COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64074722 RA644.T7 C73 What has the demonst What Has The Demonstration Done ? Should It Be Continued ? REPORT OF THE COMMITTEE ON APPRAISAL FOR THE FRAMINGHAM COMMUNITY HEALTH AND TUBERCULOSIS DEMONSTRATION COMMUNITY HEALTH STATION FR AMINGHAM, MASS. OCTOBER, 1919 RAk^-n C73 Columbia (Hnttier^ftp intljeCttpofBfttignrk COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/whathasdemonstraOOcomm / What Has The Demonstration Done ? Should It Be Continued ? REPORT OF THE COMMITTEE ON APPRAISAL FOR THE FRAMINGHAM COMMUNITY HEALTH AND TUBERCULOSIS DEMONSTRATION COMMUNITY HEALTH STATION FRAMINGHAM, MASS. OCTOBER, 1919 C13 CONTENTS Page Committees and Staff 3 Foreword 5 Appraisal Committee Recommendations 7 Key-note Sentences 8 The Report 11 Introduction 11 General Impressions 12 The Practicability of Tuberculosis Control ... 14 The Advisability of Continuing 15 Recommendations as to Continuance 17 A Five- Year Extension 17 Coordination of Local Health Agencies . . . . 18 FRAMINGHAM COMMUNITY HEALTH AND TUBERCULOSIS DEMONSTRATION APPRAISAL COMMITTEE Dr. Allan J. McLaughlin, Chairman . U. S. Public Health Service. *Prof. C.-E. A. Wlnslow, Secretary . . Yale University, New Haven, Conn. Dr. Edgar T. Sydenstricker . . . . U. S. Public Health Service. Dr. Charles V. Chapin Health Commissioner, Providence, R. I. Dr. Victor G. Heiser Rockefeller Foundation, N. Y. City. Miss Helen R. Stewart National Public Health Nursing Association. Mr. George J. Nelbach State Charities Aid Association, New York. Dr. Emery R. Hayhurst State Department of Health, Ohio. Dr. Thomas A. Storey American School Hygiene Association. Dr. Samuel McCllntock Hamill . . . University of Pennsylvania. Dr. Louis Hamman Johns Hopkins Medical School. Dr. Lawrason Brown Trudeau Sanatorium, Saranac Lake, N. Y. Dr. H. R. M. Landis Phipps Institute, Philadelphia, Pa. NATIONAL COMMITTEE Dr. Edward R. Baldwin, Chairman . . Saranac Lake, N. Y. Dr. Charles J. Hatfield, Secretary . . New York City. Dr. Lee K. Frankel New York City. Dr. Victor C. Vaughan Ann Arbor, Mich. Mr. Homer Folks New York City. Dr. Arthur K. Stone Framingham, Mass. Dr. Eugene R. Kelley Boston, Mass. Dr. Stephen J. Maher New Haven, Conn. Dr. William Charles White .... Pittsburgh, Pa. Dr. Victor Safford Boston, Mass. Dr. F. C. Smith Washington, D. C. Dr. Enos H. Bigelow Framingham, Mass. Mr. Henry S. Dennison Framingham, Mass. Mr. Theo F. Rice Framingham, Mass. EXECUTIVE STAFF Donald B. Armstrong, M.D., Executive Officer P. Challis Bartlett, M.D., Chief Medical Examiner ♦Professor Winslow has recently accepted an appointment on the National Committee. On May 3, 1916, the conception of a community tuberculosis experiment was first outlined in a letter received by the National Tuberculosis Associa- tion from Dr. Lee K. Frankel, Third Vice-President of the Metropolitan Life Insurance Company. In this communication Dr. Frankel discussed tuber- culosis work in general, and stated that, in his belief, much might be accom- plished toward the eradication of tuberculosis through an intensive experiment aimed at the control of this disease. In offering the financial aid of the Metropolitan Life Insurance Company in such an experiment Dr. Frankel stated : "To this end we are prepared to place at the disposal of the National Association for the Study and Prevention of Tuberculosis the sum of one hundred thousand dollars ($100,000.) for the purpose of conducting a com- munity experiment over a period of three years in the control of tuberculosis." In outlining the fundamentals of such an experiment and demonstration Dr. Frankel indicated that stress should be placed upon periodic medical ex- aminations for all members of the community, medical and nursing care for all tuberculosis cases, adequate dispensary and institutional treatment, the cooperation of local and state agencies, etc. This offer was accepted immediately by the National Tuberculosis Asso- ciation, and the energies of that association have been devoted to the direc- tion of the experiment since its actual initiation on January 1, 1917. Pre- vious to that date considerable time was spent in the selection of an appro- priate community, Framingham, Mass. being finally chosen for the work. As indicated above, the Framingham Community Health and Tuber- culosis Demonstration was originally planned for a three-year period. On this basis the Demonstration would have ended on January 1, 1920. In view of the fact that many phases of the program would inevitably have been unfinished on that date, the National Tuberculosis Association took steps through the National Committee in charge of the Framingham work, during the summer of 1919, to meet the following points of inquiry: 1. How much has the Experiment or Demonstration accomplished thus far? 2. In what measure has the work approached an answer to the problem originally set, as reflected by the essentials briefly referred to above? 