A.G. Holley State Hospital to go, but issue of TB patients remains

The Florida Department of Health's plan for closing A.G. Holley State Hospital, released to the public Friday, offered only a rough outline of what is to become of its 37 tuberculosis patients, hinting at the difficulty the state has had finding medical homes for patients whose care is costly and prolonged.

Tuberculosis treatment can cost as much as $274,000 yearly for people with dreaded multi-drug-resistant strains, health leaders said. Under the best-case scenario, TB requires six months of treatment with three potent antibiotics. Worst case? Treatment can take two years or more, and at least four drugs, some intravenous, all with different side effects, including liver failure, nerve damage and vision changes.

Most people with TB take their medications without incident at home, under the watchful eye of public health nurses. But about 10 percent are sent to Holley, a sprawling 1950s-era building that once was the setting of a teen horror flick, and still looks the part.

Behind a chain link fence, on the hospital's renovated top floor, 11 of A.G. Holley's patients live under court-ordered confinement because they were deemed to be a contagion risk . Others came because they couldn't seem to get well otherwise.

"One of the reasons people come here is because they have drug resistance and have underlying health problems," such as HIV infection, which makes TB tougher to treat, said Jerry Jean Stambaugh, the longtime pharmacy director at A.G. Holley. "Here, the TB is drug resistant 40 to 50 percent of the time."

The state has tried repeatedly to find other hospitals willing to take Holley's TB patients, or take over Holley, to no avail. Nonetheless, weary of paying $10 million a year to run the sanatorium, the legislature has given the Department of Health no choice: By Jan. 1, Holley must close.

So what happens next?

"The Department of Health is currently in negotiations with three potential providers for TB hospitalization services," said Ryan Wiggins, Department of Health communications director . Who those three are, the agency will not say.

The state law ordering Holley's closure demanded an action plan by May 31. But the four-page outline delivered to legislators late Thursday was thin on details. It calls for ending voluntary admissions - that happened on May 2, Wiggins said. It calls for changing existing court orders, selling off the hospital's equipment and helping with job placement needs of employees. Several charter schools and other buildings are on the property. The plan calls for minimal maintenance until those tenants can move .

The 140-acre property represents almost an eighth of Lantana's potential tax base, said Mayor David Stewart. The town is in the midst of rezoning the land so that it can become a jobs hub, Stewart said.

The land sale will become the responsibility of the Department of Environmental Protection, which manages most state land. Although the sale pleases Lantana town officials, it's clear the closure has been upsetting and alarming to many in the public health community.

An administrator assigned responsibility for A.G. Holley's closure, Julia Gill, the state's epidemiology director, abruptly resigned on Wednesday, giving just one day's notice, according to Health News Florida, a nonprofit online news site. Dr. Steven Harris, the deputy secretary of health, is responsible for the report sent to legislators, Wiggins said. He was not available for an interview.

A key issue: Hospitals usually receive a maximum 45 days of Medicaid payments for inpatient service, nowhere near the length of stay that TB patients require. Holley has an exemption from that rule, but other hospitals don't.

The health department wants the restriction lifted for community hospitals that accept Holley patients. The state asked the federal government April 12 to allow for that change, said Shelisha Coleman, a spokeswoman for the Florida Agency for Health Care Administration. If the shift is granted, then moving the patients to private hospitals shouldn't cost taxpayers more, Coleman said.

Holley's closure comes at a time when TB is in decline in the United States. There were 10,500 new cases diagnosed in the United States last year, compared with 25,000 in 2003. That year, the AIDS epidemic had caused strains of TB that were resistant to multiple antibiotics to surge.

New York City and Miami both saw serious outbreaks of multi-drug-resistant tuberculosis. New York spent more than $1 billion containing that outbreak, said Dr. Eric Nuermberger, an associate professor of medicine at Johns Hopkins University School of Medicine's Center for TB Research in Baltimore.

Tuberculosis was a leading cause of death until the advent of antibiotics. It is spread in tiny aerosolized droplets from the breath. Healthy people's immune systems usually fight it off; others cordon it off in calcified pockets in the lungs. The organism can lie dormant until

the infected person is weakened by cancer, diabetes, HIV infection or some other event. And then it can strike.

Nuermberger said public health efforts to control and eradicate TB in the United States have been very successful, but it's not the case elsewhere, especially China, India and South Africa, where multi-drug-resistant strains are appearing in newly infected people.

"It's been said, the next outbreak of drug-resistant TB is just a plane ride away," Nuermberger said.

As a crossroads for the world, with a large population of immigrants and a large share of the nation's TB, Florida is vulnerable, he said.

"I've visited A.G. Holley," Nuermberger said. "I think it would be hard to justify a center like this in every state in the union, but for a place like Florida, a place like Texas, a place like California, because of the large numbers of patients, a large number of immigrants, a large number of drug-resistant cases, in many cases care can be delivered much more efficiently in that setting."

 
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