Angel of the White Plague

By Jon Franklin

© 2000TheRaleighNews and Observer


The white plague may be forgotten but it is not gone.  It smolders.  And so twice a week public health nurses all across the nation set out to find and extinguish the embers.  InDurhamCountythe job falls to Brenda Ho, who makes rounds on Tuesdays and Fridays.

This Friday, as always, the medicine comes over from the pharmacy first thing in the morning: a tray of small paper cups heavy with white tablets. The isoniazid pills are aspirin-sized; pyrazinimide and pthambutol are larger. Several of the cups also contain huge, blood-red capsules of rifampin.

Brenda sits at her desk and checks off the medication against the records of her patients.  Behind her a little girl stares out from a poster, hugging a rag doll.

The girl’s name is Marcella, she is eight years old, and her story harkens back to the last time the plague burned it way through the American population.

Roaming the house in her illness, Marcella found the old doll in the attic.  It was ragged and had no face, but the girl loved it. But as the months passed and Marcella grew ever weaker, the doll’s blank face began to worry her.  Her father was a political cartoonist and, while he was helpless against his daughter’s illness, he could do something about the doll.  So he painted a smiling mouth and a triangular nose on the face and attached two discarded buttons for eyes.

The doll was christened Raggedy Ann, taking “raggedy” from James Whitcomb Riley’s poem “Raggedy Man” and Ann from his “Little Orphan Annie.”  Stories the father made up about the doll helped Marcella get through the long, cough-wracked nights.  She died in 1916, clutching the doll.

Now, many lifetimes later, the terror that once attached to tuberculosis has long since been transferred to another chronic killer, cancer, and sanatoriums built to house victims of the white plague stand vacant or have been converted to other uses.  Though Raggedy Ann survives, the disease that killed the little girl who first loved her so has vanished from the popular mind.

But with the white plague, forgetfulness turned out to be a terrible mistake.  And that is why, in recent years, Marcella’s story has been revived, to sear itself into the mind of anyone who will pay attention.  Because Mycobacterium tuberculosis humanis is back, and with a vengeance. It has become the planet’s most deadly contagious disease, and in the process it has mutated into new, drug-resistant and potentially uncontrollable forms.  Through the weakened bodies of the homeless, the poor, and the sick it now threatens to invade theUnited States.

As she checks the dosages, Brenda also notes the address for each patient.

The roll call of names is a familiar one, changing only very slowly over the months. On this particular day, two of the children are visiting their grandparents in another county.  Usually in such an instance Ho would make arrangements for a local public health worker to deliver the medication and observe its being taken, but in this case she considered the children’s mother particularly trustworthy and allowed her to take the drugs with her. Then there were several patients who came into the clinic for treatment.

That leaves Alejandro, Eric, Elmer, Noemi, Yaneli, Beanie, Julio . . . and of course Rahneece, the baby.

She ticks them off in her head.  Alejandro, Eric and Elmer will be at Operation Breakthrough’s day care center.  Noemi will be at Oak Grove Elementary, Yaneli at Fayetteville Street School. The old woman, Beanie, will be waiting in her apartment at a local retirement home.

Julio called yesterday and said he wouldn’t be working today, so he will meet Ho at the apartment he shares with three other men.  Then there is a handwritten note about Rahneece, the baby.

Brenda stands in the center of her small office, reading the note. The baby’s mother, recently released from jail after serving time on drug-related charges, had called to say she’d been assigned to community service today.  She would come into the office personally for her medication, but the baby would be with its grandmother.

The person who had taken the call had written the grandmother’s address on a slip of paper. But Brenda’s has been down most ofDurham’s back roads, and this address has a false ring to it. Perhaps Rahneece’s mother gave it wrong to the receptionist, or the receptionist copied it down wrong.

Either way, the implication is inescapable: One of Brenda’s patients is unaccounted for.

Brenda Ho is a tiny woman, 42 years old, no more than a hundred pounds, with a friendly face and an easy, non-threatening manner – a combination that has gotten her out of many a scrape over the years.

But as she stares at the address she scowls, her hazel eyes turn cold, and in the passage of a few seconds Brenda Ho, the friendly lady from the health department, metamorphoses into Nurse Ho, official emissary of that abstract collective interest called “the public health,” soldier of the war on tuberculosis, big sister of the white plague.  For months after you felt fine again she brought you the big, bitter, hard-to-swallow pills – whole handfuls of pills – and then she stood there and watched you take them.  If you resisted she argued and cajoled, but if you tested her will she could have you hauled off to jail.  There, they would simply force the medicine into you.

