The Champion of Directly Observed Treatment for Tuberculosis Patients
And the deadly academic error of studying "supervised swallowing"
The critics have been loud. Directly observed treatment (DOT) for tuberculosis, they argue, violates human dignity. It's coercive, paternalistic, outdated, oppressive dogma, and unscientific and unnecessary. Dr. John Sbarbaro, who died in 2011, anticipated this backlash, and his life's work provides the answer.
John earned his unofficial title as the "apostle of directly observed therapy" through rigorous science, not ideology. His 1968 paper in the American Review of Respiratory Disease introduced the revolutionary concept of twice-weekly supervised treatment. From his Denver clinic, he achieved what seemed impossible: only a 4.5% missed appointment rate among patients everyone had written off. The data was unambiguous—DOT worked.
Recently, I referenced John's legacy when I wrote about Jim Leprino, the Colorado business leader who built the world's largest mozzarella empire through quiet excellence. Both men, who were close friends, shared something essential: they let results speak louder than rhetoric. John's results echo in today's scientific literature, and the evidence has only grown stronger.
When trust transcends language barriers
The power of DOT lies not in patient check-ups but in built relationships. I learned this in the midst of New York City's tuberculosis crisis in the 1990s. One of the most memorable people I worked with there was Christian Nwigwe. (I discuss this in the chapter on effective communication in my book The Formula for Better Health.)
Christian embodied John's vision of relationship-centered care. When we encountered Jorge, a 42-year-old Ecuadorian construction worker with drug-resistant TB, the barriers seemed insurmountable. Jorge spoke limited English, had no health insurance, and feared deportation. He had hemophilia and needed crutches to walk. He had no desire to visit our clinic. He didn’t trust us. And despite my passable Spanish, I failed to convince him to participate in DOT for the thrice-weekly medication he would need for nine months to treat his drug-resistant tuberculosis.
Christian, however, was able to build trust. Astonishingly, although he spoke no Spanish, with presence and empathy, even without a common language, Christian connected with Jorge. He conveyed the care and compassion that is essential for effective outreach.
Every Monday, Wednesday, and Friday, Jorge would leave work at lunch and make his way to a street corner near his factory, where Christian, waiting in his city-owned boxy blue car, would hand him a sandwich, juice, and his medications. Christian showed up consistently—not as enforcer but as advocate.
Nine months later, Jorge was cured.
Jorge's treatment success came not from coercion but from human connection. This was DOT as John envisioned it: intensive support delivered through authentic relationships.
John understood that effective DOT requires we meet patients where they are. One patient loved to fish, so John brought worms to their appointments. Another patient refused treatment unless he could have a beer with his pills. Critics called this unprofessional, but John brought the beer. He recognized that perfect adherence with alcohol was better than perfect non-adherence without it. John's patients didn't just take their medicine; they gained trust.
DOT reduced NYC's tuberculosis incidence by half and cut multidrug-resistant cases by 80%. The secret wasn't heavy-handed supervision but comprehensive care that addressed patients' real needs. John's approach scaled globally through the World Health Organization's DOTS strategy, and it has been used to treat tens of millions of patients worldwide.
The science speaks clearly
The backlash against DOT gained momentum from misguided research that fundamentally misunderstood what effective DOT entails. An influential analysis focused on "supervised swallowing," where health workers watched patients ingest pills with no additional support, education, or relationship building. When this sterile, transactional approach showed no benefit over self-administered therapy, critics seized on the results as proof that DOT was ineffective. But the study proved only that bad DOT doesn't work—a conclusion Sbarbaro could have predicted.
New evidence validates John's insights with great precision. A meta-analysis in PLOS Medicine examined thousands of patients across multiple studies. Self-administered therapy showed significantly lower treatment success rates compared to DOT—a relative risk of 0.81 in cohort studies. Patients on self-administered therapy developed drug resistance at four times the rate of those who received DOT (relative risk 4.19).
