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 RC31 3. A2 F85 A plea for a federal 
 
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 A Plea for a Federal Commission 
 on Tuberculosis 
 
 BY 
 
 LEE K. FRANKEL, Ph.D. 
 
 Sixth Vice-President Metropolitan Life Insurance Company 
 
 New York 
 
 A Paper Read at the 
 
 Mississippi Valley Conference on Tuberculosis 
 
 Indianapolis, September 30, 1915 
 
 .i-t 
 

A Plea for a Federal Commission 
 on Tuberculosis 
 
 The interest of life insurance companies in the prevention 
 of tuberculosis can best be indicated by the facts of their 
 mortality statistics. In the year 1914, the Metropolitan Life 
 Insurance Company paid in its Industrial Department 163,339 
 claims on the lives of 113,989 people, amounting to $21,449,401. 
 Of these, 27,928 claims on the lives of 19,865 people, amount- 
 ing to $3,949,421, were paid on individuals who died from 
 pulmonary or other forms of tuberculosis. Including mortuary 
 bonuses the figure was $4,218,139. It is probable that the 
 experience of other Industrial life insurance companies is quite 
 similar to that of the Metropolitan. According to the In- 
 surance Year Book there were in force at the end of 1914, 
 31,134,303 Industrial insurance policies, of which 13,588,050, 
 or 43.6 per cent, were carried by the Metropolitan. On this 
 basis, Industrial insurance companies, during the year 1914, 
 paid claims on the lives of nearly 46,000 working men and 
 other members of their families amounting to over $9,000,000 
 for deaths due to tuberculosis. 
 
 It will be seen from the above that it is desirable from the 
 insurance standpoint to reduce mortality from tuberculosis, 
 and if such an ideal could ever be obtained, to eradicate the 
 disease entirely. If the payment of death claims could be 
 postponed, the ultimate result would be a reduction in the 
 cost of insurance. Possibilities of such postponement with 
 respect to tuberculosis are large. Of the total deaths from 
 tuberculosis in the year 1914 in the Metropolitan experience 
 70 per cent, were between ages 15 and 44. Tuberculosis 
 formed 37 per cent, of all the deaths between these ages. If 
 the disease could be eliminated or materially reduced in extent 
 it is probable that more individuals would die from diseases 
 characteristic of older life, such as the cardio-vascular diseases. 
 The tuberculosis problem from the standpoint of life insurance 
 companies is, as you will see from the above, primarily economic 
 in character. Reduction in mortality from tuberculosis or 
 
 1 
 
reduction in the incidence of disease spells, in the long run, 
 cheaper insurance. 
 
 The mortalit}^ experience of life insurance companies, if 
 it could be assembled, would bring out many interesting facts 
 regarding tuberculosis which would offer much food for thought. 
 I am unable to offer you to-day any experience other than the 
 one of the Company with which I am connected, but I am of 
 the impression that this experience would be a counterpart 
 of the experience of the other companies. For this reason it 
 can be taken as a measure of the conditions which exist among 
 the element of the population insured with the Industrial 
 companies. The advantage of these statistics is that they 
 represent definite classes of the population by age-period, sex, 
 race and occupation For this reason the data will probably 
 be as reliable as the vital statistics of the Registration Area 
 of the United States, although they are not so extensive as to 
 numbers. 
 
 I shall quote from Table 1, showing the decline in the 
 Metropolitan Life Insurance Company's white mortality from 
 seven principal causes of death for the year 1914 as com- 
 pared with the year 1911. The statistics for tuberculosis are 
 very interesting. They show that within the short period of 
 three years the death rate from tuberculosis in the Company's 
 experience dropped from 208.7 per hundred thousand to 189.6 
 per hundred thousand, or a reduction in the rate of 9.1 per 
 cent. These figures supplement those for the Registration 
 Area for the years 1901 to 1911, which show a rate in 1911, 
 83 per cent, of that in 1901. All of this indicates that the 
 campaign of education which has been carried on for over a 
 decade is bearing and has borne fruit. It is fairly safe to 
 predict that the experience of the next three years will show 
 a further reduction in the tuberculosis death rate of the country 
 and of the life insurance companies. 
 
