COVER STORY : The Invisible Foe : Urban Ills Combine to Make Tuberculosis Tough to Beat

Judy was recovering from a car accident, but doctors couldn’t figure out why she kept running a fever. Jennifer went to bed most nights feeling fine, then woke up with a hacking cough. Fernando was just weary all the time, and the rest of the family began feeling the same way.

Until a few years ago, many doctors might have prescribed lots of orange juice and rest, writing off this collection of symptoms as just another virus.

But after four years of drumbeating by the Long Beach Department of Health and Human Services, just about everybody--from local physicians to the City Council; from social service agencies to homeless people camped out in city parks--is finally becoming aware of an insidious, growing presence in the city.

Judy, Jennifer and Fernando--not their real names--didn’t have colds. Like hundreds of others in this city of 430,000, they had tuberculosis, the debilitating lung disease that has been afflicting humans since the Stone Age.

The disease, thought to have gone the way of polio and scarlet fever, is back in a big way in Long Beach and other urban areas. New TB cases in the city jumped more than 30% last year to 148, an eight-year peak, while the number of cases throughout Los Angeles County was dropping about 12%.

In 1992, the last year for which statewide records were available, Long Beach was fifth in new tuberculosis cases per capita among California cities, after San Francisco, Oakland, Los Angeles and Santa Ana. In that year, there were 25.8 new cases for every 100,000 people in Long Beach, and last year the number jumped to 33.8.

Health authorities have watched with alarm the return of tuberculosis to Long Beach like a haunting specter from the past. In April, 1990, the City Council declared a local tuberculosis emergency, making the city eligible for special state and federal funds.

“We were concerned that there might be a lot more cases unless we dealt with the disease aggressively,” said Diana Bonta, director of the city’s Department of Health and Human Services.

Bonta’s department beefed up the city’s tuberculosis clinic, sent city workers into the field to attack the disease at its sources and notified local physicians that they had to report new cases to the city. With help from the state and federal government grants, Long Beach is now pouring more than $1 million a year into the prevention and cure of tuberculosis.

The disease came as a big shock to some of its victims. “I was absolutely dumbfounded when they told me,” said one man, the son of a Midwest contractor. “I remember when there were TB sanatoriums. My father used to remodel them, turning them into college campuses.”

It wasn’t as if tuberculosis were anything new. Scientists have found evidence of the disease in 4,000-year-old Egyptian mummies.

For centuries, tuberculosis patients were relegated to remote sanatoriums, often in mountain or desert locations, where afflicted lungs could presumably breathe cleaner air. The big medical breakthrough came with the discovery in 1943 of streptomycin, the first drug to prove effective against the tuberculosis germ.

By the 1960s, after even more effective drugs had been discovered, tuberculosis was in full retreat in America. In 1985, the United States recorded its lowest number of new tuberculosis cases, 22,201, since the Centers for Disease Control began to keep track in 1917.

But homelessness, immigration from foreign disease centers, grinding poverty and AIDS have primed urban America for the return of tuberculosis as a major public health problem, authorities say. The disease has been sweeping the country, increasing 20% from 1985 to 1992. The number of cases dropped about 5% last year, according to preliminary figures released this week by the Centers for Disease Control.

Tuberculosis follows a slow, unswerving course, traveling between drug users, AIDS patients, children and down-and-outers--all with limited means to fight back.

It rarely affects perfectly healthy individuals who happen to come into contact with a carrier, doctors say. For instance, none of the city’s tuberculosis clinic workers, who deal with infected patients every day, have tested positive for the disease.

“It’s not an easy bug to catch,” says Barbara Lindsay, a public health nurse who coordinates the tuberculosis program for the city. “It usually takes quite a lot of exposure to someone who’s sick.”

But if a patient fails to take his medicine, which can render him non-infectious within a couple of weeks, he can spread the germs to other vulnerable individuals. The disease travels on droplets of moisture from coughs or sneezes, or even from singing, in crowded, poorly ventilated rooms.

Tuberculosis saps victims’ energy and eats “holes” in their lungs, where protective cells called macrophages attack the germs, forming spongy clumps. In advanced cases, the germs move into blood vessels and attach themselves to bones, the brain or kidneys, causing blindness and skin lesions--even sending victims into a coma.

Most of the disease’s victims were exposed years before the symptoms--weight loss, night sweats, fever, fatigue and a stubborn cough--ever appear, health authorities say. The rest are family members or others who live in close proximity to the infected.

