also some advance figures from a number of the states. The decline in the tuberculosis death rate in the experience of the Metropolitan Life Insurance Company was 161⁄2 per cent. from 1920 to 1921. If the same decline was manifest in the registration area, then the rate of 114 for 1920 would fall to approximately 95 in 1921. Probably the decline in the registration area will not be so marked as that for the Insurance Company. Figures already received from over half the states in the entire country give an average death rate for tuberculosis in those states of 93. From these figures we feel safe in assuming that with complete figures available for 1921 the tuberculosis death rate will not exceed 100. Since the last annual meeting the Supervisor of Field Service has accepted invitations to do field work in 64 cities scattered through all regions of the United States. This has taken him to 34 of the 53 Affiliated and Represented Associations. In 19 states one trip was made; in 8, two trips were made or cities visited; in 1, three trips were made or cities visited; in 4, four trips were made or cities visited, and in 2, five trips were made or cities visited. In addition to aid in the Seal Sale to many state and local associations, the Supervisor of Field Service made a seal sale organizing trip through all the northwestern states, in response to a request for aid. Constitutions During the year aid was given also to more than a fourth of the state associations in the revision of their constitutions, in order to make the organization more efficient and in compliance with the requirements of the new by-laws of the National Association. The Field Service has been at all times equipped with a model constitution for state and local associations. As occasion required, the constitution has been modified to meet the needs of the particular associations. Consultant Service Consultant service was furnished thirtyeight of the affiliated associations by eighteen consultants, who gave service in sixty cities. The number of addresses given in each city is always recorded as one, since we have no complete record, but the office has knowledge that it varies from one to four. These figures cover only the use of consultants arranged through the national office. The state associations were given lists which have been revised from time to time. How much use the associations have made of the consultants on this list is not known to the National Association, as they frequently and properly arrange service independently of the office. The Executive Committee of the National Tuberculosis Association has appointed official consultants in the following lines of work: and additional service being given to such associations through our Modern Health Crusade, medical, institutional, tuberculosis nursing, publicity, statistical and administrative services. It also provides the Executive Office with data helpful in planning its work. Employment During the ten months from June, 1921, to March, 1922, inclusive, co-operating with the American Association of Social Workers, placement in tuberculosis positions was made as follows: Educational secretaries, 8; executive secretaries, 6; field clinician, 1; field workers, 2; medical man in tuberculosis school, 1; occupational therapists, 2; public health nurses, 18; sanatorium superintendents, 4; sanatorium social workers, 3; total, 45. Special advertisements for workers and position were placed in space contributed by the Journal of the Outdoor Life, and occasional lists of candidates were sent to all state secretaries. This involved carrying an average of 25 open positions monthly, the making of 88 recommendations and the writing of 68 letters per month by the American Association of Social Workers, as well as considerable correspondence and many interviews by members of the National Tuberculosis Association staff. Community Chests A study of financial federations and their effect on tuberculosis work was made, in cooperation with the Publicity Service, for the benefit of and on the request of the state executive secretaries. A continuing study is being carried on, with data supplied on request to executive secretaries of both local and state associations in all regions of the country. The attitude of the National Tuberculosis Association and its policy in relation to community chests appears in the report above referred to, as well as in the new pamphlet of the Association, entitled "The Integrity of the Christmas Seal." They are briefly as follows: 1. Preservation of the Christmas seal idea. 2. Conservation and development of the local campaign against tuberculosis. 3. Recognition of the claims of the state and National associations, since tuberculosis is an inter-state problem. 4. Recognition of the place of the non-official health agency. Negro Health Week The National Tuberculosis Association was invited by the United States Public Health Service to co-operate in the promo. tion of Negro Health Week, held April 2 to 8, 1922. To this end, Dr. L. B. McBrayer acted as special representative of the National Association at a conference in Tuskeegee, Ala., where plans for Negro Health Week were developed. The Field Service of the Association, assisted by the Publicity and Statistical Services, gave special help to the state and local executives in working out the plans. Campaign Service According to the latest reports, the total income from the seal sale for 1921 will reach $3,500,000, or a reduction of approximately $157,000 from the seal sale in 1920. In this connection it is to be noted that the decrease in returns does not represent a serious loss in funds available for tuberculosis work, as the national, state and local associations have been