COVER STORY : Out of Control? : The County’s Tuberculosis Control Program Has Helped Reduce the Number of Cases Among the Homeless. Now, Expected Health-Care Cuts Prompt Fears of a Resurgence of the Disease

For two weeks last spring, Curtis Davis dozed in a plastic chair on the first floor of a Skid Row homeless shelter where 350 men prop themselves up shoulder-to-shoulder all night long.

Davis drifted in and out of sleep amid fits of coughing that erupted around the room--a sound he had come to know from so many other nights spent in shelters since 1991.

“There are a lot of bad coughs around here,” said Davis, who by the next month had a slight cough himself. The Mississippi-born 44-year-old, whose mother had worked as a nurse, knew it wasn’t the common cold. He decided to be tested for tuberculosis.

Davis found out the TB bacteria had begun to gnaw at his lungs. No doctor could tell him when or where he caught TB, but he suspected it had been during those nights in the sitting room, where the chairs are close together and the air hardly moves.

Now Davis has nearly recovered after finishing two months in a county voucher program that gives homeless TB patients food and shelter in exchange for taking their medicines. The county’s TB Control program has helped many like him, bringing down the number of TB cases in Los Angeles County from 2,198 in outbreak-ridden 1992 to 1,794 in 1994.

But public health officials are concerned the downward trend may not continue.

The Board of Supervisors is expected to cut $300,000 from TB Control’s $20-million budget this week, slashing homeless outreach and incentive programs and closing up to 35 of the county’s 45 clinics and health centers.

With the county providing less TB screening to all residents, health experts say more TB-infected people may not be identified and treated in time.

And health experts say the cuts will limit TB Control’s ability to contain outbreaks among the Downtown homeless, putting the entire county population at higher risk of catching TB.

“Anybody in Los Angeles County should be worried that a cut in public health funding will increase their personal chances of contracting the disease,” said Dr. Steven Asch, assistant professor of medicine at USC. “I certainly am.”

Tuberculosis is an airborne disease that travels in tiny drops of exhaled moisture, invades the lungs, and can eventually cause death if untreated.

Outbreaks have reportedly occurred in a matter of hours on airplane flights, but public health officials say TB tends to be transmitted over time with repeated exposure to a contagious sufferer in an enclosed, poorly ventilated space.

Tents and other encampments often provide little fresh air to the homeless who share them. And county health officials say homeless shelters, with their cramped living areas, offer ideal TB breeding grounds. Transients sometimes sleep head-to-head in dorm-style halls where the beds are placed close together.

No one knows exactly how many homeless people in the county have TB. County screenings indicate active disease levels among the homeless of Third World proportions: 400 per 100,000--comparable to the rates of poor communities in Bolivia and Haiti, according to the World Health Organization. That’s 40 times the rate of TB disease in the United States as a whole and nearly 20 times the rate in Los Angeles County. Skin tests of the Downtown homeless regularly show that 30% to 50% are infected with the bacteria.

Many of those who have it don’t know it. Transients often move on too quickly to find out test results.

But TB Control’s preventive programs have proven successful at identifying and treating homeless TB patients, who are about 90% male and notoriously difficult to keep tabs on. The voucher program that Davis completed, which persuaded nearly all of the 97 homeless patients enrolled in the program last year to stay on their medication, could stand to lose $100,000 of its $500,000 budget.

“Any significant cut into the voucher program would very negatively impact the public health of the central Los Angeles community and would ultimately impact the community outside,” said Graydon Sheperd, a senior public health adviser at TB Control. Officials agree that treatment is vital.

“If TB is not treated, it’s easily spread, expensive to control and very expensive in health-care costs,” said Jonathan Freedman, deputy director of public health programs at the County Department of Health Services. Ironically, Freedman said, if funding is cut, the public will probably pay more in hospital bills for advanced TB patients than they now pay for TB Control’s preventive programs.

To adequately address the tuberculosis problem, officials say TB Control needs more funding, not less. Davis suggested that all homeless be tested.

“I think it should be mandatory,” said Davis, standing on the littered sidewalk outside the single-room-occupancy hotel where the silver county van stops every day to drop off medication for patients in the voucher program.

Sheperd said mandatory testing is out of the question.

“We would be talking virtually millions of dollars here,” Sheperd said. “I have to use the resources I have in the manner I think I’ll get the most use of.”

To receive either a skin test, which indicates infection, or a chest X-ray, which identifies active disease, homeless people have to go to a clinic or be tested by the county’s mobile chest X-ray van. The cutbacks are likely to mean fewer visits by the van, which now checks at least 100 homeless a day several times a month.

Only about 10% of infected people develop contagious TB in their lungs, but the likelihood is higher for homeless people, more of whom are HIV-positive or have weakened immune systems because of alcohol or drug addiction and poverty. For many who care little about their health, a free fanny pack is often the only incentive to be tested. Once an active-TB patient is identified, regular doses of antibiotic medication can easily rid the lungs of the disease.

But many slip through the county’s fingers. One such man is known by the name of Devil. He didn’t seek treatment until the sickness became too much to bear. Now he’s recovering; he spends his afternoons at San Julian Park Downtown wearing a demon-adorned black cap and playing dominoes.

