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Vol. 33 Function of the Health Officer in the Control of Tuberculosis among Veterans* LOUIS I. DUBLIN, PH.D., F.A.P.H.A. Third Vice-President and Statistician, Metropolitan Life Insurance Company, New York, N. Y. ON previous occasions, I have Let us review the development of the pointed out that the tuberculosis tuberculosis problem among veterans problem in the United States is on the and what has been done to meet it. way to solution, and although war con- During the first World War, knowledge ditions may cause a setback, this may and facilities for the diagnosis of tuber- be expected to be only temporary. culosis were inadequate to screen out at There are, however, a number of diffi- induction many of the men who were culties which must be overcome before suffering from the disease, particularly our tuberculosis problem is finally re- in the early stages before symptoms ap- solved. For example, there is still a peared. This fact resulted in the later heavy concentration of the disease discovery of many active cases in the among Negroes, Mexicans, and Indians. Army; the hardships incidental to the Less serious, but nevertheless trouble- training program and to war duties pro- some, is the high incidence of tuber- duced still more. After the war, care culosis in certain occupations. Today, of these tuberculous veterans was en- I wish to call your attention to a third trusted to the newly organized Veterans' situation, namely, tuberculosis among Bureau. Many hospitals and sanatoria the veterans of our armed forces. In were erected for their treatment, and our campaign to eradicate the disease, this service became a major medical this constitutes a hurdle whose magni- activity of the bureau, and of its suc- tude and insidiousness have not been cessor, the Veterans' Administration. sufficiently appreciated. I am sure As early as 1923, there were 23,653 that health officers will wish to know veterans with tuberculosis admitted for the facts and will be eager to deal treatment in hospitals or other agencies with this difficulty, as well as with the supported by the bureau. At first, such other two which I have mentioned. -care was limited to those whose tuber- Their help is particularly needed in culosis was connected with their mili- creating a new setup for the veterans, tary service; but subsequently more now that we are involved in the greatest generous provision was made, so that war in our history, with larger numbers those whose disease was unrelated to of our own men and women in the armed their military service (non-service- forces than ever before. connected disability) also became eligible for treatment. As a result, the * Presented before the Health Officers Section of number of admissions for tuberculosis the American Public Health Association at the has continued large. As recently as the Seventy-second Annual Meeting in New York, N. Y., October 13, 1943. fiscal year 1942, after almost a quarter  1426 AMERICAN JOURNAL OF PUBLIC HEALTH Dec., 1943 century, the total hospital admissions an incentive to many men to discontinue for the year numbered 9,658. For the hospital treatment and to attempt a entire period since the last war, there cure at home. have been over 300,000 admissions of The standards of operation in tuberculous veterans to hospitals of the veterans' hospitals are of a high order, Veterans' Administration or to other as is indicated by the ample sums set government, state, or civil institutions. aside for cost of treatment. Thus, in However, as we shall see later, these 1942, excluding overhead costs, the per admissions do not correspond to that diem cost of operation for the tuber- many different patients. culosis hospitals of the Veterans' Ad- The government has been most ministration was $4.37 per patient. generous in meeting its obligation to This has brought the total direct costs tuberculous veterans. There has been of treatment during 1942 to about an extraordinary expansion in the $8,000,000. Payments to veterans with physical facilities for treatment. No either partial or total disability due to efforts or funds have been spared in tuberculosis, whether or not service- erecting hospitals of the latest type with connected, amounted to approximately excellent equipment, and with as good $40,000,000 during the fiscal year 1942. medical personnel as could be obtained. It is notable that the number of such In March, 1942, there were 5,217 beds cases for World War I still numbered in operation to meet current needs, in- 63,000 in 1942. The great majority of cluding those of veterans of the present such persons are receiving pensions for war. This figure includes beds for the permanent partial disability. The num- tuberculous in veterans' psychiatric ber receiving disability payments is hospitals. The number of beds for many times that receiving treatment in these purposes has naturally declined, hospitals. The amount paid in disa- as tuberculous admissions have become bility claims over the last twenty-five fewer. In addition to having all the years is in the neighborhood of a costs of their hospitalization and trans- billion dollars. In addition, there have portation to the hospital paid for by the been substantial payments to depend- government, tuberculous veterans also ents of tuberculous veterans who have receive a disability payment. Those died. with service-connected disability re- In spite of the extraordinary develop- sulting from active pulmonary tuber- ment of the services for tuberculous culosis receive from $70 to $100 per veterans, the experience of the veterans' month, depending upon the degree of hospitals has been unfavorable. Thus, disability. Those with non-service- in 1942, of the 9,854 cases discharged connected disability receive $40 per from these hospitals, only 1.9 per cent month, if totally and permanently dis- were designated " arrested" at dis- abled. However, those without de-- charge; only 0.3 per cent " apparently pendents receive a much