Taking It to the Streets : A Small Cadre of Community Workers and Nurses Struggles to contain an outbreak of TB--At a Time When Clinics Are in Danger of Closing.

Travon Williams is in a hurry. Tuberculosis is outpacing him.

He scurries about Skid Row in a gray minivan, peering down Crack Alley, trudging up five flights of stairs in a roach-infested hotel. In these dark and neglected corners of the city, the disease lurks silently. It is more communicable than AIDS and as ancient as the Egyptian mummies. In 20th-Century Los Angeles, as during the time of the Pharaohs, tuberculosis is spreading fast. Williams is trying to stop it.

He is a foot soldier of sorts, dressed for combat, with steel-toed boots the color of onyx, a diamond stud in his left ear, a cellular phone jammed into his jeans pocket. He’s young, hip and he’s streetwise. In his hand he carries his ammunition: a brown paper sack filled with pill bottles, prescription tuberculosis medicine.

As a community outreach worker for the Los Angeles County Department of Health Services, Williams gets paid to look for people with tuberculosis. His job is to hand out medicine that will not only make them well, but also keep them from infecting others. It can be depressing, and the money--about $22,000 a year--isn’t going to make him rich. But it beats the job he used to have, working the graveyard shift as a security guard. And Williams likes the work. “Everybody has to do his good deed,” he says.

Most of the people on Williams’ patient roster are homeless. Some are mentally ill. They often cannot, or will not, show up at a county clinic for a doctor’s appointment. Many prefer other drugs--crack, most notably--to medicine that will cure TB. Few want to be troubled by an in-your-face health-care worker who insists on watching as they stuff pills down their throats, pills that sometimes make them nauseous. But it is essential that Williams trouble them.

The county van careens to a halt in front of a dumpster near Boyd and Wall streets. Williams jumps out. He is searching for a man who calls himself Magic Johnson, and this patch of sidewalk, he knows, is where Magic sleeps.

He does not find Magic. Instead, he discovers Magic’s girlfriend. She is stretched out on a dirty mattress under a brown blanket too thick for the hot weather. Only her face is visible. Williams shakes the woman, and her eyelids flutter. She lets out a soft moan and mumbles something unintelligible, something to the effect that Magic is not here. Williams tells her he will be back. But for now, he does not stick around. “There’s certain places where you don’t stay too long,” he explains. “You just go and do your business and move on.”

This is a dance, of sorts, one that Williams performs dozens of times each week as part of a frantic effort by county officials to keep tuberculosis from breaking out of places like Skid Row, where TB has hit the hardest. Treatment often requires taking multiple medications over an extended period of time, and patients sometimes abandon the regimen. When they do, they risk developing incurable strains that resist treatment. Already, deadly forms of drug-resistant TB have emerged in New York.

It is up to Williams and 29 other community workers--along with a corps of 332 public-health nurses whose jobs are threatened by the budget ax--to keep that from happening here. They form the fragile barrier that keeps everybody who lives in the county from being put at risk by TB. But the barrier is cracking.

At a time when disease-control budgets are being pared to the bone, when clinics and major health centers are in danger of closing, tuberculosis is on the verge of reaching epidemic proportions in California--particularly Los Angeles County, where the rate is up 85% since 1988. With the exception of New York, L.A. reported more new tuberculosis cases last year than any other municipality. And the trend shows no sign of reversing.

County health officials warn that if millions of dollars more are not devoted to controlling the spread of TB, this public-health menace may quickly escape their grasp. More nurses are urgently needed to evaluate sick people and get them into treatment. More community workers like Travon Williams are needed to make sure these people take their medication until they are cured. Yet there is no money to hire them, let alone establish other preventive programs that authorities say are necessary.

As Graydon Sheperd, a senior public-health adviser for the Centers for Disease Control, who works in Los Angeles, says: “Right now, under the current circumstances, it looks pretty bleak.”

And so TB roams the county. It is spread through the air, through tiny droplets of bacteria coughed up by people who have the disease. Although TB can kill if left untreated or is combined with another disease, it is not highly fatal. The immune-suppressed--particularly those infected with HIV--are especially at risk.

