executive office was divided into seven services as follows: Administrative, Field, Modern Health Crusade, Medical, Research, Publicity, and Publications. At the present time the publicity and publications services have been combined, making six in all. On January 1, 1919, the staff of the National Association consisted of 36 people, of whom 21 were on the clerical staff and 15 on the administrative staff. On January 1, 1920, the staff had grown to 60, of whom 28 were on the clerical staff and 32 on the administrative. Taking up the various services in brief:

1-Administrative Service

The personnel of the administrative service consists of the Managing Director, Dr. Charles J. Hatfield; Mr. Philip P. Jacobs, Assistant Secretary; Mr. L. B. Whitcomb, Purchasing Clerk; Mr. F. W. Coriell, Auditor; Mr. A. J. Leverton, Office Secretary, and Miss Grace Douglass, Assistant Office Secretary. Under the administrative service come all of the problems of administration of the office both at home and in the field, all financial problems, all matters dealing with policy of the Association, the running of the office itself, the handling and distribution of supplies, and the coordination of the various departments into a harmonious working whole. The entire clerical staff is responsible in the first instance directly to the administrative service, although assigned by it to other services in accordance with their needs.

2-Field Service

The personnel of the field service at the present time consists of Mr. Frederick D. Hopkins as Supervisor of Field Service, and the six regional secretaries: Mr. L. B. Myers for the New England States, Mr. Paul L. Benjamin for the North Atlantic States, Mr. Murray A. Auerbach for the Southern States, Mr. Arthur J. Strawson for the Mississippi Valley States, Mr. John Tombs for the Southwestern States, and Mr. George Everson for the Northwestern States. The functions and ideals of the field service are:

(a) To keep in touch with all of the state organizations throughout the country and through them with the various local associations and other anti-tuberculosis agencies in their respective territories.

(b) To bring to these organizations all of the service and facilities of the National Association; in other words, to be the ambassador of the National Association to these organizations.

(c) To keep the executive office informed as to the status of work in the various states with a view to rendering the service of the home office to the different state and local organizations more intelligent and complete.

(d) To promote through conferences, personal interviews, correspondence, and in other ways a spirit of good-fellowship between the states in the respective districts and between the states throughout the country.

(e) To raise the standards of work done

in different parts of the country by bringing to bear on all states the experience of the entire country in the problems dealt with.

3-Modern Health Crusade Service

The personnel of the Modern Health Crusade Service consists of Mr. Charles M. DeForest as Crusader Executive, and Miss M. Grace Osborne and Miss Mildred Terry as Assistant Crusader Executives. The Crusade service has as its primary function the development and promotion of the Crusade. The publicity part of the Crusade service is for the most part handled by the publicity service. The management of supplies, the working up. of new ideas, the arrangement for co-operation and co-ordination with outside agencies, and the development of policies and principles of the Crusade fall under this service.

4- Medical Service

The personnel of the Medical Service at the present time consists of Dr. H. A. Pattison, Supervisor of Medical Service; Mr. T. B. Kidner, Institutional Secretary; Miss Mary E. Marshall, Secretary for Nursing, and Dr. Benjamin K. Hays, Special Educational Secretary. The work of the Medical Service is more varied than that of any of the other services with the exception of the administrative. Fundamentally, the Medical Service deals with all the medical problems that come to the Association. Immediately, its work is divided into the following fields:

(a) Educational, for the medical profession and for the laity.

(b) Institutional, to standardize construction and administration of institutions of various kinds.

(c) Nursing, to standardize and promote interest in tuberculosis and public health nursing.

(d) Cooperation with governmental agencies dealing with the tuberculosis problem, particularly from the post-war angle, such as the United States Army, the Federal Board for Vocational Education, the United States Public Health Service, the Bureau of War Risk Insurance, etc.

5-Research Service

The personnel of the Research Service consists of Miss Jessamine S. Whitney, Miss Eleanor B. Conklin and Miss Josephine McK. Stults. The Research Service handles a variety of difficult and important problems for the Association. Not only is it concerned with making particular studies and developing special information, but it deals also with editorial problems of various kinds, with the compilation and up-keep of the Tuberculosis Directories, with the filing and indexing of library material, and with a number of other related problems.

