In the 1960s and 1970s, Baltimore was at the epicentre of TB in the USA. The cure was well known, but insufficient numbers were treated, and the disease got out of control. While the solution - ensuring that people were treated – was obvious, it took real courage to act on the evidence.

In the 1960s and 1970s, Baltimore was at the epicentre of TB in the USA. The cure was well known, but insufficient numbers were treated, and the disease got out of control. While the solution - ensuring that people were treated – was obvious, it took real courage to act on the evidence.

While those who create programs and projects that are widely applied, or explain things that were previously inexplicable, are well-known in the prevention world, some pioneers are less well known. They have used other people’s programs in new ways or they have found a way of taking an existing good idea and giving it a wider application.

Patrick Chaulk, chief executive officer of Maryland Patient Safety Center, is one such individual. He was part of the team that used an existing proven model, Directly Observed Treatment, to reduce radically the incidence of TB in Baltimore. [See: Lessons from Public Health: What TB can teach us now.

According to Chaulk, the catalyst was David Glaser, then director of Community and Clinical Services for Baltimore: “He had been in Vietnam where he got infected with TB. He saw DOT ensure that men were properly treated. He was astounded by what he found when he came back to Baltimore: the same problem, but no DOT.”

He continues: “But it wasn’t as easy as replicating what was done in south Asia. We first had to make sure that everyone who spotted TB reported it. And we had to work out how to apply DOT to new types of cases: homeless people, drug addicts, and alcoholics.”

Within three to four years, the Baltimore team succeeded in making DOT the standard of care for TB. There remained a few doctors who felt they could handle it their way, but these outliers did not threaten the population as a whole. By the 1990s, TB was once more under control, even though all the risk factors – homelessness, for example - had increased.

Science, the causes and cures for TB, and the treatment were part of the answer. But so was the determination of Glaser, Chaulk and the rest of the team.

“A major challenge was the use of block grants,” argues Chaulk. “Since many health problems had multiple causes there were good reasons for breaking away from categorical funding: this pot of money for TB, that pot of money for sexually transmitted diseases, and so forth. But an unintended consequence of pooling money was for people to take their eye off the TB ball.

“People thought the disease was disappearing. But diseases don’t disappear. If you stop acting they come back. In Baltimore, that led to the epidemic.”

Chaulk also learned not to lose sight of individual cases. The attention to prevention allowed some clinicians to loose sight of what happened after treatment.

He explains: “We got to understand that you never think about discharge without a good plan and follow-up. For example, you can give people a prescription but how will you know if they have taken their drugs?”

Chaulk began his career as a health policy analyst, but after his pediatric training he volunteered in the Baltimore City Health Department and, as he puts it, “fell in love with infectious diseases”.

This combination of policy and public health produced a career that has sought new ways to bring evidence-based practices to the economically disadvantaged. That interest brought him to the Annie E. Casey Foundation, the largest single philanthropic focus on children and families living in poverty in the U.S.

Earlier this year, Chaulk became leader of the Maryland Patient Safety Center, which encourages the voluntary reporting of events that compromise patient safety including “near misses” that do not result in harm. He sees at least three major future challenges requiring the same tenacity he brought to bear on the TB crisis.

“Our immigrant and refugee populations provide new challenges for the effective delivery of health care”, he believes. “There are huge cultural challenges in the way different ethnic groups view disease, and that stand in the way of routine prevention and treatment.”

Some of the challenges that have plagued progress during Chaulk’s career persist. Health provision is still disconnected from other supports for human development, while the silos of health care remain: hospital and public health are separate worlds. This means that problems are pushed to places that cannot adequately help, while organizations and professionals are held accountable for things that are out of their control.

The third challenge is the new Health Care Act, the first tentative steps towards universal health care in the USA. Despite the obvious problems, Chaulk is optimistic about the chances of success.

“The Act is a huge step in the right direction,” he says. “Now we have to get down to the detail. The regulations that are attached to the legislation, and the way they are delegated to states, will take many years to work out. But that detail is what will be felt by patients. Part of my job at Maryland Patient Safety Center, for example, is working out what the regulations will mean for us.

“We all want to do the right thing. But doing the right thing is going to mean collaboration around extremely complex issues.”

As part of the team that tackled the apparently hopeless issue of TB in Baltimore, Chaulk is thus well-matched for his next challenge: bringing universal health care to his home city.

Links:
http://www.marylandpatientsafety.org/