New York panel offers broad anti-TB proposal

November 30, 1992|By New York Times News Service

NEW YORK -- Wading into one of the most contentious issue in modern medicine, a panel of 34 scientists, ethicists and public health leaders released a report yesterday calling for broad new measures to stem the rampant spread of tuberculosis around the nation.

Two of the panel's recommendations are likely to fuel angry policy debates: that all tuberculosis patients allow someone to watch them take their medication once they leave the hospital and that all patients receive treatment until they are cured rather than just no longer contagious. The recommendations would apply to all patients no matter what their economic background or the cause of their illness.

In its report to the United Hospital Fund, a New York philanthropy that focuses on health-care issues, the panel also rejected controversial and growing demands for mandatory AIDS testing, saying it is not necessary for effective TB screening.

People with the virus that causes AIDS are 40 times more likely to develop active cases of tuberculosis once they are infected with TB than those without HIV, and health officials say if the TB epidemic is not quickly contained by curing those who are sick, it could spread far more rapidly in the coming years. New York City reported nearly 4,000 new cases of tuberculosis last year, and many of the patients had strains resistant to drug treatment.

"This is an extremely cogent analysis of many of the issues raised by the resurgence of tuberculosis," New York City's health commissioner, Dr. Margaret A. Hamburg, said of the report.

The central recommendations and others by the panel, which include extensive workplace education and measures to protect those infected with HIV from discrimination, would have enormous impact if they are adopted by local health officials. And they would add millions of dollars to deeply strained state and municipal budgets.

Requiring patients to have people watch them take their medicine each day -- called directly observed therapy -- would force health officials to spend millions of dollars on supervising many who may be willing to take medicine without any such supervision or incentives. And the possibility of new laws that could strengthen public health officials' ability to detain patients has fueled intense debates about the murky line between civil liberties and the right of healthy people to stay that way.

"We absolutely agree that completing therapy has to be our No. 1 priority," Dr. Hamburg said. "But the reality is that it simply makes no sense in terms of our limited resources to force everyone to have directly observed therapy. I understand the problems of civil liberties and I understand who is most likely to get sick in New York. But we cannot afford to hold off on TB control efforts and wait until a damaged society is repaired. And we won't."

Many of the report's recommendations have been strongly endorsed by the New York City Health Department. Others, like the far-reaching recommendation on directly observed therapy, would require legislative approval. Dr. Hamburg said that because there was no precedent for such laws, it was unclear who would have to approve them.

The group that wrote the report, titled "Individual Rights and Societal Obligations in a Time of AIDS," included representatives from the city, the state, leading medical schools, law firms, New York's largest labor unions and such organizations as the Gay Men's Health Crisis. Because it is perhaps the broadest such study released since deadly new strains of TB have proliferated in many U.S. cities, and because it coincides with some plans already approved by the Department of Health in New York City, where the epidemic is by far the worst, the findings are expected to wield influence far beyond the city.

The panel, led by New York physicians and ethicists, worked for more than six months on the document, which it envisioned as a way to look beyond the medical facts of the TB epidemic to the more difficult social issues of poverty and class.

Curing new strains can require patients to swallow a dozen pills a day for up to two years, and the difficulties of treatment have made the resurgence of TB particularly hazardous in poor communities.

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