able to reduce expenses in conducting the seal sale during each of the past two years to an extent sufficient to effect a total annual saving that may be safely estimated at $100,000. Field Work More than four hundred orders for seai supplies were filled during the summer months of 1921, and during the latter part of the year the Campaign Service, both by correspondence and field work, to which several members of the staff were temporarily diverted, gave all the assistance possible with our limited budget to aid the state associations to organize their sale of seals along satisfactory lines. Scal Supplies Following this, and while local seal agents were still engaged in the sale of Christmas seals, the Campaign Service began in December, 1921, to make arrangements with artists for designs and advertising material for the seal sale for 1922. It During the past fourteen years the expansion and development of the seal sale throughout the United States has progressed to such an extent that the problem of providing the necessary supplies has become a considerable business in itself. involves the purchase and distribution of approximately $150,000 worth of printed matter, including nearly a billion seals and large quantities of posters and other advertising material Advisory Committee Helpful Early in January the Advisory Committee for the Christmas Seal Sale, appointed to represent the affiliated associations, met with staff members of the Executive Office to discuss plans for improving the campaign service for 1922. Mention should be made of the excellent work done by this Committee. With their assistance great improvement has been made in the artistic and advertising value of the seal, posters and other printed matter and many suggestions have been offered that will be helpful both to the National and state associations. Under the advance schedule followed this year the affiliated associations received samples of all supplies during the early part of April and they have been allowed sixty days in which to submit the final orders to the Executive Office. This is an important and helpful arrangement and will serve the double purpose of stimulating the state associations to begin earlier to plan for the next seal sale and of providing ample time for them to submit samples to their local seal agents and secure orders for supplies. Need for Further Organization Judging from a recent study made by the Campaign Service it seems apparent that sixty per cent. of the states are still in the pioneer stage of development. In such states a considerable rural area, representing a large number of counties, has not been effectively organized. This emphasizes the need for more intensive effort in promoting the seal sale. As a preliminary step, the Executive Office conducted a Christmas Seal Institute for state executives here in Washington last Monday and Tuesday, and it is hoped that the state associations will arrange similar meetings to train their local seal agents in organization and publicity methods for the seal sale. In support of such a program several members of the Executive Office staff will be available to render advisory assistance in the field during September and October. Also an effort is being made to secure funds from outside sources to finance additional field service for states in which the seal sale has suffered most severely during the past two years. All things considered, the financial outlook for 1922 is decidedly hopeful. With improving business conditions Our state associations will be encouraged to think in terms of more ambitious local programs of work, which will undoubtedly be reflected in an increased return from the seal sale.. Plans for 1923 Profiting by the experience of this year, the Campaign Service is making a still further advance in the schedule for supplies. Arrangements have been made with an artist of international reputation who, in collaboration with an art committee in New York and members of the Advisory Commitee, will shortly submit a series of sketches for the Christmas Seal for 1923, and other artists are working on the posters and other advertising matter to be included in the supply list for 1923. Tuberculosis Division of the Joint The library of the National Association was taken over by the Common Service Committee soon after the office moved to its present location. It was combined with the libraries of the American Social Hygiene Association, the National Organization for Public Health Nursing, and the National Committee for Mental Hygiene. After the amalgamation was tested out it was decided to continue the plan and if possible to secure funds for the entire maintenance of the joint library. Pending the receipt of such funds, it is necessary for each of the various agencies to continue the support of the work. The tuberculosis section of the library has been developed until it now plays an important part in the work carried on by the various services. Under the present consolidation much classifying and analyzing of material has been done by the cataloguers. The consolidation has also made available the books of more general character bearing on the field of tuberculosis. The library now has an active department of extension work which is planning, in cooperation with members of the National Association staff, to communicate with public libraries throughout the United States recommending material and offering advisory service. Special Committees Committee on Community Health and Tuberculosis Demonstration. The Framingham Community Health and Tuberculosis Demonstration continues during the present year, the sixth year of the Demonstration. While the Demonstration is maintaining all of its essential contacts, it has