Now the question hangs in the office: Where is Rahneece?

Nurse Ho stares at the note for a long, frozen moment. Then, breaking the tension with a deep breath, she transmutates back into Brenda, who raises her eyebrows in a sort of facial shrug and readjusts her perspective.  After all, how far can a tiny, premature infant go?  She’ll turn up.

Nurse Ho will find her. She generally does.

Meanwhile, there is work to do.  Brenda sits down at her desk, arranges some papers, answers the phone, and then turns her attention to the cups of medication.  Three of the eight paper cups are heavy with large white pills, and two of them also contains a red Rifampin capsule. For five of the children, those too young to swallow tablets, the pharmacist has ground the pills down to a grainy white substance.

Brenda sets one of the powders aside for Rahneece, the baby, and then opens a jar of chocolate fudge topping and adds a generous dollop to each of the remaining cups.  Using a tongue depressor, she thoroughly mixes the powder and the chocolate. Chocolate is her penultimate weapon.  The only thing better is grape drink. Grape drink is the Esperanto of the prepubescent world.

Brenda works carefully and methodically, mixing each batch of chocolate goo thoroughly, then leaving the tongue depressor in it and moving on to the next cup.  She focuses on the task at hand but, still . . . it is difficult not to think about the baby.

Brenda has a special affection for babies. As a young woman she wanted to be a pediatrician, then settled on nursing.  Her first job as a nurse had been in a neonatal unit and it had brought her immense satisfaction. At the time she had not fully appreciated it, the directness of it.  However complicated neonatal medicine might be, the underlying motivation was to nurture and preserve innocent life.  It was so simple and pure as to easily touch the human heart. Now, a veteran of almost six years with theDurhamCountytuberculosis control unit, she looks back fondly on those early experiences.

On the surface her present job seemed straightforward enough, from the outside: She delivered medicine to people. She could even call those people her patients, if she liked . . . and she did.  But that was not the truth of it, and deep down she knew it and the people she sought out and kept track of knew it too. In these libertarian days, government health bureaucrats didn’t send people to jail for their own good. Nor did the statisticians in Washington, D.C.or at the Centers for Disease Control in Atlantastay up nights worrying about Beanie or Julio.  But they stayed up nights worrying about the thing that lived in their bodies, the thing called Mycobacterium tuberculosis humanis.

Brenda hadn’t volunteered to be the county’s Direct Observational Therapy nurse; in her mind, a nurse would have to be crazy to do that. All the same, somebody had to do it. Brenda had grown up inTexas, where she had picked up some conversational Spanish – and that doomed her.  When her predecessor went on leave and didn’t return, Brenda was the logical person for the job.  So she tried to make the best of it, which meant finding her joy more in the people she treated than in the abstraction she represented. Making patients matter. That was a nurse’s job, and where Brenda was concerned it was inevitably what ended up happening.

Rahneece, for instance.  The baby.

That’s who the last cup of powder is for, Rahneece.  Brenda mixes it with orange juice until it is the consistency of a thick porridge and then, still using the tongue depressor, loads it into two blue plastic syringes.

The thing about Rahneece was that she was so incredibly small and delicate.  Preemies were all small and delicate, of course, but Rahneece was born to a life of abject poverty and all that went with it, and . . . well, Brenda found it difficult not to worry about her, even when she knew exactly where she was.

Which, at this moment, she did not.

When she is finished with the syringes Brenda puts each lot of medicine into a paper lunch bag and prints the recipient’s name on it.  A can of cola goes into seven of the eight bags, and the children also get a small carton of grape drink.

Then she pauses, her eyes on Julio’s sack.  Julio was an immigrant fromMexicowho had shown up at a hospital emergency room sick and coughing up blood. Brenda figured the three men he shared his apartment with were probably infected as well, but she hadn’t been able to test them yet.  If Julio wasn’t working today, perhaps they weren’t either.  Thoughtfully, she added three skin test kits and three more cans of soda. Everything went into a shallow cardboard box.

It is almost ten o’clock by the time she pulls on her jacket, slings her purse over one shoulder, picks up the cardboard box and heads out into a gray day dominated by low-hanging rolls of menacing clouds.  She drives her own car for the same reason she dresses in civvies. Mycobacterium tuberculosis humanis fed on the poor and the outcast, the weak and the crowded – the same classes of people, generally, that attracted drug dealers and other human parasites. Official cars attracted too much attention of the wrong kind.

