512 TUBEROLE [August, 19~

GAPS AND FLA'VS IN THE PUBLIC HEALTHADMINISTRATION OF TUBERCULOSIS.

By JANE WALKER, M.D.Medical Superintendent, East Anglian Sanatorium, Nayland.

THE public health administration of tuberculosis as such dates fromthe year 1911 , when the National Insurance Act was passed. This Actcontained important provisions with regard to tuberculosis, and in orderto deal with the problem of treatment, a Treasury Committee (Depart..mental Committee) was appointed by Mr. Lloyd George, then Chancellorof the Exchequer. This Committee drew up a scheme for the provisionfor the treatment of tuberculosis in sanatoriums or other institutions orotherwise. It began by making the dispensary the first unit in tbi.scheme, to act as a clearing house for all the insured cases in the area inwhich it was situated. Thence the patients were to be drafted tosanatoriums, homes for advanced cases, and so forth.

It is, of course, a matter of history how the rank and file of the medicalprofession opposed the working of the whole Act, and of how they weNbribed or persuaded to see it differently by the presentation to them of6d. out of the Is. 3d. per insured person provided under the Act for theprovision of treatment of persons suffering from tuberculosis. Medioaleducation was so unsatisfactory that the desirability of an expert in thediagnosis and treatment of tuberculosis to deal with the cases rather thanthe general practitioner seemed imperative at that time. Even now thegeneral practitioner, who is the person who can, if he or she will, tell u.the most about the beginnings of this or any other disease, does not forma really integral part of the scheme. It is a serious flaw in the wholeadministration of the scheme, that the general practitioner is not nearlyas intimately connected with it as he should be.

Another flaw is the position of the Medical Officers of Health in ihoscheme. In the majority of instances the entire control of tubereulosiaadministration is in their hands, and they do not always possess a personalknowledge of tuberculosis treatment.

But the really serious gap seems to me to be the absence of BoDy

organised provision for the after-care of patients who have had tre80tmeDtat an institution and are discharged. In the Report of the DepartmentalCommittee, as well as in all the various communications made to it bynumerous people pushing one or other scheme for dealing with theproblem, after-care simply means the provision of a separate bed or II

shelter, or additional help by way of food, milk, eggs, and so forth, andattention, nursing and medical, at home . The Report is most emph"tioon the subject. It declares that the importance of after-care cannot beexaggerated-unless the provision be efficient and systematic the spread ofthe. disease will not be checked . The necessity for raising patients'reSistance is, however, not adequately stressed. At the risk of beingcharged with wishing to regard a tuberculous person as always tuberculoua-certainly perhaps the larger proportion of them may be-I would urge

Au~ust, 1927j THE ADMINISTRATION OF TUBERCULOSIS 513

that no after-care is of any use that does not take into consideration thequestion of what occupation the patient can do-of course, I am assumingthat any sanatorium worth the name will have a department of occupationaltherapy. Many of the patients, perhaps the bulk, will go back to their oldoccupations. This is probably the best thing they can do, for they knowit best and so do it best, with the least anxiety and the most money.But there is a considerable number who cannot do this. Apparently, ittook a great upheaval like the war to make us realise that many patientshave to be re-educated. It is no part of my present purpose to describethe schemes for the training of ex-service men, and I will only say herethat they seem to me to have been well worth while from our point ofview-they taught us medical practitioners a great deal about humannature, as well as many other things.

Now after-care, though of paramount importance, is extremely difficultto carry out because all the schemes deal with tuberculosis on a county'and not on a national basis. If you happen to be trying to carry outafter-care by means of one of its most important provisions, viz., that ofproviding suitable occupation for ex-patients, and your institution is in areactionary county, your difficulties are immense. If patients break down,and if they have not been born where they are working (and indeed some­times even if they have), you can get no adequate treatment for them.They do not break down more often than healthier people do (sometimesonly after eight to ten years of work) but they must be dealt with. But ifa county refuses to help them in any way, what are they to do? In myown case, where out of a staff of 150 at least 64 are ex-patients, all newmembers of staff are in~ormed that if and when they break down, howeverlong they have been WIth us, they must go home and qualify in their owncounty for treatment. This may entail a delay of three months, which isthe period of time during which a person must reside to qualify for treat­ment. If it were not for the kindly manner in which we are dealt with bymany of the local authorities from whom our staff is drawn, many really83rious hardships might have arisen.

In connection with the after-care of patients, the Society of Superin­tendents of Tuberculosis Institutions has recently appointed a subcommittee to draw up a scheme dealing with the subject. It is hoped toform a sort of Employment Bureau to which those who want work canapply as well as those who are requiring workers. In the first instance,may I respectfully urge all those sanatorium superintendents, tuberculosisofficers and others, to employ ex-patients in every possible capacity, suchas nurses, domestic staff, both male and female clerks. and indeed almostany junior post. Believe me, they will be amply rewarded by the devoted,loyal service they will obtain.

To summarise, in my judgment, the chief gaps are :-(1) Non-eo-operation of the general practitioner, with whom lies the

conduct and care of the disease in its earliest manifestations.(2) The control of tuberculosis is largely in the hands of medical

officers of health, who often have no personal experience of the treatmentof tuberculous persons.

(3) The very limited understanding given to the term after-care.