Despite predictions earlier this century that infectious diseases would soon be eliminated as a public health problem (Burnet, 1963), infectious diseases remain a leading cause of illness and death in the United States. The incidence of tuberculosis, which was presumably under control has increased in several urban areas throughout the country. Furthermore, control and prevention of the disease have been undermined by drug resistance as well as lack of federal funding.
The homeless population is of particular concern as they are often immunocompromised, underserved, and disenfranchised from the traditional medical system. As a result, tuberculosis is most prevalent in cities among homeless individuals and has suffered from a twenty percent increase since 1985 (Bloom, 1995). Combined with the HIV epidemic and increased intravenous drug use, tuberculosis has become one of the leading causes of morbidity and mortality among homeless populations as a reemerging killer.
Currently, a combination of five primary drugs are used for chemoprophylaxis, as drug resistant bacteria have made single drug treatments obsolete. However, social and residential instability in homeless persons are a major obstacle in completion of the drug treatment. The most effective plan to ensure administration of medication is the use of Directly Observed Therapy, which calls for health care workers and volunteers to visit patients at shelters to visually confirm administration. DOT not only prevents the transmission of tuberculosis, but also combats the spread of multi-drug resistant strains of the bacteria. In studies done is several cities, DOT has been shown increase the number of completed regimens by over forty percent (Iseman, 1993). Nonetheless, despite DOT's success, federal funding for such programs remains grossly inadequate. As a result, there has been widespread change and expansion of health policies in many major cities.