A few minutes later Brenda parks her car on a rundown side street near an old school building that now housed Operation Breakthrough’s kindergarten and pre-kindergarten classes.  She rummages through her paper bags to find the ones marked Alejandro, Eric and Elmer.

The walls of the ancient building exude the odor of paste, chalk dust and finger paint.  Its floor tile is worn through to the concrete by the tiny feet of forgotten generations.  Brenda stops in the doorway of a basement classroom and a tiny Hispanic boy rises and comes to her. They walk down the hallway, side by side, the nurse trying office doors until she finds one that opens.  Then Brenda and Alejandro sit on small chairs, face to face.

Alejandro is four years old and plenty bright, and if he doesn’t know anything about tuberculosis he knows that for some reason he commands this attention, and he basks in it.

He pouts as she ladles one scoop of chocolate out on the tip of a tongue depressor, but he opens wide.  He closes his lips, works his mouth, looks at the ceiling, swallows, shivers, grimaces and reaches for the carton of grape drink. Isoniazid is a bitter substance, even through the chocolate. But it works better than the streptomycin it replaced – and that worked better than nothing. Before the mid 1940s and the advent of streptomycin, Mycobacterium tuberculosis humanis killed half the people it infected; in children, the toll was probably higher.

The microorganism was an ancient one, derived from a microbe that grew in the soil. Archaeologists knew from tubercular lesions on excavated bones that it had been a parasite to human beings long before they began to record their history. But the modern epidemic tracked the growth of industrial slums in the Western world, beginning around 1800.  By the early 1900s, TB sanatoriums all over the country served as virtual prisons for the ill and dying.North Carolinahad three.

But by then deaths from tuberculosis were already in a steep decline, probably for complex reasons having to do with the growing immunity of the population as well as an increased standard of living.  By the 1960s and 70s those factors, coupled with the availability of effective drugs, prompted many public health officials to raise the possibility that the disease could be effectively wiped out. But that was not to be.

Now, at Operation Breakthrough, Alejandro opens wide for his second mouthful of bitter chocolate but rebels at the third.  Instead, he slips off the chair and darts to a bookcase, from which he snatches a puzzle.  It consists of three dimensional plastic vegetables, each with a recess designed to fit it.

Brenda plays along, maneuvering the third scoop of medicine-laden chocolate as the boy puts the ear of corn in its place.  “Maize!”  A carrot.  “Zanahoria!”

“Speak English,” says Brenda, maneuvering to score another mouthful.  “Pepper!  Tomato!”  Alejandro pauses to make faces and suck on the grape drink straw and then, when he grins shyly up at Brenda, she delivers the fourth and last portion.

Eric is next on the list.  He is slightly older, and more cooperative.  He makes faces, but takes all four mouthfuls in sequence.  Elmer, down the hall, is in the lunchroom with his class. She takes him over to a corner of the room where he swallows the chocolate.  Several of his classmates turn around in their chairs to watch him.  For their benefit he suppresses his grimaces.

“That makes three,” Brenda says to herself as she leaves the building.  Which is how tuberculosis is handled, at the opening of the third millenium: One at a time.

The worst of it all, according to many tuberculosis experts, is that it hadn’t had to be that way. In 1935, for example, the mortality rate from tuberculosis was around 60 per 100,000; but by 1975, thanks largely to drugs, the disease killed almost no one.  By 1980 the incidence of contagious tuberculosis had dropped to 12 per 100,000 and was continuing to fall.  There was a feeling among the public health experts that the disease had been brought to heel, and there was talk of wiping it out, at least as a factor in public health in developed countries.

Total eradication, in the sense that smallpox had been eradicated, was never a possibility – mainly because the germ, while it lives only in humans, grows very slowly.  So there would always be an undiscovered, latent infection somewhere. But tuberculosis experts thought that with aggressive monitoring and control they could reduce the cases to perhaps one in a million, and those could be detected and treated early – “elimination,” it was called. The mood was so optimistic that a board of experts created by Congress in the 1980s to advise the CDC on the disease was named “The Advisory Committee for the Elimination of Tuberculosis.”

But the public whose health was at stake was a vague, abstract entity that was notoriously weak on foresight – and tuberculosis, once out of sight, was soon out of mind. As it lost its power to frighten it also lost its political appeal and, by the 1980s the white plague had been reduced to a boring bureaucratic duty and its funding dribbled away to other, sexier diseases. Clinics deteriorated, equipment failed, nurses quit and were not replaced.  Gaps developed in the surveillance.  InNew York, as in other hard-strapped jurisdictions, the disease slipped totally off the screen.  Public health experts made dire warnings, but then . . . didn’t they always.

