CDC History of Tuberculosis Control - Medical and Public Health ...

At first some of the nursing staff resisted the
idea of using incentives. Change was difficult
to accept; about that same time, the program
was also starting what was then called SIT
(supervised intermittent therapy), and is now
called DOT (directly observed therapy). Some
nurses could be heard griping about “spoonfeeding”
the patients. (Translated, this meant
that they felt that the patients should take
total responsibility for their treatment, and
that the nurses shouldn’t have to give them
anything to get them to be responsible.) For
some staff, it was all too much: asking them to
not only watch patients take their medicines,
but then, asking them to give the patients
small gifts as well — it was just more than they
could bear! However, as time wore on, these
same nurses became zealous about doing DOT
and giving incentives. (In fact, one nurse fell
and broke her leg during the course of giving
DOT and, in spite of a compound fracture,
she demanded that the ambulance drivers take
her on to her next two visits so she could
complete her DOT rounds.) Those big hearts
in the TB nurses were hooked and the concepts
of DOT and incentives really took hold.
Soon everyone in South Carolina was using
DOT and the stories of the incentives that
were used were told and the success rate of
completion of therapy got better and better.
In those early days the incentives were simple:
juice, hamburgers, chicken snacks, fruit,
candy, even condoms. Today, the staff have
moved to more sophisticated incentives such
as smoke alarms for fire protection in substandard
housing and swimming lessons for underprivileged
children. TB nurses and DOT
workers have big hearts and they dig deep to
personalize the incentives and enablers for
their patients.
Dr. Dixie Snider, former Director of CDC’s
Division of TB Elimination, knew about the
success of the incentives and enablers program
in South Carolina and gave us encouragement
to publicize the stories about incentives and
DOT in order to educate other TB programs,
TB Control at the Millennium
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so that they might begin to use incentives.
With the help of the ALA of South Carolina,
the booklet Using Incentives and Enablers in a
Tuberculosis Control Program was published.
The book gives the history of incentives and
helpful advice about their use. Still popular
after many printings, the book continues to
help TB workers in their use of incentives
both in the United States and in other countries.
TB workers and others love to hear the
stories and see the pictures of real patients
with their caregivers. The pictures give a real
face to TB and give encouragement to new
staff in the program that they too can be
successful with incentives. Whenever I am
asked to speak about improving compliance,
naturally I also talk about the importance of
using incentives and enablers to make our
work easier, but more importantly to bond
the caregiver with the patient in a trusting
relationship.
The successful use of DOT and DOPT in
South Carolina could not have ever happened
without the use of incentives. Who would
have thought that something as unscientific as
a red bridle for a mule, a cold drink on a hot
day, a pair of warm socks, or an old
overstuffed chair would contribute significantly
to the successful treatment and prevention
of TB in the United States?
The Denver TB Program:
Opportunity, Creativity, Persistence,
and Luck
by John A. Sbarbaro, MD, MPH, FCCP
Professor of Medicine and Preventive Medicine
University of Colorado Health Sciences Center
Four words — opportunity, creativity, persistence,
and luck — summarize the successes of
Denver’s TB program.
For decades, Colorado had been a mecca for
the victims of TB. However, along with the
demise of the sanatorium era, Denver’s TB
control program had progressively deteriorated.
As in other large cities, the insured