 If we analyse these figures according to age, sex, color, 
 occupation and locality, or compare them with the decline in 
 death rates from other diseases, we find several interesting 
 facts that are well worth our careful attention and study. 
 While it is true, as stated above, that in our experience the 
 death rate from tuberculosis has declined 9.1 per cent., we 
 find, as will be seen from the table below, that reductions in 
 death rates have been even more marked in certain other 
 well-known diseases. For example, the reduction in three 
 
 2 
 
years in the death rate from typhoid fever was 30.2 per cent., 
 from acute infectious diseases of children 19.7 per cent., from 
 acute and chronic bronchitis 23.3 per cent., from all forms of 
 pneumonia 13 per cent., from cirrhosis of the liver 17.5 per cent. 
 It is possible that the anti-tuberculosis campaign may have 
 contributed to these reductions. To the insurance company 
 the question naturally arises: Why should the reduction in 
 the death rate from tuberculosis be less than from other diseases 
 mentioned?' Has the campaign for the prevention of other 
 infectious diseases been carried on more effectively than the 
 campaign against tuberculosis? Are there other underlying 
 reasons and causes which have brought about a greater decline 
 in one disease than in the other? 
 
 TABLE 1 
 
 NUMBER AND PERCENTAGE OF DEATHS FROM CERTAIN CAUSES, 
 
 SHOWING IMPROVEMENT IN MORTALITY-WHITE LIVES 
 
 Metropolitan Industrial Premium Paying Business, 1911 and 1914 
 
 CAUSE OF DEATH 
 
 
 Typhoid fever 
 
 Acute infectious diseases of childhood (measles, 
 scarlet fever, whooping cough, diphtheria and 
 croup) 
 
 Tuberculosis (all forms) 
 
 Acute and chronic bronchitis 
 
 Pneumonia fall forms) 
 
 Cirrhosis of the Uver 
 
 External causes 
 
 Total above causes 
 
 1106 
 
 4160 
 14274 
 892 
 7700 
 1128 
 6963 
 
 .36223 
 
 4.8 
 16.3 
 1.0 
 8.8 
 1.3 
 8.0 
 
 13.2 
 
 40.7 
 189.6 
 
 12.5 
 100.8 
 
 16.5 
 
 4243 
 13221 
 976 
 7335 
 1142 
 6467 
 
 5.3 
 16.6 
 1.2 
 9.2 
 1.4 
 8.1 
 
 18 9 
 
 50.7 
 208.7 
 
 16.3 
 115.8 
 
 20.0 
 
 99.9 
 
 .30.2 
 
 19.7 
 9.1 
 23.3 
 13.0 
 17.5 
 11.1 
 
 41 5 
 
 462.2 
 
 34690 
 
 43.5 
 
 .530 3 
 
 12.8 
 
 A similar study of the death rates for colored lives insured 
 with the Metropolitan brings out equally interesting data. 
 In this group, the reduction in the death rate from typhoid 
 fever for the three years studied, has been 27.7 per cent, as 
 compared with 30.2 per cent, for white lives. Acute infectious 
 diseases of children show a decline in the death rate of 23.2 
 per cent., whereas among whites the reduction was onlv 19.7 
 per cent. Pneumonia shows a reduction of 14.5 per cent, as 
 compared with 13 per cent, for whites. But when we consider 
 tuberculosis, we find a decline of only 2.8 per cent, as compared 
 with 9.1 per cent, for white lives. The question arises: Why 
 should the reduction in death rates for typhoid fever, infectious 
 diseases of children and pneumonia be fairly close for these 
 
 3 
 
two race groups of our policy-holders, and the decline in the 
 death rate from tuberculosis be so disproportionate? If the 
 living and working conditions which bring about high death 
 rates from tuberculosis among negroes maintain, why have 
 they not exercised their influence on other diseases? Or, is it 
 possible that these conditions affect tuberculosis only? 
 