In hindsight, what happened was inevitable. Jurisdictions with the least money were precisely those where tuberculosis was most likely to spread.  The rise of AIDS also created a new population highly susceptible to infections like tuberculosis. The number of people whose immune systems were suppressed to support transplanted organs or to fight cancer added to the tenderbox. In the 1980s, in areas ofAfricadevastated by political upheaval and AIDS, the white plague flickered, caught fire and exploded.

As always, tuberculosis sought out the impoverished and the drugs, cheap by middle class American standards, were expensive by the reckoning of the destitute inBangladeshorSoutheast Asia.  Such people, and their governments, had more immediate concerns, and too often the drugs were taken only until the symptoms disappeared. Similar patterns developed amongAmerican streetpeople. They took just enough of the drug to knock out the symptoms, and allowed the most resistant bacteria to multiply into superbugs that could withstand multiple drugs.

Then, in the early 1980s, the incidence in theUnited States, which had fallen to about 9 per 100,000, began leveling off and then, inexorably, to rise.  By 1990 it was 9.5, and in the next two years it went up another full point.

Tuberculosis epidemics are slow and ponderous diseases and those numbers, though they might seem small, sent public health experts into a near panic.  Conditions were ripe for a disaster.  As the disease had all but disappeared in theUnited States, so had the natural immunity it had created, so the population was exquisitely vulnerable.  Add to this the fact that the disease was rampant in the third world, with as many as 30 percent of many populations carrying the organism.  Tuberculosis was also beginning to burn its way through aRussiain decline, striking prisons, army barracks and dormitories. Immigration from those areas was on the upswing.  The final straw was the appearance of new strains resistant to multiple drugs. To say that officials were alarmed would be an understatement.  The wolf was at the door.

In 1993 the World Health Organization took the unprecedented step of declaring tuberculosis a global emergency.  In theUnited Statesand other developing countries, public health officials demanded, and got, money to fight the disease. Fighting the disease meant finding human beings with it and making absolutely sure they got the complete therapy, down to the last pill.

Suddenly a nation that a few years earlier couldn’t afford routine preventive care found itself willing and able to staff tuberculosis control units like the four-nurse office in Durham County.  It could even afford to pay people like Brenda Ho to take an interest in the poorest, most marginalized victims.  It was expensive, all right, but the alternative was unthinkable..

Laws and procedures were put into place, along with enticements and penalties.  Adults could often be cajoled into coming into the office twice weekly, so that they could be given their medication in the presence of a nurse there. Ho spent much of her time making contacts, wheedling, enticing, bribing.

“I don’t like to pull the jail thing out,” she says.  “It doesn’t help.  It scares a lot of these people. But it’s there, and they know it.  So I try to edge their thinking around, if you know what I mean.  Get them to cooperate.”

In the process, she has relearned the ancient lesson that everyone wants something. Immigrant Mexican men are often saving every penny they possibly can, and will become much more cooperative if Ho gives them a bus pass to the clinic – and then, when they show up at the clinic, she gives them an extra one. Food store gift certificates work with some. But others are an enigma.

Ho remembers one elderly street woman who was so inured to a life of total deprivation that she seemed to no longer have any materialistic desires whatsoever. After she was released from the hospital, Ho had to hunt her down twice a week to give her the required medication.  But then, as she got to know the woman better, an Achilles heel emerged. The woman had a grandchild, and she doted on it. Brenda dangled a toy store gift certificate. Bingo! After that, the woman came to the clinic faithfully.

In such a way, Ho discovered, mandatory treatment could be made roughly compatible with a libertarian society.  Everybody, no matter who, no matter how low their status, no matter how thoroughly they had rejected the world around them, wanted something. In the face of the white plague, it had become part of public health nursing to find out what.

Children, though, are a different matter.  Rahneece, the baby . . .

The thought of the baby makes Ho silent for a moment.  She concentrates on driving. As the car heads west on State Route 98, a few fat drops of rain splatter against the windshield.  Then the sky opens up and Ho leans forward slightly as she peers at the road through the fwop-fwop-fwop of wipers.

The baby is a little unusual.  Schoolchildren make up a significant part of her case load.  Because they have to go to school, they can’t come to the office.  They also generally belong to poor families that are liable to move often, or disappear.  So they have to be kept close track of.

When children enroll in school they’re routinely given a TB skin test. A substance containing some proteins from the bacteria is injected just under the skin; if the immune system has seen those proteins before, it will mount a coordinated counterattack and the test site will become red and inflamed. Such children are rarely infectious, but they have a lifetime to become so, and so they get the Nurse Ho treatment.