3. Would an extension of time for the Demonstration be justifiable? Two principal methods were used to answer these inquiries. The first was the appointment of a Progress Committee, serving as a Sub-Committee of the National Committee, to study these problems, and to report their find- ings to the National Tuberculosis Association. The second was the creation of an outside Appraisal Committee, to render an impartial judgment upon these fundamental questions. Through the cooperation of Surgeon General Rupert Blue of the United States Public Health Service, such an Appraisal Committee was appointed, to make an unprejudiced and scientific analysis of the Framingham work. The members of this Committee have visited Framingham, two formal com- mittee meetings have been held, and the report of the committee, as sub- mitted to Surgeon General Blue, follows in this publication. After approval by the Appraisal Committee, this report was passed upon by Surgeon General Rupert Blue, by the Progress Committee on the Fram- ingham work, by the National Committee in charge of the Demonstration, by the Executive Committee of the National Tuberculosis Association, and finally by the Board of Directors of the Metropolitan Life Insurance Com- pany, with the result that the Appraisal Committee recommendations and general plan for the extension were approved, with only minor changes as to budget suggestions, and an additional appropriation made by the Metropol- itan Life Insurance Company to carry on. the work for the year 1920. The Health Demonstration staff wishes to take this opportunity, both for itself and for the National Tuberculosis Association, to extend its appre- ciation and thanks to the Appraisal Committee for their thorough and imaginative approach to the problem and for their invaluable suggestions. The Demonstration officers are particularly grateful for the work of Professor C.-E. A. Winslow as Secretary of the Committee, to whose broad knowledge and keen analytical vision, the excellence of the report is in great measure due. SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS Surgeon General Rupert Blue, U. S. Public Health Service, Washington, D. C. 1. Your committee feels that the work of the Framingham Community Health and Tuberculosis Demonstration during the past three years is worthy of high praise. It has organized and carried out a community plan for the control of tuberculosis along the lines indicated by the best modern scientific knowledge. It has given us the first reliable information as to the actual amount of tuberculosis present in a typical American community; and in the organization of a tuberculosis consultation service it has made a contribution of the first magnitude to the machinery of public health protection. In addition, it has stimulated the development of the general public health campaign in Framingham to a degree that goes far to realize the highest ideals of modern sanitary science. 2. The Demonstration has not furnished an answer to the primary question as to the practicability of the control of tuberculosis, because the period of three years was necessarily too short to make a conclusive answer to this question possible. The results thus far obtained are as promising as could be expected, but an extension of the work for a period of five years more will be necessary in order to insure with reasonable certainty a satis- factory answer to this question. 3. Your committee, therefore, recommend that a further appropriation of $100,000.00 should, if possible, be obtained for the continuance of the Demonstration experiment along the general lines indicated in the body of its report. Committee on Appraisal: Allan J. McLaughlin, Chairman, Lawrason Brown, H. R. M. Landis, Charles V. Chapin, George J. Nelbach, S. McC. Hamtll, Helena R. Stewart, Louis Hamman, Thomas A. Storey, Emery R. Hayhurst, Edgar T. Sydenstricker, Victor G. Reiser, C.-E. A. Winslow, Secretary. KEY-NOTE SENTENCES As To Results: 1. The Extent of Tuberculosis. The first step, a determination of the actual prevalence of tuberculosis infection, has been accomplished with a high degree of success, giving us for the first time a fairly complete picture of the amount of tuberculosis actually existing in a typical American community. 2. The Consultation Service. The most important of all the practical contributions made by the Demonstration is the working out of a plan for medical consultation service, which is clearly the most promising means yet devised for securing a rea- sonably complete knowledge of the amount of tuberculosis existing in a given community. The consultation service plan has attracted wide attention throughout the country. 3. Tuberculosis Treatment. The machinery adopted for the treatment of cases of tuberculosis after they have been discovered has been modelled along generally accepted lines. The work has been accomplished efficiently and successfully. 4. Standards of Diagnosis. The officers of the Demonstration have prepared a scheme of diagnostic standards for tuberculosis which has attracted wide attention. 5. Death Certification Analysis. The careful analysis of death certificates, showing that the actual deaths from tuberculosis in Framingham were 22 per cent, in excess of the reported deaths from this disease, also constitutes a valuable contribution. 6. Sanitary Studies. From the standpoint of general environmental causes effecting the spread and development of tuberculosis, the staff of the Demonstration has conducted valuable studies of schools, factories, and municipal health conditions. 8 7. General Sickness Prevalence. The medical examination drives have yielded some of the most complete data in regard to the prevalence of disease of all sorts in a random section of the population that have ever been collected in this country. 