A Concept

T ODAY a new and inspiring goal beckons to tuberculosis and public
health workers. Much has been done in the past, with our sights set upon
co~ztrol of tuberculosis. But all that has been done before is but the prelude
to the job ahead - its e~u.ddicutio~r.

That goal is eminently feasible. The tools we now have are, in the main,
basically adequate. Some new ones will have to be devised. What is need-
ed most is conviction that tuberculosis cu~z be eradicated, and the will to
do the job.

The specific goals we must work for will differ from those in the past.

Their form cannot be spelled precisely and in all details. But:
   -We must improve and expand our methods of case detection
   in order that new cases may be picked up before their disease
   has been implanted in others ;

-We must do a better job than we have ever done before in
finding the source of infection among young children and others
who react positively to the tuberculin skin test;

-We must aggressively seek supervision and treatment of every
known active case until there is no danger of infection of other
persons ;

-We must use isoniazid effectively and promptly to prevent
open, tuberculous disease among young children who are posi-
tive reactors to tuberculin and among older children and adults
who have recently converted from a negative to a positive skin test.
-We must recognize that in seeking eradication, our greatest
difficulties lie ahead. They will come into view as the eradica-
tion campaign gains experience. But so too should their solutions.

In short, we have one immediate, intermediate and final goal for our TB
eradication program: to block all transmission of infection from one individ-

THE   CRUSADER


0      n

ual to another. This must be our constant objective, even though we must
begin with specific population groups or geographic areas.

To achieve this end, we have some machinery, including health depart-
ments, sanatoriums and voluntary tuberculosis associations. But these are not
enough. The program for eradication of tuberculosis must have the enthusi-
astic support of physicians, both as individuals and as members of organiza-
tions ; other health and welfare agencies, to share in cooperative activities ;
schools, press and airwaves, to inform the public; informed volunteers to
educate, promote and demonstrate. Legislators must be encouraged to support
"all-out" eradication programs now in order that "control" programs will
not have to be financed indefinitely.

T 0 ALL of these groups there must be a new dedication: to 17:: away any
sense of complacency over past achievements. Whenever groups of peo-
ple are exposed to tuberculosis because case-finding programs have lagged,
whenever children react positively to tuberculin, whenever advanced cases
are discovered, we must ask ourselves, "Why have we failed? How can we
prevent it happening again?"

Already we have small areas where the chain of infection has been bro-
ken, where no children react to the tuberculin skin test. These "eradicated"
areas demonstrate that prevention of infection is an attainable goal. From
these small areas of already achieved victory a widening program of eradi-
cation must spread until we are able to say, "Tuberculosis is conquered."
BE IT RESOLVED, that the Wisconsin Anti-Tuberculosis Association invite
    its professional and lay co-workers, both in agencies and as indi-
    viduals, to join in seeking the goal of eradication of tuberculosis
    and not merely its control ; and

BE IT PURTHER RESOLVED, that there be explored and developed dur-
    ing the coming year specific ways and means by which the ob-
    jective of eradication may be most rapidly achieved.

Adopted at the WATA Annual Membership Meeting, April
12, 1962. Material on the following pages is abstracted
from the 1962 Annual Meeting eradication sessions.

JUNE   1962

3


ERADICATION

`?To P&k Up By The Roots"

From the Keynote address
by FRED L. SOPER, M.D., DR. P.H.

W HEN asked to name my specialty in the field of medicine, I describe
  myself as a public health administrator. But in the American Public

Health Association, I belong to the Epidemiology Section. I have never
worked in tuberculosis ; I see your problem as one of public health admini-
stration in communicable disease prevention.

I greatly appreciate the opportunity this spring to speak to several of the
state tuberculosis association meetings. I am getting a vision of the mechanism
through which eventually the eradication of tuberculosis must come in the
United States.

My title today, "Why Eradicate Tuberculosis ?" implies a choice; that
we can eradicate this disease or, by choice, leave the seed of infection as a
permanent curse on the race. My answer to the question, "Why Eradicate
Tuberculosis ?" I give you now, so we can talk about other things. It's a
very simple answer . . . WE SHOULD ERADICATE TUBERCULOSIS BE-
CAUSE IT IS POSSIBLE TO DO SO !

