Making Directly Observed Therapy Work

By Khalil Sabu Rashidi and Debra Bottinick, MPH

Recently several large urban cities have demonstrated that providing directly observed therapy (DOT) in the treatment of tuberculosis (TB) has resulted in substantial decreases in TB cases.

In DOT, a health care worker watches the patient swallow his prescribed TB medications. This leads to reductions in treatment failure, relapse and drug resistance. DOT can take place in the office, clinic, or in the community and can be used alone or with other measures.

Often the relationship that develops between the health care worker and the patient in the course of providing DOT contributes greatly to its success. The true story which follows, by Darryl Kilgore, Public Health Representative (outreach worker) at the New Jersey Medical School National Tuberculosis Center Waymon C. Lattimore Clinic, provides some important strategies for improving the success rate of DOT.

Success in DOT depends on an outreach worker's ability to problem solve, facilitate and empathize with his or her client. The first step is to establish rapport and trust with the client. A client must be viewed as intelligent and worthy of respect and compassion. Often health care workers who work with the indigent fail to do this and treat their clients in a condescending or even in a contemptuous manner. This behavior creates discomfort in the client, causing major obstacles to treatment success. Providing services with an understanding of another's culture and knowing the daily issues and problems associated with drug and alcohol use are critical skills for effective TB treatment.

Ken (not his real name) is a 46 year old, homeless man with over a 30 year history of cocaine and heroin abuse. He not only suffered from pulmonary tuberculosis but he also had a heart condition, HIV infection and bad feet. Initially Ken was distrustful of me. I represented the medical community which had shown indifference and even hostility towards him in the past.

The first thing I did upon meeting Ken was make sure he was aware of tuberculosis' effects on individuals with HIV infection. I had him tell me what he knew about TB and asked if he was interested in being cured. He told me that several of his relatives had died from TB and he did not want to die. This gave me the ammunition I would need in explaining the importance of DOT. The first couple of days went smoothly. Ken was living in a welfare motel in the city and we arranged to meet each day at 10 am for him to take his medicine. Then my first obstacle occurred: I went to the motel and discovered that Ken had been "put out" because of his failure to renew his public welfare status. Fortunately, I had gotten information on the first day from Ken identifying his relatives, where they lived and where he "hung out". I then visited three of the addresses Ken had given me.

Ken had told his relatives that I would be bringing medicine everyday. It was important to meet his family since he alternated between staying with various relatives and living on the streets. Before long I met four of his sisters, two brothers, two aunts and a number of nephews, nieces and friends. They became allies in future searches to find Ken whenever he was missing (which was often). For one month, I visited a dilapidated housing project where Ken stayed in an abandoned apartment along with other homeless substance abusers. He described his housing as a "shooting gallery", a place in which he and others injected intravenous drugs. Every Monday through Friday, I would visit this drug infested complex at 10 am and wait for Ken to emerge to take his medicine. Sometimes Ken would be there, and other times I might have to wait. I would watch the drug transactions taking place to pass time. Ken told the drug dealers that I was his "social worker" and not to "pay me any mind". I would sometimes enlist the aid of some of the locals to go and get Ken for me or they would tell me that Ken was staying with a particular relative. The technique of making oneself known around a client's neighborhood or hangout not only makes an outreach worker's job easier, but it also gives him/her a measure of safety. People actually started looking out for me, directing potential threats away. Many people in the neighborhood "adopted" me and felt a sense of pride seeing a young Black man in a position in which I was actually helping.

Occasionally, I would provide assistance to some of the people who helped me, but it never became too demanding. Folks would often ask for my assistance in calling people on their behalf at the social service agencies. I became a "neighborhood social worker". I never promised any miracles; I just assured them I would do what I could.

In my interaction with Ken I not only was responsible for his taking his TB medicine, but I also gave him rides to the clinic for doctor appointments as well as to other places, i.e., drug store, social service agencies, relatives' homes, etc. While working with Ken, I was able to get him temporary housing for people living with HIV. Unfortunately Ken became ill and was taken to the hospital which later caused the administrators at his house to panic and refuse his readmission.

The last two months of Ken's DOT were spent in the hospital where nurses provided his medications. I visited him frequently to make sure he was still there and to see if he needed anything. He often asked me to get him a meal because he hated the food or they didn't feed him enough.

After Ken's completion of treatment he was released from the hospital and would come and see me at the clinic. In fact, he still comes to see me from time to time to talk or to see if I need anything. Thus, you see, if an outreach worker approaches DOT with compassion, tenacity and the patient's best interests in mind, not only can he/she be successful, but he/she can also gain a friend. And who couldn't use that?