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Psycho-social aspects of tuberculosis : a study of cases in a low income group in a selected area of… Tadych, Mary Philomena 1952

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PSYCHO-SOCIAL ASPECTS OF TUBERCULOSIS A Study of Cases i n a Low Income Group i n a Selected Area of Vancouver by MART PHILOMEHA TADYCH Thesis Submitted i n Partial Fulfilment of the Eequirments for the Degree of MASTER OP SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1952 The University of Bri t i s h Columbia i i TABLE Or COH!EEirTS Chapter 1, The Problem of Pulmonary Tuberculosis.Today Historical perspective. The contemporary problem. Epidemiol logical principles. Importance of environmental factors. Modern methods of diagnosis and treatment. Importance of the cooperation of the patient. The psycho-somatic approach to il lness. The role of the medical social worker...... Page Chapter 2. The Sample Group Locale of the study. Seasons for choice. Ha tore of the sample. Method of case selection. Age and sex distribution. Family context. Besearch material used. Study of case records. Social character-istics of the group. "Racial origins. Occupations. Economic status. Housing. Classification of extent of tuberculosis at diagnosis. Duration of hospitalization and illness. Existing services for the tuberculous in B. C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Chapter 3. Problems of the Tuberculous Patient as an Individual Acceptance of the diagnosis. Individualized orientation to the illness. Adjustment of daily living habits to the regime of rest, graduated exercise and precaution techniques. Acceptance of medical care and hospitalization. Possible surgery. Economic adjustments. Conflict regarding acceptance of social assistance. Changes in family relationships. Acceptance of the dependency role. Physical and psychical separation from family. Substitute care for children. Rehabilitation. Vocational retraining. Locating of suitable employ-ment. Illustrative case material. Evaluation of factors determining success or failure......,, , . . . . . . . . . . . . . . . . . . . . . 55 Chapter 4. Problems of the Disease from the Standpoint of the Eamily Acceptance of the implications of the diagnosis. Understanding of and cooperation in the treatment plan. Acceptance of the necessary changes in family roles. Effects of patient»s long absence from family. Changes in family's economic status. Difficulties of manage-ment on social assistance. Problems in daily management of the illness when patient is in the home. These difficulties intensified by inade-quate housing. Viewpoints of patients and their families. Illustrative case material. Examples of successful and unsuccessful management. Evaluation of factors i n v o l v e d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Chapter 5o Problems of the Disease from the Standpoint of the Community Tuberculosis as a major public health and welfare problem. Com-munity responsibility for the development of a comprehensive tuber-culosis control programme. Essentials of the programme. "Responsibility for the development of ancilliary social services. Community*s part in the rehabilitation of the tuberculous. Provision of opportunities for suitable employment. Special problems of patients living alone. Pro-blem of the uncooperative patient - a community menace. Illustrative case material. Devising a successful approach to the uncooperative patient •» a challenge to the c o m m u n i t y , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 i i i Chapter 6. The Tuberculosis Control Program of the Future -Conclusions and Recommendations Page Evaluation of the present tuberculosis control program in B. C. Importance of the multi-therapeutic approach. Implications for the development of existing medical and social services. Importance of the role of the medical social worker in the individ-ualization of services. Specific recommendations regarding medical services, medical social work, public health services, social assist-ance, rehabilitation services and voluntary social agencies' services.... 112 Appendix Appendix A Bibliography TABLES AND CHARTS IS THE TEXT (a) Tables Table 1. Social Service Exchange Registrations regarding patients and families in the sample group..... 38 Table 2. Distribution of tuberculosis cases in the sample group according to age and sex...................................... 40 Table 3. Family context of patients in the sample group©................ 4l Table 4. Status of families with children... ............................ 4l Table 5« Racial origins of the sample group............................. 42 Table 6. Occupations of male patients.................................. 44 Table 7. Occupations of female patients.............. 44 Table 8. How cases in the sample group came to be diagnosed............. 57 Table 9. Acceptance and non-acceptance of hospitalization by the group. 69 Table 10. Economic status of patients who did not accept social assist-ance. ...... • 75 (b) Charts Fig. 1. Map of Vancouver showing social areas. 32 Fig. 2. Map of Vancouver showing Social Area 3 and Strathcona Area.,.. 35 Jig. 3. Classification of extent of tuberculosis at diagnosis.......4 7 Fig. 4. Length of illness in the sample group........... 47 Fig. 5* Length of hospitalization.......... 70 Fig» 6. Incidence of breakdowns in the group.• 87 Fig. 7. Incidence of sputum-positive cases in the group.eo............ 100 iv ABSTRACT This study examines the psycho-social aspects of tuberculosis in a low income group in an urban setting. The locale chosen was Social Area Three of the City of Vancouver. Part of this area known as the "Strathcona District" was sur-veyed in 1947 by a University of British Columbia team, of which the writer was a member, as part of a demonstration slum clearance project. This group was specially selected to give clearer focus to the important "residual area" problem in tuberculosis control, namely, that large group of the tuberculous in whom the interaction of the emotional aspects of illness and de-fects in their material environment combine to make them the hard core of the tuberculosis problem and of many other social problems in the community. A general perspective for the study is drawn from tuberculosis and social work literature from North America, Britain and Scandinavia. The details of the study are based on the case records of seventy-nine people aged eighteen to f i f t y who were almost one hundred per cent of the diagnosed cases of active tuberculosis in the white races living in Social Area Three of Vancouver in;August, 1948. The case l i s t was compiled from the files of the public health .nurses of the Metro-politan Health Committee. The Social Service Exchange registrations of patients and their families were followed up and a total of one hundred and eighty seven case records were read. Information from home interviews with selected patients was also utilized. In terms of social characteristics the sample includes; (a) patients in family settings and, (b) unattached men living alone, who numbered one quarter of the group. The group as a whole were near the border-line income brackets, but might never have Become social liabi l i t i e s but for their tuberculosis. The problems presented by the disease to the patient as an individual, to his family and to the community are then discussed. The importance of the personality of the patient as a factor in illness is stressed, and the role of the medical social worker in diagnosis and treatment is outlined. Illustrative case material is utilized. The study indicates that the three most important factors determining the successful management of tuberculosis are: (a) the existence of facilities for finding, treating and rehabilitating cases, (b) adequate ancillary social services for the treatment of the social aspects of the disease, (c) the degree of cooperation of the patient and his family in the treatment plan, which co-operation is largely determined by their degree of emotional maturity. The problem of patient non-cooperation is found to stem mainly from lack of sufficient services to meet primary human needs. Because of this lack the l i f e experiences of most people in the group in their formative years had not been conducive to the develop-ment of the requisite emotional maturity for dealing constructively with the problems of chronic illness. There is evidence that the weakness of the rehabilitation services in British Columbia vitiates much of the excellence of other treatment facilities. The principle conclusion drawn from the evidence is that the prevention and control of tuberculosis are inextricably interwoven with many other social problems, including poverty, bad housing and family insecurity, which mast be attacked in their entirety i f advances in tuberculosis control are to be continued. Poverty, in particular, shows up its paramount importance in the perpetuation of tuberculosis as a major health and welfare problem. Specific recommendations are made regarding changes in legislation, medical services, medical social work, social assistance, rehabilitation services and voluntary social agencies services. Many of these recommendations would have valid application in the treatment of other chronic illnesses. V ACZHOWLEDGMEiMS I am indebted to many people for their assistance in the compilation of material for this study, especially to the following:- Mrs, ._. Granstrom, Secretary to the Social Service Exchange; Miss M, Gourlay, Director of Welfare, City Social Service Department; Dr. W. ^ H. Hatfield, former Director of Tuber-culosis Control for the Province of British Columbia; Miss M. McKenna, Medical Section, City Social Service Department; Miss M. Shields, Unit Supervisor, Unit 1 of the Metropolitan Health Committee; Miss H, Sutherland, Director of Social Service Department, Tuberculosis Control Division; Mrs, J, Williams, Public Health Nurse, Unit 1 Metropolitan Health Committee. I would also like to thank the following agencies for permission to use their case records: Catholic Children's Aid Society; Children's Aid Society; City Social Service Department; Eamily Welfare Bureau; Metropolitan Health Committee, Division of Tuberculosis Control, Provincial Board of Health; Social Service Exchange; and Vancouver General Hospital. I am also indebted to those patients who welcomed me into their homes and allowed me to share their feelings about their illness. Especial thanks are due to Dr..Leonard Marsh of the School of Social Work, University of British Columbia, for much helpful criticism and- assistance at a l l stages of the work. PSYCHO-SOCIAL ASPECTS.GF TUBERCULOSIS A Study of Cases in a Low Income Group in a Selected Area of Vancouver CHAPTER 1. The Contemporary Taberculosis Pro blem The human race and the "bacillus tuberculosis have lived together i n conflict since the time of the earliest known ci v i l i z a t i o n s . Ho other disease has so intrigued mankind, nor continued to baffle men lik e this one; and i t i s s t i l l the most unpredictable and erratic of a l l diseases. Tuberculosis has k i l l e d more people than a l l the wars i n history. Only i n the last few generations has the balance been t i l t e d more favourably on the side of man* The recent war years, however, have shown how quickly ground gained i n the struggle can be lo s t . There i s a widespread tendency today to regard tuberculosis with complacency as a "controlled" disease, the complete eradication of which i s within our grasp. It i s true that i t has yielded pride of place as "Captain 1 of the Men of Death", and i s now eighth on the l i s t of "Principle Causes of Death" in most countries of the western world. Increase in l i f e expectancy in these countries has naturally led to a predominance of diseases of the older age group, such as arteriosclerotic and heart diseases, as overall causes of death, Nevertheless, tuberculosis i s the chief cause of death in the fifteen to forty-five age group i n these countries, and s t i l l the principle cause of death in the world today, taking a t o l l of five million lives an-nually, . The ravages of tuberculosis cannot be calculated by consideration of the mortality rate alone. Only against the background of i t s morbidity 1© The original use of this phrase i s attributed to John Bunyan, 2 can the disease he seen in its true perspective. It is estimated that tuber-1 culosis disables at least ten times as many people as i t k i l l s , - It is this capacity for crippling disablement in the most productive and enjoyable years of l i f e that ranks the disease among the foremost social problems of our day. In British Columbia in 1951» there were 19,000 known cases out of a population of approximately one million. These 19,000 would equal the total population of a fair-sized B. C, city. ^Although improvements in living standards and developments in public health measures have undoubtedly contributed to the reduction in tuberculosis mortality rates, the decline had begun at least a quarter of a century before the discovery of the bacillus by Koch in 1884, A.D., and before the initiation of specific public health measures and sanatorium programs anywhere in the world. The decline was also observed in countries which had not begun to carry 2 out vigorous control measures. Authorities are agreed that the decline was not due to any general decrease in the virulence of the bacillus - indeed, bacilli isolated at the beginning of the century are s t i l l producing the same sort of disease. Nor is i t due to the process of natural selection which, as 3 authorities agree, operates too slowly to account for the phenomenal f a l l which 4 has occurred. The precise nature of the forces which have "been at work is 1, Recent field studies in Massachusetts indicate that there are approximately nine living cases to each death, as postulated by the Framirtgham Survey in 1917. This evidence is cited by Chadwick, Henry D. and Pope, Alton S, in The Modern Attack on Taberculosis. The Commonwealth Fund, New York 1942, p. 4 2, Frost, W. H, "Age Selection of Mortality from T.B. in Successive Decades". .American Journal of Hygiene. Sect. A 30$91~6 Nov. 1939 3 , Richi Arnold R. The Pathogenesis of Tuberculosis. Charles C. Thomas, Springfield, Illinois, 1944, page 884. 