In addition to the disease’s physical effects, tuberculosis patients are often afflicted in other ways, Lindsay says. “There’s a lot of fear now,” she said, explaining why most patients ask that their names not be divulged. “There’s all of this tuberculosis around, and people don’t understand how you catch it.”

Some patients who have been publicly identified have been evicted from apartments or fired because of the “stigma” of the disease, Lindsay said.

The good news is that, even in the worst of circumstances, tuberculosis is curable. An array of new drugs can knock out the germ, tubercle bacillus, even when the disease is advanced. As a result, Long Beach hasn’t had a TB-related death in at least six years.

But curing the disease requires a fastidious dedication to the treatment, the kind of dedication that is rare among substance abusers or the economically deprived.

Patients must take the prescribed megadoses of pills, up to 22 of them at a time for periods of a year or more. Interrupt the treatment or stop taking the pills after a couple of months and the disease can come back with a vengeance.

“The patient starts feeling better, and he says, ‘I don’t need to do this for six months, I’m fine,’ ” said Bonta, the health and human services director.

Despite often dramatic improvements at the start of treatment, however, the bacterium still lurks in the body.

Let the tubercle bacillus get back on its feet and, like a boxer who has figured out how to elude his opponent’s uppercut after getting nailed a few times, it can come back stronger than before, health workers say. And this time it will be resistant to the drugs.

There’s only one way to fight this disease, medical authorities say. Aggressively. Pound it into the ground. Attack it with three or four medicines--isoniazid, rifampin, ethambutol and pyrazinamide, sometimes all together--and continue the therapy long after lungs heal and germs disappear.

Dr. Matthew Locks of the city’s tuberculosis clinic spreads three X-rays in a row on a table in his little examining room in the Health Department headquarters on Grand Avenue. They are successive pictures of the lungs of a 75-year-old man.

“You see, there’s a big hole here,” says Locks, pointing at an X-ray taken last October. On the right lung there is a circular shadow the size of a 50-cent piece. In the next X-ray, the shadow begins to be replaced with the milky white of healthy tissue, as the drugs begin to take effect. In the final one, taken less than four months after the disease had been identified, the shadow is almost gone.

“The healthy tissue expands into the hole,” said Locks, 75, the former county TB control director who has been treating the disease since the 1940s. “He’s doing fine now. And so are his family members.”

So the elderly patient is cured? Not by a long shot. “He still needs six or seven months of the drugs,” Locks said.

Long Beach health workers take the same aggressive attitude in tracking down the infected and making sure they adhere to the treatment.

“This is not just a private health problem,” Lindsay said. “It’s a public health problem.”

City health workers approach the health of the community as if it were a forest during a drought. Neglect all of the barbecue pits and campfires smoldering out there, let the wind spread their sparks, and the result can be a roaring conflagration consuming the trees, they say.

The Health and Human Services building on Grand Avenue is barely a year old, but already the first-floor tuberculosis clinic is outgrowing its space. Some days the waiting room overflows with patients, new and old, and the nurses pass out medicines like supermarket checkers dispensing groceries.

The place percolates with activity. A staff of five medical professionals, two community workers and a clerk examine patients, dig out information about others who could have been exposed and begin the challenging task of getting their commitment to cure the disease.

When a patient does not show up for an appointment, health workers such as Graciela Espinoza get involved.

“If someone doesn’t come back, if they miss their appointments, the community worker gets on the phone to find out why,” Lindsay said. “They’re bulldogs.”

If patients are persistently non-compliant, someone like Espinoza will go directly to their homes and watch them swallow their pills.

Here’s where those smoldering fires all over town are kept under control. Espinoza travels through the city with a container of medicine, tracking down prostitutes and drug users in flophouse hotels, trying to reason with a schizophrenic here, offering advice to a transvestite AIDS patient there.

Espinoza, 36, is a cheerful woman, but there is steel behind her wide smile and solicitous manner. Even the most resistant end up popping pills into their mouths under her steady gaze.

She finds Jimmy, an AIDS patient, asleep on the couch in a tiny house just west of Belmont Heights.

Espinoza bends over the young man and searches his face. “You have some water?” she says, cupping his hand in her own and dropping pills into his palm.

On the other side of town, Brad sits in a wheelchair in a bare living room, watching a daytime talk show on television. His daughter, Brenda, talks bitterly about Brad’s health and about his drinking buddies.

“He had a stroke because of all the pressure from his friends, and now he wants them to come and visit him,” she says.

“I haven’t had a drink in a month,” he growls. “Not since I got out of the hospital.”