Virtually all of the schoolchildren who test positive are in the lowest economic groups; inDurham, the majority of them belong to families of immigrants from centralMexico- which is why the Direct Observational Therapy nurse has to be able to speak Spanish.  She also has to be familiar with the requirements of machismo and able to control the situation while appearing nonthreatening.

Her size helps, in that respect.  The men often feel protective.  Julio, for example, makes it his business to worry about her safety when she delivers medication to him.  If there’s something ugly happening at his apartment, he’ll arrange to meet Ho in a well-lighted parking lot not far away.

Sunglasses, meanwhile, have become a necessary item of dress.  “They conceal your eyes, so you can avoid eye contact.  Eye contact is threatening.”

It is better, all in all, when school is in session and she can meet her patients there.

Now Brenda parks the car outsideOakGroveElementary School.  She reaches into the back seat and finds a bag with “Namoi” written on it and then, umbrella spread in protection, runs through the deluge. The principle’s office is just inside the front doors, and an administrator there immediately recognizes Brenda and picks up a telephone to call for her patient.  Five minutes later a pretty, well-groomed seven-year-old in a blue-jean jumper and flowery T-shirt comes through the office doors, a pout on her face.

For some reason peculiar to pediatric psychology, some pre-pubescent girls develop a deep phobia of medicine that must be swallowed. Naomi is a textbook case and, as bad as she hates pills, she hates the chocolate mixture even more. So she is a chore.

She sits in a chair, Ho kneeling before her, several pills arrayed on a table beside her.  She returns Ho’s smile with one that is faint and fearful. She stares at the pills.

Ho picks up one and offers it.

Naomi looks at it, hesitates, takes it, examines it, and finally puts it in her mouth.  Ignoring a cup of water offered by Ho, she tries to swallow.  Her eyes focus on a blank stretch of wall on the other side of the room.  Her neck muscles work, she begins to retch, controls it, swallows, and then reaches for the cup.

A second pill.  Naomi stares it as it, as if it were the size of a golf ball.  Ho leans forward, talking softly to her. Noemi takes the pill, swallows with difficulty and drinks.  Then she sits, barely breathing, as she fights the expellant convulsions that visibly rise from her torso.

Five minutes pass.  Another pill then, fearfully, another.  Ho soothes her with her voice. Twice a week this scene repeats it self.

Then, finally, the last pill disappears down the girl’s throat.  She drinks, relaxes, smiles broadly . . . and then her body jerks and ejects the last drink of water all over her overalls and Ho’s blouse.

The girl blushes deeply but Ho is matter of fact, no judgment evident either in word, voice, or body posture.  Her eyes flick over the wet clothing, spots tiny fragments of pills, and judges the loss was not significant. Good. She won’t have to go back for other pills.  Then she and the child go, hand in hand, to a rest room to clean up. Then it’s four down, four to go, and Ho is back on the road again.

Ho is thinking about the baby. “I know her grandmother’s address.  Somewhere in my mind I know it, but I can’t remember. Perhaps . . .”

The day has turned dark and weepy, and the cars’ tires hiss along the blacktop.  Ho steers down Holloway toward town.  A passing truck splatters her windshield.

The baby, Rahneece, is on Ho’s patient list because her mother contracted active TB while in jail.  An infant’s immune system is not well enough developed to respond to a skin test, but the child was at such a high risk that she was put on the medication anyway. You couldn’t take chances with children.

Adults are a different story.  They are usually not diagnosed until they are gravely ill.  Julio, for example, was brought to the hospital vomiting blood.  So was Beanie, the elderly lady, who was next on Ho’s list. “In fact,” Ho recalls, “given her age and the severity of her disease, we thought we were going to lose her.”

Over the years the nurse has seen a lot of tubercular X-rays, but Beanie’s stands out in her mind. On the film, both lungs looked like they were full of cotton candy.  “But she made it,” Ho says, as she parked the car beside an eldercare apartment.  “Now, in fact, the treatment is almost finished.”

Inside the building, Brenda rides the elevator up to the second floor and knocks on a door halfway down the hall. There is no response.

She raps again, harder. Nothing.

The third knock is pure Nurse Ho, the Official Knock, BANG, BANG, BANG.

An instant later there is a soft noise beyond the door. A lock snaps and the door opens to reveal a white-headed African American woman with her housecoat askew and her face puffy.

