COVER STORY : A Killer Returns : Tuberculosis, Once Considered Nearly Eradicated, Is Back at Epidemic Levels. The High-Risk Groups Include the Poor, Those Infected With the AIDS Virus and Recent Immigrants.

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Cruz Castillo can smile now as he recalls when doctors told him he had tuberculosis. Today, the 38-year-old ex-truck driver is nearly cured of the scourge that slowly eats away at the lungs. Nearly a year ago, he could barely breathe and was starting a 4 1/2-month stay in the hospital to fight his TB.

“At first when they told me what it was, I thought I was gonna die,” said Castillo, whose 10-month treatment for TB will conclude this week.

Two decades ago, TB was thought to have been nearly eradicated. The number of cases in Los Angeles, as well as the state and the nation, were dropping, as was federal funding for TB-related programs. People put the disease out of their minds and looked to more gripping health issues.


But tuberculosis has made a swift comeback in the last five years, rekindled by the AIDS virus and fueled heavily in urban areas by overcrowding, new immigrants, homelessness, substance abuse and poverty.

“We really thought (tuberculosis) was going to the way of polio,” said Marjorie Sa’adah of Homeless Health Care L.A. “Up until 1988, the TB rate was going down every year. And then all of a sudden the rate started increasing and everyone was caught off guard.”

From 1970 to 1988, the number of TB cases reported in Los Angeles County averaged 1,439 each year. But from 1988 to 1991, with the increasing number of AIDS cases and immigrants carrying the TB bacteria, cases rose more than 75%.

There were 2,121 TB cases countywide in 1991, and the disease claimed 75 lives. Officials estimate their caseload was 2,206 in 1992, and believe half the county’s homeless population is infected with the TB germ, although not all of those cases are contagious.

Data from the county Department of Health Services shows that most TB cases occur in people who dominate high-risk groups--men who are 19 and older, people with HIV, the homeless and recent immigrants infected in their native countries.

In Los Angeles, two of the areas hit hardest by TB are Downtown, with its estimated 15,000 homeless, and South Los Angeles, which has seen an influx of immigrants as well as an increase in substance abusers and people with HIV.


The homeless and those with HIV are the most vulnerable to TB because of their weakened immune systems. Of those who had the TB bacteria in 1992, 14% also had HIV.

People who are HIV-positive and have the TB germ stand a 1-in-10 chance of coming down with contagious tuberculosis, said Dr. Paul Davidson, of the county TB control unit. People with a healthy immune system who have the TB germ stand a 1-in-100 chance of contracting the disease, he said.

The number of pediatric TB cases best reflects the epidemic’s dramatic reach, experts say, because each reported case is a new infection rather than one that has recurred. Most children with the disease, especially those younger than 5, contract TB from an adult, said Dr. Emily Kahlstrom, head of pediatric pulmonary care at L.A. County-USC Medical Center.

Pediatric TB cases in Central Los Angeles have risen about 20% between 1990 and 1991. Symptoms can be so subtle--such as a cold or bad cough--that by the time the children are brought to the doctor the TB has become so severe that it has begun attacking other parts of the body, Kahlstrom said.

In children, TB affects not only the lungs, but also causes swelling of the lymph nodes, skin lesions or TB meningitis, a serious form of the disease that irritates the spinal cord and brain and can cause blindness, brain damage or coma.

Tuberculosis is spread in tiny droplets through the air when someone with the contagious TB disease coughs, sneezes or even sings. It moves with grim efficiency in poorly ventilated places such as prisons, homeless shelters, overcrowded homes or waiting rooms--and in some cases hospitals.


But one exposure to the TB germ does not mean you can contract it, most health experts say. The germ must be breathed in over a prolonged period before it settles at the base of the lungs. If a person has a healthy immune system, it kills off the germs in most cases.

Many people contract a TB infection; the bacteria can lie dormant for years and the person is not contagious. However, the TB germ can later turn into a contagious disease and the carrier can pass the germ on to others.

“Most people think they can get TB from touching food or being in an elevator with someone that has it. That’s not how the germ is transmitted,” said Debbie Davenport, nursing director for the county health department’s health district that covers Downtown. “It’s important to keep educating people on how they can get it and who’s at risk.”