4 . Ibid., p. 886. 3 unknown, so It is impossible to ut i l ize or control them* One theory is that general improvement8 in living conditions have raised people's resistance to communicable diseases in general, so that the bacillus is now confronted by more resistive host tissue than formerly. Other authorities point out that infectious diseases tend to aff l ict mankind in cycles which have a span of years, or even centuries; so that i t is possible that our present advantage is merely temporary or accidental. Even i f this abatement from "natural" causes continues, i t is not operating quickly enough to prevent the disease attacking millions of people in our own and future generations. In an era when chronic diseases have come to the fore as the major cause of social dependency, tuberculosis control programs assume a new importance. They have been in operation longer than similar control measures for ether chronic illnesses. They have, therefore, longer experience of the complexities of the economic and social aspects of chronic Illness, and the technicalities of community organization and public health administration* They have had an unprecedented opportunity to develop the teamwork approach which is characteristic of modern medical care. The very nature of the disease they have been fighting has led them to focus on the patient as an individual living in a family and a community setting. The lessons they have learned should be applicable in the development of control programs for other chronic illnesses, such as arthritis, heart disease and cancer, with which, apart from communicahility, tuberculosis has much in common. In a l l these diseases, early diagnosis is an important factor in determining the success of medical treat-ment. A l l of them involve lengthy hospitalization and rehabilitation, and the protracted economic dependency and prolonged dislocation of personal and family living patterns which make chronic illness such a drain on the resources of the patient, his family, and the community. In any community, success In tuberculosis control is a good indicator of how successfully a community is tackling its social problems in general. In every country in the world, the tuberculosis mortality rate is the most sensitive barometer of fluctuations in the living standards of the people. It is an accepted maxim that the lower the income, the higher the mortality rate from tuberculosis in any given group. "This inverse relationship between the incidence of tuberculosis on the one hand, and the standard of living on the other", says one life-long student of tuberculosis, "is one of the few tangible 1 facts to be found in the whole study of the disease". It i s against the background of these facts that the choice of this topic was made. The study aims at a descriptive evaluation, through i l l u s t -rative case material, of how a tuberculosis control program which is reputedly one of the best in the world, is actually operating in relation to the people i t is most intended to serve - namely, the low income group among whom the disease takes its greatest t o l l . It is hoped that the study will provide some basis for estimating the effectiveness of current services, and the areas where development and improvement seem to be indicated. The locale of the study, Social Area Three of the city of Vancouver, Canada, and the criteria for the selection of cases will be described in a later chapter. Before presenting the specific material of the thesis, i t is essential to review the principle facts about the disease itself, its epidemiology, and modern methods of diagnosis and treatments 1. Ustvedt, Hans Jacob, Pulmonary Taberculosis and its Treatment; John Bale, London, England, 19^ 2, p. 67» This hook, published in England during World War Two, was written by a Norwegian doctor and is in general repre-sentative of the Scandinavian approach to tuberculosis control. Etiology.of. the Disease. Tuberculosis is caused by a minute microbe called the "bacillus tuberculosis8. It is an exceedingly hardy germ, protected by a waxy capsule which makes i t resistive to drugs, and very difficult for the defences of the human body to destroy. It is extremely resistant to cold, dry heat and 1 disinfectants, but i t is: destroyed by prolonged exposure to direct sunlight. In moist, damp, dark places, i t can remain alive indefinitely, and has been found in the sweepings of dust from the rooms of tuberculous patients as long as three months after the patients have vacated them. Boiling water k i l l s the germ in twenty minutes, however, and a five per cent solution of carbolic acid takes twenty four hours to. k i l l the b a c i l l i i n an average sample of sputum. The germ i s a parasite, for though i t may remain alive outside the bodies of men and animals for varying periods .of time, i t cannot multiply except In the suitable coil of the body of its host. The bovine type of tuberculosis germ, though different from the human type, can cause the disease in humans, and reaches them principally through the milk of infected cows. Though i t can attack the lungs, i t more often attacks the bones and the lymph glands of the neck. This form of the disease is comparatively rare in British Columbia, due to the excellent control of cattle herds and the almost universal pasteurization of milk. This study confines i t s e l f to cases of pulmonary tuberculosis, because, although the bacillus can and does attack any organ of. the body, i t shows a predilection for the lungs. It is the pulmonary, form which is most common and which has created the greatest social problems. Modes of. Infection.. The etiological agent of tuberculosis is the germ itself . There can 1, ."Prolongedtt, in this connection, means over twenty-four hours, as i t has been proved that the b a c i l l i can survive in sputum lying in the direct rays of the sun for at least twenty-four hours. 6 "be no tuberculosis without the germ. Where then, do the germs come from? The great reservoirs of tuberculosis germs are the bodies of the people'who have the disease. Germs can leave their bodies in the spray of moisture they emit into the air when they talk, cough, sneeze or laugh, and can be inhaled into the lungs of others by what is called "droplet infection?'. It is estimated that germs emitted in this way float in the air, alive, for varying periods of time up to several hours or more. Some authorities are of the opinion that . 1 this is the most common mode of transmission of infection. The germ-soiled hands of sick patients can contaminate their clothes, personal belongings, dishes and any article which they touch. More intimate contact with others, as for instance kissing, is an obvious mode of transmission. In twenty four hours a sputum positive patient can cough into the air between one and four billion b a c i l l i , not a l l of which Burvive, i t is true; but a considerable number of them will remain alive indefinitely in closed rooms, in dark damp places, or mixed with the dry dust of the streets, from where they can be carried into people's homes, alive, and deposited on floors and carpets, there to become a source of infection to children and adults alike. It is known, too, that the "bacillus can be ingested in food or milk which has been contaminated by people with the disease, or by flies which having ingested tuberculous-positive sputum, then excrete the b a c i l l i . It is believed that most people - two out of three in Canada - have 2 become infected with tuberculosis germs at some time of their lives. Never-1, Lovell, Robert G, Taking the Care; The Patient's Approach to  Tuberculosis; The MacMillan Co. New York, 1948, p. 53. 2. These are the Canadian Tuberculosis Association figures for 1949. There is wide disagreement among authorities both in Canada and elsewhere as to the extent of infection in their adult populations. The only point on. which there is agreement is that infection is not ubiquitous as i t was a generation ago. No country has fig_res for their total population, but only for selected groups such as-school children, student nurses, where one might expect to find a proportionately high or low rate of infection. titleless, not a l l infected people develop the disease. Chest 2&-ray surveys i n Canada and elsewhere show that a large number of people have actually had the disease without knowing i t . I t has healed spontaneously without any outwardly recognizable c l i n i c a l symptoms; yet the t e l l - t a l e scars on the lungs remain as evidence. When the Canadian armed forces were X-rayed during World War Two, ten cut of every thousand showed tuberculosis scars, but only three out of every ten required sanitorium treatment to help heal their lesions. The rest required only periodic re-examinations and moderation i n daily l i v i n g to ensure that their lesions remained stabilized* What then are the factors involved i n the transition from infection to disease? There i s uniform agreement among authorities that, i n general, the fundamental factor which determines whether or not active disease develops i n an infected person i s the inherent capacity of the infected body to resist the invasive powers of the bacillus. Other major factors, i t i s agreed, are 1 the virulence of the particular strain of b a c i l l u s , the size and frequency 2 of the dose , and the mechanical factor of the location of the original lesion. As regards the latter, the view i s that i f the original lesion occurs at a distance from a large blood vessel, i t may be walled off and cause so trouble; but i f i t occurs near one, i t may rupture into the blood vessel and cause a rapid spread of the infection. It i s this factor which explains the rapid involvement of a whole lobe or sometimes even a whole lung after a 1* Variation i n virulence of different strains of the same type of bacillus i s known to occur. Variations i n the same strain can occur depending on such factors as whether or not they have recently l e f t the r i c h s o i l of a . hospitable human host or have been barely surviving i n the dust of the street. 2* Animal experiments have proved conclusively that there i s a limit to the number of b a c i l l i that even the highest degree of acquired resistance can successfully restrain. See, Hich, op. c i t . p. 659 8 1 relatively'brief period of symptoms as far as the patient i s concerned. As these latter factors are a l l uncontrollable, most epidemiological study has been directed towards determining, i f possible, what factors influence the resistive powers of the individual. Factors Influencing the .Besistive Powers of an. Individual. This i s one of the most controversial areas i n the whole f i e l d of tuberculosis epidemiology. There i s general agreement that a l l the factors which are now to be discussed are involved to some degree* But there are widely differing, and even contradictory viewpoints as to the comparative weighting to be accorded to each, either i n an individual case or i n the population at large* Nevertheless, their influence i s too well acknowledged to he dis-regarded i n any tuberculosis control program* Age i s undoubtedly a factor, i n the sense that people are more vulnerable at certain life-periods than others* In the f i r s t few months of l i f e children are especially susceptible, but this susceptibility tends to decrease in early infancy, and incidence is actually lowest in the three to twelve age group* Puberty brings increased susceptibility* In women, the highest incidence occurs in the twenty to twenty-five age group* In men the f i r s t peak i s reached a decade later than In women, and there has been a growing tendency in B, C. and elsewhere for the incidence curve i n males to reach a 2 second and even higher peak i n a later decade of l i f e . Middle aged and 1, Hatfield, W. H,: Handbook on Taberculosis. King ,s Printer, Victoria, B.C., 19^ 4, p* 26. \. 