“I was taking a nap,” she says, groggily smiling Ho into a tiny flat.

Beanie sits at a table and Ho puts the pile of pills before her.

“Boy,” Beanie says, “those are the biggest pills!”

Ho grins wryly.  “Beanie, they’re the same size they always were.”

Beanie separates the pills and stares at them.  She seems to move in slow motion.

Her youngest daughter and her son were just visiting yesterday, she says.

She has twelve children, and as she talks about them her fondness of them is apparent.  “The more the better. The oldest takes care of the youngest.  And then, of course, eventually all of them take care of the oldest, which is me.”  She chuckles at her own turn of phrase.

Ho has heard it before.  She is in the kitchen, opening the refrigerator door.  “Do you want some juice to take with the pills?” she asks.

Beanie considers it, meanwhile pointing to a gift she made for one of her grandsons.  “Yes,” she finally says.  “I’ll take just a little juice.”

Ho comes back with the juice and, after some consideration, Beanie takes the first pill.

Ho sits down as Beanie waxes expansive, embarking on an involved story about one of her children. Ho listens patiently for a while, then nudges her to take another pill.  Beanie complies, but very slowly, and that pill, too, is followed by a drink and a torrent of reminiscences.

Ho comments that her last dose will be along in a few weeks.

Beanie holds the red capsule in front of her face, as if studying it.

“Then you won’t come any more,” she says, sadly.

Then the pill goes down and another story comes up. Again Ho redirects Beanie’s attention to the pills, sneaking a glance at her watch.  Pills, stories, pills, stories.  Finally, the last one disappears into the woman’s mouth.

Outside, an exasperated Ho rolls her eyes.  “She used to take 24 pills.  Imagine! I’d be there an hour!”

One patient at a time, hunting each down, cajoling and negotiating, nurses like Ho have stopped the rise in active cases and are now forcing the curve down again.  But the entire public health establishment was shaken, and the complacency is gone.  Ho’s caseload is below 15, at the moment, but she can remember, just months earlier, she had 21 patients.  And, of course, a resistant organism could appear at any time.

Meanwhile, there is Julio.

Ho pulls her car to the side of the road next to a low complex of barracks-like apartments with open, walk-ways in a rough part of town. She has timed her day to arrive here in the late morning.  That, she learned early on, was the safest time.

On one of her first days as a direct observational therapy nurse, back in 1996, she had set out in search of two young boys who had eluded treatment. They were part of an Hispanic family that, according to her information, lived in a housing project not far from the health department building.  When she figured out where to go she simply got in her car and went there, without thinking about timing.

It was late afternoon when she arrived.  School was out, and children and adults of all ages were standing in around the property in segregated groups, African-Americans on one side and Hispanics on the other.  As she got out of the car, she realized that every eye was on her.

“What I understand now,” she recalls, “is that’s a bad time of day to go into a place and look for people, because what you find is that there are people out and about who don’t want to be looked for.  Someone like me, a white woman, the assumption is that I’m out for harm.  I’m going to tell on somebody, or report things.  On top of that this was a very closed community, if you know what I mean.  People knew if you didn’t belong there.  But I hadn’t figured those things out yet.

“I got there and the buildings weren’t identified, so I went up to this little black boy and asked him for directions.  And he said, ‘Aw, that’s a spic building over there.  You don’t want to go over there.’

“I remember that it hurt my heart that there was so much prejudice and hate, and he was such a small child.  And then I turned around and looked at the building.  There were men hanging all over the railings, and I saw that to get to the upstairs apartment I would have to go through a group of them.  I started walking, but they didn’t seem about to move, and at about this time I felt something hit my leg and I looked down and . . . these little kids, behind me, little bitty kids . . . they had thrown something like a tomato at my foot.”

She stood there, the hostile children behind her, the clump of Hispanic impassive men in front of her.  They were all staring at her.

For Brenda Ho, it was a moment of truth. If she backed out she could never return.  She had to go forward.

“That was my lesson,” she says.  “I learned that if I did not have the confidence I needed to have, or to portray that, anyway, I would not be able to be effective in that community.  So I just started walking and like, you know, hey, how you doing, and the men sort of scooted a little to one side and I went through and that was that.

“And, you know,” she says, laughing at the memory, “that’s nursing.  You do what you have to do and then you fall apart later.

“So I learned to plan things.  You control the situation.  You pick your time of day.  You go up to the door and knock, and you know they won’t just open the door, they’ll peek out of a window.  So you make yourself accessible to a window. You wear your sunglasses.  Things like that.  Street smarts.”