This is answer enough for those who know and remember what tuber-
culosis has meant and still means to the human race. We must eradicate
tuberculosis because we cannot, in good conscience, leave it as a heritage
to future generations.

E RADICATION requires conviction, dedication, even fanaticism, which
cannot be generated without faith in the objective. When I talk about
eradication, I speak in terms of the absolute.
In eradication, one has an advantage in measuring success always against
absolute zero. Any infection is too many.
Tuberculosis workers may well find that the lower levels of disease inci-
dence require techniques of finding infection and of eliminating transmission
quite different from those previously used so successfullly when tuberculosis
was relatively common.

4                                            THE   CRUSADER


As a special consultant for the
division of international health in
the USPHS department of health,
education and welfare, Dr. Soper
has dedicated himself to the
eradication of communicable dis-
eases. He has challenged TB work-
ers to apply his concept to the
fight against the disease.

A principle now emerging in

international health (certainly at
some future date applicable to
tuberculosis)  is that countries
which free themselves of a dis-
ease or a disease vector are en-
titled to protection against reinfection and reinfestation by measures to be
taken by their neighbors,

To be feasible, eradication must cover an appreciable area and be ready
to expand. If you want eradication in Wisconsin, you must have it in Illi-
nois, you must have it in Minnesota, and eventually in an ever expanding
periphery. Obviously, once you embark on disease eradication, you acquire
an interest and stake in the welfare of the entire human race.

T HERE is no Law of Diminishing Returns and no indestructibility of a
biological entity. The mathematics of eradication is simple; what can
be done in one square meter can be done in two square meters ; what can
be done in two square meters can be done in four. Thus, by geometrical
progression the world is soon covered.

It must be remembered that eradication is based on complete coverage
of the population and of the area concerned. So-called underdeveloped coun-
tries need not be behind the so-called developed countries in carrying out
certain specific eradication programs.

Both smallpox and malaria are being attacked with determination to bring
about biological eradication. I believe the same can and should be done for
tuberculosis.

Localized epidemics are the mechanism through which tuberculosis, as
a dangerous, contagious and infectious disease will be able to maintain itself
if it is not eradicated.            (Continued on nest page)

JUNE   1962


"We should
eradicate T
because it
possible to
do so . . .

`B
is

Experience with other eradication projects suggests that there are many
and various problems to be solved in the eradication of such a widespread
chronic infection as is tuberculosis. These problems are psychological, tech-
nical, administrative, educational and financial in nature.
The solution of entire groups of these problems, however, may depend on
decisions on a few basic points. Among them I would put the following:

1.  Definition of eradication as an absolute; acceptance by the na-
  tional and state health authorities and by interested voluntary
  agencies of eradication of tuberculosis, as thus defined, as a
  feasible and urgent objective.

    2.  The acceptance of tuberculosis as no longer essentially a social
    and economic, but rather a public health and medical admini-
    strative problem ; establishing the responsibility of the community
    to the infected individual ; but also establishing the responsibility
    of the infected individual to uninfected persons.
There is an important lesson for tuberculosis workers in the experience
with the eradication of bovine tuberculosis in the United States,

The bovine tuberculosis eradication program began in 1917. In the be-
ginning, this program was based on the certification of individual herds as
free of tuberculosis, that is, having no tuberculin test positives.

After a number of years, the program was changed and certification was
by counties and was based on the finding of a very low, below half of one
percent, positive tuberculin rate. As early as 1940, all of the counties of the
United States were certified on this basis.

The campaign has continued ; the incidence of bovine tuberculosis de-
clined until about 1954. But since 1954, it has begun to rise again.
The lesson is: there is no place to stop short of eradication!

6                                            THE   CRUSADER


"We are going

to eradicate
TB because of
the tragedy of
not doing it."

A WORD on the cost of eradication. The cost is going to be high. It
cannot be accomplished by tapering off on expenditures nor by reducing
effort. If costs are figured on the basis of cases found, and retreat is or-
dered as the cost per case goes up, eradication is doomed to defeat.
Per capita costs should 6e calculated OIZ the baCs of the fiopulatio?z pl-o-
tected agaimt infection yathes than OS the nunzbe~ of infected persons fomd
arzd treated.