2* One observer, Frost, points out that this should not be interpreted as evidence of a decreased resistance in men i n the later years of l i f e , as -i s sometimes supposed. If the group aged f i f t y to sixty i n 1930 i s followed back to birth, they f a l l within the age group which experienced the highest mortality rate, between twenty and thirty years, and are really residuals of higher rates i n earlier l i f e , W.H. Frost: "Age Selection of Mortality from Tuberculosis i n Successive Decades": American. Journal of Hygiene. Sect, A 30; 91-96, November, 1939. elderly women, on the other hand seldom develop tuberculosis. Eace i s undoubtedly a factor, though its comparative importance is difficult to evaluate. Although Africans, Negroes, Asiatics, American Indians and Eskimos at present show greater susceptibility, this does not necessarily mean that their ultimate capacity to acquire resistance to the bacillus may not prove to be as great, or even greater than the white man's, when they have been exposed to the bacillus for as long a period historically as has the white man, who first brought the germ to their lands. Nor i s i t possible to estimate how much in these groups their inherent natural capacity to resist the ravages of the disease is being undermined or at least being held in check by the appalling social and economic conditions which are generally found among these people. Share is the additional factor of the stresses occasioned by the violent change-over in mores which has accompanied their transition from nomadic l i f e to reservation l i f e and from rural to urban living. It has not been proved that any particular occupation predisposes a person to tuberculosis, except those involving exposure to s i l i c a dust and granite dust. These do not increase the virulence of the b a c i l l i but they provide conditions in the lungs which suable the b a c i l l i to multiply rapidly once they have invaded the body tissues. Physical overstrain, whether in work or play can be a factor i n the development of disease following a primary infection. Fatigue lowers the power of the body's defender cells to fight any bacteria which may gain entrance to the body, including bacillus tuberculosis. Excessive movement and bodily exertion increase both circulation and respiration and these assist in extending 1, There i s , however, some evidence to suggest that single, divorced and separated women earning their own living are more susceptible according to an article by Dr. Norman Macdonald: "The Social Aspects of •Tuberculosis", i n The Almoner. Vol. 2. No. 7. October, 1949: p. 148. 10 the areas of infection. Most doctors believe that mental and emotional strain, such as anxiety, and grief can be, and actually are in some cases, important factors influencing the transition from infection to disease. However, as psychiatrists point out, the mere presence of an upsetting event or situation in a patlent*8' l i f e does not necessarily imply that i t has pathogenic significance, unless i t can be shown that i t affected a patient specifically. "Whether or not an external event can be regarded as a precipitating factor does not depend on i ts dramatic quality, but rather on its specific character, A. grain of sand may upset the smooth running of the wheels of a machine i f the machine is such as to he upset by grains of sand. Or precipitating events may not be traceable at a l l , because, in the absence of any specific event in the patients 1 outer world, conflicts in their inner world may have to come to a climax, and thus the stage may have been set for the onset of a psychosomatic disorder.**^ The relationship between personality conflicts and pulmonary disease has been the subject of much investigation in recent years. One English observer, Dr. George Day, after many years work in sard tor i a which catered to patients of the economic middle class, - ministers, school teachers, and other such professional people - came to the conclusion thats-"Those who develop the disease ih the absence of the classical physical environmental causes, such as poverty, often do so because of some disease in their psychological environment, in their relation to themselves or to the world outside. . . . . . . In psychological distress, the patient as a whole is ready to be i l l , in fact is already i l l , and the ubiquitous b a c i l l i , both indogeneous and exogenous are there ready to oblige.. . .• Is i t more than just chance that their tissues are so hospitable?" • As a result of some of the investigations in this f ield, some re-searchers have concluded that the personalities of tuberculous patients have 1, Wittkower, Erics A Psychiatrist Looks, at Taoerculosis. The national Society for the Prevention of Tuberculosis, London, 1949, P» 107 2, Day, George, *?Some Observations on the Psychology of the Tuberculous", The Lancet. 16th November, 1946, p. 703 11 certaia features in common, and have begun to talk about "the tuberculous personality". This view has not had general acceptance, however. One of the most thorough investigations of this kind was made by a British psychiatrist, Eric Wittkower, who made an intensive survey of 300 patients, drawn from a l l social classes, each of whom underwent a psychiatric examination of at least two hours duration, and often with repeated further examinations. His con-clusions were that:-nAn inordinate need for affection is an outstanding common feature of the premorbid personality of tuberculous patients. This need for affection may be openly expressed, thinly dis-guised, well concealed or flatly denied* Coupled with i t are conflicts over dependence..... A person's mode of upbringing determines what character defences i.e. what mode of behaviour he adopts. .According to their prevailing behaviour pattern, the patients were classified as overtly insecure (sub-groupss over*dependent, leaning, self-assertive) rebellious, self-driving and conflict-harassed types.*.. In brief, individuals who develop tuberculosis seem to have in comman an Inability to deal adequately with their aggressive impulses, and are prone, though for various reasons, and in different ways, to turn against themselves.*^ As Wittkower gees on to point out, the psychological mechanisms which he has identified represent an attempt to explain the reasons behind the un-healthy mode of l i f e , and the common features in the mental upsets which, as many doctors have observed, often proceed the onset of the symptoms of tuber-culosis. They in no way invalidate the relevance of other important etiological factors, such as adverse living conditions, "They do however, help to explain why a person falls i l l and • why he falls i l l when he does, but they f a i l to explain why he falls i l l with pulmonary tuberculosis. In the light of our present knowledge, consideration of this point, though attractive, can only be tentative." 1. Wittkower, Eric, op. ci t . pp. 136-137 2. Ibid. p. 137 12 With that view, the present writer would concur. Hone of the other literature which was read seemed to justify any general conclusions i n this matter. Pregnancy though a natural and normal function, was formerly thought to impose sufficient strain on a woman to lower her natural resistance to tuberculosis considerably; and i t i s observed that many women succumb to tuber-colosis during or following a pregnancy. The occurence of pregnancy i n a tuberculous woman was in i t s e l f once considered sufficient indication for a therapeutic abortion. More recently, on the basis of numerous studies, i t has been concluded that i t i s the strain of nursing the child and attending to household duties i n the months following ..confinement that tend to activate a tubercular lesion. Nowadays, with proper care, including hospitalization three months before confinement and six months after, i t has been found possible to carry a tuberculous woman through a pregnancy without reactivation or exacer-bation of her disease. War, which imposes strains of various kinds, invariably causes an ascending tuberculosis rate. It causes more of those infected with the bacillus to develop the disease, and causes a more rapid and progressive course i n those who already have active disease. In combatant countries i n World War One tuber-.culosis mortality rates increased between 20$-100$, the increase being pro-portional to the privations suffered by the particular populations. In Germany the rate f e l l between 1919 and 1921, but rose almost to war levels again i n .1 1922-3, when food was d i f f i c u l t to obtain, and economic depression was r i f e . Traumatic tuberculosis, or tuberculosis following an accident or injury, i s often attributed directly to the injury. But to get the disease, the bacillus must become implanted i n the body's tissues, and the chances of 1. Chadwick and Pope, op. c i t . p. 31« 13 this actually occurring in the course of the injury are exceedingly remote, Nevertheless, the strain and shock of such an experience might activate an existing lesion* Personal hygiene and daily mode of l i f e can he an adjunct towards maintaining good health or an invitation to poor health, according to whether one is moderate or immoderate in daily habits of food, sleep, rest, exercise, work and play. The correlation between chronic alcoholism and tuberculosis i s largely explainable on this basis* So too, is the striking correlation be-tween mental illness and tuberculosis* The fact that tuberculosis occurs more frequently among this group than in the population at large is an indication of how the neglect of sensible daily living habits, which is often an early symptom of mental illness, has other consequences of serious social significance*' Some of the most controversial discussions among tuberculosis authorities centre around proper evaluation of the role of the hereditary factor in the development of active tuberculosis* Before Koch discovered the bacillus, the hereditary factor was considered the principal one in epidemiology, and the role of the contagious factor tended to be overlooked* Koch's discovery caused the pendulum to swing to the opposite extreme, and until recently, the Importance of, and even the existence of the hereditary factor has tended to be ignored* As a result of contemporary studies, i t i s now known that espec-ially high or low resistance to tuberculosis can be transmitted by heredity* Studies made in U.S.A. indicate that children of tuberculous parents contract tuberculosis twice as frequently as children of non-tuberculous parents, and that the incidence among spouses of tuberculous patients, while higher than in the general population, is not so high as might be expected. Canadian ex-perience can cite the example of those Canadians who endured the privations of the Japanese Prisonei^-of War Camps. Some of them showed remarkable resistance 14 to the bacillus, and did not contract the disease in spite of intimate daily contact with sputum-positive cases under the most adverse living conditions, 1 The factors involved in the inheritence of resistance are complex , and cannot, in our present degree of knowledge, "be explained. Inherited resistance may he the decisive factor in an individual case, and in certain circumstances, in determining whether an infection results in eventual disease. But i t does not thereby follow that i t is the chief factor governing incidence of tuberculosis in the population as a whole. If i t were, i t would radically alter the modern approach to tuberculosis control. Hbr i s i t always the most important factor governing the development of active tuber-culosis in an Individual case, as some authorities have contended* Some of the most thoughtful students of tuberculosis epidemiology consider that the real problem lies In the accurate weighting of the influence of the hereditary factor, against the influences of a l l the various environmental factors which might alter the level of both native and acquired resistance, and depress them to the point where they could not withstand the invasive powers of the bacillus* Importance of Adverse. Socio-economic.Conditions, in Lowering Resistive Powers. • There has already been some discussion regarding the non-medical factors governing human resistance to tuberculosis. Discussion of the most 1* One American researcher, Irwin, found that even after sixty gener-ations of brother-sister matings in animals, marked differences in individual resistance to tuberculosis were s t i l l present* Two others, Wright and Lewis, thought that 50$ - 60$ of the variations in resistance that they observed in their cross-breeds were unexplainable on the basis of heredity, and were due to unknown factors. This and other evidence which he cites, compels Rich to say "We are in no position to state, even approximately, the degree to which heredity may influence the incidence or mortality rate of tuberculosis in man. Any extremist view of this most important question is decidedly unwise, and probably mistaken1** Rich* op. cit , p. 136. 