8. The Tuberculosis Death Rate. From the standpoint of mortality, the tuberculosis death rate has fallen from 93 per 100,000 in 1917 to a rate corresponding to 76 for the first five months of 1919. This is an encouraging showing, in view of the fact that the tuberculosis death rate in similar Massachusetts communities, has in general materially increased. As To Framingham: 9. The Town's Response. The town of Framingham has responded with vision and effectiveness to the remarkable opportunities offered by the establishment of the Demon- stration. The local Board of Health, the School Committee, the Civic League, and many of the employers of labor, have met the challenge to make Fram- ingham the model "Health Town" with constructive responses of a high order. 10. Local Health Development. Even more important from the practical standpoint has been the notable development of public health work in Framingham along a wide variety of lines. 11. The Health and School Departments. The local health department has grown to be a strong and effective one, and the system of medical inspection of school children, organized under the Department of Education, represents one of the best examples of such service to be found in the United States. 12. The Community Benefited. It seems clear that if the Framingham Demonstration should cease on January 1, 1920, the local community will have benefited materially and many important contributions will have been made to the practical control of tuberculosis. 13. Need for Local Coordination. It seems to us if the Demonstration is to be continued that it might be of service to organize in Framingham a Health Council which would include the Health Officer, or a Board of Health representative as Chairman, with repre- sentatives of the School Committee, the Civic League, the Framingham Hos- pital, the Red Cross, the medical society, and the Demonstration, — this council to serve as a clearing-house for the coordination of health activities and the planning of the most effective public health machinery for the com- munity as a whole. We deem it to be of great importance to transfer the work to them (the local agencies) as rapidly as possible. In General: 14. The Foundations Laid. The foundation has been well laid; a program for the control of tuber- culosis by early diagnosis and hygienic care has been organized on ideal lines ; local sentiment both in the medical and lay circles has been successfully developed in support of the campaign ; and all conditions are favorable to its success. 15. Continuation Vital. These statistical calculations have led us to the conclusion that the Fram- ingham Demonstration should be continued for a period of at least five years in order to render the attainment of definite results of reasonable certainty. It would furnish for the first time a definitely established working program for the practical control of tuberculosis. 16. Appreciation. We desire to express our warm appreciation of the many courtesies ex- tended to us by the staff, and the opportunities offered to form a sound judg- ment as to the character of the work, through conference with local individ- uals and agencies, both inside and outside the Demonstration circle. 10 Report of Committee on Appraisal FOR THE Framingham Community Health and Tuberculosis Demonstration Surgeon General Rupert Blue, U. S. Public Health Service, Washington, D. C. Dear General Blue: — 1. Introduction. The Committee on Appraisal for the Framingham Community Health and Tuberculosis Demonstration was appointed by you last May to investi- gate the work that has been done in Framingham under the direction of the National Tuberculosis Association, and to report upon the results so far attained and the desirability of continuing the work beyond the three years originally planned. The purpose of the Framingham Demonstration, as we understand it, was to apply the most complete program for the control of tuberculosis indi- purpose OP* THF cated by present scientific knowledge, with the view to determine whether demonstra- and in what degree it is possible with the information at our disposal to obtain definite and tangible results from such a campaign. Your committee has held two formal meetings, at Atlantic City on June 8th, and at Framingham on August 14th, and between these dates most of the members of the committee have visited Framingham and made a per- sonal study of the work on the ground, while full and extensive documentary data in regard to the Demonstration have been furnished us by Dr. D. B. Armstrong, its Executive Officer. We desire at this point to express our warm appreciation of the many courtesies extended to us by Dr. Armstrong and his staff, and the opportunities offered to form a sound judgment as to the character of the work, through conference with local individuals and agencies both inside and outside the Demonstration circle. 