And the initial cost of eradication in a local community is not the
end. To get the benefits of eradication for ourselves we must help our
neighbors to eradicate. This we must do gladly and willingly, because only
so can we protect ourselves.

It makes no difference what eradication costs! It makes IZO difference what
effort is ueeded. The stake is so enormous. it will be woytb it.
Eradication as an objective is salable; salable for itself for new health
dollars not in competition with other health programs for dollars already
earmarked for health. Let us have the courage to advocate eradication of
tuberculosis, for which no effort is too great, no price too high.
  WE ARE GOING TO ERADICATE TUBERCULOSIS BECAUSE OF
THE TRAGEDY OF NOT DOING IT.
You, along with other similar groups, have the possibility and the re-
sponsibility of starting this program of world eradication of tuberculosis.

Dr. Fred L. Soper's paper, "Problems to be Solved if the Eradi-
cation of Tuberculosis is to be Realized," presented at the 1961
annual meeting of the American Public Health Association, was
published in the June, 1962, issue of the National Tuberculosis
Association Bulletin. Free reprints may be obtained on reques:
to the WATA.

JUNE   1962

7


ERADICATE TB

Is It Feasible?

A Panel Piscussion

T. A. DUCKWORTH

Senior vice-president and secretary, Employers Mutuals of Wausau

Medical science tells us that this goal can be accomplished, that we can
eradicate TB. But will we? That is the next question. What people cdn do
and what we will do are entirely different.
I think we have to recognize that we live in a world of emotion and not
in a world of reason. And we have to appeal to the emotions of the citizenry
as well as to the reason.

I think eradication is a tremendous idea and I think it's going to live on.
Men live for ideas and most of us underestimate the power of ideas. Men
come and go and ideas live on forever.
We do not yet have an informed public which understands the concept of
eradication and at the moment, therefore, is not in a position to oppose,
support or otherwise have an opinion.

It will be necessary to receive the support of the public, the communities,
the region, the states and the nation as a whole for the bigger effort which
will be required for eradication to be launched and continued to the end.
The public will need to know that tuberculosis continues to be a dangerous
disease and that any incidence is too much where the means of blotting out
the disorder are at hand.

I was impressed with Dr. Soper saying zero is our goal. I think Ameri-
cans and the world at large have to work toward goals.
I was impressed with the fact that he mentioned the word f&h.
If the world at large has the faith and accepts zero as the goal there is
no doubt that at once we can work toward eradication.

A. C. EDWARDS, M.D., M.P.H.
  Commissioner of Health. Rdcine

The acceptance of eradication is an interesting challenge.
Dr. Soper impressed me with the idea that tuberculosis is no longer a

THE   CRUSADER


social and economic problem, but rather a public health and medical admini-
stration problem.

I think the Wisconsin Anti-Tuberculosis Association for many years has
fostered the idea that tuberculosis was a social problem with a medical as-
pect. It seems to me I've heard that many times at these sessions, and I'm
glad to see that Dr. Soper feels the time has come when we have to forget
about the social aspects and look at it as a problem of administration.
As he says, if we can eliminate tuberculosis in cattle handled in Minne-
sota, it ought to be possible to eliminate tuberculosis in human beings in
Wisconsin.

WILLIAM STEAD, M.D.
  Associate professor of medicine, Marquette University School of
  Medicine; clinical director, Muirdale Sanatorium
I think that there is a great deal of merit to Dr. Soper's approach. We
must not be satisfied with reducing tuberculosis infection to a "reasonable
level" and then cutting the budget and the effort. We must go further than
that if we are to achieve eradication.

As the number of tuberculin positive people drops, should WC not begin
to think of changing to a careful follow-up of only those who are positive
as our primary control effort rather than using chest x-rays of the entire
population as our principal tool ? We must look for the TB germ in its
places of hiding so that we may search it out and prevent its spread.
Detection of disease before it becomes contagious and before it is trans-
mitted to children is true primary prevention. A completely effective pro-
gram of this kind would yield wonderful results in one generation, but
would require an increase in the effort of all of us.
Eradication is more than just "more control." Among other things we
shall have to reassess many of our present ideas and methods. Further infor-
                     (Continued 011 page I 3)

JUNE   1962


To Achieve
Absolute

A panel discussion of practical
means to achieve eradication

R. P. JAHN, M.D.
  WATA medical director, Milwaukee

There is a tremendous job ahead-a job of eradication which will
occupy all of our time for a long time to come. Eradication is the creed whose
adoption is really worth working for.