15 important environmental factor has purposely "been left to the last. In the writer*s opinion i t proveB conclusively that the importance of the hereditary factor is, for a l l practical purposes, distinctly subordinate to the very real importance of those environmental factors which can be grouped under the heading of "socio-economic conditions", and which, unlike our hereditary constitutions, we can i f we wish, control to our advantage rather than to our disadvantage* A l l attempts a l l over the world to correlate tuberculosis and socio-economic conditions, show that tuberculosis flourishes in poverty* In a l l countries the highest mortality rate is at the lowest economic level,, and the lowest rate at the highest economic level* When a community is divided accord-ing to income, there is a noticeable correlation between increasing tuberculosis 1 mortality and decreasing income* 2 Poverty, as one authority points out, is a complex condition* In addition to inadequate income and the constant strain to trying to make ends meet, poverty usually involves inadequate nutrition and resultant lowered • resistance to disease in general, hard work, Inadequate medical care, poor hous-ing, and possibly ignorance of good health habits, anxiety, insecurity, frust-ration, discouragement and apathy* "Poverty, therefore", say two of the lead-3 ing authorities,  n.ie the predisposing cause of tuberculosis". 1* Occupation, used as a guide to income was utilized in the Whitney Survey in U.S.A. in 1934, using material compiled from the U*S.A. census bureau in 1930 to estimate tuberculosis mortality rates in males aged 16>60* It showed that even allowing for the inevitable errors in classification* the mortality rate among unskilled workers was more than twice as high as in skilled workers and foremen; three times as high as in clerks, and six times as high as in professional men. 2* Pinner, Max: Pulmonary Tuberculosis in the Adult. Chas. C. Thomas, Springfield, Illinois, 1945. p. 516 3* Chadwick and Pope. op. cit. p* 31 16 Of a l l the factors associated with poverty, poor nutrition is consid-ered to he the most important in the relation between low standards of living and tuberculosis. It is'true that some poor people who develop the disease may be comparatively well«fed, but in dealing with tuberculosis epidemiology It must be remembered that any. one factor may be outweighed by a combination of others. The importance of adequate nutrition in resistance to tuberculosis was well illustrated by the experience of neutral countries in World War One, In those affected by the blockade a rise in tuberculosis mortality occurred; in those unaffected or only intermittently affected, tuberculosis mortality declined. Even in combative countries, there was a lower mortality in agricult-ural countries like Hungary than in highly urbanized countries like Germany* The example of Denmark's experience illustrates most graphically of a l l the importance of nutrition in tuberculosis control* Daring the f i r s t three years of the war the Danes exported most of their dairy produce to combatant countries. Though highly profitable commer-cially, this drained the home market, and the tuberculosis mortality rate rose over twenty-five per; cent though living conditions were practically unchanged. In 1917, when German submarines cut Denmark off from her export markets and the Danes had to live on their own produce, in one year, 1918, the tuberculosis 1 mortality rate f e l l to pre-^rar level. Poor housing is universally recognized as an important factor in the spread of tuberculosis, because i t usually involves poor sanitation, poor ventilation, inadequate, facilities for garbage.disposal and overcrowding; a l l of which tend to increase opportunities for infection and facilitate trans-miss ion, English researchers have shown that there is a definite correlation 1, Gited by Eich, op. cit. p. 224. 17 between density of population and tuberculosis, and a significant relationship 1 between the number of persons.per room and incidence of tuberculosis* In the slum clearance project at Liverpool, England, i t was noted that i n the new housing estates b u i l t i n the same areas as the old, and rehousing the same fam-i l i e s that had previously lived there, the tuberculosis mortality rate f e l l from 2 4.00 per thousand to 1.9 per thousand. Influence of Total Environment on the Development of Tuberculosis. This i s strikingly illustrated by the findings of a group of South African physicians. In a survey of some 20,000 Bantus i n Hatal they found that differences i n the incidence and type of tuberculosis i n these people of uniform r a c i a l stock were directly associated with the conditions under which they lived 3 and worked. In those Bantus l i v i n g on the reserves, the infection rate was between 40$ and 50$, and cases of active disease were few; i n those l i v i n g on the Mission Beserves, where l i v i n g conditions were crowded and there was more contact with the outside world, the incidence of active progressive tuberculosis was three times as high; i n those l i v i n g i n the peri-urban areas where there was not only over-crowding i n t i n shanties, but inadequate nutrition as well, the incidence again rose and the proportion of progressive primary and severe re** infection types of i l l n e s s was much higher; i n the urban areas, where there was gross overcrowding, deficient diet and i n addition heavy physical work, the infection rates were 70$ -80$, and the morbidity rates six to eight times 1* A Glasgow Survey showed that the infection rate i n one and two roomed houses was double that i n three and four roomed houses. 2. Hatfield, op. c i t . p. 30. 3* Dormer, B. A.., IViedlaiider, J., and Wiles, J. "F. "A South African Team looks,at Tuberculosis" i n the Proceedings of the Transvaal.Mine Medical  Officers* Association. Nov. 1943. cited by Chadwick and Pope, op. c i t * p. 34. 18 as high as among the Bantus on the native reserves. The authors stated "that in this case the conclusion that the determining factors in the development of tuberculosis in an infected population are environmental seems, inescapable." There is enough evidence in the annual statistics of countries of Western civilization to merit the conclusion that adverse socio-economic conditions are of paramount importance in the perpetuation of tuberculosis as a major public welfare problem. The Hature of the Disease...  In order to understand modern treatment of tuberculosis i t is neces-sary to have some understanding of what happens when the germ invades the body tissues. As soon as the bacilli enter the lungs, Injury to the tissues begins, or can begin. At once the body's defender cells challenge the invaders. Depending on the strength of the body's resistive powers,-the patient may suffer a mild clinically unrecognizable form of the disease, which nevertheless leaves tell-tale scars visible on the x*ray plate; or a chronic illness of varying length and severity, in which the body eventually overcomes the invader; or ther disease may pursue a rapid and irreversible course towards death, , : >, The fierce battle between the body's defender cells and the invading bacil l i takes place.on the battleground of the lung itself which is injured in the process. The poisons from the bac i l l i and the dead defender cells are., damaging to the lung tissue. This damaged tissue takes on the characteristic nodule-like appearance known to medical men as the "tubercule", from which the disease gets its name. The body forms cobweb-like strands of fibrous scar tissue which i t wraps around each tubercule in an effort to wall off the invader and prevent the spread of infection. Sometimes a further degree of healing known as "calcification" takes place in which lime salts are deposited to harden the tubercule further. The healing process is not accomplished either easily 19 or quickly, and i t takes nature many months or even years to make the wall strong enough to hold the invader i n check permanently. One of the usual accompaniments of this lenthy process i s the "caseation" stage, during which the centre of the tubercule softens and undergoes liquefaction and the "bacilli multiply and spread. This softened material may "break into a bronchus, from which i t i s coughed up from the chest. A cavity i s the space l e f t i n the lung by this softened tissue which has been coughed out. When a patient i s coughing germs from his body i n this way he i s said to be an "open case". A closed case i s one i n which germs do not leave the body i n this way. Periods of alternating liquefaction and hardening are characteristic of the disease. Infective material from the f i r s t cavity may be aspirated into other bronchial tubes and thus spread patches of infection throughout one or both lungs, perhaps resulting i n further cavitation. I t i s quite possible for a patient to have a considerable degree of healing i n some cavities and progressive liquefaction i n others. Hot u n t i l a l l cavities and lesions are healed i s a patient considered well. Symptoms. Early tuberculosis i s usually symptomless as far as the patient i s : concerned. . Since the use of the x-ray as a diagnostic tool in tuberculosis, i t has been realized that by the time the disease gives rise to c l i n i c a l l y recognizable symptoms, i t i s no longer early, lesions and even cavities show on the X-^ray plate before the patient has begun to feel the lassitude and the vague malaise caused when the poison produced, by the b a c i l l i invades the blood stream. Chronic fatigue i s a symptom of numerous illnesses, .Many people, r recognizing that i n our hlghrpressure way of l i v i n g i t can be due to prolonged 20 emotional tension, often resort to self-medication with their favorite tonic, or go on a vacation rather than for a medical check-up, when they are troubled by i t . Other symptoms such as loss of weight, repeated colds, mild laryngitis, mildly elevated temperatures in the afternoon, upset digestion, constipation, shortness of. breath, aenemla, and ammenorrhea i n women are not generally con-sidered by the average layman to be the accompaniments of early tuberculosis. Yet medical men are f u l l y aware of how often these symptoms are part of the early presenting picture when the patient later gives his history. These are also conditions! which many people do not regard as sufficiently serious to warrant prompt medical attention, and which, i t i s true, may be entirely unre-lated to tuberculosis. The occurrence of c h i l l s , night sweats, a persistent cough with sputum or mild hemorrhage are l i k e l y to prove sufficiently disturbing to most people to influence them to consult a doctor. By that time, however, the disease i s often quite far advanced. Although the onset i s usually slow and insidious, i t can begin abruptly with high fever and hemorrhage, although this does not mean that the damage is necessarily greater than when onset i s more gradual. The severity of the disease cannot be judged by the presence or absence of the characteristic cough, nor by whether the cough i s productive or unproductive. Productive coughers may be consistently sputum-negative, and conversely, patients producing only small amounts of sputum may be highly sputum-positive. There i s usually l i t t l e or,no sputum before the cavitation stage i s reached, or i f there i s i t i s usually negative for b a c i l l i , Never-theless, some authorities, including Hatfield, are of the opinion that a l l 1 patients with sputum should be regarded as infectious, 1, Hatfield, op, c i t , p, 21 Diagnosis* Diagnosis i s not always easy i n early tuberculosis, though with modem diagnostic aids, i t i s easier than i t used to be* Many other diseases cast on the X-ray similar shadows to tuberculosis lesions, and a differential diagnosis can only be made through the use of additional examinations and tests such as fluroscopy, skin tests, stomach lavage and sputum tests. The blood sedimentation rate test, while not specific for. tuber-culosis, i s an important aid i n assessing the acti v i t y of the disease, once 1 diagnosed. Modern Methods of. Treatment  The aim of a l l modern treatment for tuberculosis i s to assist the bodily defences to come into play, as f u l l y and effectively as possible i n order to overcome the infection. Any. inflamed organ needs rest. Therefore the diseased lung must be given as much rest.as possible. This i s accomplished through general rest of the whole, body which includes bed rest plus mental rest i n the sense of freedom from anxiety and from the ordinary responsibilities of everyday l i v i n g . As an additional aid, local rest of the diseased lung i s often u t i l i z e d . This i s done through use of one of the modern medical or surgical procedures which w i l l induce p a r t i a l or complete collapse of the lung, either temporarily or permanently, and thus through shrinkage of the lung area, assist i n the closing of cavities. When i t i s considered that the lungs in the normal activity of breathing move about 25,000 times ft day, the value of such a r t i f -i c i a l forms of rest can be appreciated. 