smaller pay- arrested," and only 0.8 per cent ment during hospitalization-$20 in " quiescent." If we combine these three service-connected cases and $8 in non- categories, the fact emerges that only service-connected cases. For men who 3 per cent of the patients discharged are treated at home, there is available during the year were medically re- an additional payment of $50 per month habilitated. The remainder of the cases to the wife or other person attending were discharged as "condition im- the patient. I should point out here proved " 32.7 per cent; " condition un- that these financial arrangements have improved " 28.9 per cent; " dead " had the unfortunate effect of providing 19.5 per cent; and " condition not Vol. J33 TUBERCULOSIS AMONG VETERANS 1427 stated " 16.0 per cent. It is clear that cases in these three categories-61 per the vast majority of the patients dis- cent of the total discharged. The ex- charged were not yet ready to be re- perience of the Mount McGregor Sana- leased to civilian life. The so-called torium of the Metropolitan Life Insur- " improved " cases represent, for the ance Company for males discharged be- most part, patients with unstable tween 1919 and 1936, and excluding lesions. As a matter of fact, a very incipient cases, showed that 48 per cent, large proportion of them left without or practically half of the cases, were authorization or consent. Thus, the "arrested," "apparently arrested," or Veterans' Administration itself classi- "quiescent" on discharge; and even fied the hospitalization of 58 per cent for the cases far advanced on admission, of the cases as " incomplete." The this proportion was 34 per cent. 1942 figures on condition at discharge There are clear reasons why this de- from the Veterans' hospitals are rather plorable situation among tuberculous typical, somewhat worse but not greatly veterans has developed. The failure is different from those of earlier years. not due to lack of desire to help these At no time since 1929, when the men. It was certainly the aim of present type of report of the Veterans' everyone connected with the service to Administration began, has the-total for do as much as possible for them. The the "arrested," "apparently arrested," chief difficulty was lack of appreciation and "quiescent" reached 6 per cent. on the part of legislators and others Admittedly, one cannot make exact interested in veteran welfare, of certain comparisons among various sanatoria fundamental conditions necessary for as to results of treatment on the basis the effective treatment of tuberculous of crude figures of this type. This is patients. In part, outside pressure was particularly true now, for with the brought to bear to liberalize financial passage of the years, the usual case ad- provisions for these veterans. The mitted to the veterans' hospitals is of effect of these measures has been to re- the chronic type common among duce control over the movement of middle aged and older persons. Thus, tuberculous patients to a minimum. of recent admissions, only 4 per cent The veterans are not subject to the were "incipient" cases, 22 per cent usual type of hospital restrictions, but were " moderately advanced," and 74 may come and go almost at will, per cent were " far advanced." With irrespective of their condition and all due allowance for this fact, there is against medical advice. There are cases a painful contrast between these recent on record where veterans with tuber- figures (as well as those of earlier culosis have left and then been read- years) and the results obtained in well mitted as many as 24 different times. managed state, municipal, and private Six to 8 admissions of the same patient sanatoria. Thus, in a country-wide sur- are a common occurrence in spite of vey of tuberculosis hospitals and sana- much effort on the part of Administra- toria in the United States during 1933- tion officials to educate and persuade 1934, made by the American Medical patients to stay in hospitals until com- Association, patients with tuberculosis pletion of treatment, and in spite of "arrested," "apparently arrested," or certain measures to control offenders "quiescent" on discharge, accounted through exclusion from re-hospitaliza- for 29 per cent of the total discharged. tion for certain periods. The type of A survey of discharges from the discipline that is so essential to success Michigan State sanatoria from 1930 to in the care and treatment of the tuber- 1934 also showed a high proportion of culous patient is lacking, for the most 1428 AMERICAN JOURNAL OF PUBLIC HEALTH Dec., 1943 part, in veterans' hospitals. Indeed, methods of improving matters, and, in the laws and practices relating to these due course, the necessary legislative veterans have so developed that it is measures will come up for consideration. often financially advantageous for the In an effort to get tuberculous veterans patient to leave or to stay away from to resume sanatorium treatment and the hospital altogether. This, of stay until satisfactory results are ob- course, is an impossible situation. It tained, the American Legion is launch- has served to undermine the morale ing a campaign to have each local both of the tuberculous veterans them- branch do the necessary missionary selves and of the doctors and other work among members in its own locality members of the professional staffs and to see that the veterans continue serving them. hospital treatment until discharge by But the situation in the veterans' the doctor. hospitals has had results which most As health officers, you can help in health officers will consider more seri- many ways. First of all, you can ous even than failure to rehabilitate bring pressure to bear for revision of men already suffering from the disease. the generous but ill-advised legislation The discharge of men before they are that has been in part responsible for cured has left its toll on the entire present conditions. The current laws country. It has allowed thousands of are altogether too