A tale of two cities: tuberculosis control in Nicaragua and New York City

The tuberculosis (TB) control programs in Managua, Nicaragua, and New York City are compared, including their methods of case finding, treatment, follow-up, data collection, and cure rate. In all areas, Managua's program has proven more successful than New York City's, despite the enormously greater resources available in the latter. Nicaragua's TB program concentrated on active cases, had immediately available diagnosis with a microscope in each clinic, had nearly 100% directly observed therapy during at least the first 2 months, and sent its workers into the field immediately after a patient broke an appointment. New York City's program has fewer than 2% of its patients under directly observed therapy, operates a laboratory and clinic system in which obtaining sputum smear results requires 10 to 20 days, and has delays of weeks to months in returning patients to supervision after a broken appointment. The numbers speak for themselves: the Nicaraguan TB program cured nearly 80% of the patients enrolled in the mid-to late 1980s, whereas New York City's program rarely cured 50% and in some areas cured less than 15%.