nevertheless materially reduced its budget. This has been made possible by the taking over, on the part of local, official and voluntary agencies, of very nearly all of the practical services originally established or developed by the Demonstration itself. In this connection, it is significant to know that the community is spending now about $2.15 per capita per year, in contrast to the original 40 cents per capita per year being expended for all kinds of health work at the beginning of the Demonstration period in January, 1917. The results to date, as measured particularly by the tuberculosis mortality rate in 1921, were most gratifying. Beginning with a rate of 121 per one hundred thousand as an average for the pre-demonstration decade (1907-16), the rate, carefully corrected yearly since 1907 for resident and certification errors, has shown a gradual though consistent decline. After five years of intensive work, the rate for 1921 was 40 per one hundred thousand, a reduction of about two-thirds under the pre-demonstration standard, a reduction both in degree and rate not equalled in any known community in spite of the striking declines which have prevailed quite generally throughout the country. In marked contrast to this Framingham decrease of 67 per cent. is the very modest decrease of 18 per cent., as shown by the seven control towns used throughout the Demonstration as a basis of comparison in Massachusetts. The work continues to be financed by contributions from the Metropolitan Life Insurance Company, and it is probable that on a diminishing basis, a continuing period of observation over two or more additional years will be justified and indeed necessitated. This seems necessary not only from the point of view of mortality observation, but also to give great accuracy and substance to the many very significant preliminary findings as to sickness incidence, ratio of cases to deaths, hospitalization facilities necessary, etc., upon all of which problems Framingham experience has thrown unprecedented illumination. Committee on Indigent Migratory Consumptives At the 1921 annual meeting the Committee on Indigent Migratory Consumptives passed a resolution urging that some large city of the east or middle west be chosen as a control city, and that a study similar to the ones made in the southwest should be undertaken in that city. Cleveland was suggested. In accordance with this resolution, the National Tuberculosis Association, in co-operation with the Anti-Tuberculosis League of Cleveland, undertook this study. Miss Whitney spent the month of January, 1922, and part of February in Cleveland getting data from the various health agencies. That material is now being tabulated and the report will be available directly after the annual meeting. The findings in Cleveland will give added emphasis to the data from the southwestern cities, and the entire report of the Committee, including the Cleveland material, will be published in pamphlet form within a few weeks. Committee on Mortality From Tuberculosis in Dusty Trades The final report of this Committee has now gone to press. It includes a study by Dr. Frederick L. Hoffman in regard to the economic and social factors involved, and a medical report by Dr. E. R. Baldwin, based on physical and x-ray examinations. These reports will be published by the U. S. Bureau of Labor Statistics. Copies should be available during the summer. Committee on Medical Research The Committee on Medical Research, under the chairmanship of Dr. William Charles White, has continued its study of the various fields of research which could be aided materially with small amounts of money. On recommendation of the committee the budget of the Association this year contains an appropriation of $12,000 for medical research. Disbursements have been continued for the work started in 1921. Those participating in the studies undertaken by the Committee will report at a joint meeting of the clinical and pathological sections on Saturday of this week. Colonization Committee During the period of the last annual meeting the Colony Committee met two or three times and submitted a preliminary report. At the first session of the Committee there were present a number of men and women who had had considerable experience in the treatment, training and placement in employment of tuberculous persons. They gave their opinions as to the feasibility of various employment projects. The complete report of the Colony Committee, which was prepared by the Medical Service, comprises 102 typewritten pages. Arrangements were made for a meeting of the Committee on May 3rd, immediately preceding the 1922 meeting of the National Association. Committee on Tuberculosis Among the Indians Under the direction of the Committee, a questionnaire has been sent out to state boards of health and tuberculosis associations in states having Indian reservations. Dr. Kober, Chairman of the Committee, will report at this meeting on the information gathered by the Committee. Committee on History of the National Tuberculosis Association The Committee on History of the National Tuberculosis Association has completed its labors with the publication of the volume of history which has already been reported in the list of publications issued during the past year. Opportunities for Further Service In addition to the report of work done, it may be well to point out some of the special work that the Executive Office belives should be undertaken or further developed without delay. In the face of great opportunities for service, it is disappointing to find it necessary to state that our only reason for deferring a start on these desirable undertakings is a lack of sufficient funds. In the expectation