Was the First Public Health Campaign Successful?

The Tuberculosis Movement and its Effect on Mortality

D. Mark Anderson

Department of Agricultural Economics & Economics

Montana State University

Kerwin Charles

Yale School of Management

Claudio Las Heras Olivares

Banco de Chile

Daniel Rees

Department of Economics

University of Colorado Denver

Introduction

• The United States experienced a dramatic decline in mortality from

infectious diseases in the first three decades of the 20th century.

• Cutler et al. (2006) attributed this decline to the introduction of basic

public health measures.

– There is strong evidence that clean water (e.g., sewer systems and

chlorination/filtration) contributed to the decline in mortality due to dysentery,

typhoid and other waterborne diseases (Cutler and Miller 2005; Alsan and

Goldin 2015).

– We do not know, however, whether public health measures contributed to the

decline in mortality from other important diseases such as diphtheria, influenza,

measles, scarlet fever, tuberculosis, and whooping cough.

194

TB mortality per

100,000 population

154

113

71

46

1900 1910 1920 1930 1940 1950

23

In 1900, 194 out of every 100,000 Americans

died of tuberculosis (TB), making it the

second-leading cause of death in the United

States (just behind influenza/pneumonia).

Notes: Based on Jones, David S. and Jeremy A. Greene. 2013 “The Decline and Rise of Coronary Heart Disease:

Understanding Public Health Catastrophism.” American Journal of Public Health, 103(7):1207-1218.

By 1930, the TB death rate had fallen to 71

deaths per 100,000 population, equivalent to the

current best guess of the COVID-19 death rate

in New York

Source: National Center for Health Statistics. (2016). Health, United States, 2015. Hyattsville, MD. Racial categories

include individuals of both Hispanic and non-Hispanic origin.

194

154

113

71

46

1900 1910 1920 1930 1940 1950

23

Although an effective treatment would not be

introduced until after the Second World War,

the TB mortality rate fell dramatically

-In 1944, streptomycin was

discovered as the first effective

antibiotic against TB

-In 1952, isoniazid represented

the first oral mycobactericidal

drug

Notes: Based on Jones, David S. and Jeremy A. Greene. 2013 “The Decline and Rise of Coronary Heart Disease:

Understanding Public Health Catastrophism.” American Journal of Public Health, 103(7):1207-1218.

TB mortality per

100,000 population

• Several explanations for the decline in TB mortality have been

proposed:

– 1.) Less crowded living conditions

– 2.) Greater resistance to infection resulting from natural selection

– 3.) Reduced virulence

– 4.) Improved nutrition

– 5.) The tuberculosis movement

• Drawing on newly digitized data for the period 1900-1917, we

explore whether the U.S. tuberculosis movement contributed

to the decline in TB mortality in the United States.

Introduction

• The U.S. TB movement pioneered many of the strategies of

modern public health campaigns (Jones and Greene 2013).

– Spearheaded by voluntary associations composed of both laypersons and

physicians

– Supported by the sale of Christmas seals

• Even today, the American Lung Association’s mission is

largely funded by the Christmas seals (www.christmasseals.org)

– Dedicated to eradicating a specific disease, TB

• The TB movement inspired subsequent public health campaigns in

the U.S. and around the world.

• Although remarkable in its scope and intensity, the effectiveness of

the TB movement has not been studied in a systematic fashion.

Introduction

• Our data are at the municipal-year level and cover 548

municipalities across the U.S.

• Exploiting within-municipality variation and controlling for

common shocks at the national level, we find:

– Adoption of a TB reporting ordinance is associated with a 6%

reduction in pulmonary TB mortality.

– The opening of a state-run sanatorium is associated with an almost

4% reduction in pulmonary TB mortality.

• Despite these findings, we conclude that the TB movement

had, at most, a modest effect on pulmonary TB mortality.

Introduction

• TB is an infectious disease that can affect bones, the central nervous system, and

other organ systems, but it is primarily a disease of the lungs.