Devil, who declined to give his real name, said he used to live in a Downtown hotel and paint commercial buildings for a living. During the cold winter months, he came to Skid Row to eat breakfast and dinner in shelters where he said as many as half the people were coughing. Then in January, the sickness hit.

As soon as the 54-year-old lay down at night, he began to cough. Soon the hacking turned to chronic nausea.

“I could not stay in my bed until I had thrown up what I ate,” said Devil, who dropped from 150 pounds to 118 pounds in six weeks.

In February, he finally checked into County-USC Medical Center with a fever of 103 degrees. When doctors returned with masks on, Devil found out--he was contagious.

He was placed in isolation for nearly two weeks and spent a total of 100 days in the hospital before being released and placed on the voucher program--rescued from the disease that killed 56 county residents in 1993, according to the latest available figures.

Now, after 2 1/2 months sleeping in a 9-by-10-foot hotel cubicle provided by the county, Devil weighs nearly 150 pounds again. On his Spartan dresser sit four prescription bottles with pills he takes to relieve lingering pains. The county van picks him up two mornings a week to go to the county’s Satellite TB Clinic on 4th Street, where he takes five other medications. Devil was alarmed when told that TB Control programs will probably lose funding.

“It doesn’t make sense to cut back the money,” Devil said. “There are too many sick people down here.”

The Downtown poor face a high risk of transmission because too many of them live close together. Beds are packed into the 150 shelters in the county to accommodate the bulging ranks of street people. There are about 70,000 homeless in the county on a given night, according to Jane Steinberg, director of TB education at Homeless Health Care L.A., but only 10,000 shelter beds. Demand for beds is high, and the number of homeless is growing.

Staff efforts to control the disease have been inconsistent and often inadequate, Steinberg said. Some facilities regularly decline her offers of free staff training, not realizing the worth of knowing the basics about TB prevention in their high-risk occupation.

Among other lessons, Steinberg trains staff to stock shelters with tissues to block sneezes. She also teaches them to watch for visual signs of TB such as malnutrition, pale skin and intense coughing.

Sheperd of TB Control said shelters should take precautions and encourage screening. If shelters at least screen their staffs regularly, which the county is beginning to recommend, then outbreaks can be detected and dealt with more quickly.

“As long as TB remains the public health problem that it is, particularly in central Los Angeles, we would definitely urge the shelters to take an active role in preventing the spread of the disease,” Sheperd said.

Some shelters have already taken a stand against TB.

The Midnight Mission, for example, instituted mandatory TB screening for its more than 100 long-term residents after a 1992 outbreak in which five staff members were found to have active tuberculosis.

All must take a skin test every six months, and new long-term residents are screened upon arrival. Short-term residents, however, who fill 21 barracks-style beds in a corner of the large sleeping room upstairs, are never tested. Nor are the hundreds who fill the dining hall each day.

Shelters that offer beds on a night-by-night basis generally find it impractical to test hard-to-track residents. The St. Vincent’s Cardinal Manning Center, for example, doesn’t require that any homeless who fill their 55 overnight beds be tested. It does, however, make sure that all staff members are tested yearly.

Other shelters are less prepared to fight the disease. And budget cuts mean the county will have fewer resources to keep an eye on such shelters.

At the Emmanuel Baptist Rescue Mission, testing isn’t mandatory for the 65 short-term residents who filter in and out weekly. Nor is it mandatory for the five employees and the eight long-term residents in the Bible study program.

Brother Raymond Penn said the privately funded mission has not required staff screening because “it hasn’t been a problem.”

Along a side street next to the early 20th-Century building at Crocker and 5th streets, addicts gather to sell and smoke crack against a muraled wall. Those who come inside the mission can bring no drugs and must move on after seven days to make room for others in the beds open to transients. They fill cramped multi-guest bedrooms with no fans to circulate the air.

Although the downstairs sanctuary is air-conditioned, as many as 150 homeless men crowd into pews each day as they wait for meals and are encouraged to raise their voices in praise to God. Health officials say tuberculosis can travel out of the lungs even when singing, although coughing and sneezing are more likely methods of transmission.

Penn said a new building would be nice, of course, but at this point, the mission can hardly afford a new paint job for its peeling walls. “None of us have received a salary since we’ve been here, so we’re basically volunteering at this point,” said Penn, the mission’s director of food service, who came from a similar job in Chicago. It’s no surprise to Penn that TB rates run high among shelter workers--he said it’s part of the job.

“Most of my friends who work in missions have TB,” Penn said. So does he. Penn receives chest X-rays regularly to make sure the infection doesn’t progress into disease. He will be infected for the rest of his life.

Every day, Penn preaches the gospel to give hope to those who come in off the street.

“I’m what you call the soul-winner,” he said. But when it comes to fighting TB among the homeless, Penn said he is virtually powerless. “I just got to rely that God knows what he’s doing.”

On the Cover

Jonathan Fereda, who has been homeless for eight years, sleeps at St. Vincent’s Cardinal Manning Center, a shelter on Skid Row. Cuts in the county budget may impede the ability of TB Control program to contain outbreaks among the Downtown homeless, putting the entire county population at higher risk of catching the disease.