Now, as she parks the car in front of the apartment complex where Julio lived, she glances at her watch. It is late morning. “That’s why I’m here, now, at this time of day.”

The rain helps too, of course.  There is nobody to be seen.  All the same, Brenda finds her sunglasses and puts them on.  Then she is out of the car, an umbrella in one hand and the paper bag of medicine in the other, running across the lawn, jumping puddles, coming finally to the scant shelter offered by an overhead walkway, knocking on a loose screen door.  There is no answer except for the loud throb of music.

Brenda knocks louder, and then louder.  But not even the Official Knock can rise above the music.

Hesitantly, she opens the door a few inches.  JULIO! HELLO, JULIO! IT’S BRENDA!”

The music dies abruptly and a young Hispanic man appears from the back of the apartment.  Ho exchanges pleasantries with him in Spanish.  His roommates are at work, he says, but he thought they might be at home on Saturday morning.

Julio takes the pills quickly and matter of factly.  There are a lot of them.  Generally, when an active case of tuberculosis is discovered the doctors hit it with all four of their front line drugs; later, after the slow-growing organism has been cultured out and its sensitivities identified, the prescription is altered accordingly.

Julio isn’t contagious any more, but neither is he very far along in his treatment, and he’s allergic to Isoniazid, so he gets a hefty dose of the other three: One Rifampin capsule, eight Pyrazinamide tablets and seven and a half Ethambutol tablets.

While he takes the pills, Ho considers coming back Saturday to talk to his roommates. Saturday is simply not a good day for her to be here. Most people will be home. Friday night and Saturday is when a lot of drug deals go down. People will be drunk, or high, or for some reason won’t want to be seen by someone from the county government.

On the other hand, on Saturday morning people would still be sleeping. Especially if she came early.  Maybe she would bring someone with her. And it was important to test those men.  They had breathed the same air Julio had breathed.

Sure, she tells him, as she leaves.  Tell his friends she’d be back Saturday morning.

The next stop is supposed to beFayetteville Streetelementary school but Brenda is thinking about Rahneece, the baby, and the suspect address, and she decides to confront the problem right now. That way, she’ll have time to figure out what to do if her intuition is correct.

The gravel street specified in the note proves easy to find; it is down by the train tracks, in an area thick with low, sprawling commercial buildings.  The houses are old and most of them are weathered a paintless gray.  Some of them have addresses on them, and she can deduce the addresses of others nearby. But many of the houses that had once lined the street had been torn down, so the guesswork is iffy. Brenda drives slowly along the street, bending down to search for house numbers through the right window. The rain has stopped, now, and gravel popped under the tires.

Eventually Brenda stops the car next to a numberless house with several toys in the front yard.  Toys meant children.

“Do you suppose?” she said, softly, to herself.

She shuts off the engine and goes up onto the sagging porch. As she knocks, she stands well to the side of the door.  That was something else she’d learned: not to stand in front of strangers’ doors. Stand to the side. Then you’d be out of the way if something came flying through. Furniture. People. Whatever. A public health nurse never knew.

But in this case, there is no response.  Ho knocks again and then tries the Official Knock. Nothing.

Back in the car she sits for a long moment, then pulls out.  At a nearby corner there is a woman with a baby carriage, and Ho stops and asks directions.  But the woman has never heard of the address.

Brenda drives up and down the road several times, from the railroad tracks to the place, several blocks away, where the road ended.  Nothing. It is precisely as she had feared.  There is no such place.

She parks in front of the house with the toys in the yard, picks up her cell phone, and dials a number.

“Will you page someone in TB for me?”

Presently she is relaying her dilemma and asking the person on the other end of the line to find the chart.  “See if there’s a phone number for grandma.”

She waits for a long time.  The sky darkens, a few raindrops fall, and then it lightens up again.  There is no sign of life from the house with the toys, no other traffic on the road. Finally someone from the office comes back on the phone and Nurse Ho listens impassively as she is told the records can’t be located.

Brenda stares out the window, digesting that. Not only is the baby missing, the baby’s chart is missing. Absolutely unacceptable.

Then she puts the car in gear and heads for Fayetteville Street School. But when she arrives in the school office, paper bag in hand, she is told that Nellie is home sick.  “Again,” the school administrator adds.

This, too, sits poorly with Brenda.  She mutters about it as she pulls the car back on the road.  In her opinion, the child misses far too much school.  “Her mother is very young,” she allows.  “She probably doesn’t know any better.  Still . . . ”

Often, Brenda considers going to child welfare authorities with her observations, but she is very hesitant.  If word gets around that she rats on her patients, life will get very difficult. Her patients may get harder to find, which might lead to some of them slipping through the net.  That, too, is unacceptable.