– In our sample,

• 141.5 pulmonary TB deaths per 100,000 population

• 17.6 non-pulmonary TB deaths per 100,000 population

• In 1882, Robert Koch demonstrated that TB is caused by Mycobacterium tuberculosis,

which can be spread through coughing, sneezing, or spitting.

• Over 90% of TB infections are latent—cause no symptoms and are not contagious,

but can become active (Lawn and Zumla 2011).

– There is a 10% chance of latent TB becoming active and risk is much higher in people

who have compromised immune systems (e.g., HIV, malnourished, smokers).

• Roughly half of active cases ultimately result in death if left untreated (Rutledge and

Crouch 1919; Gideon and Flynn 2011).

Background: Tuberculosis

• Symptoms of active pulmonary TB include a chronic cough, fevers, night

sweats, fatigue, loss of appetite, and loss of weight.

– The terms “consumption” for the disease and “consumptives” for its sufferers refer to

this latter symptom.

• Today, TB is still one of the leading causes of mortality in

developing nations, with 1.5 million deaths per year

(WHO 2015).– About one out of every 4 people alive today has a latent TB infection

(Houben and Dodds 2016).

• Majority of active TB cases can be cured by antibiotic

treatments, the length and type of treatment depends on factors

such as age, overall health, location of infection, etc.

Background: Tuberculosis

• Currently, while most active TB infections can be treated, the WHO

(2015) estimates that 3.3% of new TB cases are multidrug-resistant.

• With multidrug-resistant TB infections on the rise, experts have

suggested that it may be “time to bring back sanatoria” (Dheda and

Migliori 2012).

Background: Tuberculosis

Everything you ever wanted to know about the

TB movement...

• Contemporary observers credited the TB movement for the dramatic

reduction in TB morality (Emerson 1922).

• Historians are not so sure...

– Bates (1989) wrote that, “in the absence of controlled studies,” we may never

know “whether or to what degree the tuberculosis movement contributed to

the declining death rate in the United States or improved the health of

tuberculosis patients.”

– Tomes (1989) argued that historians “cannot conclusively prove that the

tuberculosis movement as a whole played no role in the ‘retreat’ of the disease.”

• Between 1900 and 1917, hundreds of state and local TB associations

sprung up across the United States.

• TB associations provided financial support to sanatoriums and TB

hospitals, where patients with active TB were isolated from the

community at large.

• TB associations distributed educational materials and press releases;

they sponsored lectures and exhibits.– Men were urged to shave their beards and carry pocket

spittoons, women were urged to stop wearing trailing

dresses, and children were taught to play outdoors, keep

their face, hands and fingernails clean, and cover their

coughs and sneezes.

TB Associations

• Sanatoriums provided a place for TB patients to rest, breathe fresh air,

eat nutritious food, and – with luck – recover.

• In 1900, there were only 3 municipalities in our sample that were served

by a sanatorium; by 1917, 80 municipalities in our sample had a

sanatorium.

• Although TB patients admitted to sanatoriums had similar recovery rates

to those who went untreated (Daniel 2006), medical professionals at the

turn of the 20th century were convinced of their effectiveness (Wethered

1906).

• In addition to offering the promise of a cure, sanatoriums isolated TB

patients from the community and taught them how to avoid infecting

others.

Sanatoriums

The Texas State Tuberculosis Sanatorium opened in 1911. It could only keep patients

for six months at a time because of overwhelming demand.

Appendix Figure 1. The Growth of Sanatoriums: Evidence from the NASPT

1905 1910

1917

• Open-air camps (aka “day camps”) were seen as a low-cost alternative to

sanatoriums for ambulatory TB patients (Robbins 1906).

• During the day, patients received care

and were taught how to avoid infecting

their family, friends, and coworkers. At

night, they returned home “to practice

the lessons learned” (Townsand 1909).

• In 1900, only one municipality in our

sample was served by an open-air camp;

by 1917, 60 municipalities were served by an open-air camp.

