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Cultural Barriers to Treating Tuberculosis in America
Dr. Neil W. Schluger's main area of academic interest has been in tuberculosis, including clinical trials, molecular epidemiology, development and evaluation of diagnostics, and human host immune responses. He is the principal investigator at Columbia University for the Tuberculosis Trials Consortium, a CDC-funded collaboration in clinical trials in which patients are enrolled in trials of treatment of latent tuberculosis infection and active tuberculosis disease. In addition, Dr. Schluger has led studies examining the transmission dynamics of tuberculosis in New York City, using tools of molecular epidemiology. He has a long standing interest in the development and evaluation of new tools for the diagnosis of tuberculosis.
More recently, in addition to his studies in tuberculosis, he has led clinical trials for the use of retinoids in the treatment of emphysema and for the use of interferon gamma in the treatment of idiopathic pulmonary fibrosis.
Question: How do you tailor treatment plans to immigrant patients?
Neil Schluger: So in the United States more than half of all patients with TB are people who were born outside this country and in New York it’s about two thirds that were born outside the U.S. and recent immigrants have all sorts of challenges in terms of their health care as I mentioned before. Many of them don’t speak English or don’t speak English well and that creates a certain set of challenges. We have most of our patient education materials available in Spanish for example but it creates those sorts of issues. Many recent immigrants work at the margins of the economy. They take whatever jobs that they can find. They’re often low-paying jobs and the labor supply is pretty plentiful and it’s difficult to take time off to go see the doctor. If you miss a day or two of work, your employer might just fire you and find someone else who is willing to do that. So the city and actually the Department of Health TB Control Program has developed a program to really try to be as sensitive to these needs as possible so as I mentioned all our patient education materials are available in a variety of languages, the common languages that are spoken in New York, Spanish, Chinese, and other languages. We prefer that patients with TB take their medicine in a directly supervised way so we know they can do it. It’s hard to take medicine in general. It’s hard to take TB medicine. It has a lot of side effects. So we prefer it if they come to the clinic every day or three times a week and we can watch them take their medicine. If that’s impossible we’re willing to go- the City is willing to go where they live, where they work, and meet them there because we think it’s important. So I think the City’s TB Control Program is remarkably successful. TB rates in New York City have dropped 75% or more in the last 15 years in a difficult population of patients, and the New York City program I think is viewed as a model. New York City has been lucky that the heads of the TB Control Program have been some of the most talented, dedicated public health professionals around, people many of whom have gone on to very important roles in public health around the world. So we’ve been lucky there but it really is a challenging program and up in northern Manhattan where I work we see it all the time. We have a group of patients- a group of workers in the clinic who can speak many languages and that helps. The common language in our neighborhood is Spanish. Most of us can get along in Spanish but it’s quite challenging.
Question: How do you deal with patients who are suspicious of modern medicine?
Neil Schluger: So I think the first challenge when you deal with people who come from other cultures and have particular beliefs about the health care system or medicine or sometimes it’s just dealing with authority frankly-- The TB program in New York is run by the New York City Department of Health and for a lot of people that means coming into contact with authority and that can be frightening. The first thing I think is just to respect people for who they are and listen to their concerns and try to understand what they’re telling you and why they’re telling it to you. So we try to respect everyone and gain their trust really by listening to their concerns. At the same time it’s very important for us to get the medicine that we know works into them so patients will come and sometimes bring all sorts of home remedies or other beliefs, and the worst thing you can do is say, “Look. That’s just a pile of junk and witch doctors do that and we don’t do that.” You can’t do that. You have to sort of listen and respect them. We don’t care what people do as long as they take the medicine that we think they should take but sometimes it is quite challenging and the challenges are different in different populations. We’ve had a few patients from eastern Europe for example, patients who came from Russia, the former Soviet Union, where routinely governments just lie to them about everything, and many of those patients will never believe anything we tell them. We tell them, “You have tuberculosis.” They don’t believe it. And we tell them, “You have to take all these medicines” and they don’t believe it because they’re just used to being lied to by people in authority. So there are all these sort of interesting challenges that come up. Patients from countries where they’re vaccinated against tuberculosis don’t believe that their tests for TB are positive because they’ve been told their whole life that it’s positive just because they had the vaccine. That’s a huge challenge for us. Fortunately, we have some new tests that are going to replace the skin test so people don’t know about this yet and so they- it doesn’t occur to them to say that this new test will be positive because they were vaccinated so that’s good for us.
Recorded on: 04/25/2008
Over half of tuberculosis patients in America were abroad, Schluger says. Many are suspicious of modern medicine. How does a doctor deal?
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