Espinoza listens patiently and watches him take his medicine. Brad gives each pill a dubious examination, places it in his mouth and then, with excruciating slowness, chews it like a horse eating oats.

There are a lot of reasons why patients fail to take their medicine, Espinoza said. Long Beach is increasingly a city of immigrants, and the city’s tuberculosis patients reflect it. More than three-quarters of the city’s tuberculosis victims are foreign born, many of them from Mexico, the Philippines and Cambodia, where TB rates are high.

“The perception is, ‘What’s the big deal?’ ” Lindsay said. “They say that everyone they know has a positive reaction (to TB screening tests). Some even tell us they were born that way.”

Many of the foreign-born have more faith in folk remedies than in modern medicine, Espinoza said. “People from the ranchos (in Mexico) have their curanderos (healers),” she said. “Mostly they prescribe herbs. It’s not enough to cure TB.”

But some patients fail to take their medicine because they are on a course of self-destruction, inviting health problems. “We have a lot of alcoholics who, because of their drinking, don’t pay too much attention to their health,” Espinoza says.

When Espinoza loses a patient into the underground of Long Beach’s rootless and impoverished, she brings in the health department’s investigative services unit.

Jeff Kingsbury, one of the nine field investigators who tracks down patients with infectious diseases, steps in. An imposing Utah native with yard-wide shoulders, Kingsbury is a Health Department Joe Friday, following the lukewarm trails of the homeless and transients into shelters, cheap hotels and city parks.

“Pieces of paper,” he calls the missing patients. For each, there is an order sheet with information on the most recent sightings and, if Kingsbury is lucky, a Polaroid picture.

On this day, Kingsbury is looking for a man named Bruce, an itinerate follower of the rock band the Grateful Dead, who showed up at the Long Beach health department in January, asking for medicine after he lost his bus ticket to San Francisco. Kingsbury also is looking for Jorge, a recently released jail inmate. If he finds either, he’ll whisk them back to the clinic for testing and a dose of medication.

But nobody remembers seeing the Dead Head in the tie-dyed shirt, and Jorge hasn’t made an appearance at the city’s shelters or assistance centers yet.

The investigator is luckier in North Long Beach, finding members of a tuberculosis-afflicted immigrant Filipino family at home. The parents and two sons have submitted to the treatment, but two grown daughters, both of whom work full-time jobs, have failed to meet appointments at the clinic to be diagnosed.

“It’s hard for them,” the mother says. “They don’t get time off during the day.”

But Kingsbury gets an assurance from her that the daughters will call him the following day and make arrangements to be tested.

“I could get a legal order against them,” he says afterward, “but it goes against my grain. I think you can get a lot further if you show concern rather than threatening them.”

In rare cases, the adamantly non-compliant are arrested and placed in a closed clinic in the county jail, where they are forced to accept treatment. “There was one ornery old man who was consistently recalcitrant,” Kingsbury said. “Finally we said, ‘Either take your medication or go to jail.’ ”

The man was eventually confined in the jail clinic for five months. It was only the second such case in the past three years.

The city’s ton-of-bricks approach to the disease may begin to pay off in a year or two, said Bonta. “We’ll probably keep on at the present rate in ‘94,” she said. “Then we might start going down.”

Tuberculosis Cases In Long Beach 1986-1993 1986: 90 1987: 68 1988: 59 1989: 128 1990: 117 1991: 109 1992: 114 1993: 148

Source: Long Beach Dept. of Health and Human Services

Tuberculosis Rates*

Southeast Area Health Districts

The tuberculosis rate has increased unevenly in the Southeast area--even dropping in some areas. Rates in Southern California cities, while high, trail those in the nation’s worst TB hot spots.

1992 1991 Bellflower (includes Hawaiian Gardens, Norwalk, Lakewood) 22.9 16.7 Compton (includes Paramount) 20.4 21.6 Whittier (includes Pico Rivera, Santa Fe Springs) 10.5 7.7

* Cases per 100,000 residents

Source: Los Angeles County Department of Health Services

U.S. Cities With Highest Tuberculosis Rates

Cases per 100,000 City residents 1. Atlanta 78.2 2. Newark, N.J. 68.3 3. New York 52.0 4. San Francisco 48.7 5. Miami 47.5 6. Houston 42.4 7. Honolulu 37.4 8. Oakland 33.9 9. Santa Ana 31.8 10. Los Angeles 31.1 11. Tampa, Fla. 28.7 12. Chicago 28.6 13. Louisville, Ky. 27.1 14. Long Beach 25.8 15. Washington, D.C. 24.8

Source: Centers for Disease Control