There are some things we emphatically should not do. One of them is to
desert prematurely certain tried, true and effective measures and procedures.
There is great danger in becoming too visionary and saying everything is
going to be new and everything is going to have to be done differently.
I do not maintain that we should continue to do everything as we are.
We must add, we must supplement, we must go along further. But let us not
abandon those things which are working today.

RAYMOND EVERS, M.D.

Superintendent and medical director, Rocky Knoll Sanatorium and
Hospital, Plymouth

I feel very strongly that if we use the tools we have available now in the
way they should be used we can eradicate tuberculosis in the not distant future.
We can accomplish this purpose by two very easy methods that we are
using already. First, we can do more tuberculin testing.
I would like to see a law passed making it compulsory for every person
to have a tuberculin test, I would like to see a record kept in the county
nurse's office and the city nurse's office. I would like to have a city-county
department, of course, with all the records in the same place and with a
record of every person in the county who has a positive tuberculin test.
Second, the prophylaxis of tuberculosis is probably the most exciting pro-
cedure that we have available at the present time.
All of us who work in tuberculosis should make more use of isoniazid.
We should take people who have been patients in the past and have never
had isoniazid therapy and start them on prophylactic treatment.

10

THE   CRUSADER


Probably in the near future we will be treating with isoniazid any person
who has a positive tuberculin test. I may be wrong but this method in the
long run may be very effective.

JEANETTE PAYER, R.N.

  Supervisory nurse, West Allis Health Department
No matter what the concept might be, public health nursing will not
make a dramatic change.

We have a job to do before we begin. We have to go home and tell our
cohorts what we have learned. This is our first way of spreading the good
word. For this. program to be effective, we must spread the word and we must
spread it to everybody, not just to a few people who are in health work.
We are all concerned about the patient. But what about the contacts? Do
we give the contacts nearly the amount of consideration and treatment we
do the patient?

That is very important. It is another stepping stone toward eradication.
Catch them early before they are communicable.
If the public is apathetic, it is our fault. As public health nurses, we
have contact with the public and I think we have to stir people up a bit. It
certainly can help to educate the public in eradication rather than control.
Can we talk it up enough?

MILTON FEIG, M.D., M.P.H.
  Director, section on preventable diseases, State Board of Health,
   Madison

If we are to achieve further marked progress in tuberculosis control, we
must know where we now stand. We must also look back, we must try to
reason how we got to our present situation.
                   (Continwd 012 lrext page)

JUNE   1962

11


Absolute Zero, cont. from page 11

We must make up our minds also where we want to go and most im-
portant of all when we wish to arrive at this goal regardless of what the goal is.

T HE methods that have been used before may no longer be satisfactory
or they may have to be modified somewhat or improved. Or perhaps new
methods might become available to us.
I think it is very important not to set eradication before the public as an
end point. We should seize on an intermediate objective in the community.
I suggest that we try to cut down the case rate of 20 per 100,000 persons
to 10.

I propose that we set a time limit for five years, and if we have achieved
this goal, we can then go on to the final end point.

SOL LIFSON, M.P.H.
  Director, Education and Public Relations, National Tuberculosis As-
   sociation

The challenge before us is to put what we currently know about treat-
ment to work to rid our country of this age-old disease.
We must convince our legislatures that it makes good fiscal sense
to invest large sums of money now for eradication programs, since it will
mean that the bill to the community in years to come will be infinitesimal
compared to what it now costs.

As I see it, the voluntary tuberculosis associations must take the lead in
promoting the concept of eradication. Each member of a board of directors
must convince himself that eradication is possible. He must also be willing
to work assiduously for the achievement of this goal.
When we have convinced ourselves and other responsible leadership
groups, the really big job is before us. We must educate each person in
our communities to the idea that he has a responsibility and obligation to
know what his tuberculosis status is and to take action in accordance with
that status.

There must also be an educational program directed at the physicians
of the community.

Nurses, social workers and all other professional workers related to health
must become partners in the all-out eradication program. Industry should
play a primary role. Schools and colleges need to devote time to teaching
the facts about tuberculosis and to looking for active cases through tuberculin-
testing programs.