11 2. General Impressions of the Framingham Community Health and Tuberculosis Demonstration. The officers in charge of the Demonstration have accepted what appears at present the soundest current viewpoint, that the most effective practical procedure for the control of tuberculosis lies in the development of machinery for its early detection and for the hygienic care of individuals affected or threatened with the disease, — while at the same time taking such opportu- the extent nities as offer to minimize the spread of the infectious agent. The first step tuberculosis a ^ on g this line must be a determination of the actual prevalence of tuber- determined cu i ous infection, and this end has been accomplished with a high degree of success by the organization of medical examination drives, by the organiza- tion of a tuberculosis consultation service, and by the establishment of infant, school, industrial and other clinics. Efforts along this line have been strik- ingly successful in giving us for the first time a fairly complete picture of the amount of tuberculosis actually existing in a typical American commu- nity. The conclusion that in the medical examination drives nearly one per cent, of the persons examined were suffering from active tuberculosis while somewhat over one per cent, more were arrested cases, is an important one. This finding, if assumed to be representative of the whole community and compared with the death rate for the town, would indicate a ratio of 9 or 10 active cases during the year to one reported death. The best way to esti- mate this factor would in our judgment be to compare the number of active cases under observation during a given year with the number of deaths occurring among that group of cases. The actual experience of the Demon- cases A for VE stra ti° n nas Deen tnat tw0 hospital beds have been required for each reported one death death; but the period is too short and the number too small to warrant far- reaching deductions. Furthermore, it should be noted that it would have been difficult to fill this indicated ratio of beds without the effective machinery for locating cases, at the disposal of the Demonstration. On a basis of the active advanced cases in which the need for hospitalization was most acute, the ratio indicated by the Framingham experience would be nearer one bed to each reported case. The careful analysis of death certificates showing that the actual deaths from tuberculosis in Framingham were 22 per cent, in excess of the reported deaths from this disease also constitutes a valuable contribution, although the small number of cases involved makes it impossible to apply this conclusion in any general way. In connection with the problem of diagnosis, the officers of the Demon- stration have prepared a scheme of diagnostic standards for tuberculosis which has attracted wide attention. consultation The most im P ortant of a11 the Poetical contributions made by the 5ESX2SLS?* Demonstration is the working out of a plan for medical consultation service IMPORTANT ° . contribution wn ich is clearly the most promising means yet devised for securing a reason- 12 ably complete knowledge of the amount of tuberculosis existing in a given community. This work has been carried on by Dr. P. C. Bartlett with admirable scientific skill and exceptional tact and judgment. The physicians of the community almost without exception avail themselves freely of this service and aside from the direct results in the detection of early and doubtful cases, the stimulating effect upon the local medical profession constitutes an invaluable service to the cause of public health in Framingham. The con- sultation service plan has attracted wide attention throughout the country 'and under the auspices of the State Department of Health and the State Tuberculosis League such a service has been offered for three months in the Cape Cod district of Massachusetts with great success. The plan is already in operation, or is proposed, in sections of Illinois, New York, Ohio, Oklahoma, Vermont and Wisconsin. The success of this organized campaign for the discovery of tuberculosis is indicated by the fact that nearly 200 cases are now under observation in Framingham as compared with 27 at the beginning of the Demonstration, decrease in and it is particularly encouraging to note that during the first year 42 percASES NCED cent, of the new reported cases were of an advanced type, while in the second year only 16 per cent, of the cases were advanced, and in the first five months of 1919 only 23 per cent. The machinery adopted for the treatment of cases of tuberculosis after they have been discovered has been modelled along generally accepted lines, involving sanatorium treatment, or hygienic advice furnished through the service of a public health nurse, as circumstances may dictate in the individual efficient case. There has been nothing here that is particularly novel, but the work has been accomplished efficiently and successfully along the lines indicated by the best current practice. In view of the great difficulty of securing adequate sanitary control under such home conditions as are frequently met with, particularly in the later stages of the disease, we desire to emphasize the importance of extending facilities for local hospital treatment. It is our opinion that such treatment can be applied most effectively by the development of hospital facilities within convenient street car radius of the homes of the patients. From the standpoint of the general environmental causes effecting the spread and development of tuberculosis, the staff of the Demonstration has conducted valuable studies of schools, factories, and municipal health condi- tions, and the general situation as it affects tuberculosis seems to be as satis- factory as could reasonably be expected. Only two important points which VALUABLE directly concern the control of tuberculosis appear so far not to have been sanitary covered, — the establishment of a central pasteurizing station for the milk supply of the community and the organization of a comprehensive system of industrial clinics for the smaller manufacturing plants. Both of these meas- ures have been contemplated by the officers of the Demonstration, and it seems to us most important that these two gaps should be filled. 