Nellie lives with her mother and father in an apartment complex not unlike Julio’s, with open wooden walkways running along the upper floor.  As Brenda steps out of the car a child’s small face appears above her in a window, and when the nurse mounts the steps the door opens a few inches and one eye peeks out halfway up the crack.  The window curtains move.  Then a teenaged Hispanic woman opens the door and lets Brenda in.

Nellie is a pretty child, and obedient.  She opens her mouth for the chocolate and takes it without making a face.  Then she pulls long on the straw on the grape drink box. The apartment is sparce, and the couch is broken down, but the everything is scrubbed clean. There are a few toys lined up in front of the living room wall.

Brenda leaves Nellie sucking on her grape drink straw and heads back for the office.  When she gets there another nurse tells her there’s an Hispanic man waiting for her in the waiting room. “He’s been here for a while.  He has a handful of pills.  Says it’s you he has to see.”

At this time of the day the Health Department is very busy.  There are a dozen or so people in the waiting room, and county employees scurry about with charts, equipment, and trays of medicine. The man waiting for Brenda turns out to be a TB patient who had gone to Virginia to work.  He had told Ho about it, and she had made the necessary arrangements, but somehow the bureaucracy got confused and the man got a stern warning letter from the state. So he came back.

“He was terrified it might go legal on him,” Brenda remarks to another nurse.  “I reassured him.”

Everyone in Brenda’s office is now looking for the baby’s records. “Grandma has had a TB test,” Brenda reasons out loud, “so we OUGHT to have her number . . .”

Five minutes pass. Ten. A drawing of Marcella, holding her Raggedy Ann, stares out of Brenda’s poster.

Then an anguished “awwwwww . . . ” rises above the other noises.  It is Brenda’s voice.  She emerges from her office at the same time another nurse rounds a corner waving a patient folder in her hand.

“I have the number already,” Brenda says, ruefully.  “All we had to do was look in the phone book.”

The other nurse grins and hands her the baby’s folder.  “It was misfiled,” she says.

Rahneece, it turns out is at home.  Her mother skipped her assigned community service – which, Brenda mutters darkly, “is her problem. But as long as I’m going, I might as well take her medication too.”

Rahneece’s mother lives in an apartment complex that Brenda considers to be particularly dangerous, and she glances at her watch as she drives.  It’s later than she would prefer. On the other hand, the rain is her friend.

As she turns into the complex there is a well-dressed man parked beside the road in a long black car.  He looks startled, his engine roars to life, and he disappears down the road.

A few minutes later Brenda knocks on the door. Once politely, then more insistently, then the Official Knock. The door opens and she goes inside and upstairs.  A few minutes later she comes down, an incredibly tiny baby in her arms.

The living room is cramped by a huge entertainment center that stretches along one wall. Against the other wall is a washer and a dryer and a large pile of soiled clothes.  Next to that is a couch.

Brenda sits on the couch with the Rahneece.  The baby is floppy, like a rag doll, but Brenda handles it gently and expertly, supporting its back and neck, laying it across her knees. The infant stretches and arches its body, its hands balled into fists, its eyes squeezed tightly shut, its mouth puckered.  The tiny lips close eagerly around the opening of the syringe and sucks deeply.  Then it stops, and its eyes pop open in surprise.

“Yeah,” whispers Brenda, “it tastes funky all right.”

For a moment the baby struggles, the impulse to cry at war with the desire to suck.  Then hunger trumps taste and the tiny eyes slowly close as the suckling lips surrender themselves to the white paste. Brenda leans over the baby, cooing, thumb on the plunger, feeding the medication into the small body.

When the second vial is empty Brenda carefully lifts the baby into a sitting position and bounces it gently on her knees, whispering to it, coaxing out a small burp.  With an expert motion she moves the infant to her chest, draping its head over her shoulder, patting it with the palm of her hand.  The baby snuggles into the conformations of the nurse’s body and Brenda allows herself to sink back into the couch.

Outside, the wind gusts and the rain comes down with renewed vigor, but inside the house it is warm and dry. The simmering white plague seems far removed and with it the bureaucratic abstraction of public health, the whole notion of nursing a civilization.  All that matters for this brief moment is the nurse, who knows perhaps too much of the corruption called _Mycobacterium tuberculosis humanis_, and her tiny patient, who in her innocence will remember none of it.