1, There have been recent press reports about the discovery of two new blood tests to detect active tuberculosis by Dr. Gardner Middlebrook of the "Rockefeller Medical Institute i n Hew York. These tests are improvements on the former ones he devised for the same purpose. The new tests are said to use two elements i n the patient's blood which can be checked against each other to determine activity of the bacillus. 22 The most commonly used of the temporary forms of collapse is ar t i f i c i a l pneumothorax, which is a method of introducing air into the space between the pleura and the chest wall, thus collapsing the lung. Air needs to he replaced at intervals "because i t is gradually absorbed into the body* Phrenicotomy, which is a severing of the phrenic nerve either completely or partially, causes the diaphragm to rise and compress the lower part of the lungs, and can be used as a temporary or permanent measure* The most common of the permanent forms of collapse is thoracoplasty, a major surgical procedure, usually done in three or four stages, in which the lung is made to collapse by removal of part of the ribs on the affected side* The removal of a whole lung which is called pneumonectomy; or of part of a lung which is called lobectomy, are permanent and drastic measures which may be resorted to in severe cases* Which of these procedures is indicated In an individual case, and the timing of them so that the patient receives maximum benefit are matters of medical judgement* Drug therapy is an adjunct to surgical treatment of tuberculosis, though i t can be used alone. There has been a great deal of publicity given to the modern wonder drugs, many of which have proved disappointing for use in tuberculosis therapy. The ever-resilient bacillus has, in response to the use of at least one of them, namely streptomycin, developed certain strains that are resistant to the drug, and one strain which is believed to thrive only in the presence of streptomycin. In spite of a l l the claims being made for the 1 latest developments in this field , Hydrazid, or Eimifon or Marsalid, the most cautious observers believe that no drugs yet discovered, nor any collapse therapy 1. See articles "Tuberculosis Milestone", in Life magazine, March 3rd, 1952. p. 20. 23 has- substantially shortened the period of bed rest which is s t i l l necessary to enable the body to complete the healing process. A high standard of nutrition is universally recognized as one of the most potent weapons in assisting the body to overcome the disease. Climate and altitude, once considered of paramount importance, are not now considered so in modern treatment. Bo one climate has been proved 1 superior in the treatment of tuberculosis. There is considerable difference of opinion as to the value of fresh-air treatment, as opposed to climate. This is not utilized to any great degree on this continent but is considered very 2 important in Scandinavia and Britain, though not universally so. i Because of the nature of modern treatment measures, i t is advisable for a l l patients to have a period of sanitorium care. The purpose of modern sanatorium care is not merely to Isolate an infectious person from the community, but to teach him how to apply the general principles for care of the disease to his own case, how to protect others, and most important of a l l , to enable him to have medical observation in order to estimate his capacity to cope with hie disease and to evaluate which of the modern treatment procedures would be most 3 beneficial in his case. 1, It is acknowledged however, that for the minority of patients who suffer from secondary catarrhal bronchitis, or post tuberculosis bronchiectasis with profuse sputum, a warm dry climate can spell the difference between invalidism and almost normal capacity to work. But they must live in a warm dry climate permanently i f they are to benefit by i t , 2, Rich, op. ci t , p. 6^5, thinks that fresh air treatment is not so valueless as many would have us believe. Even the most healthy organism is stimulated and invigorated by continuous living in the open air. It is true that the most important effects may be on the psyche, but as Rich points out, that is important, too, 3 , (Jhadwick and Pope, op, c i t , p. 121, estimate that 60 to 70$ of a l l patients are potential candidates for some form of collapse therapy. Out of the sample group of 79 patients, only 3 recovered on bed rest alone. 24 Serial X-rays taken periodically during the treatment process are used to assess changes in the clinical status of the disease. Increase in the size of shadows indicates greater spread of the disease; decrease indicates healing. But the X-ray does not show the degree of encapsulation of the lesions or cavities. Even calcified foci can contain viable baci l l i which are a potential source of reactivation of the disease. "Many an unexplained relapse" says one doctor, "is due to incomplete encapsulation which breaks down." Ibr this reason the patient's resumption of normal activity must be carefully graded. When the X-ray and other tests indicate that the disease is quiescent, the patient is taken off strict bed rest, and allowed "bathroom privileges". Then he is allowed up for one meal, then for two meals, then for a l l meals. Hext, in addition, he is allowed a fifteen minute exercise period once per day. This is increased to thirty minutes, then to one hour, until the patient is taking as much exercise as is medically safe; always with the accompaniment of a mid-day rest. Then he is allowed part-time light work, then full-time light work. The patient is considered convalescent and his disease is classified "quiescent" when he can undertake f u l l physical exertion without showing any signs of fatigue, maintain a steady and normal temperature, has no cavities, negative sputum, and his lesions are stationary according to X-ray. When the patient has maintained these gains for three months, during the last two of which he has been taking one hour's walking exercise daily or its equivalent, his disease is classified as "apparently arrested". When he has maintained his gains for six months during the last two of which he has been taking two hour's exercise daily, his disease is classified as "arrested". If he can maintain these gains for a period of two years under ordinary conditions of l i f e , and is proved on examination to have tuberculosis-negative sputum and 25 negative stomach washings, not only "by concentration and microscopic examination, hut also by culture or animal inoculation, his disease is classified "apparently cured". Importance of the Cooperation of the patieat. Modern treatment methods in tuberculosis of their very nature require the active participation of the patient in the treatment plan. Though this is true of a l l illness, i t is especially true of tuberculosis* This fact was recognized long before i t became the fashion for medical men to shed some of the secrecy surrounding treatment procedures and share more fully with the patient information as to what was being done and why, "Ho fool" said Osier many years ago, "ever recovered from tuberculosis,,,. The fate of a person with tuberculosis depends much more on what he has in his head than on what he has in his chest," Most modern tuberculosis control programs endeavor to give the patient the opportunity to assume as much responsibility as possible in the treatment plan for his individual case, Eecognition of the importance of the cooperation and participation of the patient involves much more than intellectual orientation and education of the patient to the facts regarding the disease. It includes, or should include, recognition of the personality of the patient as an important factor in the management of the disease and even in the prognosis. Some medical men are of 2 the opinion that the personality of the patient is the controlling factor. 1« These are the standards set according to the "Diagnostic Standards and Classification of Tuberculosis" published by the National Tuberculosis Association of U.S.A., New York, l$kO, p. 21 and 22, 2, See Coleman, Jules 7., Hurst Allan and Horbein, Buth, "Psychiatric Contributions to the Care of Tuberculosis Patients", Journal of the American  Medical Association. Vol, 135» Eo, l l , p. 699* — 2 6 Importance of the Psychosomatic Approach i n Diagnosis and Treatment The influence of the personality of the patient as a factor in i l l n e s s has long "been recognized "by clinicians, hut i t has "been given new importance "by the developments i n psychosomatic medicine which have taken place i n recent years,, Psychosomatic medicine i s not a new speciality i n medicine, "but an approach to the whole of medicine, which stresses the inter-relationship of the psyche and the soma, that i s , the emotions and the "bodily symptoms, i n a l l sick people. This approach to medicine i s not new in i t s e l f •— indeed i t i s an old as Hippocrates, "but in recent years i t has "been given a s c i e n t i f i c validation "by the researches and demonstration work which have "been done i n this f i e l d . As a result of recent studies, i t has come to "be recognized that i n a l l illness there are three components, f i r s t the physical or organic; secondly, the psychological or emotional; and thirdly, the social or environmental. A l l of these components and their interaction need to "be evaluated and taken into consideration, "both i n diagnosis and treatment This concept of illness stresses two important facts about people which have tended to "be overlooked i n the era of specialization i n medicine which has developed i n the past generation in response to innumerable discoveries which have made i t impossible for one man to master medical science as a whole. These are f i r s t , the unity and i n d i v i s i b i l i t y of the human being, and secondly, the fact that illness i s an aspect of behaviour. As a result of these r e a l i z -ations the tuberculosis patient has ceased to be regarded as primarily a "pair of diseased lungs", but rather as an? individual who is part of a particular family and a particular social environment, and who has his characteristic individualized way of reacting to ill n e s s as to other experiences. In an ill n e s s such as tuberculosis i t i s especially important to know 27 •the nature of the individual personality, "because the patient's emotional makeup, the nature of his conflicts, defence mechanisms, areas of satis-factions and frustrations, compensation patterns, and especially the degree of anxiety in his makeup and his ability to adjust, will largely determine how he copes with his part in the management of his disease* Comprehensive medical care should provide for individualized handling of the patient's case,, "based on a f u l l understanding of the interaction of the organic disease process, the patient's personality pattern and the part-icular social environment of which": the patient is a part* The advantages of modem medical science are made available to the patient through what has come to be called the Hreatment team", of which the patient's own physician is the captain, and the hub around which rotate the services of the other members of the team; nurse, dietician, physiotherapist, laboratory technician, X-ray technician, occupational therapist, and medical social worker. The services of these specialists are enlisted by the patient's doctor according to the needs of the patient. The Bole of the. Medical Social Worker in the Treatment Team.. The medical social worker's role on the team developed in response to the need to have a scientific approach to the psychological and social aspects of illness such as had already been developed towards the physical. The medical social worker is professionally trained to assess the role which 1 emotional and social factors are playing in a patient's illness. She brings 1. It should be noted that the use of the feminine pronoun in refer-ence to the medical social worker is merely for purposes of convenience, in order to differentiate between the worker and the patient and also between the physician and the worker. It is not meant to imply that medical social workers are exclusively feminine, nor that patients and their physicians are exclusively masculine* 28 her findings to the doctor for correlation with other diagnostic material, and works closely with him i n the development of a treatment plan for the solution or alleviation, of whatever emotional and social d i f f i c u l t i e s are affecting the patient's i l l n e s s . The aim of the, medical social worker i s to assist the patient to obtain maximum benefit from medical treatment by helping him overcome those personal and social factors which have a bearing on his illness and which are interfering with diagnosis, treatment or recovery. She helps the patient mainly through casework which i s her chief professional tool. Social casework has been defined asj "an art i n which knowledge of the science of human relations and s k i l l in relationship are used to mobilize capacities in the individual and resources in the community, appropriate for better adjustment between the client and a l l or any part of his t o t a l environment".