13 data F on ANT Believing that the control of tuberculosis is closely connected with all sickness conditions which tend to build up the health of the community, the officers of the Demonstration have devoted a considerable share of their attention to the formulation of a general health program beyond the specific field of tuber- culosis itself. The medical examination drives have yielded some of the most complete data in regard to the prevalence of disease of alksorts in a random section of the population that have ever been collected in this country. These data are of much value as indicating the prevalence of such conditions and development tne unit costs involved in such examinations. Even more important from healtt^ tne practical standpoint has been the notable development of public health activities work in Framingham along a wide variety of lines, which has resulted directly or indirectly from the activities of the Demonstration. The amount of money spent for health protection in Framingham has been increased during the life of the Demonstration from 39c. to $2.00 per capita. Half of the latter sum is contributed from public sources by the Department of Health and the Department of Education, and the other half from private sources through the Civic League, and the industrial clinics established by public-spirited manu- facturers. The local Health Department has grown to be a strong and effec- tive one and the system of medical inspection of school children organized under the Department of Education represents one of the best examples of such service. to be found in the United States. Machinery for protecting the health of infants and children of the pre-school age has been worked out under the auspices of the Civic League, and with the advances made during the present summer includes four infant clinics, and a pre-school clinic. On the whole, this work seems somewhat less satisfactory than the other phases of the local health movement, but a foundation has been laid upon which progress will no doubt be made in the future. The work of the Demonstration has been extended in certain directions somewhat beyond the field of definite public health activity, and the Com- mittee on Appraisal feels that such appropriations as those made for the Com- munity House of the Civic League and for the maintenance of the Day Camp for subnormal children might well be discontinued in the near future. -Yalu- i able as these enterprises are, it seems to us unlikely that they will yield tangible results in the saving of life. 3. Conclusions to be Drawn from the Demonstration in Regard to the Practicability of the Control of Tuberculosis. The object of the gift made by the Metropolitan Life Insurance Company to the National Tuberculosis Association was not as we understand it, pri- marily to benefit Framingham or any other local community, but to deter- mine the practicability of the control of tuberculosis by the full application of the best known methods. The really important question before your com- mittee is not, therefore, the extent to which Framingham has benefited by the 14 development of an admirable scheme of local health organization, but the Rf £J" ££T E degree to which this organization has been effective in controlling tuberculosis. Success along this line might obviously be measured in two ways, by a de- crease in new cases, or by a decrease in the tuberculosis mortality. With the progress of the Demonstration and the improvement of machinery for finding early cases, the recorded morbidity at first materially increased, but it is interesting to notice that during the first five months of 1919 only 40 new cases came to light, as against 5 5 new cases for the corresponding months of 1918. Obviously, however, no conclusions can be drawn from this isolated comparison. From the standpoint of mortality, the tuberculosis death rate (after eliminating non-residents, and adding deaths of residents occurring out- side of the town) has fallen from 93 per 100,000 in 1917 to 79 in 1918, and to a rate corresponding to 76 for the first five months of 1919. This is an encouraging showing (in view of the fact that the tuberculosis death rate in similar Massachusetts communities has in general materially increased) ; but again the period is so short and the actual number of deaths so small that no reliable conclusions can be drawn. The member of your committee representing statistics (E. T. S.) has prepared a computation of the probable errors involved in the problem and concludes after fitting the rates for 1907-1916 to the curve of probable error, and allowing for the mean error in any given rate projected for 1919-1923, that in order jtojvaj;raiit^ reasonably safe conclusions. -one or the other of the following combinations of tuberculosis death rates must be reached during the latter period. A rate of 30 or less for any 1 year A rate of 45 or less for any 2 years A rate of 60 or less for any 3 years A rate of 75 or less for any 4 years A rate of 90 or less for all 5 years. It is obvious that rates between 70 and 80 for 1918 and 1919 cannot possibly be considered as significant, and it could scarcely have been expected in dealing with a disease of the nature of tuberculosis that any conclusive results could be reached in a period so short as three years. 