Results in Baltimore. Results have been achieved in Baltimore by reason of a well-managed Health Department, acting in close co-operation with the institutions of both city and state. The tuberculosis machinery consists of a staff of seventeen special nurses; three special dispensaries with a physician in charge; a laboratory for sputum examinations; a fumigation corps and a steam sterilizer. With this force, we work in connection with three other tuberculosis dispensaries, and six institutions for the care of early and advanced cases. Some of these institutions are maintained by state appropriations, others by both public and private funds. The co-operation between these institutions and the Health Department is absolute; if the control was all through one, instead of a dozen different centres, it could not be more complete or harmonious. Failure in any one direction is felt down the line, consequently each is stimulated to its best effort. Thus, the nurse knows that if she fails to persuade her patient to enter the hospital, the hospital is useless, or that if the bad food of the hospital drives the patient back again to his home, the nurse’s work goes for nothing. Each reacts upon the other, and as all are working for the same end, there is constant incentive to become a strong, rather than a weak link in the chain. The results obtained cannot be measured in terms of individuals—we cannot point to so many patients improved, so many working, and so forth. Individual welfare is too shifting and too questionable a standard by which to judge. The only absolute standard is that afforded by the death-rate. A declining death-rate means also a decreasing morbidity—fewer people die of tuberculosis and fewer are infected. While our tuberculosis death-rate is still enormously high, it is nevertheless falling year by year. Thus we see:

Deaths from Pulmonary Tuberculosis:
19091400
19101234
19111165
19121189
19131129

There is nothing spectacular about this. It is heartbreakingly slow—needlessly, uselessly slow work. Yet it is progressing in the right direction.

Tuberculosis and Poverty. Throughout the foregoing pages we have considered the direct method of dealing with tuberculosis—the removal or segregation of the distributor. But there is also an indirect method of dealing with tuberculosis, namely the abolishment of poverty. Tuberculosis recruits full fifty per cent. of its ranks from people of a certain social level—the very poor. This class is composed of people habitually overworked, underpaid, and subject to all the deteriorating influences of unsanitary and vicious environment, and to the ignorance and degradation which follow in the wake of extreme distress. The root cause of these conditions is our present unjust economic system, which produces an excess of luxury and frivolity on the one hand, and on the other an army of people who must forego the barest necessities of life. One class is maintained at the expense of the other. Every movement which seeks to abolish this injustice, and to substitute a fairer and more equable system, is a movement which at the same time tends to raise the standard of public health. Any legislation, social or revolutionary, which makes for the improvement of industrial conditions, raises the level of public health through raising the welfare (i.e., resistance) of the individual. Therefore, sweeping readjustment of social and economic conditions would automatically eliminate an enormous amount of disease, by reducing the number of highly susceptible individuals. To increase the number of people with high resistance—or to decrease the number of people with low resistance, whichever way one chooses to put it—would probably diminish the amount of tuberculosis by about one half.

This indirect method—the readjustment of social conditions and the abolishment of poverty—valuable as it would be, would still leave the problem unsolved. Even diminished by one half, the amount of tuberculosis would still be formidable, and we should have to attack it as vigorously as ever, if not to the same extent. The disease would still exist, just as it now exists in well-to-do families in small towns, in rural districts, and in other circumstances attributable to neither poverty nor bad industrial conditions.

A thousand years ago, industrial conditions were as distressing as those which exist to-day—yet in those days the poor staggered under the additional burden of leprosy. A hundred and fifty years ago poverty was complicated by smallpox, the scourge of Europe. The rigid segregation of lepers in the Middle Ages relieved the situation of leprosy, while the discovery of vaccine has practically eliminated smallpox. The submerged classes, while their economic condition remained unchanged, were at least relieved of the added weight of these two great diseases. So in our present fight against tuberculosis. An aggressive campaign against this disease will not necessarily improve industrial conditions, but those who suffer most from these conditions will be relieved of one more handicap.

In our present warfare against tuberculosis we are not impelled by the blind fear that made society in the Middle Ages demand segregation, and refuse to tolerate an infectious disease at large in the community. Nor has any vaccine or similar agent been discovered by which the disease may be wiped out. Instead, we must depend upon a campaign of education—wholesale, widespread education, conducted amongst all classes of society. We know the path to be travelled, and the machinery by which we may gain our ends. If at any time we become impatient with our slow rate of progress, we can accelerate our speed by the extension and multiplication of the three fundamental agencies in the anti-tuberculosis campaign—the Hospital, the Dispensary, and the Public Health Nurse.

INDEX