These numbers represent real people who face preventable suffering. Drug-resistant tuberculosis kills. It spreads to family members, coworkers, and communities. John understood that incomplete treatment doesn't just harm individual patients—it threatens entire communities.
Community-based DOT is even more effective than clinic-based approaches; it leads to a substantial increase in treatment success. This aligns perfectly with John's original vision of accessible, patient-centered support.
Beyond surveillance to support
Critics rightly object to DOT implemented as mere surveillance. John would agree. His early work at Denver's Eastside Neighborhood Health Center—one of America's first community health clinics—demonstrated his commitment to dignity and respect. He served patients others ignored and proved that effective care requires genuine relationships.
Transactional DOT, where a patient is watched when they swallow pills, is not very effective. Relationship-centered DOT addresses housing instability, food insecurity, mental health challenges, and social isolation. It transforms health workers from watchdogs into advocates and creates partnerships that extend far beyond tuberculosis treatment.
Modern innovations build on John's foundation. Video-observed therapy allows patients to receive supervised treatment without transportation barriers or time away from work. Community health workers provide culturally appropriate care in patients' own languages and neighborhoods. These advances honor John's core insight: effective DOT adapts to patient needs rather than forcing patients to adapt to rigid systems.
The path forward
Today's DOT critics raise legitimate concerns about coercive implementation and human rights violations. John's legacy provides the solution. He proved that DOT works best when delivered with compassion, flexibility, and genuine partnership.
The goal isn't control but care.
We must reject false choices. Respect for patient autonomy doesn't require the abandonment of effective interventions. The science overwhelmingly supports DOT, particularly for the prevention of drug resistance. Our obligation is to implement DOT in ways that honor both scientific evidence and human dignity.
Over four decades, John Sbarbaro perfected this balance. He mentored physicians and influenced global tuberculosis policy through quiet persistence and methodical excellence. His Denver Public Health colleagues honored him with a memorial lecture series to ensure that his insights reach new generations.
Evidence-based but humane, systematic but flexible, authoritative but respectful
The tuberculosis bacteria doesn't care about our ideological debates. It exploits every gap in treatment, every missed dose, every incomplete regimen. John Sbarbaro dedicated his life to closing those gaps through science-based, relationship-centered care. His legacy reminds us that public health's greatest achievements come not from the choice between effectiveness and compassion, but from the refusal to accept that choice at all.
Modern DOT must embody John's vision: evidence-based and humane, systematic and flexible, authoritative and respectful. The data proves DOT saves lives and prevents drug resistance. It also suggests that DOT results in faster community-wide control of tuberculosis. John showed us how to implement it with dignity intact. That mission continues in every community health worker who builds trust across language barriers, every clinic that adapts treatment to patient needs, and every program that chooses partnership over paternalism.
John Sbarbaro got it right from the beginning. The science has caught up with his wisdom.
Dr. Tom Frieden is author of The Formula for Better Health: How to Save Millions of Lives – Including Your Own.
The book draws on Frieden's four decades leading life-saving programs in the U.S. and globally. Frieden led New York City's control of multidrug-resistant tuberculosis, supported India's efforts that prevented more than 3 million tuberculosis deaths, and led efforts that reduced smoking in NYC.
As Director of the CDC (2009-2017), he led the agency's response that ended the Ebola epidemic. Dr. Frieden is President and CEO of Resolve to Save Lives, partnering locally and globally to find and scale solutions to the world's deadliest health threats.
Named one of TIME's 100 Most Influential People, he has published more than 300 scientific articles on improving health. His experience is, for the first time, translated into practical approaches for community and personal health in The Formula for Better Health.
Thanks Tom. Well written piece but more importantly it brought to mind fond memories of John.
Simply put, treating patients like people is more successful than treating people like their diseases.
I think this is why we so often hear (and see) that patients their NP (usually a woman) over the MD (often a man), or indeed any male provider. Generally speaking women tend to connect better.