loose in their benefits veterans with active tuberculosis to re- to veterans. There must be new con- turn to civilian communities each year. trols to make these benefits not only It has made it possible for fairly large liberal but medically effective. Legis- numbers of open cases to live at home, lation must discourage the uncontrolled under little or no medical supervision. movement of tuberculous veterans until These men have traditionally been the disease is " arrested " or at least looked upon as wards of the federal until it is not a community menace, government and consequently the state just as the movement of psychiatric and local health officers have taken veterans is supervised and curtailed. little responsibility for them. Actually, Second, you can co6perate with the however, the control of the Veterans' Veterans' Administration in the fol- Administration over these men has been low-up of tuberculous patients who rather loose. Few of the patients have have left veterans' hospitals. The gotten well; the great majority have Veterans' Administration has indicated constituted an army of discouraged men that it will release such information to who have become centers of infection state and local health officers, and for new cases of tuberculosis in the routine procedures for getting such communities to which they have re- reports should be set up without delay. turned after treatment in the veterans' It will be the responsibility of your hospitals. departments to make available locally The authorities in the Veterans' the necessary social and medical serv- Administration, as well as leaders in ices for those tuberculous veterans who veterans' affairs, have become aroused are unwilling to use the federal facili- to the need' of correcting this whole ties. If these men are still in need of situation. It will not be any easy task sanatorium care, they should be hos- because it involves a rather complete pitalized either in state or local sana- change in viewpoint, and it touches toria. Whenever it seems necessary to what may be called a "vested in- invoke your legal power to enforce terest " in certain benefits. Considera- compulsory hospitalization or isolation, tion is now being given to specific you must do so. Vol. 33 TUBERCULOSIS AMONG VETERANS 1429 Apart from this, I would suggest that lack of discipline and mistaken gener- each of you investigate independently osity may not only take their toll of the facts with reference to tuberculous these young men-who should by all veterans in your own state or com- reason get well and be sent back to their munity. A canvass and follow-up of communities to take up a useful life the list of those who are reported to again-but may also seriously delay our have tuberculosis would probably show control of tuberculosis in the general many such cases in your jurisdictions. population of the country. As I have indicated, most of them are But we can avoid such a situation. I middle aged men, many of them centers am calling these difficulties to your of infection and chronic offenders attention because they can be met and against all reasonable hygienic precau- rectified right now, if we all work- tions. Because of their status as together toward a sensible program at veterans and their habituation to the the start. The present situation is loose hospital discipline which I have far more favorable than it was during mentioned, they feel privileged to do the last war. We have at our disposal pretty much as they please. These men excellent medical facilities and improved should be sought out and cared for, and, skills in treatment. The new crop of if necessary, isolated for the protection tuberculous veterans is more apt to be of their families and their neighbors. I in the early stage of the disease, when am convinced that this situation in your cure or arrest is most rapid and sure. local communities constitutes one of the The Veterans' Administration and the most serious difficulties in the national American Legion are both aware of effort to eradicate tuberculosis. the seriousness of the situation and are Frankly, I do not know how much eager to cooiperate with the state and we shall be able to accomplish with the local health officer in any plan to help old veterans. But I feel that a genuine veterans to be cured and to protect the and earnest effort must be made to pro- families of the men from infection. tect the new and large crop of tuber- Working toward the same objectives, culous veterans who will inevitably you health officers, together with these emerge from the present war. As early two, organizations and with a public as the beginning of July, 1942, their and government both increasingly aware number had already exceeded 800. By of their responsibilities toward the vet- this time, the war's tuberculosis victims erans of this war, should be able to are probably counted in thousands. bring about really constructive action. From present indications, there is dan- Through such an outlook and such ger that the Veterans' Administration teamwork, the young tuberculous vet- may be compelled to function under the erans should benefit by every medical same regulations and procedures which facility and enlightened service we can govern the care of veterans of World offer. There is every reason why a large War I. There is already evidence that proportion of them should return all is not well with the new tuberculosis to their homes as productive citizens, victims, and that they are showing the rehabilitated medically and industrially. same restlessness, the same abandon- As health officers, you have an extra- ment of regular hospital care, which has ordinary opportunity to contribute to produced such calamitous results among this program, and to shape the future the older men. The stage may be set of these veterans, as well as of the for another great medical tragedy; and tuberculosis movement all over the unless we take action, I believe that country.
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