Downtown, Hollywood and Southeast health districts report the most cases, but all areas of the county are now affected. Three Glendale infants are infected by a baby-sitter working at a church in La Crescenta. A 13-year-old boy who is bussed to a magnet school in the San Fernando Valley comes down with tuberculosis, and the school nurse tells him that all his classmates--180 children--must now be tested. A housekeeper from Silver Lake unwittingly infects the Thousand Oaks family she works for. A secretary who works in a hospital comes down with TB; she has no contact with patients and has no idea how she got sick.

Meanwhile, as the budget crunch tightens, Gov. Pete Wilson, who declared last July Tuberculosis Awareness Month, is calling for laws to strip illegal immigrants of access to health care. Some angry doctors and nurses say the ban would trigger a communicable disease disaster in this region, where the majority of tuberculosis cases--66% last year--occur in immigrants, who bring the germs with them from their native lands.

“This is not an issue of whether we are treating immigrants, whether we are treating aliens, whether people should have the right to free health care,” says Dr. Joel Ward, an infectious-disease specialist at Harbor/UCLA Medical Center in Torrance. “Treating tuberculosis is important for everybody in our society. These are people that society neglects and doesn’t want to consider. Yet these are people who share the streets with us, share the buses, share the airports.”

The federal government is beginning to pour money into the control of TB in L.A. County, but many doctors and nurses here believe the effort is too little, too late. They look to the East, where tuberculosis cases in New York have nearly tripled in the past 15 years. And they wonder: Will Los Angeles be next?

THE STATISTICS ARE NOT ENCOURAGING. AFTER THREE DECADES OF steady decline--a virtual nose dive from 84,304 cases in 1953 to 22,255 in 1984--tuberculosis in America is now traveling an upward spiral, with an average of 24,000 new cases reported each year since 1985, and 26,072 cases reported this year, according to the CDC. During that time, the number of cases of TB in children nationwide increased a staggering 35%. A congressional report released this month criticized the Reagan, Bush and Clinton administrations for not having allocated sufficient funding to fight the disease.

“We have before us the prospect of the nightmare that has been with us from the start of the AIDS epidemic,” wrote Dr. Stephen Joseph, dean of the University of Minnesota’s School of Public Health, in a recent issue of the American Journal of Public Health. “That the disease is an ancient one (tuberculosis) rather than a new one (HIV) makes little difference. This is ‘back to the future’: a 19th-Century epidemic threat.”

As Joseph suggests, tuberculosis is almost an anachronism. It evokes images of a seemingly prehistoric era in medicine, of days when doctors threw up their hands in defeat and packed their ailing patients off to sanitariums for a cure thatrelied not on drugs, but sunshine and fresh air and rest. Since the Stone Age, tuberculosis has been a killer nonpareil, claiming an estimated 1 billion lives. Some of the world’s greatest writers and musicians--Emily Bronte, John Keats, Frederic Chopin--were lost to TB, and during the 19th Century the sickness took on a fashionable aura of tragedy, as though in stripping them of their bodily strength, tuberculosis somehow accentuated the creativity in their souls.

In those days, TB was known as consumption, or wasting disease, and with good reason. Untreated, it literally consumes the body, wasting its victims away to nothing.

Modern medicine wiped out this scourge--or so people thought. With the advent of new drugs in the 1940s and ‘50s, TB became quite curable. While tuberculosis remained rampant in Third World nations, across the United States, the disease went the way of polio, with case rates plummeting so quickly that proud public-health officials boldly proclaimed it might be wiped out in this country by the 1980s, or at least the year 2000. Sanitariums were shut down. The number of hospital beds set aside for TB patients dwindled to almost zero. Screening programs were dismantled; health-care outreach workers lost their jobs. Money for scientific research into tuberculosis dried up. Laboratories were closed. By the 1960s, tuberculosis in America was considered an obscurity.

The truth is, tuberculosis never really went away, especially not in Los Angeles County, where case counts remained low but fairly constant throughout the 1970s because of steady immigration from nations such as Mexico and Korea, where the disease is endemic. But in the mid-1980s, fueled partly by the AIDS epidemic, tuberculosis came galloping into American hospitals and clinics again, bowling over doctors and health officials who now concede that they had let down their guard way too soon.

