THE FIGHT AGAINST TUBERCULOSIS

By CHR. JENSEN

Administrative Director of the National Society for Combatting Tuberculosis.

Twenty-five years ago, 23 out of every 10,000 of the town population of Denmark died of tuberculosis. Nowadays the figure has decreased to 10. Taking pulmonary tuberculosis alone, the figure twenty-five years ago was 17, and is now seven or eight. Denmark has become the country in Europe with the lowest tuberculosis mortality rate.

The fight against tuberculosis has been waged by means of a practical collaboration between the State and private initiative. Small countries, of course, have certain advantages which enable them to take the lead with respect to social and humane measures. Where the geographical boundaries are narrow, and the people and the conditions under which they live easily observ. able, there are as a rule both a more spirited initiative and better conditions for the rapid and certain realisation of farreaching reforms than in countries with widely extending frontiers and large populations. The smaller the community, the more intimate the relationship. The helping hand is more easily stretched out to those with whom one lives in close contact than to those at a distance. The defects of society and the distress of the individual compel attention more among the sparse population of restricted areas than among the crowds of the great States, and the driving wheels of the machinery of national hygiene and philanthropy are more easily and rapidly set in motion in small than in great communities.

In many aspects of social and humane legislation Denmark has been a pioneer land, and in many directions private initiative in this respect has been more profuse and strong in its deve lopment than in most other countries. This is also true of the campaign against tuberculosis. Private initiative took up the great preparatory work, and then followed the comprehensive tu

berculosis legislation, which is doubtless still the most far-reaching and humane in Europe, and in sympathy with which private initiative still continues to exert itself and to open up new territory. This constant reciprocation of mutual endeavour between the State and private initiative has been and must continue to be of the very greatest importance to the rational combatting of tuberculosis in Denmark.

The basis of the fight against tuberculosis as carried on in Denmark during the past twenty years lies in the two Acts of Parliament which were passed in April, 1905, and which have repeatedly been revised and extended since: (1) Act regarding Measures for Combatting Tuberculosis, (2) Act regarding State Support for the Medical Treatment of Tuberculous Persons. A number of legislative measures less comprehensive, but each important in itself, had preceded these two, and had done useful pioneer service, and private initiative had for many years displayed great activity and attained clearly perceptible results. So long ago as the year 1875 the first seaside hospital for the treatment of children suffering from scrofula and surgical tuberculosis was opened on the peninsula of Refsnæs; in 1896 a coastal sanatorium was opened for children with lighter forms of scrofula, and before the change of the century work was well in hand with the erection of the first tuberculosis sanatoria. In January, 1901, the National Society for Combatting Tuberculosis was formed, and before the great Tuberculosis Acts were passed in 1905 there were already in operation, besides the institutions above referred to, three large and two smaller tuberculosis sanatoria with accommodation for nearly 500 patients. An historical review of the various stages in the development of the movement from its commencement down through the years is, however, beyond the scope of this article: it is merely the intention here to describe the conditions as they are now and to sketch the main lines of the work as it has formulated itself within the frames set up by the Law and as it has been practised by means of cooperation between State and municipalities and private initiative.

The Act regarding Measures for Combatting Tuberculosis (last amended on March 12th., 1918) imposes upon every doctor the duty of notifying every case of tuberculosis of the lungs or larynx coming under him for treatment, whilst every case of death from tuberculosis must be immediately notified to the

medical officer. House disinfection may be ordered in cases of death from tuberculosis, and also in cases of the removal of a patient, and this work is done at the public expense. Clothing and bed-linen which has been used by a person suffering from infectious tuberculosis may also be cleansed and disinfected at the public expense, and unless it has been previously properly disinfected it may only be sold, given away, lent out, or in any other way allowed to be used by others if permission is given by the doctor in attendance, and not even then if the medical officer forbids it. In certain cases compulsory isolation at the public expense may be ordered in respect of persons who, suffering from tuberculosis, live or work under conditions that make them a particular danger of infection to others. No woman suffering from tuberculosis may accept service as wet-nurse, and persons suffering from infectious tuberculosis may not work in children's homes, asylums, créches, etc. Children may not be put in charge of foster parents in homes where there is infectious tuberculosis, and children who have tuberculosis may not be put in charge of foster parents in homes where there are other children. The Epidemic Commission may prohibit children suffering from infectious tuberculosis from attending the ordinary schools, and efforts must then be made to see that such children are given a suitable education outside those schools and if necessary in special schools for tuberculous children. Without a medical certificate to the effect that he or she does not suffer from tuberculosis of the lungs or larynx, no person can be engaged as a school-teacher, as a priest of the national Church, as a district midwife, or as a nurse at a public lunatic asylum, or enter any other branch of the public service which involves such close contact with the people that there would be undoubted danger of infection. If any such person should later on contract infectious tuberculosis, he may be relieved of his post, in which case two-thirds of his salary could be granted as annual pension, irrespective of age or length of service. These regulations are the principal contents of the Act regarding Measures for Combatting Tuberculosis.