^ Casework i s the prime a c t i v i t y of the medical social worker. Through the dynamic relationship which i s b u i l t up between worker and patient during interviews the patient comes to regard the worker as a friendly understanding person who accepts him as he i s , who w i l l not censure him, who w i l l respect at a l l times his right to make his own decisions, with whom he can discuss freely and with f u l l protection of confidentiality, the problems which con-front him, from whom he can draw enough support and encouragement to take action to improve his situation i n ways he could not do unaided. The patient can, through casework, gain insight into the role which social and-emotional factors are playing in his i l l n e s s , and can be helped to make the 1, Bowers, Swithin, Q.M.I., "The Hature and Definition of Social Casework: Part three," i n the Journal of Social Casework. Yolume 30, Ho. 10. Dec. 19^9. p. 417 29 maximum effort of which he himself is capable towards the solution or alleviation of his d i f f i c u l t i e s . He can also be helped to accept and u t i l i z e help from available community resources. The s k i l l s and methods of the social work profession are the same in whatever f i e l d they are practiced, whether in family welfare, child welfare, recreation, corrections, or medical social work. It i s the nature of the f i e l d , however, which determines the worker's focus. In a medical setting, the social worker focuses on personal and social problems connected 1 with i l l n e s s . She gives casework service at the request of the doctor, studies a patient's problems as they appear to him, assesses the meaning they have for him, studies his family background and social circumstances i n order to help the doctor discover the reasons behind the patient's behaviour i n i l l -ness and his response or lack of response to medical treatment. She helps the patient to f e e l that i n spite of busy hospital and c l i n i c routine, his individual needs are understood and are being taken into consideration i n treatment. She assesses the role the family i s playing i n the patient's i l l -ness, interprets to them the total situation regarding the patient and their specific part i n the treatment plan. She helps them to accept i t and carry i t out. She helps other professional personnel caring for the patient to understand him as an individual, and thus assists i n the adjusting of the treatment plan to the patient's individual needs. She takes the i n i t i a t i v e in mobilizing community resources to meet the patient's needs and helps him and his family to understand and accept these services. 1. It i s preferable, but not essential, that a l l referrals for the social worker's service should be made by the patient's doctor. Sometimes, however, i t i s the nurse, dietician, relative, friend, community agency, or even the patient himself who requests the worker's services. When this happens the medical social worker acquaints patient's doctor with the request and the reasons for i t . He makes the decision whether or not he wishes the worker to give service. 30 If referral to other social agencies i s made, she often under-takes in association with them a job of cooperative casework for the benefit of the patient„ She interprets to other agencies the meaning of illness and hospital experience to the patient, and the social implications of the medical treatment plan, so that the agency concerned understands the total situation, and can help further the plan for the patient's medical care. The medical social worker's job i s important and indispensable in i l l n e s s . Through her contribution the doctor i s enabled to understand the patient as a person and so to individualize the treatment plan. CHAPTER 2 The Sample Group The c i t y of Vancouver, on the Pacific Coast of Canada, has grown i n l i t t l e more than half a century from the small lumber settlement of "Gastown" to the third largest city i n the country, with a population of approximately 350*000. It i s a thriving seaport, the proud possessor of one of the world's finest natural harbours, and occupies a strategic position i n commerce between Occident and Orient. The major industries of the Province of British Columbia i n which Vancouver is situated, are lumbering, pulp and paper making, fishing, mining, smelting; and most recently, o i l . Such rapid growth was almost inevitably accompanied by undesirable social features which have l e f t their mark on the city as i t exists today. Social Area Three i s a "blighted area" type of neighbourhood, unfortunately a common feature of many c i t i e s i n both the Old World and the Hew. It i s a d i s t r i c t which originally possessed, and s t i l l retains many desirable features, and which was f i r s t settled as a residential section close to the cit y centre i n the early days of the city's history. In the era of expansion which followed, the d i s t r i c t lost i t s original character. Today i t i s a confused mixture of dwellings, and industrial structures of many varieties. Many of the dwellings i n the area are the old-fashioned type of frame house, some s t i l l substantial and well kept and housing a single family, but for the most part run-down, dilapidated looking structures, now housing Fig. 1 Map of Vancouver Snowing Social Areas 33 1 several families, There i s also a number of roughly constructed wooden dwel-lings of incredible shapes and sizes which qualify as houses in name only, and would be more appropriately designated as shacks. There are also rows of cabins, originally constructed for the coolie laborers on the railroads, and which were condemned many years ago, but are s t i l l inhabited. There i s a high percentage of rooming houses, a few of which were originally built as such, but which are mostly inadequately converted structures of various kinds with defective u t i l i t i e s i n which there i s considerable overcrowding. Thus the area has become one of second hand housing, inhabited principally by people whose income level does not permit them to rent or buy i n a more desirable neighbourhood. The area represents 2.8$ of the total area of the city, but about 10$ of i t s built-^up area. (See Figure 1, page 32). Most of i t i s l a i d out on the gridiron system, but there i s a considerable amount of haphazard development, a residue of potentially useful land, and a conspicious lack of parks and open 2 spaces. It i s not, however, the area of greatest density, nor does i t contain the worst slums, though i t faces on a water-front which is one of the most color-f u l and exciting i n the world, and i s within two blocks of the ci t y intersection reputed to be the centre of the drug exchange t r a f f i c in the Canadian West. The area has a high percentage of arrests for drunkenness and vagrancy, and a high accident rate. It contains the part of town to which transients naturally gravitate. In i t are to be found those establishments to which the underworld 1. Marsh, Leonard C. "Rebuilding a neighbourhood". Eeport on a Demon- stration Slum Clearance and Urban Rehabilitation Project i n a Key Control Area  in Vancouver. University of B r i t i s h Columbia, Vancouver, 1950, p. v i i In this Survey of the Strathcona District, covering about 43 blocks i n Social Area Three, Dr. Marsh estimates that single houses form three quarters of the dwellings, and that one i n four has sub-tenants or boarders. 2. Ibid, p. 8. The Strathcona area's population is between 7000 - 7500, and though there are hundreds of single men, i t i s predominantly (62$) a family area. 34 operator can repair when i t is expedient to rent a room without "being asked inconvenient questions. The area is a racial melting pot, containing most of the city's Chinese population, and most of the foreign born of European extraction. It is the place where the immigrant can find a cultural or religious organization serving the people from his homeland, and where he can live t i l l he has learned the language, assimilated the customs, and is economically able to move to a better district. Nevertheless, the district has a high percentage of life-long 1 residents, and white people of Anglo-Saxon origin s t i l l predominate. The locality was chosen because i t was considered that the case studies of people living in such an area would well illustrate the problem of tuber-culosis as i t exists today in many cities of the western world. It is hoped that the study will highlight the ways in which the disease is s t i l l a chal-lenging problem; a personal one for the patient and his family, a social one for the community, and a professional one for the doctor, the public health nurse and the social worker; and how i t is inextricably interwoven with other social problems. The area was also chosen with reference to the fact that the writer participated in the housing survey conducted in the area in the summer of 1947 by Dr. Leonard Marsh of the University of British Columbia, in which a concen-trated examination was made of the Strathcona Area, a district of about forty blocks within Social Area Three, which is illustrated on the accompanying map. (Figure 2, page 35) • The writer thereby gained a first-hand knowledge of the living conditions of the people, and met and talked with many residents of the area, including some of the people whose case histories have been utilized in 1. Marsh, op. cit. p. 8 . In the Strathcona area 30$ of the residents were of British or North American extraction, and practically a l l of the children Canadian born. 36 this study. Selection of Cases. A count was made of a l l the diagnosed cases l i v i n g in the area i n the month of August, 1948* The choice of this particular year was made "because of the housing survey of the previous year, to give some perspective to the study, and to lessen the chance of identification of case histories. The age group eighteen to f i f t y was chosen as representative of the life-period in which the disease takes i t s greatest t o l l and presents the great-est problem. 1 2 Chinese and Indian cases l i v i n g in the area were excluded because i t i s generally acknowledged that these races have a lower resistance to tuber-culosis, regardless of the level of their environmental hygiene, than have the white races. There were also the added d i f f i c u l t i e s of language and culture which prevented the obtaining of adequate social case history material for use in this survey. The actual cases were located by reference to the f i l e s of the public health nurses assigned to the area. It was found that the area's boundaries did not coincide with those of the di s t r i c t s assigned to the nurses, but con-tained parts of the territories assigned to four of them; so an address check was made to ascertain which of the patients on their f i l e s were resident i n Social Area Three. The case l i s t thus compiled represents practically one hundred per cent of the diagnosed cases of the white race l i v i n g in the area. This i s because 1. According to Marsh, op. c i t . p. 8, 28$ of the population of the Strathcona area are Chinese. 2. Twenty-five per cent of the Indians of Canada l i v e i n . the Province of Bri t i s h Columbia. The tuberculosis mortality rate among them i n 1948 was 480 per 1,000 as compared with 30 per 100,000 other Canadians. 