In certain impoverished pockets of America, the incidence of TB is astounding. In Harlem, an estimated 222 of every 100,000 residents are infected--a rate comparable to that of some underdeveloped countries. In Los Angeles, authorities estimate that 50% of the estimated 15,000 downtown homeless people are infected with TB.

However, only a small percentage of those infected develop active tuberculosis. In the majority of otherwise healthy people, the germ remains dormant. But the immune-suppressed are another story; experts estimate that over the span of a decade, people who are infected with HIV and TB will develop active tuberculosis.

The most horrifying development has been the reoccurence of incurable strains of tuberculosis. Doctors and nurses are especially endangered; the CDC reported recently that since TB began re-emerging in the late 1980s, 17 health-care workers nationwide have become infected with drug-resistant tuberculosis, and five have died.

No city has been hit as hard by these deadly new strains, or by the resurgence of TB in general, as New York, which reported 3,811 new cases last year, more than three times that of the city of Los Angeles. More than 200 cases of drug-resistant TB have been documented in city hospitals, where patients who come in to be treated for other ailments are becoming infected and dying.

The reason for the outbreak is simple; New York, as did many other cities, dismantled its tuberculosis control program in the early 1970s, when the federal government ceased funding on a national level. The last time there were this many TB patients in New York--in 1968--the city had 23 clinics and 1,000 hospital beds for TB patients. Now, there are 10 clinics and fewer than 50 beds.

Alarmed officials are now playing catch-up. The city’s budget for controlling the spread of the disease has increased tenfold during the past five years, from $4 million to $40 million. More doctors and nurses are being hired, as well as what Dr. Thomas R. Frieden, who directs tuberculosis control for the New York City Department of Health, describes as “an army” of 400 outreach workers who will track down every TB case in the city and make sure that every patient gets a full course of medicine. “We are really turning things around here,” says Frieden. “But it took 20 years to dismantle this system and it is not going to be repaired overnight.”

Experts, including Frieden, agree that Los Angeles County is far better situated than New York. The drug-resistant strains sweeping the Big Apple have cropped up here but have not spread. And because Los Angeles had a steady TB caseload throughout the 1970s and 1980s, its control program was never dismantled the way New York’s was.

Even so, 2,198 new cases were reported in L.A. County last year alone. Twenty-six of every 100,000 county residents were found to have TB last year--a rate 2 1/2 times the national average. While immigrants make up the majority of the county’s caseload, doctors are seeing a dramatic rise in cases among African-Americans and children.

A little more than a decade ago, the American Lung Assn. proclaimed that “the new infection rate in American children is so low it is difficult to measure.” Today, L.A. County epidemiologists report that the number of new TB cases in children has more than doubled since 1985.

Now, Los Angeles County, which has 3% of the nation’s population, accounts for 8% of America’s tuberculosis patients. “We see a doubling of tuberculosis cases,” Harbor/UCLA’s Ward says of cases in his hospital, his voice rising passionately. “We see many more children with tuberculosis. Tuberculosis is difficult to diagnose and it is becoming more difficult to treat. And we are getting more and more of this disease, a disease that should be controlled, if not eradicated.

“Tremendous strides were made between 1930 and 1980. To me, some of the greatest accomplishments in medicine were made in the eradication of tuberculosis, and to have this reappear as an important public-health problem affecting children, when it is completely preventable, I think is a failure of our society to accept an absolutely essential responsibility.”

Says Dr. Emily Kahlstrom, a pulmonologist at Los Angeles County-USC Medical Center: “I think California is New York waiting to happen. Without a decent public-health program that is adequately funded, you, me and everybody else in this state is going to be at risk, and if we get drug-resistant TB we are heading back to the 1930s, when people had TB and people died of it.”

ONE NEED NOT GO BACK TO THE 1930S. IT IS RIGHT HERE, IN 1993, AT THE Oakdale Memorial Park cemetery in Glendora, where 33-year-old Gustavo Loera was buried on a smoggy September Saturday at the stroke of noon. The bell tower played a soulful tune as Loera’s gold-colored casket was lowered into the ground. A week earlier, the man mourners called “Gus” lay near death behind a set of sliding glass doors in the intensive-care unit at Olive View/UCLA Medical Center in Sylmar.