4. Conclusions in Regard to the Advisability of Continuing the Framingham Demonstration. It seems clear that if the Framingham Demonstration should cease on January 1, 1920, the local community will have benefited materially and many important contributions will have been made to the practical control benefit to of tuberculosis; but that the main question for which the Demonstration was community endowed will remain unanswered. In the judgment of your committee this would be a most unfortunate contingency. Our best authorities on tuber- 15 DEMONSTRA- TION WILL ANSWER VITAL QUESTIONS RACE STOCK FINDINGS IMPORTANT culosis have been subject during the past few years to a growing skepticism in regard to the adequacy of methods which have been advocated for the control of this disease and have turned eagerly to the Framingham Demon- stration as the first real opportunity to set their doubts at rest. If the Experiment should be abandoned at this time it would be necessary to begin all over again somewhere else, for a test of the best methods now available is absolutely essential for future progress in this field. If on the other hand it should be possible to continue the Demonstra- tion for a sufficient period to yield results of statistical accuracy, your com- mittee feels confident that the question as to. the soundness of the current anti-tuberculosis program will be definitely answered one way or the other. The foundation has been well laid; a program for the control of tuberculosis by early diagnosis and hygienic care has been organized on ideal lines; local sentiment both in medical and lay circles has been successfully developed in support of the campaign; and all conditions are favorable to its success. Given a sufficient period for the continuance of the Demonstration and for the study of the results obtained, both morbidity and mortality records should furnish a clear answer to the question of whether or not such a program is effective. In addition to the fundamental conclusion as to the practicability of the control of tuberculosis by the methods used in Framingham, a continuation of the Demonstration should throw important light upon the theoretic factors which contribute to the development of tuberculosis as a disease, and should therefore make it possible to modify our program along more purposeful lines in the future. The investigations made at Framingham have as yet led to no far-reaching conclusions in regard to these factors. The most suggestive point that has been brought out is perhaps the variation in disease incidence among different race stocks. The combination of a very high proportion of tuber- culin reactions with a low mortality among Italians and the precisely opposite condition among persons of Irish race stock is of considerable significance. The study of the subsequent history of the large number of arrested cases now under the observation of the Demonstration constitute, in itself, an invaluable opportunity to determine some of the factors which convert latent into active disease. In the continuation of the work of the Demonstration, we would urge that special attention be paid to the intensive study of environmental condi- tions, in the home, the factory, and the community, with a view to throwing more light than has yet been obtained upon the possible effect of each condi- tion upon the spread of tuberculous infection and the development of active disease. We are inclined to believe that the detailed study of even a few hun- dred cases should yield results of real value in this connection; — if correlated with observation of the environmental conditions surrounding a properly selected control group of families free from tuberculosis. 16 5. Recommendations in Regard to the Continuance of the Demonstration in the Future. The statistical calculations cited above have led us to the conclusion that FIVE years . , EXTENSION the Framingham Demonstration should be continued for a period of at least necessary five years in order to render the attainment of definite results of reasonable certainty. It is, of course, possible that the prolongation of the Demonstra- tion experiment through 1922 might be accompanied by a tuberculosis death rate of 60 or less for all of the three years involved, but since a death rate of 60 corresponds to only 12 deaths, it is obvious that a chance combination of circumstances might easily interfere with such a result. In this contingency we should once more face the possibility that a large sum of money had been spent without the attainment of the primary object in view. The effect of such an experiment should be cumulative, and each year added to its life greatly increases the chances of ultimate success. A five-year period should, we believe, yield results reasonably certain to answer "the question as to the practicability of the control of tuberculosis. If successful, it would furnish for the first time a definitely established working program for the practical control of tuberculosis. If unsuccessful, it would indicate with equal clear- ness the need for the adoption of measures of a different sort from those that have recently been recommended as adequate and necessary. 