 If we study the tuberculosis death rate in terms of age, 
 sex and color classes, other interesting facts are at once observed 
 and are shown in Table 2. Comparing the death rates given 
 for the two years 1911 and 1914, it is found that while there 
 has been a decline in the death rate for all ages for white males, 
 white females and colored females, there has been an increase 
 in the death rate among colored males. If we consider white 
 males separately, we find there has been a decline in the death 
 rate at all ages, except between ages 1 and 5, and ages 45 and 54, 
 Similarly, among white females there has been a decrease in 
 the death rates in all ages except between ages 10 and 14, 
 where there has been an increase of 5.1 per cent. The increase 
 in the death rate from tuberculosis among colored males at 
 all ages is accounted for by the marked increases between 
 ages 25 and 54, the increase being 6 per cent, between ages 
 25 and 34, 15 per cent, between ages 35 and 44, and 10.3 per 
 cent, between ages 45 and 54. If we attempt to explain this 
 increase on occupational grounds, we are at once confronted 
 by the fact that at the same ages among white males there 
 has been a decrease between ages 25 and 44, whereas at ages 
 45 to 54 there has been an increase in the death rate of white 
 males corresponding almost with the increase among colored 
 males. Again, if we study the death rate among colored 
 females, we find a decrease at all ages excepting ages 15 to 19, 
 where there has been an increase of 2.6 per cent., and at ages 
 45 to 54, where there has been an increase of 8 per cent. 
 
 These peculiar facts raise questions to life insurance com- 
 panies which are difficult to answer. It is difficult to under- 
 stand why white girls between ages 10 and 14 should show a 
 higher death rate in 1914 than in 1911, or why there should 
 be an increase in the death rate among colored men between 
 the ages 25 and 54 (particularly in view of the fact that the 
 death rate among colored males, as is well known, has always 
 been considerably higher than among white males). 
 
 If the campaign for the prevention of tuberculosis had been 
 uniform in its effects, it would have followed that a reduction 
 
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in the death rate would have been shown at all ages for both 
 sexes and for negroes as well as whites. The question which 
 I propound is this: What explanation can be offered for the 
 irregularities in the death rate above indicated? 
 
 Studied from the standpoint of occupation, tuberculosis 
 mortality again offers significant data as indicated in Table 3. 
 Experience of the Metropolitan shows that 20.5 per cent, of 
 the deaths of occupied white males, ages 15 and over, are due 
 to tuberculosis of the lungs, whereas 35 per cent, of the deaths 
 among clerks, bookkeepers, office assistants are caused by this 
 disease. On the other hand, only 14 per cent, of the deaths 
 among railway enginemen and trainmen and only 5.8 per cent, 
 of deaths among coal miners are caused by consumption. If 
 we remember that coal miners live and work under conditions 
 which, presumably, are favorable to the development of tuber- 
 culosis, namely, in dark and often badly ventilated places, it 
 becomes difficult to reconcile this low mortality with our pre- 
 conceived views on the subject. 
 
 If we study this table according to age groups, other in- 
 teresting facts are developed. Among clerks, bookkeepers and 
 office assistants, 35 per cent, of all deaths over 15 years of age 
 are caused by tuberculosis, and between ages 25 and 34, 51.2 
 per cent, of the deaths are due to this disease. Only 21.9 
 per cent, of the deaths among painters, paper-hangers and 
 varnishers, all ages over 15, are due to tuberculosis, and at 
 ages 25 to 34 only 42.9 per cent, of the deaths are caused by 
 tuberculosis. Do these figures mean that resistance among 
 painters, paper-hangers and varnishers is greater than among 
 clerks at the younger ages, or are there occupational con- 
 ditions which influence the mortality in the clerk group more 
 than they do those in the painter group? If we study the 
 age period 35 to 44 we find that tuberculosis kills off 346 
 painters out of every 1,000 painters who die at these ages, and 
 that only 334 clerks, bookkeepers and office assistants die from 
 tuberculosis out of 1,000 deaths in this occupation group and 
 age period. What do these figures mean? Is the influence of 
 occupation, particularly the influence of lead poisoning begin- 
 ning to manifest itself among painters as they grow older and 
 does a clerk who has passed age 25 show greater resistance to 
 tuberculosis? 
 