6-Publicity and Publications Service

The personnel of the Publicity and Publications Service consists at the present time of

Mr. Basil G. Eaves, Miss Helena V. Williams, Dr. Allen K. Krause and Dr. George Mannheimer, in addition to Mr. Jacobs and Mr. Leverton, who give part time to this service. Under this service come:

(a) The three monthly publications of the Association: the JOURNAL OF THE OUTDOOR LIFE, the American Review of Tuberculosis, and the monthly Bulletin.

(b) The routine newspaper publicity put out by the Association.

(c) The development and organization of campaigns, such as the Christmas Seal Sale,

etc.

(d) The handling of a variety of special educational services, such as the motion-picture service, the loan service, etc.

(e) The development of membership in the National Association.

7-Framingham Demonstration

The staff of the Framingham Community Health and Tuberculosis Demonstration is an integral part of the Association's staff, though located at Framingham. Dr. Donald B. Armstrong is Executive Officer of the demonstration and Assistant Secretary of the National Association. Dr. P. Challis Bartlett is Chief Medical Examiner of the demonstration. The work at Framingham is co-ordinated with the rest of the Association's work.

8-Denver Office

The Association has, since January, 1919, maintained an office in Denver for the Committee on Indigent Migratory Consumptives, with Dr. Severance Burrage in charge.

III. CHRISTMAS SEAL CAMPAIGN

From the time of the annual meeting in Atlantic City until the first of January a considerable amount of the energy of the National Association was expended in the development of the Christmas Seal campaign. The enthusiasm engendered at the Atlantic City meeting proved contagious, and the state associations through out the country planned for the organization of a much larger campaign than had heretofore been developed in this country. The aggregate budgets of the 47 state and 4 local associations participating and dealing directly with the National Association amounted to nearly $8,000,000, although the goal announced for the campaign was $6,500,000. The sale, according to present estimates, was approximately $4,000,000. We are informed by the National Information Bureau that the results of the campaign as contrasted with the goal aimed for are more favorable than those obtained by any other large national organization conducting a campaign in 1919. The experience of the Christmas Seal campaign, while it has been trying in some respects, has been helpful in the main. Most of the state associations are provided this year with more money than they had even in 1919. In a few states the campaign was not successful.

The lessons learned from the Christmas Seal campaign have already been put into practice for the development of the campaign next fall. The progress now being made in this direction is extremely gratifying. The design has been selected, some of the preliminary plans have been worked out, and in general after certain points have been decided at this meeting the campaign can take shape rapidly. The seal will this year be a distinctively tuberculosis seal, featuring the double-barred cross.

IV. MODERN HEALTH CRUSADE

Next to the Red Cross Seal, the Modern Health Crusade has afforded one of the most significant developments of the year's work. While it is impossible to give an accurate figure as to the number of children now engaged in doing Crusade chores, Mr. DeForest estimates that no less than 6,000,000 have been enrolled as Crusaders. All of the state and most of the local associations are developing Crusade work, and so popular has it become that in many instances this movement is the major activity of anti-tuberculosis organizations. Some conception of the magnitude of the Crusade and the amount of work involved may be gained when it is realized that during the calendar year 1919 over $125,000 worth of Crusade supplies were handled through the executive office. This meant a turning over several times of a considerable capital.

In a number of counties and in two states the Crusade has now been recognized officially as part of the school curriculum, and is supplanting the usual physiology and hygiene

The demands for the institutional service have been constantly increasing. Already the institutional secretary has been able to adjust difficulties and save considerable sums of money to institutions and boards in various parts of the United States from as far west as Idaho to the Atlantic seaboard. The growing accumulation of information and knowledge on the part of the institutional service will help materially to standardize construction and methods of administration in all parts of the United States. The relatively small investment of the National Association in this regard should be the means of saving many thousands of dollars to private and public agencies.

