LA community-based funding for TB wiped out

ESL screening, other programs land in the ICU

In East Los Angeles, administrators at English as a second language (ESL) classes, where immigrants who attend receive TB skin tests, worry whether the nuns from Ultimate Health Service will be back to read the skin tests. At Ultimate Health Services, Sister Mary Jo Piccione, SP, RN, and TB coordinator for the organization, worries about whether she’ll lose her outreach mission.

"These people work so hard all day, and then they work hard learning English at night," says Piccione. "They’re so motivated."

Piccione’s work is complicated by the fact that many of the students land jobs and move away. Plus, she adds, "they have so little time to come by the health center every month for a bottle of [isoniazid] pills." Still, she adds, a lot of them do anyway.

What seems like a lot to Piccione evidently wasn’t enough to the number-crunchers at the Centers for Disease Control and Prevention’s Division of TB Elimination, or DTBE. That’s one way Paul Davidson, MD, head of county TB control, tries to account for what happened late last year when cooperative agreement funding cuts were meted out.

He had expected to take some hits, Davidson adds; plus, TB honchos at the CDC had begun issuing storm warnings last year, letting programs know that they’d be penalized for "friv olous" screening programs that skin-tested but didn’t get patients through a round of preventive drugs.

"We knew we were probably looking at some cuts, but we were thinking it would give us the chance to look carefully at these community organizations, and to see which were the most productive, and which needed some work," says Davidson. "Now, that chance is gone."

Instead, the $1 million dollars the county used last year to fund TB screening among 11 different community-based organizations, or CBOs, was completely wiped out. The cut amounts to about 14% of the overall TB control budget, Davidson adds.

The city that invented CBO partnerships

Ironically, Los Angeles County practically invented partnerships with CBOs, even convincing a state legislator to go to bat for the concept, Davidson says. Convincing Congress to pay for such an idea was just the first step; county workers resisted the idea that suddenly, outsiders were getting paid to do what they considered to be "their" jobs, Piccione recalls.

The work paid off, though, and Los Angeles gradually became known as the prototype model for CBO partnerships. Over the past six years, CBOs serving hard-to-reach immigrant populations have screened about 100,000 people for TB, Davidson estimates; of that total, about 10,000 have completed all six months of preventive therapy.

That accords with Piccione’s estimates of her own numbers. At Ultimate, she and her colleagues have skin-tested 1,300-plus ESL students over the past year. About half tested positive; of those, 365 showed up at the county health center for a chest X-ray. So far, postcards and phone call reminders and the promise of $20 gift certificates have coaxed about 50 to completion; by the time the rest of the year’s cohort has worked its way through, another 50 will probably finish a full six-month course of INH.

Davidson says he’s not convinced the CDC actually set out to eliminate his CBO partnerships. The decision to assess targeted testing as a separate activity, judged by its own set of rules, is what brought the situation to its current pass, he believes: "It was their own process that did them in, I think," he says.

But the result is still lamentable, he adds. With 70% of its TB cases among the foreign-born, and with half of those being among Hispanics (a group especially apt to skirt the usual overseas screening mechanisms), Los Angeles has lost a big piece of its TB control program. The county, in turn, accounts for a big chunk — 13% to 14% — of the United States’ TB cases among foreign-born people.

Oddly, other jurisdictions in the state that applied for funding for targeted testing programs existing so far only on paper got all the money they asked for, Davidson adds, and the amounts awarded to other jurisdictions roughly equal what Los Angeles lost.

"It’s as if they just shifted the money around," he says ruefully. To make it worse, Davidson says he and other county TB experts sat down with at least one jurisdiction whose application was approved and patiently explained how Los Angeles had set up its CBO partnerships.

Once, says Piccione, an ESL teacher assigned thank-you notes as a homework assignment. "I got all these lovely notes, in English and on paper they’d decorated by hand, from 30-, 40-, 50-year-old men and women, thanking me for coming to the classroom," she recalls.

To her, that suggests some benefits of the program, while they may be harder than others to measure, are real nonetheless. "The education we get to do there is like a wave that gets bigger as it moves along," she says. "Once people understand something like TB, they no longer fear it. That’s part of what’s made this ministry so special to me."