Big blue and black stickers sent out an urgent warning: “Isolation room. Patient inside highly infectious.” Visitors were required to don masks, gown and gloves and report to the nurse before entering. Loera was comatose, his body connected to a confusing maze of clear plastic tubes--two to breathe for him, one to eat, one to void his bowel and another for his bladder, one to administer drugs, four to suck the fluid out of the lungs that his doctor said were so riddled with holes they looked like Swiss cheese. His eyes were shut, his breathing shallow. He spent nearly a month hooked up to the high-tech machinery.

Loera’s death was a medical throwback, a reminder of the time when people routinely succumbed to tuberculosis. He was kept alive in a hospital whose past is intricately entwined with the disease. Olive View was once among the largest of the nation’s TB sanitariums. It began in 1920, with four wards and 95 patients, a collection of red-tile-roofed buildings just north of what was then the Sylmar Olive Grove. Its first superintendent, a physician named William Henry Buchner, recorded this history in his memoirs during the mid-1930s:

“The demand for beds constantly increased . . . (A)t this time there are 33 wards, five of them for preventorium children, and two for children with adult type of disease. There are now nearly 1,000 patients in the wards, and over 50 in the Convalescent Camps. . . . Before entering the Sanatorium, the question of payment is settled by the Property Department; but once within the walls of Olive View all patients are treated alike whether they pay the maximum of $67.50 per month or nothing at all.”

Today, Olive View is a sleek, six-story building of gray glass and steel, rebuilt after it was destroyed in the 1971 Sylmar earthquake. A stay is more expensive now; Dr. Irwin Ziment, chief of medicine at Olive View, estimates that it cost taxpayers approximately $2,200 per day to keep Loera in the intensive-care unit. Had his condition been diagnosed earlier, this expense--and, far more important, Loera’s life--could have been saved.

He was a Jack-of-all-trades, his sister Mary says, a gardener, cement maker, fixer of electronic gadgetry. He was not married and lived with his parents in his hometown of Duarte. Nobody has any idea how he contracted TB.

“I really can’t understand what happened to him,” says Mary Loera. “This could have been a cough or a cold that he never told us about. He was never seriously sick to where it would show that he was anything near tuberculosis. When he got diagnosed six months ago, he told me that he was coughing up a little bit of blood. We went downstairs to clean his room and it looked like a massacre in there.”

According to Ziment, Loera was treated for TB at another hospital. When he came to Olive View, his left lung was so scarred by the disease that he had begun to bleed internally. Although TB patients rarely undergo surgery these days, the doctor says that the scarred lung probably should have been removed months before. “He drowned in his own blood,” Ziment said.

A world away from Skid Row and Olive View, in a subdivision of new Mediterranean-style homes and manicured lawns, a Thousand Oaks couple and their three young daughters have unwittingly become entangled in the disease’s ever-widening web. They do not want their last name used. Explains the mother, Renee: “We don’t want to be known as the tuberculosis family of Thousand Oaks.”

Their encounter with TB came in August, 1992, the day before the family was to move from Northridge to their new home. Boxes were everywhere. The movers were on their way. In the middle of the chaos, the telephone rang. The woman on the other end of the line was straightforward and serious, and she didn’t waste any time with what she had to say.

“I’m a public-health nurse,” Muriel deKoning told Renee. “I’m from County-USC hospital and we have seen a patient here in the last few days. She told us that she wanted us to call you and let you know that she has active tuberculosis.”

“Can you die from this?” Renee blurted out.

“Left untreated, yes,” DeKoning said.

The woman was the nanny who had recently left the family’s employ. She had not been feeling well for at least six months. By the time she stumbled into County-USC and into the care of Muriel deKoning, she had several holes in her lungs, a sign that her tuberculosis was extremely advanced. De Koning told Renee that the children--then 8, 5, and 1--must be tested immediately, especially the baby.

The entire family took tuberculosis skin tests; everyone was positive except the father. X-rays revealed that Renee and the two older girls had not developed active tuberculosis. But doctors found a small spot on the upper region of the youngest child’s left lung, a strong indication that she was well on her way to getting sick.