Open-air camps

• By 1908, several prominent public health experts had come to the

conclusion that sanatoriums were inadequate to the task at hand

(Bloede 1908; Brown 1908; Newsholme 1908).

• More resources, they argued, should be devoted towards isolating

the most infectious patients – those with advanced pulmonary TB

(Hutchinson 1911; Flick 1912).

• From 1908 to 1917, the number of municipalities in our sample

served by TB hospitals increased from 31 to 69 as local TB

associations worked with municipal governments to open more

facilities.

TB hospitals

TB patients receive “fresh air treatment” on the sun porch at Waverly Tuberculosis Hospital in Louisville, KY.

• TB associations advocated forcefully, and often successfully, for the passage of

public health measures designed to prevent the spread of the disease.

• Reporting requirements were viewed as crucial to success of the anti-TB

campaign (Teller 1988; Rothman 1995).

– At the turn of the 20th century, it was common for physicians to conceal a TB diagnosis

from their patients (Ambler 1903; Cabot 1908).

– Physicians feared their patients, upon being told they had an incurable disease, would

seek a second opinion or remove themselves to a sanatorium (Fox 1975).

– By obligating physicians to notify local health officials of active TB cases, reporting

requirements were designed to put an end to this practice and facilitate the monitoring

and education of TB patients.

• From 1900-1917, 71 municipalities in our sample adopted reporting requirements.

Reporting requirements

Appendix Figure 2. The Growth of Municipal Reporting Ordinances: Evidence from the NASPT

Notes: Based on data from Appendix Table 1. Only municipal reporting ordinances that contributed identifying variation to estimates based on equation (1) are shown.

1905 1910

1917

• Prohibitions on public spitting

Other anti-TB laws

• Although anti-spitting laws are no longer enforced in the U.S.,

authorities in Beijing, London, and Mumbai have justified recent

efforts to discourage spitting on public health grounds (Yardley

2007; Pettitt 2015; Sujit and Iyer 2015).

• Disinfection of premises after TB patient died or was removed.

– Attending physician was required to notify public health officials so that premises

could be disinfected.

– Health officers directed the disinfection and, when deemed necessary, the

renovation of the premises.

• Prohibitions on the use of the “common cup”– Common drinking cups were located in schools,

trains, and next to water pumps.

– Gave rise to drinking fountains and dispensable cups

(e.g., the Dixie Cup).

Other anti-TB laws

• Dispensaries were considered the first line of defense against TB.

• Dispensaries diagnosed TB cases, handed out educational materials to

the public, and served as “clearing houses” sending patients to

physicians, sanatoriums or hospitals for treatment (Knopf 1911;

Bynum 2012).

– Dispensaries provided medicines such as cod liver oil or opiate-based cough

mixtures (Bynum 2012), which offered temporary relief but could not cure TB.

– If dispensaries had an effect on TB mortality, it would have been through their

efforts to educate the public and isolate TB patients.

– Hansen et al. (2017) estimated the relationship between TB dispensaries and TB

mortality at the city level using data from Denmark for the period 1890-1939.

They found that the opening of a TB dispensary was associated with a 16%

decrease in the TB mortality rate, an effected they attributed to dispensaries

“facilitating a local diffusion of (hygiene) knowledge about the disease.”

Dispensaries

Data

• Mortality counts at the municipality-year level come from

Mortality Statistics, published annually by the U.S. Census Bureau.

– Cause of death was obtained from the death certificate and coded using

the International Classification of Diseases.

• First issue was published in 1900 and contained mortality counts

by cause for over 300 municipalities.

• By 1917, mortality counts from over 500 municipalities were

available.

– These data are available through 1922, but we chose to focus on period

1900-1917 to avoid the potentially confounding effects of the 1918

influenza epidemic.

From 1900 to 1917, the pulmonary TB mortality rate fell by 28%.