When we reach the stage where having tuberculosis is socially un-
acceptable, we will probably be close to the eradication of this unnecessary
disease.

12                                           THE   CRUSADER


Is It Feasible?, cont. from page 9

mation on the natlcral history of tuberculosis will be needed to guide us in
achieving the goal of eradication.

JAMES M. WILKIE, M.D.
  Medical director, Morningside Sanatorium, Madison

The goal of eradication is a proper one. We have reason to believe that
we can approximate such a goal.

It means we are going to have to change our methods and our ideas about
how to approach tuberculosis. Much of our old thinking is going to have
to be thrown away.

In the field of cost alone, we are not necessarily going to think of doing
that type of examination where we will find the most new cases of tubercu-
losis for the least cost. We are going to reach the point where each new case
is going to cost us a lot of money.

And we are not always going to look for tuberculosis in the place where
it is most apt to be found. We are going to have to look for tuberculosis in
the places where it is least apt to be found.
This is going to take time and tremendous effort.
We are going to have to make up our minds to the fact that there will
be a mass of tubercle bacilli in living people and that these people will
carry those seeds of potential infection in their systems for the rest of
their lives.

Those people will all have to be watched to be sure that those germs do
not break loose and become a danger to the public.
At the same time we will have a younger generation growing up.
And it is here where eradication possibly reaches its climax. By carefully
examining all the younger people who are uninfected and doing everything
that we can to prevent them from becoming infected, we may eventually
reach a point where we will have generations coming on who have not had
the experience of any tuberculosis.

This I think is the goal that we should shoot for.

F. L. SOPER, M.D., Dr. P.H.

We must change our point of attack. We must change our point of focus.
One of the very simple and one of the easiest things to do is to stop
talking about rates. Stop talking about so many deaths per 100,000 or so
many cases per 100,000.

Let's try to individualize the cases. Let's try to make people out of these
cases and say that so many persons have tuberculosis or so many individuals.
We have to build up the public acceptance, and we can build up the
public acceptance only as this group becomes convinced that eradication is
possible and that it is worthwhile.

JUNE   1962

13


John Lindner, Sr.

T HE president of the board of trustees
of Mount Washington Sanatorium

received the WATA's 1962 distinguished
service award at the annual meeting
luncheon, April 13.

The citation describes John Lindner,
Sr., as "the immigrant boy. . who found
in America the opportunity to achieve
material success . and the opportunity
to serve his fellow-men."

The Rev. Walter Piehler (right), retiring WATA
president, presents the WATA 1962 Dirtin-
guished Service Award to Mr. Lindner, Sr.

The Eau Claire businessman's first job in the United States was as a fireman
in a Chicago hospital. He later moved to northern Wisconsin to farm, then became
a sales representative for road machinery companies. He rose to the presidency of
one of those firms.

In the words of the citation: "Material success did not limit his life."
In 1928, Mr. Lindner was elected a trustee of Mount Washington. Under his
leadership as board president, the sanatorium was one of the first to convert to a
dual-purpose operation . . . caring for tuberculosis patients and serving as a home
for the aged.

Mr. Lindner is a charter member and past president of the Wisconsin Sanatorium
Trustees Association and has appeared frequently before legislative hearings. He
speaks "plainly, almost gruffly, but with a salty and disarming humor" in backing
legislation to aid sanatoriums and their patients.
As the citation puts it. . . . "He has, in fact, been an unforgettable personality."

The CRUSADER

            of the
WISCONSIN ANTI-TUBERCULOSIS ASS'N

Q @

Published monthly except July and August at
       1700 west Wells Street
MILWAUKEE (1)     Telephone WEst 3-1161

14

Founded in 1910 by Dr. Hoyt E. Dearholt and
edited by him until his death, July 12, 1939.
  Edited by Dr. Oscar Lotz, 1939-1951.

Executive Secretary & Editor. . .C. W. Kammeier
Managing Editor . .Gordon Krenn
Assistant Managing Editor .A1 Eberle
Editorial Associate. . .., . Jim Bruflat
Medical Consultant. . .R. P. Jahn, M.D.

JUNE, 1962             VOL. 55--o. 6

Second-class postage paid at Milwaukee, Wisconsin.
5oc per year.