The Act regarding State Support for the Medical Treatment of Tuberculous Persons (last amended on March 29th., 1924) lays down the regulations in accordance with which the Treasury may grant funds towards the erection of tuberculosis institutions

of various descriptions, and also towards the cost of the treatment of patients in those institutions. To obtain State aid, the institutions must be recognised by the Government and the proposed grant must appear in the Finance Act. Government recognition may be extended to (1) Seaside Sanatoria for the treatment of children suffering from scrofula, principally in a lighter form; (2) Seaside Hospitals for the treatment of patients with surgical tuberculosis, more severe forms of scrofula, and lupus; (3) Tuberculosis Sanatoria for patients with tuberculosis of the lungs or larynx principally those in the earlier stages of the disease; (4) Tuberculosis Hospitals for patients with tuberculosis of the lungs or larynx in various stages principally those who cannot derive advantage from treatment at a sanatorium; (5) Convalescent Homes or Recreation Homes for patients who have been treated at a tuberculosis sanatorium or hospital; (6) Nursing Homes for patients with tuberculosis in lungs or larynx who are incapable of working but for whom sanatorium or hospital treatment is not considered necessary.

The charge for in-patients at these institutions is fixed by the Act. The present charge for the tuberculosis hospitals, sanatoria and seaside hospitals is 4 kroner per day (about 4 sh. 6 d.), and rather less for the other institutions. Of these 4 kroner per day the Treasury pays 3 kroner quite automatically and without the necessity of application or special formalities for all patients without means (the term »>without means« is very liberally and widely interpreted); for patients who are members of State recognised sick clubs the last quarter of the charge is paid by the clubs; for patients who are not members of any sick club and who are unable to pay this quarter, it is the duty of the municipality to pay, and this payment is not in any way regarded as poor relief. Neither is money paid by the public in support of families whose bread winners are patients in one of the institutions comprised within the provisions of this law to be regarded as poor relief.

Besides the institutions named, State recognition with the right to receive support from the Treasury may be extended to Tuberculosis Stations (dispensaries) which, under medical supervision, give hygienic attention to tuberculous persons and their families and homes, and from which also assistance can be given in connection with nursing, healthier dwellings, the distribution

of beds, bed-linen, towels, expectoration vessels, etc., as well as the washing of the clothing and bed-linen of infectious patients. The Government grant may either be given to private institutions working for these objects, in which case it must amount to one third of the expenditure on condition that the local municipality contributes at least one third, or to municipalities desiring to have tuberculosis stations, in which case the grant amounts to one half of the expenditure.

The two Acts, the contents of which have been briefly described, form the basis of the campaign against tuberculosis in Denmark. The provision that on certain conditions assistance from the Treasury may be also granted towards the erection of the institutions named has been taken advantage of by most of the institutions which have come into being since the enactment of the Act of 1905. Including a seaside hospital with accommodation for 53 patients now in course of construction, and expected to be ready for use in the beginning of 1927, there are now the following tuberculosis institutions in Denmark:

Of these institutions all the seaside sanatoria, 2 seaside hospitals with accommodation for 230 patients, one tuberculosis sanatorium with 158 beds and 2 recreation homes with 28 beds, are exclusively for children. Of the tuberculosis hospitals one with 17 beds is attached to the prison service as a tuberculosis hospital section for convicts, and 4 with a total of 70 beds are attached to lunatic asylums and hospitals for the mentally deficient. Of those named under (1) and (6), one seaside sanatorium with 130 beds and 3 recreation homes with 43 beds are only open during the summer; the others are open all the year round.

The four tuberculosis sanatoria referred to under point (3)