173

125

Empirical Strategy

ln(Pulmonary TB Mortalitymt) = β0 + Xmtβ1 + vm + wt + Θm∙t + εmt

• X: contains the anti-TB measures listed above

• vm: municipality FEs control for municipal-level determinants of pulmonary

TB mortality that were constant over time

• wt: year FEs control for common shocks to pulmonary TB mortality

– Although, it should be noted that there were no national newspapers or commercial radio

broadcasts during the period under study; efforts to educate the public about TB and

encourage good hygiene were undertaken entirely at the local level until 1908, when the

National Association for the Study and Prevention of Tuberculosis (NASPT) established

a press service that released bulletins to newspapers and wire services (Teller 1988).

• Θm∙t: municipal-specific time trends account for the possibility that

pulmonary TB mortality rates evolved at different rates in municipalities that

adopted anti-TB measures as compared to those that did not.

Descriptive Statistics

Mean

(SD)

Description

Pulmonary TB Mortality 141.5

(78.7)

Pulmonary TB mortality per 100,000 population

Sanatorium .078

(.268)

= 1 if municipality had a sanatorium, = 0 otherwise

TB Hospital .087

(.281)

= 1 if municipality had a TB hospital, = 0 otherwise

Open-Air Camp .068

(.251)

= 1 if municipality had an open-air camp, = 0 otherwise

Reporting Ordinance .131

(.338)

= 1 if municipality required reporting of TB cases, = 0 otherwise

State Reporting Law .510

(.500)

= 1 if state required reporting of TB cases, = 0 otherwise

Disinfection Ordinance .067

(.249)

= 1 if municipality required disinfection of premises after death or

removal of a TB patient, = 0 otherwise

State Disinfection Law .079

(.269)

= 1 if state required disinfection of premises after death or

removal of a TB patient, = 0 otherwise

Spitting Ordinance .273

(.446)

= 1 if municipality had an anti-spitting ordinance, = 0 otherwise

Notes: Unweighted means with standard deviations in parentheses.

Descriptive Statistics (continued)

Mean

(SD)

Description

Common Cup Ordinance .018

(.134)

= 1 if municipality had a common cup drinking ban, = 0 otherwise

State Common Cup Law .110

(.314)

= 1 if state had a common cup drinking ban, = 0 otherwise

Municipal TB Association .360

(.480)

= 1 if municipality had a TB association, = 0 otherwise

State TB Association .697

(.451)

= 1 if state had a TB association, = 0 otherwise

Dispensary .261

(.439)

= 1 if municipality had a TB dispensary, = 0 otherwise

Notes: Unweighted means with standard deviations in parentheses.

Pulmonary TB Mortality and Public Health Interventions

(1) (2) (3) (4)

Sanatorium -.017

(.026)

-.014

(.025)

-.016

(.024)

-.018

(.024)

TB Hospital .022

(.029)

.022

(.028)

.021

(.029)

.023

(.028)

Open-Air Camp -.021

(.021)

-.019

(.019)

-.017

(.022)

-.015

(.020)

Reporting Ordinance ... -.057**

(.026)

-.061**

(.030)

-.062**

(.028)

State Reporting Law ... -.008

(.014)

-.007

(.015)

-.011

(.016)

Disinfection Ordinance ... .040

(.030)

.042

(.032)

.035

(.032)

State Disinfection Law ... -.020

(.025)

-.024

(.028)

-.021

(.029)

Spitting Ordinance ... ... .019

(.026)

.014

(.023)

Common Cup Ordinance ... ... .010

(.021)

.014

(.021)

State Common Cup Law ... ... -.021

(.021)

-.022

(.022)

Municipal TB Association ... ... ... .005

(.016)

State TB Association ... ... ... .023

(.020)

Dispensary ... ... ... .019

(.019)

N

R2

7,439

.882

7,439

.882

7,439

.883

7,439

.883

Anti-TB Indices• State Anti-TB Index: Sum of the state-level anti-TB measures

• Municipal Anti-TB Index: Sum of the municipal-level anti-TB measures

• State and Municipal Anti-TB Index: Sum of the state- and municipal-level anti-TB measures

Municipal and State Anti-TB Indices

State Anti-TB Index -.003

(.008)

... ...