Reports of housekeepers infecting families surface a few times a year, says Dr. Shirley Fannin, director of disease-control programs for the Los Angeles County Department of Health Services. “We find people all the time who hire people right off the street to do things like child care,” she says. “They never think about having testing done (on people they hire) before they turn over their children. People take risks when they do not insist on hiring people that have had an evaluation, especially if they are new immigrants. That doesn’t say don’t hire somebody from another country, it just says, ‘Look, why not invest in getting a skin test, or a chest X-ray, for heaven’s sake?’ ”

Indeed, Renee knew none of this. But now that her family has been exposed to tuberculosis, she is fluent in the language of the disease. She knows about isoniazid, rifampin, pyrazinamide and ethambutol--the drugs most commonly prescribed to treat TB. For nine long months, she and her daughters took these medications (unlike 20% of TB patients, who don’t finish their medication, one national study found); now they are no longer at risk. She knows about sputum samples and smear tests and that drug-resistant TB can develop if you do not take all the medicine. She knows that the apical, or upper, region of the lung is the area most commonly attacked by the TB germ. She knows that the old, four-pronged needle test for TB is out, and that the name of the new method--in which a small amount of extracted TB bacteria is injected into the outer layer of the skin--is Mantoux, after its inventor.

“I had no education about this,” she says. “My kids would get their skin tests for TB, and to me, it was an overly cautious medical treatment. You know how kids get the juice for polio and the skin test for TB? Nobody ever gets polio anymore that we know, right? Nobody gets tuberculosis anymore that we know.

“My thinking was that tuberculosis is for the people on Skid Row, tuberculosis is not going to affect me. You say to yourself, ‘That’s a poor man’s disease.’ But I can tell you how many people I know that have nannies and housekeepers, and I wonder, ‘How many of them have this silent thing?’ ”

DR. PAUL T. DAVIDSON IS the man in charge of seeing to it that Angelenos do not get TB. The soft-spoken, graying physician is a tuberculosis expert who for the past 10 years has directed tuberculosis control for the Los Angeles County Health Department. His is not an enviable job. This is a time of the county’s health-care budget being cut by $78 million, and of having to do more with less. The county was forced to beg for $72 million in tobacco tax revenues that will fill the budget void and keep open 20 small health centers and four of six major centers in Los Angeles, Long Beach, the San Fernando Valley and East L.A. Patients sit in waiting rooms for hours hoping to be seen, often simply giving up in frustration. Hospitals and health centers are short on supplies; one county doctor laments that his X-ray machine--vital in diagnosing tuberculosis--leaked radiation for months before he got a new one.

This is a time for shutting down programs, not starting up new ones. Yet that is exactly what Davidson says must be done if tuberculosis is to be controlled. Sitting in his Spartan office, on the fifth floor of a fading government building, he speaks slowly, carefully.

Davidson insists that with the right moves--improved health education, mobile X-ray screening clinics for the homeless, more programs to induce homeless TB patients to continue taking their medicine, additional public-health nurses to track down and monitor infectious people--some inroads might be made. “We also need a quicker way to diagnose this disease and a better way to find out who is infected,” he says. Davidson adds that if the current TB vaccine, which has had limited success around the world, is much improved, “that would cut down TB much more rapidly.” But all this will take a sustained effort, he cautions, lasting five or 10 years or more.

And with the wrong moves--the potential closure of the health centers and clinics--or no moves at all, Davidson warns that TB cases will go through the roof. Early this month, Gov. Wilson signed a bill reauthorizing the $72 million in tobacco tax funds. But the money will last only until June, and then the budget battle starts anew. “If they close those health centers,” Davidson says bluntly, “we might as well pack up our bags and go home.”

Of particular concern to him is the rise in childhood tuberculosis. “If we have increasing TB in little kids, that means I’m not finding the adults fast enough, and they are infecting another generation,” Davidson says. “That is a fairly good hallmark that something is happening in our jurisdiction that isn’t right.”

This was the stinging conclusion of a blue-ribbon panel of national experts that convened this year to examine the county’s public-health system. Headed by Lester Breslow, a professor of public health at UCLA, the panel faulted top officials at the health department for paying too little attention to preventing tuberculosis and for running a top-heavy bureaucracy that bungled the management of federal TB funds.

Of the estimated $23 million the county spent on tuberculosis last year, the panel noted, less than 10% was spent on prevention, with the rest going to diagnosis and care for patients who were already sick. Moreover, the experts complained, the department was forced last year to return a $1-million federal matching grant for TB because the county, which had imposed a hiring freeze, would not match the funds. Davidson and his staff wanted to use the money to hire more nurses, but the bureaucracy was so convoluted that their request had to pass through six levels of administration to be approved. It never made it.