6. Suggested Plan for a Five-Year Extension of the Framingham Demonstration. In planning for a continuance of the Framingham Demonstration for the purposes indicated in the preceding paragraphs, it seems to your committee best to limit the work somewhat strictly to the definite problem of tuber- culosis, and to plan for no new work that does not directly bear upon the fundamental questions involved. It might seem desirable to continue a JjJPjJJfJJJ* 1 * grant of $2,000 to the Civic League for its general public health work for a ^sential period of one year, but this should, in our judgment, cease after 1920, and we feel that the wisdom of continuing to maintain the Day Camp as a part of the Demonstration activity is distinctly problematical. On the other hand, an appropriation for the development of industrial clinics in the smaller man- ufacturing plants for a period of at least two years seems to us important as a part of the anti- tuberculosis program; and we feel that any plan made should provide for one more general medical examination drive which might profitably be conducted in 1923, leaving 1924 free for the analysis and diges- tion of the results of the experiment as a whole. The re-examination of individuals already examined in previous drives should prove particularly $100000 ^ significant as a measure of the effect of an educational campaign such as that ^fo^ OPRIA " conducted by the Demonstration. On this basis we have prepared a tenta- recommended tive budget, indicating the general lines along which a second appropriation of $100,000.00 might profitably be spent. 17 The budget* calls for annual expenditures as follows: 1920 $24,600.00 1921 21,600.00 1922 18,800.00 1923 21,700.00* 1924 13,300.00 Total $100,000.00 FURTHER RESEARCH While an appropriation of $100,000.00 should ensure the successful com- pletion of the primary experiment, it may be pointed out that there are excep- tional opportunities for special research in connection with tuberculosis, along such lines as the accumulation of an extensive series of radiographs of contact cases, the intensive study of the relation of race and occupation and home environment to tuberculosis, the study of nutrition as a predisposing factor in tuberculosis, and the like. Additional appropriations for research along such lines could be expended with excellent results at Framingham or else- where. It must be remembered that even if the measures used at Framing- ham should prove definitely successful, they would presumably require to be simplified and made more economical for general use; and the application of research funds in any direction that may lead to such simplification is earn- estly to be desired. TOWN'S RESPONSE ADMIRABLE 7. Coordination of Existing Health Agencies as a Factor in the Success of the Framingham Demonstration. In the main, the town of Framingham has responded with vision and effectiveness to the remarkable opportunities offered by the establishment of the Demonstration. The local Board of Health, the School Committee, the Civic League, and many of the employers of labor have met the challenge to make Framingham the model "Health Town" with constructive responses of a high order. The work of these various agencies has not, however, so far as we can judge, always been coordinated as closely as might be desirable. The Framingham Hospital which directs the district nursing service of the community might play a more active part in the general health campaign than is the case at present, and the great possibilities of service latent in the local Red Cross organization have not been fully utilized. local It seems to us if the Demonstration is to be continued that it might be tion through of service to organize in Framingham a Health Council which would include HEALTH COUNCIL *The proposed annual appropriations were classified according to medical, nursing, research, office and other expenses, and are not given in detail here. This budget was in fact some- what modified by the National Tuberculosis Association committees, the major expenses being concentrated into an extension period of three years for intensive work, with a smaller appropriation for an additional two-year period for subsequent observation. 18 TRANSFER the Health Officer or a Board of Health representative as Chairman, with representatives of the School Committee, the Civic League, the Framingham Hospital, the Red Cross, the medical society, and the Demonstration, — this council to serve as a clearing-house for the coordination of health activities and the planning of the most effective public health machinery for the com- munity as a whole. It is obvious that in order to be of general application, the method of control used at Framingham must be susceptible of execution by existing local J^SJV^ T0 health agencies and we deem it to be of great importance to enlist the active agencies cooperation of the Health Department, the hospital, and civic bodies, and to transfer the work to them as rapidly as possible; although it seems clear that the observation of results as regards tuberculosis should until 1924 remain in the hands of the officers of the Demonstration. Ultimately a fairly complete degree of consolidation should be attained, particularly in regard to the public health nursing service. Infant welfare nursing, school nursing, tuber- culosis nursing, communicable disease nursing and general visiting nursing might, with advantage, be combined under the direction of a nursing director of training and experience. 19 PQT TJIXTDT A TTXTTT7'T7<'D CiTfTiTr T TT)T» A TlTTTiCt DUE DATE This xpiratic. t>rovi -erne- \\ : \y 0? .- rfvtt DUQ4J JUN 9 2 s~\ ' OCT ]06 Printed in USA COLUMBIA UNIVERSITY LIBRARIES 0022314270 Ann^x RA644.T7 073 Committee on appraisal for the Framingham community health and tuberculosis demonstration. ■*WK