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ANTI-TUBERCULOSIS ORGANISATION IN AMERICA.

By JOHN DUFFY.

A MERICAN public health and social workers were amongst the first to realise the significan.ce of the voluntary association as a definite weapon in the anti-tuberculosis

armamentarium, one with possibly :greater potentialities for the eradication of tuberculosis than the sanatorium movement then coming into vogue. IWithin ten years of Koch's momentous announcement in 1882, Biggs in New York and Flick i n Philadelphia--the two largest cities in America at that t ime-- conceived the possibilities of community organisation to fight the disease.

Without any official backing, in 1892 Flick organised the Pennsylvania Society for the Prevention of Tuberculosis. This was the first voluntary association in the United States. At this time three European countries were already in the field of the voluntary movement: von Schroetter, at Vienna, had organised the Society for the Establishment of Sanatoria for the Con- sumptive Poor in 1890; Armingaud, at Bordeaux, formed the French League Against Tuberculosis in 1891; whilst in the same year the National League for the Campaign Against Tuberculosis of Denmark was organised by Lorentzen and Rordam. At this time also Philip, at Edinburgh, was in close touch with the Ch~arity Organisation Society with a view to founding the Royal Victoria IIospital Trust of Edinburgh, which serves all Scotland.

In 1893 Biggs worked out a very comprehensive programme for the control of tuberculosis in New York City; to this he added during the next decade additional measures, rounding out to a large extent his conception of what a complete local tuberculosis p~'ogramme should be. Amongst other items he recommended the organisation of '.~ non-official voluntary tuberculosis associ- ation of a community organisation designed to supplement the activities of ¢he Health Department and to promote opinion favourable to the development of the official programmes.

One of the first of such organisations with a full-time executive was the Committee on the Prevention of Tuberculosis of the Charity Organisation So.ciety of New York, formed in 1902. The purposes and programme of this early committee were:

1. Research into the social aspects of tuberculosis. 2. Education of the public in regard to the nature,

treatment and prevention of tuberculosis. 3. Encouragement of movements f~r the building of hospi-

tals, sanatoria and provision of other agencies for the care and treatment of tuberculosis.

4. Relief of indigent consumptives.

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With the growth of the tuberculosis campaign the last o~ these four purposes has been gradually shifted to the sho~ldera of specialised relief-giving agencies, public and private, leav']n~' most of the effort of the tuberculosis associations ~L:ee t(~ cxpe~d itself on the other three.

To co-ordinate these pioneer activities and to establi:.~T~ ~ew ones was largely the task of the National Tuberculosis Associ- ation, founded in 1904=. When it opened its office in 1905, it found very little organisation for the control of tuberculosis ou!:side the larger cities such as New York, Philadelphia, Boston and Baltimore. No state organisations were functioning in a broad way. Of clinics there were about 25, most of them poorly equipped, and with little real conception of their task. There was a number of institution, s for the treatment of tuberculosis, but most of them were eitl~er private sanato~ia or public institu- tions with low standards. The field w,~s largely, therefore, ~ virgin one. The National Tuberculosis Association conceived as its first task the education of the public with regard to the nature, prevention and treatment of tuberculosis. A brosd extensive educational campaign was organised for several yeats. Its second great task was the development of organisatio~ on a state-wide basis for the control of tuberculosis. It w~s nr.,~ until about 1917 that this task was finally completed. Its third aim "~,as the standardisation of tuberculosis work, and its fourth out- standing task has been and still 'is the promotion of research in the social and medical aspects of tuberculosis.

There are at present some 1,500 tuberculosis associations duly organised and constituted for the purpose, as well as another group of 600 organisations functioning directly and indirectly with the tuberculosis campaign. According to the best practice they are democratically organised, and give representation on their directing boards to all groups having a definite interest in tuberculosis. They are organised on municipal, county or state lines, and are all under the regis of the National Tuberculosis Association.

From the point of view .of form and programme the tuber- eulosis association is essentially a community organisation, representing the community interests ~of the city, county or state which it serves, and engaged in a comprehensive community pro- gramme. It is non-official, that is, organised, operated and main- tained without the support of any public tax funds, and independent of ,all public agencies. In addition to creating public opinion favourable to the working of official health departments, it fulfils a vital function in maintaining for the l:atter favourable public opinion and support. It is really the " conscience ef the people ", always on guard to see that the best interests of the public are maintained, and also, on the other hand, ready to commend and help forward by every me'arts in its power the work of the official public health departments. Thus the distin- guishing feature of the programme for the control of tuberculosis

ANTI-TUBERCULOSIS OR(?,ANISATION IN AhIERICA 55

in the United States is the peculiar vhle and sometimes major participation of the voluntary association. To a large degree this participation of non-official agencies ret:lects the individual character of democracy in the United State as contr:~sted with Europe. I t is also a reflex o¢ that spirit of philanth~'opy com- bined with business organisation so characteristic of the American people. In England and on the Continent there are uon-offlcial tuberculosis associations in most communities, but they ere not ef the same character, nor do they exercise the functions of similar m'ganisations in the United States. They are for the most part designed either to provide aid and relief for a limited clientele of tuberculous patients, or to supplement the specific programme of some governmental agency. Very few have a broad community programme or organisation, and they assume as a matter of course that the local or national government is the real agency ~hat is carrying on the tuberculosis campaign. In America, on the other band, governmental participation and leadership in tuberculosis work is not taken for granted. In fact there is no central governmental programme in America worked out for the 48 states, as in En~'land and Australia for instance. The stimulus to local and state 'action comes largely from the voluntary groups, who are thus in great measure responsible for lhe extensive and intensive development of the tuberculosis movement. I t is not too much to say that without these non- official associations the tuberculosis movement in the United States would not have reached its present state of efficiency.

To attempt any estimate of the beneficial effects of the work of such an organisation as the National Tuberculosis Association would be well-nigh impossible. In 1900 the death-rate from tuberculosis in the United States was 200 per 100,000 of the popu- lation and in New York City it was 300. In 1940 the rates were 46 and 54 respectively. In 1900 there were only 4,485 beds in 19 different institutions in the United Stetes. In 1938 there were 98,801 beds in 1,140 institutions. (Miller, J. A. (1942) : Am. Reu. Tub., 45, 637.)

A child-health education movement begun in 1916 by the National Tuberculosis Association has been so successful that all school children are now receiving systematic health instruction as a routine part ,of their school curriculum. Tuberculin testing and x-ray surveys are now an established procedure in an increas- ing number of high-schools, colleges and universities. By keeping the problems of tuberculosis continually before the public, by collecting and distributing information, by advocating the adop- tion of new and improved methods to fight ~he disease, in these and 100 other ways the National Tuberculosis Association has proved itself a most effective weapon in the tuberculosis campaign in the United States.