 Studied from the standpoint of locality, more questions 
 arise which interest and at the same time mystify life insurance 
 
 6 
 
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 companies. I could cite statistics from various sections of 
 the United States which would show marked differences in the 
 death rates in various cities. For example: our colored death 
 
 7 
 
rate, all causes, is the same in Cincinnati as it is in Louisville. 
 On the other hand, our death rate per hundred thousand from 
 tuberculosis on colored lives is 375.4 in Louisville and 479.2 in 
 Cincinnati. I have cited the above statistics, not with the 
 intention of definitely establishing any hypothesis, but rather 
 to elucidate the thought which I had in mind in the presenta- 
 tion of this paper. It is quite probable that other statistics 
 may be quoted, which would negative any deductions drawn 
 from the data herein contained. 
 
 Those of you who have been interested in the tuberculosis 
 campaign will probably concede that there has been a change 
 of attitude in the past few years with respect to the value of 
 the campaign and the results obtained. I can recall how more 
 than a decade ago we took as the slogan for our work: "Tuber- 
 culosis is not only curable, but preventable." Based upon the 
 results obtained in the cure of tuberculosis we accepted as correct 
 the belief that the conditions to effect a cure such as fresh air, 
 proper and sufficient food, proper living conditions, etc., were 
 necessary also to prevent tuberculosis. We have accepted 
 these as fundamentals in our anti-tuberculosis work. Any 
 anti-tuberculosis association, which has come into existence 
 within the last ten years, has spent its funds and carried on 
 its campaign largely along these lines. Only recently have 
 we begun to question whether our foundations are built on 
 sand or on solid rock. Do we really know the etiology of 
 tuberculosis? Are we acquainted with the conditions under 
 which the tubercle bacillus develops and thrives? Is our 
 campaign against tuberculosis the proper and logical one that 
 will lead to the final extinction of the disease? Do statistics 
 and other facts indicate that we have made or are making 
 headway? Are we convinced that our efforts to prevent 
 spitting, to sterilize milk, to have working men employed under 
 proper sanitary and hygienic conditions, to see that families 
 are properly housed, are really the lines along which we ought 
 to work in the future in the hope that the primary purpose 
 of the tuberculosis campaign may be developed? 
 
 I have no wish to stand here to-day as a critic of the things 
 that have been attempted since the anti-tuberculosis crusade 
 was started, and yet we must realize that, unless we are willing 
 to examine our work carefully and honestly, critics may arise 
 from the outside who may condemn our efforts in no unmeasured 
 terms. I need not recall to you at this time the fact that 
 
there are those who doubt whether the reduction in the death 
 rate from tuberculosis in the last ten years can be attributed 
 to the efforts of the anti-tuberculosis movement. It is even 
 claimed that similar reductions have taken place for a number 
 of earlier decades and probably would have taken place without 
 our efforts, in line with the general improvement in mortality. 
 There are doubters who contend that infection through sputum, 
 except in early childhood, is of rare occurrence, and that in 
 fact most of us become infected during childhood and set up 
 an immunity which protects us from reinfection. It seems 
 quite clear from investigations and autopsies which have been 
 made in many places that this theory has good ground for 
 support. While it is true that there has been a reduction in 
 the mortality, we have no data to indicate whether there are 
 fewer cases of tuberculosis than there were ten years ago. 
 Until we have morbidity statistics it will be impossible for us 
 to say whether our campaign has been at all successful along 
 preventive lines in reducing the numbers of individuals annually 
 afflicted with the disease. 
 
 I think it is time for us to pause and consider why the 
 results which have been obtained have not been larger. Even 
 admitting that there has been a pronounced and gratifying 
 reduction in the death rate, I have indicated above by the 
 statistics submitted that there have been even more marked 
 and greater reductions in death rates of other diseases. Can 
 we consider these facts as they are and endeavor with the 
 material at hand to formulate to our satisfaction the reasons 
 for this difference so that we may possibly elaborate a pro- 
 gram for the future. 
 
