Address, “The Problem of Tuberculosis”
Dr. Farrand—Mr. President, Ladies and Gentlemen: The problem of tuberculosis in the United States is simple in its outlines. Stated in their lowest terms, the figures which describe it are sufficiently impressive and appalling. Increasing experience and added knowledge serve only to confirm earlier estimates and to emphasize the seriousness of the situation which confronts us. The vital statistics of our country are notoriously faulty and incomplete, but the lesson they teach must arrest the attention of every thinking citizen.
According to the census of 1910, treating the non-registration area on the same basis as that from which mortality reports were recorded, there were 150,000 deaths from tuberculosis in that year. This is, of course, an under statement by many thousands. Rigidly conservative estimates agree that the mortality from tuberculosis in this country is at least 200,000 each year and very probably considerably more. Let us for the moment, however, deal with the demonstrable facts and not enter the field of estimate.
The real problem is not the number of deaths from tuberculosis, but the number of living cases of the disease. In calculating this different methods have been employed. For many years, the ratio of three living cases to each death was used as an index of the situation in any community. It was quickly realized by those familiar with the situation that this proportion was far too low, but with our almost total lack of registration, figures to demonstrate the discrepancy were not available. With the improvement in recording the facts of disease in certain typical centers of population, it became certain, however, that a ratio of five to one was not only conservative but below the truth.
More recently records of great value have been obtained which confirm the convictions of experts and allow still sharper definition of the problem.
It has remained for the city of Cleveland to work out during the past two years a system of tuberculosis registration and administration which is undoubtedly the most complete in the country for a community of its size and complexity. Without going into details of method, notification, and registration have been brought to such a point in Cleveland that of all the deaths from tuberculosis now occurring approximately ninety per cent. have been previously recorded and under observation by the Department of Health, before death is reported. This is an achievement for a city of its population of extraordinary significance. There are in round numbers something over 700 deaths a year from pulmonary tuberculosis in that city of 600,000 inhabitants. There are in register and under observation at this time approximately 4,600 cases of tuberculosis. Allowing for the ten per cent. in the mortality not reported before the death, it is obvious that the number of living cases is over seven times the number of deaths and with slight allowance for the very large number of active cases in any community which have not yet come to diagnosis, we can demonstrate in that city a ratio of eight living cases for each death.
It is singularly fortunate that this demonstration has taken place in a community of sufficient size to include the problems in some degree of all our larger cities and to be regarded as reasonably typical of the situation throughout the country. It has also been shown that except for certain centers, where the problem of congestion is extraordinarily prominent, the rural situation in the United States does not differ appreciably from that obtaining in all cities and towns so far as the presence of tuberculosis is concerned. I have no hesitation, therefore, in asserting that we must from this time on raise our figures and use a ratio of at least eight to one in calculating the prevalence of tuberculosis on a basis of the recorded deaths from that disease.
Apply these figures to the country. The Bureau of the Census indicates 150,000 deaths a year. On this basis we have 1,200,000 living cases of tuberculosis. Let us not forget, however, that 150,000 recorded deaths is far below the actual number, for it is easy to show in most of our communities that many deaths properly to be assigned to tuberculosis are reported under other terms, and the area of the United States from which no statistics are forthcoming includes precisely those States where the mortality is high and the prevalence of tuberculosis demonstrably widespread. We are still absolutely certain that the mortality from this disease is at least 200,000 each year, and the number of living active cases more than a million and a half.
Such, numerically speaking, is our problem. What are the efforts for its solution?
Since the discovery of the bacillus as the cause of this disease in 1882, an organized campaign has gradually been developed. The inferences from the discovery of the cause were perfectly inevitable and indicated the lines of operation. It became entirely clear that tuberculosis, being due to a specific germ, was infectious, and it was equally clear that the bacillus and its life history being known, the disease was theoretically preventable. Here, too, the outlines of the campaign are simple, even though the details of operation are varied and the end in view baffling to attain.
It was inevitable that the first sporadic efforts based upon slight experience should have been more or less random, and that years of trial and proving should precede the establishment of definite method. Some degree of order is, however, emerging, and we are witnessing an increasing clearness of purpose and definition of attack in the preventive movement against tuberculosis which is now sweeping over the country and the civilized world.
While recognizing the unfortunate complexity of the social conditions whose maladjustment is perhaps the chief underlying factor in the problem, while recognizing fully the obligation to lend all possible aid to the betterment of those conditions, the administration of the campaign against tuberculosis has still conceived its specific task to be a direct attack on the sources of infection; this, because experience has indicated such procedure to be the best and most feasible means of prevention. As the logical conclusions of laboratory discovery and clinical experience began to express themselves in organized movement, it was recognized that the preliminary task in prevention was one of education; an education which should impress upon the public mind not only the fundamental facts that tuberculosis is infectious and preventable and the methods of its infection and prevention, but an education that should bring about an improved knowledge of public and private hygiene, and particularly an education which should create a public sentiment which could appreciate conditions and would support and even demand those measures which expert advice and experience might indicate as necessary. This educational propaganda, now so familiar, has been in the United States the particular province of private organization. The union of professional and lay effort in this latter day crusade has been one of the most inspiring of social phenomena and has already resulted in accomplishments of imposing dimensions.