and hope, therefore, that a recital of these needed extensions of work will be of assistance, I wish to call your attention to the following: Rating of Sanatoria 1. A proposed rating scheme for tuberculosis sanatoria as drawn up by the American Sanatorium Association at the suggestion of the National Tuberculosis Association has been before us for consideration for two years. It was the recommendation of the Sanatorium Association that the rating be done by the National Tuberculosis Association. Because of lack of funds it has been impossible to make more than a beginning, although the desirability and urgency of an attempt to improve the standards of sanatoria under the auspices of the sanatoria themselves is recognized. Estimated cost, $10,000 a year for several years. Home Treatment 2. The plan for the standardization and supervision of home treatment of tuberculosis patients, as outlined by the Medical Service of the Association, has not yet been tried out in any community. It is hoped that in the near future several experiments of this character will be started, but the supervision of staff members of the National Association is needed so that the work will be carried out according to plan, and also that accurate observations may be made of the merits of the plan with a view to modifications. Estimated cost, $3,000 a year for at least two years. Industrial Research 3. At the request of the Federal Board for Vocational Education, a study of the health hazards of industry was undertaken in September by the National Association, as already reported. Unless further funds are secured shortly, it will be necessary to abandon this work or to maintain it on such a small scale that it cannot be completed for several years. The study as it has thus far progressed indicates, we believe, that its discontinuance would be a very great misfortune. Estimated cost, $20,000 a year for three years. Follow-Up Study 4. Our follow-up study of sanatoria cases, the first effort of its kind to ascertain, on a large scale and over a period of years, the progress of patients after leaving the sanatorium, has been curtailed on account of lack of funds, and it has become necessary to refuse to accept data from additional sanatoria desiring to benefit by the study. A few of the interesting results of the study already apparent will be reported on at this meeting, but the possibilities have just begun to be realized and a fund is needed for continuance and development for at least another three years. Estimated cost, $4,000 a year. Surveys 5. The Statistical Service should be expanded so that additional surveys can be undertaken in various state and local communities. The demand for this type of service has been much greater than we could meet during the past year. This is one of the most valuable types of field service because it provides basic data on which the future tuberculosis work of the community can be determined. Estimated cost, $6,500 a year. Field Secretary 6. For two years the executive office has reported the need for at least one additional field secretary. The demand for general field service continues, the requests being for a great variety of help. During the past year the Supervisor of Field Service has been able to answer only a portion of the calls. Estimated cost, $8,000 a year for salary, travel and incidental expense. Crusade Development 7. A fund for the development of the Modern Health Crusade is urgently needed. At present the Crusade supplies required for use in the schools are purchased on order from various states and communities, but practically no money has been available for the promotion of the Crusade in its national aspects. Money is needed for national tournaments, contests in health essays, posters, essays, etc., and for other national projects promoting the solidarity of the movement. The promotion of national features of the Crusade is of very great importance to unify the movement and to give all localities the benefit of the experience of the whole country. Estimated cost, $7,500 for the first year. Printing Fund 8. A fund of at least $5,000 is needed for the production of printed material to be sold at cost. Each year the Association provides a large amount of material for free circulation, but it is recognized that there is a growing demand for publications which, on account of the initial expense, cannot be issued free of charge. Such a fund, therefore, would be in the nature of a revolving fund, the money received from the publications to be returned to the original fund as they are sold. Publications of this character, which the Association is having difficulty in financing, include new directories of sanatoria, tuberculosis associations, dispensaries and traveling clinics; a revised edition of our pamphlet on dispensary methods and procedure, which is now out of print; a revised edition of our pamphlet on the effect of tuberculosis institutions on surrounding property, etc. Field Service in Seal Sale 9. A fund which can be used to provide additional field service to our affiliated associations preceding and during the Christmas seal sale is needed. This fund would provide much more than field service in a mere money-raising campaign, because the campaign itself is an educational effort primarily, and must be based on a showing of accomplishments during the preceding year and on a program and budget of work for the coming year. The development of the plans for the seal sale, therefore, is intimately concerned with the development of right methods of tuberculosis work, and also with the best methods of educating the community as to the work already accomplished and the needs for the future. Estimated cost, $15,400 for the year 1922. |