 If I may be permitted to express my own views, I will say 
 that the causes which have most largely affected the com- 
 paratively slight results obtained are inherent in the disease 
 itself. One of the great difficulties in the eradication of the 
 disease lies in the fact that it is a chronic disease whose onset 
 is slow and whose progress in most instances covers compara- 
 tively long periods of time. It is because of this chronicity that, 
 notwithstanding all that has been written about phthisiophobia, 
 real fear and horror of the disease have never taken possession 
 of the great masses of the people. We have learned to accept 
 the affliction of tuberculosis with a certain fatalism. Much 
 of the early belief in the heredity of the disease still maintains, 
 and, in fact, is being accentuated by the most recent researches 
 
 9 
 
which lead to the beUef that heredity does play a part, if not 
 in the transmission of the disease at least in its development. 
 I am convinced that if tuberculosis were an acute disease, 
 whose onset was short and rapid, whose course was in most 
 instances fatal within a comparatively short time, we would 
 long since have found the means to prevent the disease, pre- 
 cisely as we have done with smallpox, yellow fever, Asiatic 
 cholera, malaria and typhoid fever. I am not certain whether 
 our slogan of proclaiming tuberculosis to be curable has not 
 injured rather than benefited the cause. The very hopeful- 
 ness of our attitude has tended to weaken efforts on the part 
 of individuals and communities to adopt necessary prophy- 
 lactic measures and to institute radical campaigns of prevention. 
 Is it not, therefore, necessary for us at this time to reassemble 
 our facts and determine whether with the information at hand 
 we shall proceed along the lines which we have laid down, or 
 whether it is not necessary for us to establish new criteria and 
 new bases for future action? 
 
 If I may be permitted another personal expression of 
 opinion, I would venture the suggestion that the weakness of 
 our campaign is due to the fact that we have accepted certain 
 premises which have not been scientifically and accurately 
 demonstrated. Statistics have shown us that tuberculosis 
 seems to thrive best where there are bad housing conditions, 
 poor and inadequate food, overwork, bad light and bad venti- 
 lation, and yet as a matter of fact there are no reliable scientific 
 data to establish any of these beliefs. The illustration which 
 I have given above of the small proportion of deaths from 
 tuberculosis among coal miners, who frequently work under 
 a number of the bad conditions just mentioned, indicates 
 rather clearly that most careful investigations are still necessary 
 to determine whether our theories are correct. The peculiar 
 variations which I have shown in the Metropolitan experience 
 with respect to age, sex, color and locality all indicate that we 
 are only at the beginning of accurate scientific investigations 
 regarding the etiology of tuberculosis. What is needed is 
 an exhaustive, comprehensive and intensive study of the 
 many complicated and complex factors which are involved in 
 the persistence of this disease. 
 
 If our present methods are inadequate, have we any data 
 which point the way for the future? I think the facts are so 
 clear that he who runs may read. If we compare the typhoid 
 
 10 
 
death rate in Cincinnati with that of other cities in the same 
 geographical area we find marked differences. The typhoid 
 fever death rate in Cincinnati to-day is among the lowest in 
 the United States. The Metropolitan experience for 1913-1914 
 shows only one colored and ten white deaths. The reason for 
 this is obvious. Ohio River water had long been known to be 
 the source of infection. Cincinnati deliberately spent millions 
 of dollars to provide its citizens with a proper water supply. 
 The results were immediate and conclusive. If the same 
 concerted and deliberate action had been taken with respect to 
 tuberculosis, if the city of Cincinnati had been prepared to 
 expend equally large sums in a campaign against tuberculosis 
 after an intensive study of the causes which produce it, it is 
 no exaggeration to say that the tuberculosis death rate per 
 hundred thousand would to-day no longer be expressed in 
 three figures. 
 