With our political organization such as it is, this enlightened public sentiment is an absolute essential if the responsibility for the situation is to be an official one, and not left for the suggestive and stimulating but less final and efficient efforts of private philanthropy.
The insistence upon official responsibility has been made an essential point in our American campaign and toward its intelligent acceptance by public authorities all efforts are directed. As may well be appreciated, the attainment of this desired end is slow, even though ultimately inevitable.
In planning the campaign, an ideal program was not difficult to lay down. It included as fundamental:
1. The education of which I have spoken, not only as it applies to tuberculosis but as contributing to the solution of that problem of misery which is, after all, the chief problem of the day and which reduces in the last instance largely to terms of good or ill health.
2. Enactment or enforcement of protective laws of which the basis was that notification and registration agreed upon as preliminary to official knowledge and control of the situation.
3. Adequate institutional provision for all classes of cases; the sanatorium for the curable; the hospital for the advanced and hopeless, and dispensaries for early diagnosis and as centers for that all-important field of action, education and treatment in the homes of the poor.
The developments of the years have not served appreciably to modify the main features of this program. Emphasis has shifted from time to time and will continue so to shift, but the fundamentals remain more firmly established than ever.
In developing the movement in this country, the most effective means of stimulating action in our various communities has been the voluntary association for the prevention of tuberculosis. In organizing these societies the local community has been recognized as the essential centers of action. The effort has been made, therefore, to obtain in every community of considerable size an organization embracing elements both medical and lay which shall charge itself with the task of securing adequate official treatment of the tuberculosis problem as it there presents itself.
In many of our commonwealths such organizations can best be brought about through the action of a State society, whose special function becomes one of organization and of securing desired legislation. In other cases the initiative is local in origin. Where State societies exist, these act as co-ordinating agents for the affiliated local societies, and the National Association for the Study and Prevention of Tuberculosis acts as a clearing house for them all.
It will be seen at once that such organization is but preliminary, and would be entirely futile, did it not result in preventive measures of a definite sort. There is, however, no other index equally valuable of the vigor and growth of this movement in the United States. Speaking from the national point of view, the organized campaign in this country has been in existence exactly seven years. In 1905 there were in the entire country but twenty-one of these societies, while at the present time there are no less than 660, working in co-operation and presenting a united front to the enemy. There is no considerable area that does not contain some such center of intelligent action.
The carrying out of the program outlined a moment ago is the special function of the organized movement. In the development of this program it is historically interesting that it was institutional provision for tuberculosis that first obtained support. It was the sanatorium for the cure of curable cases with its peculiar appeal which first engaged attention. From our present point of view, it was perhaps not the logical beginning, but it was certainly the obvious and perhaps the most fortunate point of attack. The sanatorium with its promise of restoring to a wage-earning capacity those unfortunates who formerly had been regarded as doomed to a speedy and inevitable death, was peculiarly fitted to arrest public attention and to engage public support.
As the movement for sanatorium establishment developed momentum, attention turned to the need of special dispensaries as logical centers of preventive work. Time will not permit even an outline of this phase of the problem. Suffice it to say that with the first general survey of the movement in the United States, six years ago, there were in the country but eighteen dispensaries exclusively devoted to tuberculosis. There are today more than 400 such foundations and their number is increasing at a rapid rate. All those who deal hand to hand with the problem become impressed at once with the fact that tuberculosis is pre-eminently a disease of social life, of living and working conditions. In the absence of adequate institutional facilities it is unavoidable that the problem should be attacked in the homes and workshops of the people, and with such weapons as may be at hand or which can be devised. With early diagnosis and careful instructive nursing supervision, much can be done even in the distressing conditions which characterize the crowded and poorer quarters of our great cities. The center of activity in this field is everywhere the dispensary, and the elaboration of its function to include supervision in the homes of indigent patients has been one of the most interesting and important of recent developments.
The third and possibly the most important aspect of institutional provision was the last to be taken up with energy. Every survey of our equipment during recent years has served to emphasize the shocking lack in our facilities for the care of advanced cases of tuberculosis. It has become increasingly evident that as centers of infection the consumptive in the advanced stages presented the most serious problem. Equipped as we were, with a healthily growing movement along educational, sanatorium and dispensary lines, the time seemed ripe for a vigorous attack on this point of weakness. The result has been that during the last four years there has been a concentration of energy in this direction and a notable advance has been made. Without pausing to specify various kinds and degrees of hospitals and sanatoria for the treatment of tuberculosis in the United States, it is encouraging to note that we now have over 500 in the country, as compared with 111 seven years ago. The number of beds contained in these institutions is approximately 30,000, a number small when compared with the need, but encouraging when compared with the situation but a few years since.