Municipal Anti-TB Index ... .003

(.008)

...

State and Municipal Anti-TB Index ... ... .0001

(.007)

N

R2

7,439

.883

7,439

.882

7,439

.882

Controlling for municipal anti-

TB measures listed in Table 1?

Yes No No

Controlling for state anti-TB

measures listed in Table 1?

No Yes No

A closer look at sanatoriums

• Many U.S. cities were served by multiple sanatoriums by the end of

the period under study.

• Private sanatoriums were often located in rural areas where air

pollution would not interfere with recovery.

• In 1900, there were no state-run sanatoriums in the country; by the

end of the period under study, state-run sanatoriums represented a

substantial portion (≈ 40%) of total capacity.

– State-run sanatoriums were considered more desirable than county-run or

municipal sanatoriums.

– Unlike other publicly funded sanatoriums, state-run sanatoriums often charged

weekly fees to “keep out the riffraff” and prioritized admitting incipient TB

cases over chronic and advanced cases.

– State-run sanatoriums were typically located outside of urban areas.

A Closer Look at Sanatoriums

(1) (2) (3) (4) (5)

Sanatorium ... ... -.014

(.023)

-.019

(.024)

-.019

(.023)

Number of Sanatoriums in Municipality .018

(.020)

... ... ... ...

Number of Sanatorium Beds in

Municipality (100s of beds)

... -.002

(.003)

... ... ...

Any Sanatorium in State ... ... .002

(.017)

... ...

Number of Sanatoriums in State ... ... ... -.003

(.005)

...

State-Run Sanatorium ... ... ... ... -.038**

(.016)

N

R2

7,439

.883

7,439

.883

7,439

.883

7,439

.883

7,439

.883

Extensions and robustness checks

• Add leads and lags of the municipal reporting requirement indicator

• Add leads and lags of the state-run sanatorium indicator

• Control for typhoid mortality

– There is descriptive evidence that efforts to improve water quality (e.g., chlorination and filtration)

reduced mortality from non-waterborne diseases, including TB (Sedgwick and MacNutt 1910; McGee

1920).

– Some contemporary researchers suggested that TB might be transmitted through waste water (Brown

et al. 1916; Fink et al. 1917)

– More likely explanation is that typhoid and other gastronomical diseases weakened the host,

increasing susceptibility to TB infection (Ferrie and Troesken 2008).

– Using data from Chicago for the period 1855-1925, Ferrie and Troesken (2008) found that an

additional death from typhoid fever was associated with 1-1.5 additional deaths from TB and

pneumonia.

– Our concern is that the adoption of TB reporting requirements or establishment of state-run

sanatoriums were correlated with municipal chlorination and filtration projects.

• Restrict sample to municipalities with a population greater than 50,000

• Restrict sample to municipalities with a population greater than 50,000 and

population densities in the top 50th percentile

– Overcrowding could have facilitated the spread of TB

• Restrict sample to municipalities that contributed 18 years of data

• Test whether municipal reporting requirements or state-run sanatoriums were

related to non-pulmonary TB, which was usually caused by contaminated milk

– Reporting requirements were specifically aimed at reducing the human-to-human

transmission of pulmonary TB.

– Bovine TB was not effectively controlled until after 1917, when the USDA undertook a

campaign to eradicate the disease (Olmstead and Rhode 2004).

– In 1909, Chicago became the first city to require the pasteurization of milk. By 1921, most

large cities in the U.S. required pasteurization, which protected consumers from bovine TB

and other milk-borne diseases such as typhoid (Meckel 1990).

