How Boston stamped out a TB outbreak thanks to bartenders and barbers

BOSTON — The nurses of Boston City Hospital weren’t in the habit of stopping by the bar on their way into work. But that was where they began finding themselves every morning, starting in the mid-1980s.

They would show up as early as 8 a.m. at now shuttered bars in South Boston. They got to know the neighborhood’s bartenders, but not because they were ordering drinks: The nurses were using the bars to see their patients.

The tuberculosis outbreak then raging among Boston’s homeless population had started in early 1984. By July of 1985, the US Centers for Disease Control and Prevention was calling it the most severe outbreak ever documented among America’s homeless population, according to Boston Globe reporting from the time.

Dispensing medications from bars, barbershops, and corner stores, Boston’s medical experts managed to rein in the outbreak. Since then, the story of their innovative plan has largely been forgotten by all but those involved. But it helped bring tuberculosis under control in the city, and set the precedent for similar interventions used today in developing countries, where TB is still widespread.

Tuberculosis is spread through the air, and is highly contagious. Bacteria enter the air when a person with the disease coughs or speaks, and others breathing that air may get infected.

In the close quarters of Boston’s homeless shelters, tuberculosis began spreading like a match to tinder. Complicating the problem, the drug regimen for the illness was demanding: Up to two years of multiple types of antibiotics taken every day. For homeless people, shelters had no way of knowing if a person would even return the next night, let alone months into the future.

And if the whole antibiotic course wasn’t finished, the patient risked developing drug-resistant TB, which is more difficult to treat. Medications for drug-resistant forms of the disease also have serious side effects.

So doctors and nurses got creative, and after weeks of puzzling over how to tackle the outbreak, they realized they needed to take treatment to the patients.

“It was a lot of trial and error, using common sense, and adapting the system to the population,” said Dr. John Bernardo, TB Control Officer at the Massachusetts Department of Public Health, who played a key role in caring for the homeless during the crisis.

The work was divided between Boston City Hospital and the city’s newly established Health Care for the Homeless program.

“We had to do things like get on our bikes and go find them every day to give them their medication,” recalled Dr. Jim O’Connell, president of the Boston Health Care for the Homeless Program.

Other clinicians found their patients at their favorite watering hole. An 8 a.m. beer at a bar on Broadway in South Boston was the routine of two homeless patients — and turned out to be the most consistent place to see their nurses. If one of the men missed a day, the nurses relied on the bartender to report back when he was next seen.

One man wanted to take his medication at work, but didn’t want his coworkers to see — so an outreach worker met him in the bathroom each morning, said Bernardo.

In some cases, medical officials in other parts of the country needed to follow patients. “One fellow went to New York, and because we told him to, he got in touch with them and he continued the therapy — then he came back here and got plugged back into our system,” Bernardo said in a report in the Globe dated July 19, 1985.

Clinicians kept these efforts up for over a decade. Still, the number of TB cases among the homeless across the United States remained 150 to 300 times higher than the nationwide rate through the late 1980s and only started to fall in the 1990s, according to the CDC.

Since then, the idea of deputizing community members to help treat diseases has become the World Health Organization’s recommended strategy  for treating TB around the globe.

Dr. Paul Farmer, working in Peru in the 1990s, pioneered a treatment strategy in which a trained community member observes and supports TB patients on medication. Anyone from an employer to a nurse to a family member could take on this role.

Similar efforts in South Africa and India have found that community volunteers can be just as effective at dispensing TB medications as medical staff. One study from India found that volunteers were more successful than staff at health facilities at supervising patients, in part because they lived closer to the patient.

Such tactics aren’t in general use in the US any longer — TB cases in 2015 were just 3 per 100,000 people. But certain groups, including African Americans, immigrants, prisoners, and the homeless remain at higher risk than the general population for contracting the disease.

In the US, the focus has now shifted to prevention — but this, too, benefits from a personalized approach, like the one that worked in the 1980s, says Bernardo.

“Public health is personal,” he said. To reach Boston’s Haitian community — in which TB is highly stigmatized — Bernardo and his colleagues hosted a morning radio show. Many people started calling in with questions, and the number of patients coming to the clinic increased, too, he said. “It’s not rocket science,” said Bernardo.