The third feature of the program already mentioned, that of legislation, is less susceptible of numerical expression, but it is in many ways the most fundamental and most significant of advancing intelligence. The principle of compulsory notification and registration has been insisted upon from the outset, and it has now come to be fairly generally accepted in all parts of the country. With few exceptions the more important States provide for registration by enactment either of the Legislature or of the State health authorities. In most of our larger cities local regulations are also on the statute books. Unfortunately the enforcement of these regulations is far behind their expression, but the situation is rapidly improving, and the example of such cities as New York in initiating the principle, and of Cleveland in demonstrating its possibilities, is of inestimable value.
In dealing with the question of public hospital establishment, the best adapted political unit has caused much embarrassment where a given community is not large enough to support an independent institution. Federal provision is agreed upon as being out of the question. The State as such is in most instances regarded as having the same limitations to a lesser degree as the national government. It is fairly generally accepted that where the municipality is of sufficient size it should accept responsibility for its problem. In those sections where communities of lesser population are the rule, the county is now in the focus of attention.
Little difficulty has been encountered in procuring the necessary legislation for local and county institutional provision. We have now reached the point where the possibility of mandatory State legislation is being considered with care and some favor. In this connection one should note the recent passage by the Legislature of the State of New Jersey of a law which undoubtedly represents the most advanced legislation in the United States and probably in the world. Without going into details, the law in question provides for the establishment of special tuberculosis hospitals in all the counties of the State, for the payment by the State of a certain sum ($3.00 per week per patient) toward the maintenance of such hospitals, for the compulsory segregation in such hospitals of dangerous and incorrigible cases of the disease, and for the general supervision of these provisions by the State Board of Health, though the primary responsibility is placed upon the local health officer. This legislation is of the highest interest, not only in its promise of results, but as an enactment into law of principles formulated as necessary by expert experience even though in advance of public appreciation.
Reaching into every field of social activity as this campaign must do, it is inevitable that new phases of importance should successively make their appearance and demand attention. I should say that perhaps the most striking is the essential importance of the child in the tuberculosis problem. With improved methods of diagnosis and wider facilities for examination, there has been shown a prevalence of tuberculosis in children of school age that is most alarming. It is a conservative statement that there are today in the public schools of the United States 100,000 children who will die of tuberculosis before they reach the age of eighteen if the present rate of mortality be continued. A very recent estimate presented by the United States Bureau of Education states that at least 15,000,000 children now in attendance in the schools of the United States are in need of a physician’s attention, and that of this number 1,000,000 have or have had tuberculosis. It has become clear that if our educational campaign in the interest of preventive medicine and public health is to achieve success, the attention must be concentrated upon the coming generation rather than upon those who have already passed their years of plasticity.
We see, then, on every hand the tendency to attack the problem in the schools, and this not only by the establishment of provision for open air teaching and the improvement of the undernourished and the predisposed, but upon insistence of regular and intelligent instruction as to the prevention of disease.
Such in its general outlines is the plan by which we are working. With such a situation and with such a campaign what then is the outlook? I have little sympathy with the enthusiasm which deals in specific predictions or which assigns a date for the practical achievement of theoretical possibilities. It is perhaps inevitable that an impatient public should demand results before definite results can be forthcoming. There is, on the other hand, a corresponding obligation for conservatism in expression when indicating probable or even possible results. A drop in the mortality curve of a slowly developing and slowly progressive disease such as tuberculosis, is not a matter of months but a matter of years. It is unjustifiable to expect results from the specific campaign against tuberculosis in an observable diminution of mortality for some years to come. I believe, however, that we have reached a point where our equipment is such as adequately to test our basis of operations and to warrant an optimism as to the future if our reasoning and method be correct.
Believing as we do, that the soundness of the procedure is certain, it would seem reasonable to expect a response in the mortality tables within five years, and that ten years should afford indisputable proof.
There is, of course, no doubt that tuberculosis is diminishing and has been diminishing for a generation. This decrease is not to be assigned to the specific warfare against the disease, but is doubtless correlated with other factors. It is uncertain whether we are to assign as its cause the general improvement in public hygiene or whether there may be perhaps an acquisition of immunity gradually extending through the civilized world. In my own judgment this decrease in the prevalence of tuberculosis is associated with the improvement in hygienic conditions which has been so marked during the last fifty years. I believe we are justified in expecting an acceleration in this diminution as a result of the specific measures now being adopted not only here but in Europe. While we cannot interpret them with confidence, there are already appearing certain figures of possible significance. It should not be forgotten that the first result of all concentrated activity and interest is a greater accuracy in mortality and morbidity statistics, and that an actual decrease in tuberculosis might appear in official reports as an apparent increase in the disease.
Taking all these factors into account and viewing the situation candidly and with all the precautions possible, I do not hesitate to assert that optimism as to the future is justified, and that the end of the present decade will witness the beginning of another drop in the mortality curve comparable to that which was seen in the closing years of the last century. (Applause.)
President White—Dr. W. C. Mendenhall, of the United States Geological Survey, at Washington, was expected to be here this morning to speak upon the subject of “Water as a Natural Resource.” He is unable to be present, and Mr. Jacob P. Dunn, Secretary of the Indiana Historical Society, will now have ten minutes to discuss “The Conservation of Navigable Streams.”