. Am J Med Sci 1971;262:269-273
CrossRef | Web of Science | Medline4
Mushlin AI ,Appel FA . Diagnosing potential noncompliance: physicians' ability in a behavioral dimension of medical care. Arch Intern Med 1977;137:318-321
CrossRef | Web of Science | Medline
Author/Editor Response
Professor Annas replies:
To the Editor: All the writers and I share the goal of reducing the incidence of tuberculosis and preventing the spread of multidrug-resistant tuberculosis. How can this goal be most efficiently and fairly accomplished? I disagree with the statement of Trachtenberg and Oravec that addicts should never be paid for adhering to tuberculosis-treatment regimens. If this argument is correct, it would also seem that addicts should never be employed because we are concerned about how they will spend their salaries.
Contrary to Roberson's statements, the standard of clear and convincing evidence is required only for involuntary confinement, not for mandatory directly observed therapy. Second, it should be possible to discern noncooperation well before multidrug-resistant tuberculosis develops and certainly before it is spread. “The fact of infection itself” is no more a sufficient reason to confine patients with tuberculosis than it is to confine people with HIV infection. Likewise, whether we accept “voluntary” quarantine at home of a hypothetical patient with smallpox should depend on an individualized assessment of the patient.
Reichman and Mangura join Roberson in support of universal directly observed therapy. I support voluntary directly observed therapy. The statistics I cited suggest that over the past 15 years more than 80 percent of Americans with tuberculosis successfully completed 6 to 12 months of continuous chemotherapy1. Therefore, making directly observed therapy mandatory for everyone is a “wasteful, inefficient, and gratuitously annoying” overreaction2. Moreover, this strategy improperly assumes that no patient can be trusted and simultaneously redefines the tuberculosis problem in the United States as one of noncompliant patients, rather than as the complex multifactorial social problem that it is. We should try to make compliance with treatment easier, not harder.
Reichman and Mangura ask how I am “going to predict just who [the compliant] patients might be?” The short answer is that I am not; the treating physicians must make this assessment. This assessment will be more accurate if the focus is on “individualized case-management strategies and monitoring” rather than disease-based stereotyping2. For any outpatient treatment to be successful, the patients must be actively involved and the meaning of disease understood from their perspective3. Since “much patient nonadherence can be traced to difficulties of understanding and communication in the doctor-patient interaction,”3 it seems reasonable to focus attention on this interaction. This is preferable to abandoning the individualized doctor-patient treatment model in favor of a standardized and mandatory model of public health prevention that assumes all patients with tuberculosis are untrustworthy.
3 ReferencesGeorge J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 021181
Bloom BR ,Murray CJL . Tuberculosis: commentary on a reemergent killer. Science 1992;257:1055-1064
CrossRef | Web of Science | Medline2
Annas GJ . Control of tuberculosis -- the law and the public's health. N Engl J Med 1993;328:585-588
Full Text | Web of Science | Medline3
Freund PES, McGuire MB. Health, illness, and the social body: a critical sociology. Englewood Cliffs, N.J.: Prentice-Hall, 1991:200.