THE   CRUSADER


You'll be interested
to know that. . .

o Former WATA Publications Director
Harold Holand has been named to the
new position of assistant to the executive
secretary. The author of the WATA his-
tory, "House of Open Doors" became
director of the research and publications
department in 1943.

Named to succeed

Mr. Holand is Gor-
don Krenn, a grad-
uate of the Univer-
sity of Wisconsin.
Mr. Krenn has
worked as a reporter
for radio station
WIBA and the Cap-      6. Krenn
ital Times in Madison and for WTMJ --
WTMJ-TV News in Milwaukee.
o George C. Owen, M.D., Milwaukee,
was named president-elect of the WATA
at the annual business meeting, April 12.
Dr. Owen succeeds M. S. Dailey, Osh-
kosh, who took over as president.

Harry G. Marsh, Madison, was elected
vice-president. Elwood P. Mason, M.D.,
and James P. Fitch, Milwaukee, were re-
elected as secretary and treasurer.

Named to the board to replace retiring
Mrs. Marie Hoyer, Oshkosh, was Arthur
W. Bouffard of Green Bay, district super-
visor, state rehabilitation division.
@ Richard P. Jahn, M.D., WATA med-
ical director, was named president of the
Wisconsin Thoracic Society at its business
meeting, April 14. Others elected were
Ben R. Lawton, M.D., Marshfield, vice-
president; William Stead, M.D., Milwau-
kee, secretary ; and J. Richard Johnson.
M.D., Madison, treasurer.

* Below, Elizabeth L. Ryan, director,
WATA health education-local association
department, receives an award from James
E. Perkins, M.D., managing director, Na-
tional Tuberculosis Association, for her
work as a professional staff state TB
association member.

THE WATA IS G

            OFFICERS
M. S. Dailey*  . . . . . . . . . . . . . . . . . . . . . President
George C. Owen, M.D.* President-elect
Harry G. Marsh* . Second Vice President
Elwood W. Mason, M.D.*. . Secretary
James P. Fitch* ..,................. TrEZlSUret

           DIRECTORS
        Term Expires 1963

Henry A. Anderson, M.D.**. _.
Edward H. Borgelt**. . .
Charles W. Chapman. . . .
T. A. Duckworth**. . .
Milton Feig, M.D..
Rev. Chester L. Harries.
Mrs. Konrad Testwuide, Jr.. .

U

[IDED BY THESE

Term Expires

E. A. Bachhuber, M.D..
James - -.
    P. rltch.. . . .
EIWOOI zl W. Mason. M.D..
Harry A. I\ Mson** . . . .
George C. ( hwq M.D.
Rev. ' Walter Piehler.
Tames Al. Wilkie. M.D.**.

        Term Expire
EImer Anderson.. . . . . . .
Arthur W. Bouffard . . .
rM. S. Dailey.
Einar R. Daniels, M.D..
Helen A. Dickie, M.D.**.
Harry G. Marsh .
0. A. Sander, M.D.**. _.

1964
......... Milwaukee
........ .Milwaukee
......... Milwaukee
.......... .Madison
........ .Milwaukee
........... .Merrill
.......... .Madisoa
1965
........ .Eau Claire
........ .Green Bay
.......... .Oshkosh
. .Milwaukee
.......... .Madisan
.......... .MdiSOtl
......... Milwaukee

*Ex-Officio Members of li'xecutive Committee
  **Members of Executive Committee

JUNE   1962                                                 15


Attention Nurses

A series of one-day tuberculosis nursing institutes is planned for this fall
as a "review and up-dating" regarding the nature and treatment of TB.

Institute Director:

   Miss Ruth Leininger, R.N., assistant director,
   Nursing Advisory Service of the
   National Tuberculosis Association - National League for Nurses.
Co-sponsored by:

University of Wisconsin, Madison
Wisconsin Interorganization Committee on
Tuberculosis Nursing

Plan now to attend at one of the following locations:
   La Crosse, September 11
   Rice lake, September 12
  Green Bay, September 14
For more information write: Case-Finding Department, WATA
              Box 424, Milwaukee 1, Wisconsin

The CRUSADER

      Milwaukee 1, Wis.

of the Wimmsin Anti-Tuberculorb Ass'n

   Entered as Second Class Matter
       -@m-u