Health department director Robert C. Gates chalks the incident up to his agency’s failure to adequately monitor the way federal funds are spent, and he claims the bureaucracy since has been streamlined. But the report outraged county Supervisor Gloria Molina, who publicly lambasted Gates after the report came out and complained in a recent interview that the health director did not seem to look upon TB as “a top priority issue.”

“It was being treated as some kind of a little bureaucratic problem, but in the meantime we have a TB crisis,” says Molina, whose district is one of the hardest hit. “Worst of all, it was embarrassing for me, who is always trying to go out and lobby D.C. for more funds, particularly in the area of public health, and to see that we weren’t utilizing the resources that were available.”

To Davidson, however, the panel’s criticism was hardly big news. Two years earlier, he had served on a local task force that warned that disease and death rates from tuberculosis were “unacceptably high” and would continue to rise unless more attention was paid to prevention. “The present efforts to control and eliminate TB in Los Angeles County are failing,” the task force stated at the time, and it asked for an additional $8 million in county funding. The Board of Supervisors appropriated $2.6 million over the following two years--an amount Davidson and his staff say was not nearly enough, even when supplemented by a dramatic increase in federal dollars.

Last year, the county received $1.2 million in assistance for tuberculosis from the federal government; this year it is getting $5 million. While some of this money has been used to help drug clinics and AIDS treatment agencies develop tuberculosis outreach programs, most has been used to fill empty nursing and other health-care positions that the county once paid for.

“We’ve got no net gain,” complains Sheperd, the CDC official. “The federal funding is not increasing enough to keep the level up to where we could do all the things that we should be doing for TB control. “What we have got to do is, first, find all the cases, and then start treating them and start a downward trend. Right now we are in an upward cycle, even with the federal monies.”

“The reality is that in Los Angeles County,” Molina says, “we have a tuberculosis epidemic. We need to be more aggressive in outreach work with the communities that are affected. Tuberculosis, after all, knows no boundaries.”

KATHLEEN SMITH, A PUBLIC-HEALTH nurse, is on the front line of defense against TB. “They talk about the police being a thin blue line,” she says. “Well, I don’t know what color we are, but I’m telling you, we are a thin line.”

Tall and athletic-looking in casual pink cotton pants and matching T-shirt, Smith, 41, works the toughest TB district in the county: downtown Los Angeles. Last year, 112 of every 100,000 people in the county’s Central Health District--which includes downtown, portions of Silver Lake, Echo Park and Koreatown--were infected with TB. That figure is nearly 11 times the national rate. Last year, the main tuberculosis clinic in the district handled nearly 5,700 patient visits.

Smith is responsible for approximately 75 square blocks of some of the most densely packed residential buildings in Los Angeles. Theoretically, she keeps tabs on all the health needs of the people in these neighborhoods: lead poisoning in children, prenatal care for poor women, sexually transmitted diseases. But at least half her time, she says, is spent on tuberculosis.

It is Smith’s job to launch an investigation every time a TB case turns up on her turf. How did the patient contract it, she wants to know. How many others might be infected? Can I track down the source and thus prevent the spread of the disease?

“We are steadily getting new cases, and each case represents lots of different people,” she explains. “The whole family has to be skin-tested, the positive ones have to be X-rayed and there are some who have to go on medicine. Some of these households have 20 people in them. Say you have a kid who’s 3 who has a positive skin test. Well, they haven’t lived that long. Whoever gave them that infection may still be around. Occasionally you’ll find a grandma who, unbeknown to everybody, has active TB and is giving it to everybody else.”

Of crucial importance in controlling the spread of tuberculosis is making sure that patients take their medicine, and this is where community workers like Travon Williams fit in. They are not trained as nurses--in fact, they have no special training at all, just a willingness to trek through some of the most dangerous corners of the county.

One bright light in Los Angeles’ effort to control TB has been a year-old program that offers the homeless on Skid Row free room and board if they show up at a county clinic for directly observed therapy. The program is so successful the county is now hoping to expand it to other neighborhoods. In an ironic twist, some homeless people have been rushing into clinics, hoping to be diagnosed with tuberculosis so that they can cash in on the food and lodging.