TB is commonly detected through a skin test, called a tuberculin test, or X-rays. If the skin test is positive--or if it is negative and the patient is experiencing TB symptoms--X-rays and sputum smears also are performed.

The disease is usually treated with the drug isoniazid in combination with other medications. In some cases, people with active TB who are contagious take as many as 13 pills a day for six to nine months. Those who are not contagious take smaller dosages.

But the treatment has not eased the panic that the surge of tuberculosis has caused.

“In the early days of AIDS we categorized people as belonging to risk groups and that bolstered the stigma against people with AIDS,” said Mark Senak, deputy director at AIDS Project Los Angeles. “TB has stigmatized groups all over again and now people are afraid of the homeless.”


Dr. Wilbert Jordan, head of the Oasis AIDS Clinic at Martin Luther King Jr. Hospital/Drew Medical Center in Watts, said people fear TB because it is relatively easy to contract and because of a new, more severe form of the disease called drug-resistant tuberculosis, which affects about 10% of those with TB in the county.

The chronic symptoms of TB are coughing, weight loss, nausea, night sweats, fever and fatigue.

Most people, including Castillo, are not sure how they became infected. He believes he may have been infected while growing up in Blythe, in the Imperial Valley.

Castillo said he did not know what tuberculosis was when doctors told him last March that he had the disease. At first he thought it was similar to a bad cold and then said he remembered hearing about it when he was young. But, Castillo said, he thought it went away--like typhoid and cholera.

Castillo had trouble breathing for three months before seeing a doctor last March. He initially thought it had something to do with his drinking and lack of eating. He was first treated for pneumonia and doctors later detected that he had TB. Today, Castillo gets his medicine--and food and housing voucher forms--from the county’s Skid Row clinic.

Tuberculosis is primarily a disease of the poor and is prevalent in the nation’s larger cities. In Los Angeles County, TB has occurred in minorities nearly seven times more often than in whites. Of the county’s TB cases reported in January through November of 1992, 782 were Latino, 404 were Asian and 311 were African-American.


In 1991, 63% of the county’s TB cases were immigrants, most of whom come from Latin America or Asia.

While new immigrants make up many of the TB cases among Asians and Latinos, health care experts attribute TB cases in the African-American community to homelessness, substance abuse or HIV.

“This is something that tears away at your lungs and if someone’s immune system is already low, it’s that much harder to stop it,” said Sa’adah of Homeless Health Care L.A.

Graydon Shepard, of the health department’s TB control unit, said the disease has spread to middle-class communities. In Glendale, San Fernando and Canoga Park, the number of reported cases were 67, 41 and 36, respectively, in 1992.

As the number of TB cases escalates in all communities, health-care workers continue to stress that this is a preventable epidemic; it can be treated and cured. But fighting TB is not that easy.

The county’s public health workers battle the disease with limited resources and funding. They struggle with patients who refuse to take medication and face a new enemy in drug-resistant tuberculosis.


During the 1970s and ‘80s, with the numbers of TB cases stabilizing, the county health department cut back on its TB control program. Now, some of the county’s 33 health clinics have up to three times more TB patients than in past years, lack X-ray and sputum diagnosis machines, and need more community health workers to do outreach work.

In 1991, the county spent about $20 million to treat TB cases--a 25% increase from the 1988-89 fiscal year. Less than 6% of funding for the county health department’s TB programs comes from the state and federal governments.

In contrast, the county spent $74 million in fiscal 1992 on AIDS prevention and treatment.

Years ago, although the county still provided some funding to treat TB, federal money was not issued for TB programs. Each budget year from 1981 to ’87 during the Reagan Administration, a proposal for a federal TB program was repealed. In 1988, when federal funds for public health programs increased, they were diverted to AIDS programs. Now, more federal funding is being funneled to tackle tuberculosis.

The county Board of Supervisors voted in December to allocate $600,000 in federal funds for TB prevention and treatment to the county health department and some private health agencies to conduct skin tests for tuberculosis.