Extensions and robustness checks

Leads and Lags of Municipal Reporting Ordinances

(1) (2) (3) (4)

3 Years Prior to Reporting Ordinance ... ... ... .012

(.021)

2 Years Prior to Reporting Ordinance ... ... -.017

(.020)

-.011

(.027)

1 Year Prior to Reporting Ordinance ... -.033

(.028)

-.039

(.034)

-.034

(.042)

Year 0 -.067**

(.031)

-.078**

(.037)

-.085*

(.043)

-.079

(.051)

1 Year After Reporting Ordinance -.056**

(.027)

-.068*

(.034)

-.075*

(.041)

-.069

(.051)

2 Years After Reporting Ordinance -.060*

(.030)

-.074*

(.037)

-.082*

(.043)

-.075

(.053)

3+ Years After Reporting Ordinance -.091**

(.037)

-.108**

(.044)

-.117**

(.051)

-.109*

(.062)

N

R2

7,439

.883

7,439

.883

7,439

.883

7,439

.883

Leads and Lags of State-Run Sanatoriums

(1) (2) (3) (4)

3 Years Prior to State-Run Sanatorium ... ... ... .005

(.017)

2 Years Prior to State-Run Sanatorium ... ... .021

(.030)

.023

(.033)

1 Year Prior to State-Run Sanatorium ... -.014

(.017)

-.004

(.024)

-.001

(.029)

Year 0 -.037**

(.013)

-.043**

(.018)

-.033

(.021)

-.029

(.027)

1 Year After State-Run Sanatorium -.049**

(.020)

-.056**

(.025)

-.044

(.026)

-.040

(.033)

2 Years After State-Run Sanatorium -.025

(.023)

-.033

(.026)

-.019

(.026)

-.015

(.033)

3+ Years After State-Run Sanatorium -.041

(.025)

-.050*

(.029)

-.035

(.029)

-.031

(.035)

N

R2

7,439

.883

7,439

.883

7,439

.883

7,439

.883

Extensions and Robustness Checks: Reporting Ordinance

Control for

typhoid

mortality

Cities with

population

> 50,000

Densely

populated cities

with population

> 50,000

Cities with 18

years of data

Dependent

variable:

(Non-pulmonary

TB Mortality)1/4

Reporting Ordinance -.057**

(.027)

-.067**

(.031)

-.075*

(.042)

-.071**

(.029)

.019

(.021)

[.639]

Mean of TB mortality

N

R2

141.5

7,439

.884

162.0

1,693

.924

164.6

931

.915

143.9

5,254

.884

17.6

7,439

.608

Extensions and Robustness Checks: State-Run Sanatorium

Control for

typhoid

mortality

Cities with

population

> 50,000

Densely

populated cities

with population

> 50,000

Cities with 18

years of data

Dependent

variable:

(Non-pulmonary

TB Mortality)1/4

State-Run Sanatorium -.037**

(.014)

-.043**

(.019)

-.044

(.026)

-.034**

(.015)

.011

(.019)

[.391]

Mean of TB mortality

N

R2

141.5

7,439

.884

162.0

1,693

.925

164.6

931

.916

143.9

5,254

.884

17.6

7,439

.608

From 1900 to 1917, the pulmonary TB mortality rate fell by 28%.

173

125

50

100

150

200

Mort

alit

y r

ate

per

100,0

00 p

opula

tio

n

1900 1905 1910 1915

Influenza and pneumonia mortality rate

Other airborne illnesses mortality rate

Notes: Based on annual data from Mortality Statistics for the period 1900-1917, published by the U.S. Census Bureau.Other airborne illnesses include measles, scarlet fever, whooping cough, and diptheria/croup.

Figure 2. Influenza, Pneumonia, and Other AirborneIllnesses Mortality Rates, 1900-1917

106

46

Mortality from other airborne diseases

• Did the TB movement contribute

to the mortality trends

documented in Figure 2?

• Several anti-TB measures could

have, in theory, reduced mortality

from other diseases transmitted

through respiratory secretions

such as diphtheria, measles, scarlet

fever, and whooping cough.

Spillover Effects on Other Airborne Illnesses?