On any given Monday or Thursday morning, dozens of homeless people jam the waiting room of the TB “Satellite Chest Clinic”--a depressing box of a place next to the county welfare office on Alameda Street. This is where Skid Row TB patients, most of them men, come to take their medicine.

The clinic is a waiting room, a small examining area and not much else. There is no bathroom. Patients who have to give urine specimens must go next door, to the welfare office, where a guard lets them use the public facilities. The pale blue walls are bare except for a few ragged posters issuing warnings: “Cover your cough! Cubrase la Boca!” and a handwritten sign proclaiming: “Noncompliance Means Long Treatment.”

Travon Williams sits near the door, greeting the men as they come in. This is how he gets to know his clientele. In exchange for taking their medication, he offers them vouchers for meals at a downtown homeless center and lodging at the Russ Hotel, a Skid Row single-room-occupancy facility that the county has selected to house participants in the TB homeless program, about 40 on average. The Russ is a cavernous, no-frills place. Here, these men will find a room with a bed, a closet, a sink and a few toiletries, on the house. The going rate for paying customers at the Russ is $63 a week; pay three weeks in advance and get the fourth week free. But for these men, the county picks up the tab.

For some, however, that is apparently not enough. On one Monday in August, 20 of the 60 patients who were supposed to show up for their medicine did not. That afternoon and the following day, Williams set out to find them.

Among the “BAs”--shorthand for “broken appointments”--is Magic Johnson, the homeless man who sleeps on the sidewalk at Boyd and Wall streets. An hour after his first, failed attempt to find Magic, Williams returns to this spot. The mattress is rolled up and sits atop a dumpster. Magic and the girlfriend, who is seemingly not infected, are sitting by a makeshift table, listening to the radio.

They know what Williams is here for. Magic stands up and shuffles about in ragged jeans and fuzzy slippers, open at the heels. Williams pulls out a vial of red and white pills, spilling them into Magic’s opened palm. This is a trick of the trade: never hand the entire bottle over to the patient; he might run off with it, or dump the pills somewhere and hand back the empty bottle, or pretend he is swallowing when he is not.

“These guys are professionals down here,” Williams later explains. “Some patients, we have to tell them, ‘Open your mouth,’ because they try to keep it under their tongue.”

Magic offers little resistance, but grows angry when asked why he does not stay in the Russ Hotel. His complaint is an oft-heard one on the streets: The Russ is for men only. No women, not even visitors.

“How come they don’t have women down there where you gonna send me?” Magic hollers. “It’s going against the laws of nature! That’s an abomination against God! And if you don’t believe me, just check in the book here, the Bible.”

He continues ranting, waving an empty plastic jug, demanding to know whether Williams has any water to wash the pills down with. Williams does not, and this sets Magic off.

“This is cruel, man!” he yells belligerently. “This is cruel! No water!”

Williams chuckles and rolls his eyes. “You a fool, man,” he says.

Magic gulps the pills, makes a face and stalks off. His business complete, Williams hops in the van and hustles on, hurrying to keep up with tuberculosis. He does not, however, sound particularly optimistic.

“I think TB’s gonna be around for a while,” he says. “They need places for more testing. Everybody needs to be screened for tuberculosis everywhere. You never know who has it. The guy standing next to you could be the one that’s positive, then he could move to Beverly Hills and start spreading it out there. You’re not gonna catch every TB case, just like you’re not gonna catch every crook.”

TUBERCULOSIS RATES

Rates per 100,000 population (1992): Los Angeles County: 26 New York City: 52

RATES BY HEALTH DISTRICT* Per 100,000 population:

Less than 15: San Fernando, East Valley, West Valley, West, Torrance, Whittier, El Monte

15-30.99: Foothill, Glendale, North East, Alhambra, Pomona, San Antonio, South, Compton, Bellflower, Harbor

31-45.99: South West, Inglewood, East L.A.

46-60.99: Hollywood, South East

More than 61: Central

* Long Beach and Pasadena do not report to Los Angeles County.

Sources: Bureau of Tuberculosis Control; New York City Dept. of Health; Tuberculosis Control Program, Los Angeles County Public Health Programs