The Last Sanatorium

Juan Jose Reyes sits quietly in a conference room on the first floor of A.G. Holley State Hospital in Lantana with his hands folded in his lap and his eyes cast down. His gaunt face, partially hidden by a baseball cap, is expressionless. When he does speak, his voice is barely audible.

This is his monthly medical conference, a time set aside to discuss his treatment with doctors. Today the news is not good. Reyes' tuberculosis has mutated into a strain doctors here have not seen before. And they are not yet sure how to treat it. That means his six-month, court-ordered stay at Holley is probably going to be extended for a long time.

So he has a choice. Reyes can either volunteer to stay on at Holley until doctors give him a clean bill of health, or he can go back before a judge, who will decide if he presents enough of a threat to public health to keep him at the hospital against his will.

Reyes is from Mexico and doesn't speak English. He gets the bad news via Dr. Elena Hollander, a Holley physician fluent in several languages. She puts a hand on his forearm and leans in close to tell him. Her words make him flinch, and he responds softly in Spanish. Hollander translates: "He says he wants to go back to the judge. He says he doesn't want to stay here voluntarily."

That puts him in the majority at A.G. Holley, where 75 percent of the patients are held against their will because they pose a significant risk to public health. Once a sprawling, state-of-the-art TB sanatorium out in the wilds of Lantana in Palm Beach County, A.G. Holley is now a court of last resort for patients and the public. At the height of the sanatorium movement, something like 600 such places dotted the country, providing bed rest, fresh air, and the only hope of a cure from one of mankind's most pernicious diseases. It wasn't particularly effective, but there wasn't any other medical option.

Holley is the only one of the 600 left. Modern hospitals have wings or clinics devoted to treating TB, but only Holley exists to do nothing else. It is the last sanatorium. And for now it's in no danger of being closed.

Far from being a disease of the past, TB still poses a very real threat to public health in this country, and it is one of the few illnesses that can land you in court-ordered treatment. Contagious people put TB in the air by coughing, sneezing, singing, or talking. Anyone cooped up in an enclosed space -- a prison, a nursing home, a homeless shelter -- with someone contagious is at risk.

South Florida is a TB hot spot, thanks to the high rate of immigration from places like Haiti and Mexico, where infection rates are many times higher than in the U.S. Most cases of TB can be easily and cheaply treated at home, provided the patient is cooperative and hasn't developed a resistance to the most commonly used TB drugs.

Tougher cases end up at Holley.

Reyes is HIV positive and has been homeless. He has worked as a sandblaster and cement cutter, medically noteworthy because breathing silica dust tends to exacerbate TB infections. He doesn't know how he caught the disease, though he was likely exposed to it when he served time in a Miami-Dade County jail in 1998. While there, doctors biopsied a lump on his neck, which turned out to be a tubercular infection of his lymph nodes. (Though TB is commonly thought of as a disease of the lungs, it can actually infect any organ in the body. It is not uncommon to see TB in the neck, a condition known as scrofula; in the spine; or in the brain.)

Reyes got out of jail and was put on a supervised course of drugs but didn't follow up with his health care worker -- a big no-no. Health care workers tracked him down and started him on a second round of drugs but lost track of him again in June 1999. In October Reyes got sick -- TB patients say the disease feels as if your "lungs are hollow," report extreme pain when breathing hard, and also suffer from fevers, chills, and night sweats. He was likely contagious and may have developed a drug-resistant strain that could be passed on to others. When he checked himself into a hospital, a judge ordered him to spend six months at Holley.

For all infections that require antibiotics, it's important to finish the course of medicine. Not doing so invites the bacteria to become immune to the antibiotic prescribed to kill it. That's what happened to Reyes, says Holley medical director Dr. David Ashkin.

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Bob Whitby