Tuberculosis by chenboying


									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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