Some of the funding will be used to hire more health-care workers to directly observe patients taking their medication.

Yolanda Moreno, who has worked in the county’s TB control program for four years, has struggled to get patients to take their medicine so they avoid developing multi-drug resistant TB or a recurrence of the infection.


Moreno recalled the 23-year-old Mexican woman in Pico-Union who infected three of her relatives before realizing she had TB. In 1991, she began receiving injections and 12 pills daily to fight the disease. She felt better after two months and stopped going for medication. Three weeks later the disease resurfaced. Now she is back to the original daily dosage of injections and pills until November. She hates the pills, Moreno said.

“They essentially feel they’re slaves to the disease because they can’t go very far, especially with the injections,” Moreno said. “Some days she says she wants to throw the medicine back up because she’s tired of taking it.”

Many of the people Moreno sees in Pico-Union afflicted with TB are on drugs or are homeless. The disease destroyed nearly an entire lung of a 27-year-old woman who has lived on the streets and used drugs for five years and has taken medicine sporadically to fight the tuberculosis.

“Health is not the main concern on the streets,” said Luther Terrell, a community worker who visits homeless shelters and hotels along Skid Row. “Where can I get my next meal, my next high? Their feeling is ‘What can you do for me?’ ”

The county has been using a voucher program that provides food and housing to the homeless if they take their medication.

But as important as getting patients into clinics for care is getting community health workers into the neighborhoods to do outreach work.


“A big problem of TB in South-Central is with men between 18 to 35. We don’t get to this population by sitting behind a desk,” Shepard said. “You have to go out into the community. But we don’t have the funding to do this.”

On Skid Row, workers go out every day, scouring under bridges, in warehouses and abandoned buildings to bring medication to homeless people. In East L.A., Koreatown, Pico-Union, South-Central and Watts, community workers visit people in their homes to make sure people are taking their medication.

“Tuberculosis is a problem that we have to get rid of any way we can,” Davenport said. “We want to be proactive in how we approach the disease. That means screening the high-risk groups, tracking down the people who aren’t compliant, making sure we cover all the bases any way we can.

“What is unsettling,” she said, “is that this time the tuberculosis is not going away without giving us a hard fight.”

Tuberculosis Makes a Comeback

Tuberculosis was thought to have been wiped out 20 years ago, but TB cases in Los Angeles County have jumped 75% since 1988. The comeback of the disease has been kindled by the AIDS virus and fueled by overcrowding, new immigrants, homelessness, substance abuse and poverty. The figures for each of these health districts--the most recent available--were provided by the Los Angeles County Department of Health.

1989 1990 1991 Central 310 286 327 East 51 42 60 Southwest 72 102 129 South-Southeast 103 76 165 San Antonio 54 82 81


Tuberculosis Testing Sites

Tuberculosis information and testing are available through: * Los Angeles County Department of Health Services: Any of the county’s health centers can give a skin test for tuberculosis. Many of the health centers also have chest X-ray machines. County-USC Medical Center, 1200 N. State St., also has a TB control unit that handles pediatric cases. To find the nearest clinic, call (213) 744-6160. * Altamed: La Clinica Sunol, 133 N. Sunol Drive, Los Angeles 90063. (213) 266-1122. * American Lung Assn. of Los Angeles County: 5858 Wilshire Blvd., No. 300, Los Angeles 90036. (213) 935-5864 * Community Health Foundation of East L.A.: 3945 E. Whittier Blvd., Los Angeles 90023. (213) 266-4690 * Family Health Clinic, Chinatown Service Center: 600 N. Broadway, Suite A, Los Angeles 90012. (213) 680-9955 * King/Drew Medical Center: Pulmonary Unit, 12021 S. Wilmington Ave., Los Angeles 90059. (310) 603-4595 * Korean Health Education Information & Referral Center: 981 S. Western Ave., Los Angeles 90006. (213) 732-5648 * Koryo Health Foundation: 1058 S. Vermont Ave., Los Angeles 90006. (213) 368-6040 * Watts Health Center: 10300 Compton Ave., Los Angeles 90002. (213) 564-4331