Flu and

Pneumonia

Mortality

Flu and

Pneumonia

Mortality

Other Airborne

Illnesses

Mortality

Other Airborne

Illnesses

Mortality

Spitting Ordinance -.046

(.030)

[-7.78]

-.050*

(.026)

[-8.56]

-.019

(.043)

[-1.49]

-.017

(.044)

[-1.29]

Common Cup Ordinance .020

(.103)

[3.41]

.046

(.069)

[7.76]

-.041

(.033)

[-3.20]

-.016

(.044)

[-1.24]

State Common Cup Law .060

(.043)

[10.1]

.064

(.039)

[10.8]

-.029

(.044)

[-2.23]

-.032

(.047)

[-2.45]

Municipal TB Association -.021

(.025)

[-3.62]

-.027

(.028)

[-4.64]

.008

(.021)

[.639]

.015

(.023)

[1.19]

State TB Association .004

(.039)

[.743]

.011

(.037)

[1.83]

.053**

(.024)

[4.12]

.043

(.026)

[3.34]

Mean of mortality rate

N

R2

Other anti-TB

measures?

148.1

7,439

.739

No

148.1

7,439

.743

Yes

51.9

7,439

.567

No

51.9

7,439

.568

Yes

Gauging the Overall Impact of the TB Movement

• First, we examine the contribution of municipal reporting requirements to

the overall decline in pulmonary TB mortality.

– 91 municipalities in our sample had adopted ordinances requiring that active TB cases be

reported to local health officials by 1917.

– The adoption of such an ordinance is associated with an approximately 6 percent decline

in the pulmonary TB mortality rate.

• To gauge the impact of reporting ordinances, we calculated what the

pulmonary TB mortality rate would have been had none of the

municipalities in our sample required reporting of active TB cases.

120

140

160

180

Pulm

on

ary

tub

ercu

losi

s m

ort

alit

y ra

te

1900 1905 1910 1915

Pulmonary TB mortality rate

Predicted pulmonary TB mortality rate

Based on annual data from Mortality Statistics for the period 1900-1917, published by the U.S. CensusBureau. Predicted pulmonary TB mortality rates are calculated under the assumption that city reportingordinances were not implemented. Shaded area represents 90% confidence region around predictedpulmonary TB mortality rates.

Figure 3. Actual vs. Predicted Pulmonary Tuberculosis Mortality Rates:The Effect of City Reporting Ordinances

Gauging the Overall Impact of the TB Movement

• Next, we use a similar strategy to gauge the combined contribution of all the

anti-TB measures adopted during the period under study.

– Recall, from 1900-1917, the pulmonary TB mortality rate among the municipalities in our

sample fell by nearly 28 percent, from 173 to 125 per 100,000 population.

• Had no anti-TB measures been adopted, we predict that the pulmonary TB

mortality rate would have been 122 per 100,000 population in 1917.

– Using the upper bound of the 90 percent confidence interval, we predict that the

pulmonary TB mortality rate would have still fallen by 22 percent, to 135.5 per 100,000

population, had no anti-TB measures been implemented at either the municipal or state

levels.

100

120

140

160

180

Pu

lmo

nar

y tu

ber

culo

sis

mo

rtal

ity

rate

1900 1905 1910 1915

Pulmonary TB mortality rate

Predicted pulmonary TB mortality rate

Based on annual data from Mortality Statistics for the period 1900-1917, published by the U.S. CensusBureau. Predicted pulmonary TB mortality rates are calculated under the assumption that none of theanti-TB measures listed in Table 1 were implemented. Shaded area represents 90% confidence regionaround predicted pulmonary TB mortality rates.

Figure 4. Predicted Pulmonary TB Mortality Rateshad Anti-TB Measures not been Implemented173

125

The pulmonary TB mortality rate fell from 173 to

125, or 28%.

135.5

Using 90% CI, we predict the pulmonary TB

mortality rate would have still fallen by 22%, had

no anti-TB measures been implemented.

Conclusion

• Although remarkable in its scope and intensity, the effectiveness of the U.S.

tuberculosis movement has, to date, not been studied in a systematic fashion.