In the field of medical nursing and education some progress has been made, but there is need for an additional medical field secretary before increased development along this line can be shown.

Such

In the realm of coordination, the medical service has proven distinctly valuable. Through it practically all of the various governmental agencies dealing with the tuberculous soldier still in the army or the discharged tuberculous soldier have been reached and helped. agencies as the Medical Service of the U. S. Army, the U. S. Public Health Service, the Bureau of War Risk Insurance, the Federal Board for Vocational Education, and many others, thanks to the activities of the medical service, assisted in a very helpful manner by the Committee on Federal Legislation, have been brought into a closer working harmony than ever before. Similarly, the medical service has been able with the American Legion and the American Red Cross to bring sufficient outside pressure to bear to secure a more desirable coordination of effort.

In working out and securing the adoption of several agreements and statements of policy on nursing, the medical service has helped every state and local organization in the country, and has helped materially to promote good feeling and delimit responsibility between the National Association and such agencies as the American Red Cross, the National Organization for Public Health Nursing, and the U. S. Public Health Service.

The work of Dr. Hays in teaching tuberculosis to tuberculous soldiers is not only of great practical value, but is also contributing a considerable amount of technique in this field. Dr. Hays has sought at two of the large army tuberculosis hospitals, Oteen and Denver, to instruct the patients and those who deal with them concerning tuberculosis, with the two-fold aim of improving the morale of the hospital, and of increasing the length of stay and interest in getting well. At both hospitals this work has been successful.

Patterned after the Trudeau School of Tuberculosis at Saranac Lake, the medical service is promoting similar post-graduate courses in different parts of the country. A school has been opened at Colorado Springs and others are being planned.

VI. FIELD WORK

For the first time in the history of the National Association an effort has been made during the past year to cover the entire United States with field representatives. The regional secretaries have been in constant communication with practically all of the states in their respective districts. The employment of regional secretaries is still in the experimental stage. The opinions of secretaries with regard to their usefulness differ materially.

It has been demonstrated, however, that in problems of reorganization or in problems involving difficulties with individual states where continued arbitration is necessary, and also in problems relating to the standardization of methods and programs of work, the use of the regional secretary is highly desirable, and the value of this type of field service seems to be proven. If the Regional Secretary plan is retained. the increasing familiarity of the regional secretaries with the states in their respective districts will undoubtedly increase the value of the service they can render.

The home office staff has been less in the field than usual, although several members have made extensive trips for special work. The use of members of the home office staff in the field is a problem that involves not only considerable expense, but also a disruption of the routine work assigned to staff members. It is hoped that the home office staff may be used more or less as specialists, and that their trips into the field may be so arranged in conjunction with the regional secretaries that instead of making several short trips, those of the staff who are in demand can be cailed upon once or twice a year for a continuous round of service involving a period of several weeks, thereby saving time and expense to all concerned. This plan can easily be worked out with the regional secretaries.

In general, the field service of the National Association is aiming to strengthen the weak spots in the campaign throughout the country, and to bring the experience of the stronger states to bear upon those which have had less. VII. PUBLICITY

The publicity in conjunction with the Red Cross Seal campaign was by far the most significant feature of that movement. Through it the needs of the tuberculosis campaign were brought to readers by every conceivable channel of publicity, including newspapers, magazines, house organs, trade journals, foreign papers, and many other media of a similar character. The results of this publicity are being felt throughout the United States, not only in the National Association office, but in various state and local offices. For the first time the people of this country have realized something of the magnitude of the tuberculosis problem and something of the needs.