37 a l l cases diagnosed through Tuberculosis Control are automatically referred to the d i s t r i c t public health nurse for follow-tip. A l l cases diagnosed by private doctors must be reported to Tuberculosis Control, which i n turn notifies the public health nurse, who then offers her services to the doctor concerned. Even i f the patient elects to attend a private doctor for treatment, most doctors u t i l i z e the services of the public health nurse for follow up of the case from the public health aspect. For public health purposes, tuberculosis cases are divided into two categories, primary and secondary. A primary case i s one i n which the patient has active tuberculosis, and i s , or should be, under regular medical and public health supervision. The public health nurse v i s i t s these patients regularly. A secondary case i s one i n which a patient's tuberculosis i s no longer active, and his lesions have become sufficiently stabilized for him to be allowed to undertake full-time light employment. This latter group i s not regularly v i s i t e d by the public health nurse. These patients are contacted by her only i f they f a i l to keep a checkup appointment at Tuberculosis Control. In the month of August, 1948, there was a total of seventy-nine primary cases and sixty-two secondary cases, plus three unclassified cases, which came within the scope of this study as previously defined. A spot survey of this nature ensured representation of a l l the different phases of the disease -prehospltallzation, hospitalization, convalescence and rehabilitation — and the problems associated with each. Research Method Identifying information regarding both primary and secondary cases was submitted to the Vancouver Social Service Exchange, which supplied a l i s t of the registrations concerning the patients and their immediate families with the various social agencies of the city. The Metropolitan Health Committee 38 Table 1, Social Service Exchange Registrations regarding patients  and their families Name of Agency People l i v i n g i n families People l i v i n g alone Total Prior t< illness Since illness Prior to illness Since .llness No. P.O. 1. Metropolitan Health Committee 59 20 79 100 2. Taberculosis Control Social Service Dept. 55 20 75 95 3. City Social Service Department 27 3 18 65 82 4. Children's Aid Societies 13 11 1 25 31 5. Family Welfare Bureau 12 2 14 23 6. Vancouver General Hospital Social Service Dept. 5 2 1 8 11 7» Child Guidance Clinic 3 2 5 8 8. Child Welfare Division 2 i 5 1 1 9 12 9» Family Court 1 2 2 3 10. John Howard Society 4 1 3 8 11 11. Provincial Mental Hospital 2 1- 3 5 12. Vancouver Preventori-um 3 3 5 13o Victorian Order of Nurses • 3 3 , 5 Total 58 | 171 10 60 299 Sources- Public Health Nurses f i l e s for a l l diagnosed white cases of active tuberculosis l i v i n g i n social area three of the City of Vancouver in August, 1948, submitted to the Social Service Exchange for checking of social agency registrations. 39 registers a l l diagnosed cases of tuberculosis with the Exchange, and that agency's information regarding patients and their families had already been ob-tained from the f i l e s of the public health nurses* It was found that seventy-five out of the seventy-nine primary cases were registered with at least one other social agency, in addition to the Metropolitan Health Committee* Ninety-five per cent of the cases i n the group were registered with the Social Service Division of Tuberculosis Control* The remaining five per cent were newly diagnosed, so that the f u l l impact of the disease had not yet h i t them and their families. A l l registrations with the Tuberculosis Control Social Service Department, and with the City of Vancouver Social Service Department, the Children's Aid Society, the Catholic Children's Aid Society, and the Family Welfare Bureau were then followed up, and a l l the case histories pertaining to the sample group were read. This represented a total of 187 case records out of a total of 220 registrations, excluding the registrations of the Metropolitan Health Committee, as illustrated i n Table 1 (page 38). The information was supplemented by discussions with the social workers and public health nurses who knew the patients and their families. Through the assistance of the public health nurses, v i s i t s were made to a sampling of patients and families i n the group* Analysis of the secondary group of sixty-two cases revealed that twenty-five of them had been known to at least one other social agency i n ad-dition to Metropolitan Health during the course of their i l l n e s s . Of the re-mainder, twenty-five proved to be cases whose X-rays showed evidence of a tuber-cular lesion, and were therefore called i n to report to Tuberculosis Control; but as within the relatively short period of three to six months their lesions proved to be stabilized, they were allowed to resume their normal routine within this period, though cautioned to observe moderation in l i v i n g and working habits. 40 Most of these people had never been aware that they had had a tubercular i n -fection. The rest of the secondary group were twelve healed cases who were neglecting to report for regular checkup. For purposes of this study, therefore, attention was focussed on the seventy-nine primary cases, regarding whom considerable social data was a v a i l -able, and whose case histories i l l u s t r a t e the crux of the tuberculosis problem. A l l the tables and charts i n the study have been computed on the basis of these seventy-nine cases. In most of the tables, computations are made separately for people i n family settings and people l i v i n g alone. This i s because i t i s con-sidered that the management of the disease presents special problems to both the patient and the community when the tuberculous patient lives alone. Age and Sex Distribution of Cases The sex distribution of the group was 57$ male, (45 cases) and 43$ female (34 cases). The distribution of cases according to age followed closely the current trend i n the tuberculosis morbidity rate for the population as a whole, with a concentration of 61$ of the female cases in the 18-25 age group, and 48$ of the male cases i n the 37-50 age group, as illu s t r a t e d i n the ac-companying table. (Table 2) Table 2 Distribution of tuberculosis cases i n the sample group according to age and sex Age Group Men Women Ho. •P.C. No. 1 P.C. 18-25 yrs. 15 33 21 61 26-36 yrs. 8 19 8 23 37-50 yrs. 22 48 5 16 Total 45 100 3k 100 Family Context of Cases The family status of the patients as illustrated i n TaHe 3 (page 4l) 41 shows that every type of family context was represented in the group* Hence the thesis material is illustrative of the problem of tuberculosis as i t affects different family members husband, wives, parents, single people living within a family group, and people without any family attachments, living alone. It is to be noted that 25$ of the total group were unattached people, living alone, and 90$ of these were men. This group encounters special problems in relation to tuberculosis which will be discussed later. Table 3. Family Context of Patients in the Sample Group •family status Number of P.C. Total cases P.C. 1. Married couples with children 36 (a) Husband tuberculous 9 12 (b) Wife tuberculous 19 25 2. Married couples without childrex 16 (a) Husband tuberculous 6 7 (b) Wife tuberculous 7 9 3. Single people within a family 8 (a) Men 4 5 (b) Women. 2 3 4. Tuberculous "families" i.e. 15 more than one family member with active tuberculosis (a) Men 8 10 (b). Women 4 5 5. People living alone. 25 (a; Men 18 22 (b) Women 2 3 Total 79 100 100 Table 4. Status of Families with Children Family Status No* P.C. 1. Normal families (Both parents in the home) 16 48 2. Broken families (One parent absent) | Death 2 Separation 6 Divorce 5 ' Unmarried mothers 2 52 Total 31 100 42 It i s significant that over one third of the total cases i n the group occurred among married couples with children. Of these 31 families with children, "barely half were normal families in the sense that both parents were present i n the home. The other half of the group were broken families i n which one parent was absent due to death, divorce, separation, or some unusual marital arrangement. (See Table 4, page 41). There were 55 children under the age of sixteen l i v i n g i n these families. Of the total sample group, 15$ lived i n families where more than one member had active tuberculosis. This group l i k e the group l i v i n g alone, encounters special d i f f i c u l t i e s i n the management of their tuberculosis, which are discussed in a later chapter. Bacial Origins of the Sample Group The rac i a l origins of the group were extremely varied, as Table 5i (page 42) shows. The largest single racial concentration was the Anglo-Saxon, with the Slavonic group a close second; though there was a high subsidiary group of Scandinavians and Finns among the males. Yet twenty per cent of the men and twenty-five per cent of the women were Canadian born, and there were no recent immigrants i n the group. A l l had been in Canada at least eighteen years. Table 5. Bacial Origins of the Sample Group Bacial Origin Men Women No. PoC. No. P.C. 1. Anglo-Saxon (English and German) 9 20 I 1 5 ' 44 2. Celtic (Irish, Scottish, Welsh) 4 9 o 0 3« Finnish 7 15 1 3 4. French-Canadian 3 7 2 6 5. Latin (French, Italian, Spanish) 5 11 2 6 6. Scandinavian (Norwegian, Swedish, Danish) 4 9 1 3 7. , Slav (Russian, Polish, Ukrainian) Czech, Yugo-Slav 13 29 13 38 Total 45 100 34 100 43 Residence and Mobility It proved impossible to get sufficient information about residence to estimate group mobility, but from the information available, mobility was not as high as might have been expected i n such a group. At least sixty per cent of the total group had been resident in Vancouver for five years or more. There seemed to be a very small minority that were highly mobile. Yet even those i n seasonal employment tended to room at the same address over a period of years, whenever they were in town. One of the most frequent reasons for change of address was the necessity of obtaining cheaper accommodation when on social assistance. Economic Status. The occupations of the people i n the sample group were on the whole i n the unskilled and semi-skilled classification. (See Table 6 and Table 7, page 44) No less than sixty-two per cent of the men were engaged in heavy manual work* an important factor i n rehabilitation planning for this group. About half of the women Were housewives, which is also an important factor i n rehabilitation planning. On the whole, apart from the usual seasonal unemployment in logging and a l l i e d industries, there was l i t t l e chronic unemployment i n the group u n t i l after the onset of tuberculosis. Only 20 out of 79 cases had been i n receipt of social assistance prior to the diagnosis of tuberculosis. The agency records showed that the majority of those who had received social assistance prior to diagnosis had done so during depression years. Only a small minority from the group were registered as patients of the Vancouver General Hospital Outpatients' Department which indicates that most of the group either purchased medical care privately or went without i t . I t was interesting to note that thirty-seven per cent of the cases in the group were registered with child welfare and family 44 Table 6. Occupations ef Male Patients at Diagnosis 1. 2* 4. 5. Type of employment Heavy Manual Work Logging. Labouring...... Mining......... fishing*. Cement mixing*. Longshoring.... Skilled and Semi-skilled Carpentering.......... Truckdriving.......... Shipwright..... Seaman Marine engineer....... Painter. Service Occupations Hospital orderly. .1 Salesman. Barber. Kitchen help....... University Students........... "Unofficial occupations" Professional gambler....... Boo tlegger, Receiver of stolen goods.., Total Ho. 14 5 4 3 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 45 P.O. 62 18 4 7 100 Table 7. Occupations of female Patients at Diagnosis Type of employment Ho. P.O. 1. Semi-skilled occupations 12 1 1 1 1 2. Service occuoatioas 21 1 1 3 1 1 Unskilled occupations 9 l 3 17 55 1 3 Total 34 100 45 welfare agencies "before the onset of tuberculosis, which i s an indication of the presence of social problems within these families severe enough to require out-side help. There were however only sixty Social Service Exchange registrations regarding the total group prior to tuberculosis, an average of less than one registration per case, as against a total of 231 registrations following the onset of tuberculosis, an average of 2.9 registrations per case. The conclusion seems inescapable that problems connected with chronic illness are one of the ' major reasons why people seek help from social agencies. Other indications of the economic status of the group are to be found in the fact that ten per cent owned their own homes. It i s true that some of the houses were of very inferior quality, yet the aspirations of the home-owning group in terms of good family l i v i n g and good citizenship cannot be gainsaid. Moreover, twenty-six per cent of the group had either savings or insurance, while a larger majority indicated their appreciation of the value of t h r i f t habits, but had never been able, due to economic stresses, to plan any further ahead than their next pay-day. Housing The general housing conditions of the group have already been des-cribed. The more specific deficiencies of their l i v i n g accommodation as regards the management of tuberculosis w i l l be discussed i n a later chapter. Extent of Tuberculosis at Diagnosis The stage at which tuberculosis i s diagnosed i s an important factor in determining prognosis. Cases are classified medically as minimal, moderately advanced, and far advanced, according to the extent of lung involvement. A l -though there i s an increasing tendency in B r i t i s h Columbia for cases to be dis-covered in the minimal stage, i n the,survey group forty-seven per cent were i n the moderately advanced