 There are other apt illustrations to show us the course we 
 must pursue. At the meeting of the American Public Health 
 Association held in Rochester a few weeks ago. Dr. Gorgas 
 detailed the campaign which had been carried on in Cuba 
 to eradicate yellow fever. He described the original belief 
 that yellow fever was a dirt disease, and told of the incessant 
 campaign waged in every part of Cuba to clean up. No effort 
 was spared to put the island in sanitary condition, and yet 
 the campaign was a failure so far as the prevention of yellow 
 fever was concerned. Only after the discovery of the cause 
 of infection, the yellow fever mosquito (stegomya fasciata), 
 which, as you know, was the result of a series of most elaborate 
 researches and studies, was the correct method of preventing 
 the disease found and applied. It is of importance to point 
 out here some of the things that were done by General Gorgas, 
 with practically the power of a Czar and with practically 
 unlimited financial resources. Among other things, he estab- 
 lished not only a marine quarantine, but a land quarantine 
 as well. No individuals were allowed to enter what were 
 practically segregated cities cither from the land or from the 
 sea excepting after careful inspection and examination, A 
 thoroughly organized campaign to exterminate the mosquito 
 was developed. The result after fourteen years, as Dr. Gorgas 
 put it, is that yellow fever disappeared from the island. 
 
 Will you endeavor to visualize with me another island, 
 preferably smaller than Cuba, in which an attempt would be 
 
 11 
 
made to get at the root of the tuberculosis problem in a manner 
 similar to the one in which General Gorgas handled yellow 
 fever. I can conceive of such an island being placed in charge 
 of a sanitarian of the Gorgas type and given almost autocratic 
 power. He would not lack necessary funds to carry on the task 
 assigned him. Such a man with competent assistants would 
 carry out a well-defined policy of experimental research to 
 determine not merely the medical and bacteriological causes 
 which produce tuberculosis, but would supplement such 
 research with exhaustive studies into the social causes which 
 enable the disease to develop and persist. When these had 
 been determined, our sanitarian would use the unlimited 
 powers which had been placed at his disposal to see to it that 
 there were no infractions or violations of any laws, rules or 
 ordinances which he might enact tending toward the elimi- 
 nation of conditions causing infection. 
 
 Fantastic as the idea may appear to us at the present time 
 with our limited vision, I can conceive that on this mythical 
 island every resident, irrespective of his state of health would 
 be subjected to a rigid medical examination. A careful record 
 would be kept of his social and medical history. He would 
 be re-examined periodically to determine whether any changes 
 had taken place in his physical condition. If his family history 
 showed hereditary tendencies to tuberculosis, such examina- 
 tions would be conducted at more frequent intervals. Each 
 resident of this island would be studied with respect to age, 
 sex and occupation. The conditions under which he lived and 
 worked would be carefully recorded. The influences which 
 these conditions might have upon his state of health would 
 be determined. On this ideal island no one would be per- 
 mitted to enter who could not conform to the standards set 
 up by a board of medical experts and students of social problems. 
 A land and water quarantine, similar to the one established by 
 General Gorgas in Cuba, would be an accepted fact on this 
 ideal island. 
 
 These things would, however, be only preliminaries. Our 
 sanitarian would undoubtedly provide for a careful inspection 
 of all the food supplies used by the people who lived there. 
 Milk inspection would not be a perfunctory act. The pre- 
 vention of spitting would be more than an unenforced statute. 
 Inventors would be asked to design practicable receptacles 
 for sputum, and the furnishing of these in sufhcient number and 
 
 12 
 
in convenient places would be as much a duty of the authori- 
 ties as a good water supply, sewers or comfort stations. 
 
 Nor would preventive measures end here. Every case of 
 tuberculosis that was found would be carefully studied to 
 determine the conditions under which it arose. Sanatorium 
 treatment would be given to the early cases. The people 
 would be educated as a matter of public and personal duty, to 
 bring to the notice of the authorities any symptoms which 
 might indicate the beginnings of a tuberculous infection. Ade- 
 quate hospital facilities w^ould be provided for advanced cases. 
 For those whose condition was hopeless and for whom segre- 
 gation was required, opportunity would be given to pass their 
 remaining days in modern institutions with attractive surround- 
 ings, in which every consideration would be given to their care 
 and comfort. 
 