The withdrawal of the Red Cross emblem from the Christmas Seal and the necessary development of the double-barred cross emblem have placed upon the publicity service a responsibility for working out plans for a

Crusade of the Double-Barred Cross or some similar movement during the next few months that will aim to make the emblem of the tuberculosis movement as popular as is the Geneva cross. As a part of this movement an effort to copyright the double-barred cross is being made. Suggestions have been received from state secretaries and others, and on the basis of these a program is being developed. Routine publicity has been going forward to the newspapers, and will continue in increasing volume during the next few months, leading up to an intensive effort next fall. VIII. PERIODICAL PUBLICATIONS

The American Review of Tuberculosis, which began its fourth volume with the March number, has in the brief course of its existence made for itself a most enviable reputation. It is now recognized in this country and in Europe as the leading scientific publication dealing with tuberculosis. Like most publications of this character, it does not pay for itself, and the Association is obliged to pay for about half of the cost in excess of the income from subscriptions and advertising. The subscription price of the Review to nonmembers has been raised to $5.00, but the price to members remains the same, $2.00 per year. The educational value of the Review in stimulating the interests of the medical profession in respect to tuberculosis can hardly be overestimated.

The JOURNAL OF THE OUTDOOR LIFE has continued in popularity. The series of essays by Dr. Krause has been commented upon with great favor. The appeal of the JOURNAL to the tuberculosis patient as well as to the tuberculosis worker has become recognized as of considerable significance. Steps have been taken by the National Association to take over the JOURNAL OF THE OUTDOOR LIFE, which has heretofore been operated by an independent corporation, although nominally a part of the Association's program.

The Monthly Bulletin has increased in size and popularity. At the present time nearly 12,000 copies per month are being distributed. Besides handling the news of the National Association and serving as a clearing house for ideas from all parts of the field, the Bulletin has a special Crusade section, a special department for the Framingham Demonstration, and a special department on occupational therapy. The Bulletin is furnished free and has no income from advertising. It costs the Association at the present time approximately $450 per month.

The last annual volume of Transactions consisted of over 600 pages and cost the Association approximately $1.50 per volume to produce.

IX. MOTION-PICTURE AND LOAN

SERVICE

The motion-picture service rents and sells films dealing with tuberculosis and related public health problems. At the present time the service is handling nine films, including

"Jinks," "The Modern Health Crusade," "Playing the Lone Game," "The Great Truth," "The Price of Human Lives," "A Town Under the Microscope," "The Priceless Gift of Health," and "The Public Health Nurse." In addition to these more or less popular films, the service is also handling a technical film prepared by the United States Army on "The Diagnosis of Tuberculosis." During the last year the films rented by the motion-picture service were working, all told, 1,157 days. The return to the Association from the service including rentals and net profits on sales was approximately $1,500, which just about pays for the wear and tear of films and the cost of replacing them.

The Association has also provided a loan service consisting chiefly of scrapbooks, photographs, cuts, etc. The scrapbooks on county hospital methods, traveling clinics and other phases of tuberculosis methods are in great demand. As this phase of the Association's work develops, it will become more and more useful to secretaries throughout the country. X. LEGISLATION

Through its Committee on Federal Legislation, and largely through the untiring efforts of its able Chairman, Mr. William H. Baldwin, the National Association has been able to express itself in a number of matters on legislation and governmental policy. The original plan for securing a division of tuberculosis in the U. S. Public Health Service was altered on the advice of powerful leaders in the United States Senate, and the Association was influential in securing a considerable appropriation for the U. S. Public Health Service for tuberculosis work without a division, but with an advisory council or committee to the Public Health Service. This and other legislative activities on the part of the Committee on Federal Legislation have meant constantly keeping in contact with governmental offices and have involved a great deal of effort. The resignation of Mr. Baldwin from the chairmanship of the Committee means a great loss to the Association.

XI. RESEARCH

In the past the National Association itself has not conducted as much active research work as it should have done. The demands upon it for education and organization have been such that all of its available funds were necessary for such purposes. During the last year, however, more direct research than previously has been accomplished. The most significant study has been that conducted under the Committee for the Investigation of the Genetic Factors in the Morbidity and Mortality from Tuberculosis, by Dr. Raymond Pearl at Baltimore. The executive office has conducted an extensive bit of research in a study of economic costs of tuberculosis, a summary of which will be presented at this meeting.