– Prominent scholars have, however, questioned whether the TB movement contributed

meaningfully to the decline in TB mortality (McKeown 1976; Daniel 2006).

• The adoption of a reporting ordinance is associated with a 6% reduction in

pulmonary TB mortality.

• The opening of a state-run sanatorium is associated with an almost 4%

reduction in pulmonary TB mortality.

• However, these and other anti-TB measures can explain, at most, only a small

portion of the overall decline in pulmonary TB mortality observed from 1900

to 1917.

• About one out of every 4 people alive today has a latent TB infection (Houben

and Dodds 2016).

• Most TB infections, if they become active, can be successfully treated with

antimicrobial medicines, but the WHO (2015) estimates that 3.3% of new TB

cases are multidrug-resistant.– The recommended treatment for drug-susceptible TB lasts 6 months, but treatment for

multidrug-resistant TB takes 20 months, requires more toxic drugs, and has a much lower

success rate.

• It is perhaps more important than ever that we accurately assess the

effectiveness of basic, “low-tech” public health measures, many of which were

pioneered by the TB movement.– With multidrug-resistant TB infections on the rise (Lange et al. 2014), some experts have

suggested that it may be “time to bring back sanatoria” (Dheda and Migliori 2012).

Conclusion

Appendix: Other airborne diseases

• Diphtheria– Diphtheria is an infection caused by the Corynebacterium diphtheriae bacterium.

– Diphtheria is spread (transmitted) from person to person, usually through respiratory droplets, like from coughing or sneezing.

Rarely, people can get sick from touching open sores (skin lesions) or clothes that touched open sores of someone sick with

diphtheria. A person also can get diphtheria by coming in contact with an object, like a toy, that has the bacteria that cause diphtheria

on it.

– Diphtheria once was a major cause of illness and death among children. The United States recorded 206,000 cases of diphtheria in

1921 and 15,520 deaths. Before there was treatment for diphtheria, up to half of the people who got the disease died from it.

– Starting in the 1920s, diphtheria rates dropped quickly in the United States and other countries with the widespread use of vaccines.

In the past decade, there were less than five cases of diphtheria in the United States reported to CDC. However, the disease continues

to cause illness globally. In 2014, 7,321 cases of diphtheria were reported to the World Health Organization, but there are likely many

more cases.

• Measles– Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through

coughing and sneezing. Also, measles virus can live for up to two hours in an airspace where the infected person coughed or sneezed.

If other people breathe the contaminated air or touch the infected surface, then touch their eyes, noses, or mouths, they can become

infected. Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also

become infected.

• Scarlet fever– Scarlet fever is caused by the bacterium Streptococcus pyogenes, or group A beta-hemolytic streptococcus. This is the same bacterium that

causes strep throat.

– When the bacteria release toxins, scarlet fever symptoms occur.

– Scarlet fever transmits from human-to-human by fluids from the mouth and nose. When an infected individual coughs or sneezes, the

bacteria become airborne in droplets of water and can be inhaled.

– The bacteria can land on surfaces, such as drinking glasses, work surfaces, and doorknobs, and infect people who touch them with

their hands and then touch their own nose or mouth. The bacteria may also be inhaled.

– If someone touches the skin of an individual with a streptococcal skin infection, there is a risk of becoming infected. People who

share towels, baths, clothes, or bed linen with an infected person are at risk.

– A person with scarlet fever who is not treated may be contagious for several weeks, even after symptoms have gone. Additionally,

some individuals can carry the infection and be contagious, without ever showing any symptoms - only people who are susceptible to

the toxins released by streptococcal bacteria develop symptoms.

• Whooping cough– Whooping cough (also known as pertussis) is a bacterial infection that gets into your nose and throat. It spreads very easily,

but vaccines like DTaP and Tdap can help prevent it in children and adults.

– Whooping cough is dangerous in babies, especially ones younger than 6 months old. In severe cases, they may need to go to an ER.

Appendix: Other airborne diseases