 It is only necessary to add that in this mythical island 
 every phase of modern public, personal and industrial hygiene 
 would be developed. In particular the influence of occupation 
 on health and as a factor in producing tuberculosis would 
 receive the closest attention. In time the authorities would 
 probably ascertain, by careful and accurate experiment, what 
 influence housing, air and ventilation have in the spread of 
 tuberculosis, and whether race, wages, nationality, sex, age, 
 occupation, alcohol, venereal disease, and heredity play im- 
 portant or negligible parts. 
 
 I think I have said enough to indicate to you the thought 
 I have in mind, namely, that we shall not begin to handle 
 the tuberculosis problem effectively until we institute methods 
 similar to those that were employed in Cuba and in the Philli- 
 pines. These methods involve (1) accurate and painstaking 
 scientific research along both medical and social lines, (2) the 
 application of the results of such research to isolated and if 
 necessary segregated groups of individuals who may be kept 
 under constant observation, (3) authority to enfore regulation, 
 and (4) adequate finances. The science of medicine has 
 reached its present highly developed state by reason of 
 years of endless and painstaking research. The profession 
 of chemistry would still be in the unenlightened period of 
 alchemy had it not been for the laboratories devoted to scientific 
 investigation. Other professions and arts tell the same story. 
 Medical research has proven beyond pcradventure that tuber- 
 culosis is a specific infection of the tubercle bacillus. How it 
 
 13 
 
thrives and develops is in part known and in part assumed. 
 If the disease is ever to be eradicated, we must definitely know 
 facts and dispense with assumptions. That this has been done 
 with other diseases is too well known to require further com- 
 ment. Precisely the same course as has been pursued with 
 these diseases must be followed with tuberculosis. 
 
 The question may be asked, "But what of the cost?" I 
 reply, that we may not consider cost with respect to a disease 
 which to-day causes more deaths than any other. As it is, 
 according to the statement of the National Association for 
 the Study and Prevention of Tuberculosis, there was spent 
 last year over $20,000,000 in the campaign against tuberculosis 
 in the United States. This included the amount spent for 
 institutional care and treatment. In fact, over $18,000,000 
 was spent for these purposes, largely curative in nature. Less 
 than $2,000,000 was spent in the entire preventive campaign, 
 including so far as is known all educational movements and 
 all research work. This is a paltry sum when the extent of 
 the disease is considered. I have no doubt that if we could 
 spend $20,000,000 in a determined, enlightened and compre- 
 hensive plan, such as I have outlined above, we could look 
 forward with confidence in the next decade to seeing as marked 
 a reduction in the mortality of tuberculosis as we have seen in 
 smallpox, yellow fever, etc. 
 
 You will ask, "Is not this work for the great insurance 
 companies of the United States?" My reply would be, "Yes, 
 if money were the only need." I can conceive of no better 
 purpose to use insurance surplus, and, if necessary, even divi- 
 dends, than for the eradication of tuberculosis. Money, 
 however, is only one great requisite; the other is authority. 
 An experiment such as I have suggested will not come within 
 the scope of private enterprise. It will be distinctly a function 
 of the Federal Government. Only the latter would have the 
 sovereign power, not only to inaugurate such a campaign, but 
 to enforce the social and medical conditions under which such 
 an experiment should be made. 
 
 In conclusion, let me suggest for your consideration the 
 adoption of a resolution calling upon the Congress of the 
 United States to authorize the President to appoint a Federal 
 Commission on Tuberculosis composed of eminent specialists in 
 the medical, economic and social phases of the subject. vSuch 
 a commission would have to be vested with sufficient power 
 
 14 
 
and authority and be given ample financial support to make 
 an intensive investigation into the etiology of tuberculosis. I 
 am confident that the report of such a commission would show 
 definitely and unmistakably the path along %vhich the future 
 campaign against tuberculosis must proceed, if we are ever 
 to eradicate the disease. 
 
 [Since the presentation of this paper, the recommendation 
 contained in the last paragraph has been adopted by resolution of 
 the Mississippi Valley Tuberculosis Conference, the South Atlantic 
 Tuberculosis Conference, the New England Tuberculosis Confer- 
 ence and the North Atlantic Tuberctilosis Conference.] 
 
 15 
 
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