The Committee on Mortality from Tuberculosis in Dusty Trades under the active chair

manship of Dr. Frederick L. Hoffman has during the year pursued some valuable studies particularly among the granite cutters in Vermont. Two preliminary reports of the Committee have been published, one by the U. S. Bureau of Labor, and the other by the National Association. The study of the Committee in this important field will be a distinct contribution to our knowledge of tuberculosis and its prevention.

A study of the negro tuberculosis problem is about complete and ready for the printer.

The Association has also helped to finance a special study of tuberculosis among the Indians, made by the Nebraska Tuberculosis Association. This report will soon be ready for publication.

The Tuberculosis Directory has been completely revised and published in three separate volumes.

The study made several years ago on tuberculosis legislation is being revised and within a few months will be ready for publication in new form. Similarly the study made seven years ago on the influence of tuberculosis sanatoria on surrounding property is being brought up to date and revised. "Diagnostic Standards," prepared originally by the Framingham Committee, has been adopted by the Board and published for popular distribution.

The Association has in addition stood for the promotion of research on the part of local associations and has assisted the Henry Phipps Institute through a special committee in an effort to secure funds for current work and endowment.

XII. CONFERENCES AND MEETINGS

In addition to the annual meeting of the National Association, there have been held during the year six sectional conferences and a special conference for all state secretaries, besides a considerable number of conferences for localities or special groups of people. The Executive Committee and the staff of the National Association have travelled over two hundred thousand miles during the last year in performing their necessary duties. The six sectional conferences held in October in Des Moines, Boise, Los Angeles, Providence, Asheville, and Philadelphia proved very helpful to their several districts. In January, 1920, a special conference of state secretaries to discuss ways and means for the Christmas Seal campaign this year, and for the program of 1920 was held at Chicago and resulted in benefit to the entire campaign.

Under the direction of Mr. Jacobs two institutes for the training of tuberculosis workers have been held during the last year at the New York School of Social Work, and another one will be held in June of this year. These institutes are attracting new personnel to the tuberculosis movement and are helping the personnel already in the field.

Following the plan of the institute, two special training courses for vocational officers and federal employes interested in vocational work were held under the direction of Dr.

Pattison in New York and in Colorado Springs during the months of January and February. Special institutes are being planned under the direction of regional secretaries and other members of the staff for the coming year.

XIII. REPRESENTATION AT BRITISH

CONGRESS

By authorization of the Board of Directors, the National Tuberculosis Association was officially represented at the anuual meeting of the British National Association, held in London on October 7th, by Dr. David R. Lyman, Dr. William Charles White, and Dr. Charles J. Hatfield. Mr. Frederick L. Hoffman also attended the conference representing the Association. The visit of Dr. Hatfield, Dr. Lyman and Dr. White to London and later to Paris has not only served to strengthen the relationship between the tuberculosis movement in this country and that abroad, but has also given to these organizations a better grasp of our methods and programs. In turn the National Association has been benefited through a better comprehension of the manner in which anti-tuberculosis work is being carried on abroad. More and more the National Association is compelled to take an international outlook. The demands for service are coming to us from all parts of the world. The United States itself, whose territory we represent, circles the globe. At the present moment we have with us a representative of the Philippine Islands Anti-Tuberculosis Association who has been studying in this country for over a year under the direct supervision of the National Association. The Executive Committee has authorized, as soon as the personnel can be made available, a campaign in Porto Rico. The National Association is represented in Hawaii and, in short, wherever the flag of the United States flies. This world-wide scope of the Association brings us inevitably into contact with our foreign neighbors, and both for our own sake and for theirs we must assume more of an international point of view.

XIV. DEVELOPMENT OF STATE AS

SOCIATION WORK

For years, as the state associations have developed, there has been a growing desire on their part to secure more definite representation and to assume more direct responsibilty in the affairs of the National Association. A special committee of the Board of Directors is studying a plan which it is hoped will meet the desires of all concerned and will secure adequate representation of the state associations in the management of the National Association and at the same time will preserve the national and international character of the Association itself. The various parts of the tuberculosis movement are inextricably bound together. The state associations cannot exist by themselves; neither can the National Association exist by itself. What is advantageous for one is advantageous for the other. (Continued on page 182)