stage at diagnosis, and twenty-three per cent i n the far 46 advanced stage, as Figure 3 (page 47) shows. If the people l i v i n g alone are con-sidered as a separate group, one half of this group was i n the far advanced stage at diagnosis. There was l i t t l e difference i n the proportion of men and women i n the minimal and moderately advanced groups, "but there was an overwhelming pre-ponderance of men i n the far advanced group. Length of ..Illness and Incapacitation. On average, as Figure 4^shows, tuberculosis incapacitated patients i n the survey group for a period of two to three years, A minority were fortranate enough to overcome their infection and return to normal l i v i n g within a year. About twenty per cent of the group were incapacitated for five years or more* Though some of them attempted to return to normal l i v i n g their lesions "broke down and a reactiveation of the disease occurred, "Estimation of length of i l l -ness for purposes of this survey has "been computed from length of time between diagnosis and certification " F i t for full-time light workw. This certification i s the maximum recommendation which the medical profession considers advisable for ex-tuberculous patients. Services for Tuberculous Patients i n British Columbia The B r i t i s h Columbia Division of Tuberculosis Control was set up i n 1935 "by the Provincial Board of Health i n order to centralize the work of tuber-culosis control throughout the Province, The Central Institute of the Division i s i n Vancouver, There are no private or municipal tuberculosis c l i n i c s i n B r i t i s h Columbia, and a l l institutions treating tuberculosis come under the control of the Division, This does not mean that the local health authorities are relieved of responsibility for tuberculosis control. They undertake a great deal of survey work and follow-up work under the guidance of the Division, The Division how» 47 f lgsa?e( 3 Classification of extent of tubegeaiosis at Ala^not Samplegroup i a the 23$, ^ 5 5 \ ~| People '. |& a. f am|%' alone ! l • ' M M .. • If .Wemea Scale - 1mm. = 1 case . I-aniaal Active" '. M6&®m%&'^: Advanced ;| far ,Aataae,ed- Active Figure 4 Length,of Illness;,,la,^ S8imole,/::<3^ ,B^ -. Hutaoer of eases . 14 i t 10 9 8 7 :' 6 ' 5' 4 .1 2 1- a. 6=12 12-18 18=24 2-3 3^ 4-5 6*7 7*0 8*$: ©OS.*. . BIOS, . mos> ^ ? S i . - ' # ® » ' , .^ •Ojwa-. 48 ever, provides equipment, personnel and f a c i l i t i e s which would "be too costly for the municipalities to duplicate* Hospital Services 1 The Division maintains three hospital units. The Vancouver unit has 232 "beds and a complete range of specialist services for treatment of compli-cations ensuing from tuberculosis. It also has the largest outpatient depart-ment in the Province. The Tranquille unit has 356 beds and a smaller out-patient department. There is also a unit of 75 beds i n Victoria. The Jericho Beach unit i n Vancouver cares for chronic fibroids and some convalescents. St. Joseph"s Oriental Hospital i s u t i l i z e d for the treatment of Asiatic and negro patients, though these patients are also admitted to other units, depend-ing on the type of treatment required* These figures do not include the tuberculosis beds maintained by the Indian Department nor those of the Department of Veteran's Affairs, "Shaugh-nessy Hospital" in Vancouver. The Preventorium which has 40 beds, takes children between the ages of two and twelve who have been infected with tuberculosis but not yet developed the frank disease, i n order to build up their health and prevent the risk of further infection. It i s jointly subsidized by the Province, the City of Vancouver and voluntary organizations. Adequacy of bed complement for the treatment of tuberculosis i s measured against the generally accepted standard: "Bed capacity should equal 1. These figures relate to bed capacity i n 1948. There has been no significant addition since this survey was undertaken u n t i l the opening of the Pearson Unit of 264 beds in May 1952, in-Vancouver. Plans are under way to complete this unit and to add further beds at Tranquille, and by 1954 i t i s hoped that the province w i l l have 1,000 beds for the treatment of tuberculosis. St. Joseph's Oriental Hospital is now no longer used for tuberculous cases* 49 three times the annual number of deaths". B r i t i s h Columbia's bed capacity at the time of this survey did not quite reach this standard.1' Clini c Services Diagnostic services i n British Columbia are free. The Division main-tains stationary diagnostic c l i n i c s i n Vancouver, Victoria, New Westminster and Kamloops, and stationary survey c l i n i c s at Vancouver, Victoria and New West-minster. There are also three mobile survey c l i n i c s and five travelling eon* sultative c l i n i c s . There are forty centres i n Br i t i s h Columbia where the patient can get pneumo-thorax. Local doctors have been trained, and equipment provided by the Division. The Province has a good case-finding service as evidenced by the high ratio of known cases to deaths. There are over twenty registered cases per death in British Columbia, while elsewhere the general average i s five known cases per death. Specialist Services The Division also maintains in hospitals and c l i n i c s specialists such as dieticians, medical social workers and v i s i t i n g psychiatrists. The Medical Social Service Division gives service to a l l patients who are referred by their attending doctors, and also carries the family case-work i f another social agency i s not already active on the case. In the latter event, the medical social worker actB as consultant to the family worker regarding the medical and social aspects of the case, but do6s not directly v i s i t the family. Public Health Nursing Services The Province has a good public health nursing service which covers eighty per cent of the whole Province, In the Greater Vancouver area these services are provided through the Metropolitan Health Committee. The public health nurse provides follow-up services from the public health point of view. 1. Tuberculosis Control st a t i s t i c s for 1948 show that with 780 beds and 286 deaths i n the other-than-Indian population (the only figure obtainable) the ratio was approximately 2,8 50 l It i s her responsibility to arrange for the carrying out of isolation and pre-caution techniques i n the patient's home; to instruct the patient and his family regarding tuberculosis and general hygiene; to search for and arrange for the examination of contacts; to trace i f possible the source of the patient's infection; to provide regular supervision of the family regarding the public health aspects of the disease; to provide a report on a patient's home situation when hospital admission or discharge is recommended, or at any other time when such a report would prove helpful; to know and use a l l local community health and welfare agencies which can assist the patient and his family; and i n general to act as li a i s o n between the patient, his physician, and the services of tuber-culosis control* Social Services In the Greater Vancouver area there i s a well-developed program of social welfare services, both public and private, available to the tuberculous patient and his family. Of the public welfare programs the most important are those provided by the City Social Service Department* It was recognized from surveys made by Tuberculosis Control that many patients were requiring re-admission to sanatoria with breakdowns i n which inadequate nutrition and unsuitable housing had played a considerable part. In May, l°Ak, certain changes were made i n the social assistance regulations extending to tuberculous patients certain privileges not given to other recipients of social assistance. The most important change was i n e l i g i b i l i t y requirements. E l i g i b i l i t y was to be based on diagnosis plus willingness to 1, Instruction in the techniques of bedside nursing are given i n the Greater Vancouver area by the Victorian Order of Burses, a private and voluntary organization which undertakes this aspect of public health nursing* 51 1 accept medical care, and not on destitution. The standard social allowance was to he supplemented i n the following ways ~ f i r s t , "by a rental allowance which was to "be calculated on the basis of the difference between the standard rent allowance paid to social assistance recipients and that currently being paid by the patient's family; secondly, a special dietary and comforts allow-ance of $7*50 per month for the patient i n addition to the usual food allow-ance, with a special diet allowance of $5.00 per month for any member of the family l i v i n g at home who i s infected with tuberculosis as shown by skin or X-ray tests, which allowance i s to be continued for six months after last close contact with an infectious patient; thirdly, the patient also to receive comforts allowance of $3*00 per month while in the sanitorium i f he i s i n receipt of 2 social assistance before admission, or i s without funds* As regards assets, single patients are allowed to have up to $250*00, and families up to $500.00 in savings without affecting the allowance given© If the patient has liq u i d assets i n excess of this amount, the allowance payable is to be reduced by 3$ in excess of $500.00, or $250*00, as applicable. Allow-ance i s also made for instalments on essential furniture and any other neces-r sary payments such as premiums of l i f e insurance policies. Certain allowances for mortgages and taxes might also be met at the discretion of the adminis-trators. A housekeeper might be provided i n certain circumstances, but i f the 3 man i s earning $125 — $150 or more, no housekeeping service would be provided. 1. Ho social assistance allowance i s granted to patients who sign them-selves out of sanitoria, and no tuberculosis extras are granted unless the patient reports regularly for checkup. 2. This has been raised to $5*00 since the time of the survey. There have also been increases i n basic social allowance rates. 3. These figures relate to 1948, but there has been l i t t l e significant increase i n this estimate since that time. Ho exact maximum can be quoted at present but i t i s true to say that housekeeping service i s not provided by the department unless the mother i s the patient and there are several children i n the family, and other individual circumstances that seem to warrant i t . 52 Patients are also provided with free transportation to and from c l i n i c and hospital, and a free supply of paper handkerchiefs and sputum cups. The services of a nutritionist and "budgeting help are also available to patients and their families. The City Social Service Department also provides "boarding home care for ambulant convalescent patients but these f a c i l i t i e s are limited. The services of the private social agencies of the community are a v a i l -able to the tuberculous patient and his family on the same basis as to any other citizen. Many of the problems with which the family and child welfare agencies are called on to assist are related to the problem of illn e s s within a family group. Rehabilitation Services "Rehabilitation services are a most important part of the tuberculosis control program. Studies made by the Tuberculosis Control Division indicated that many patients between the ages of 20 « 50, because of lack of rehabilitation services, returned to their former employment which was in many cases unsuitable and helped to cause a breakdown. On the other hand many retrainable patients were remaining on social assistance as unemployable. The Vancouver Occupational Industries was founded in 1939 to provide retraining of tuberculous patients and other handicapped people. Vancouver thus became the f i r s t city i n Canada to have a program for retraining sanatorium patients. But the project was not successful i n actuality. Due lit 1 some measure to war economies, an attempt was made to put the sheltered workshops programs on a commercial basis, which in i t s e l f made them therapeutically unsound. Also* the i n i t i a t i o n of the assembly line method, by which patients made only one part of an ar t i c l e , soon resulted i n a loss of interest on the part of the patients. Many of them l e f t sheltered employment and turned to more remunerative work. The project was eventually abandoned. 53 There are at present f a c i l i t i e s for psychological and aptitude tests for patients, and some retraining courses are available,. There i s also some marketing of art i c l e s produced in occupational therapy, some assistance i n job placement by the Special Placement Division of the National Employment Service; but there i s no adequate retraining and job placement program as suche A great deal of rehabilitation work i s currently being done by the Br i t i s h Columbia Tuberculosis Association. Voluntary Agencies i n Taberculosis Control The most important voluntary agency i n the f i e l d of tuberculosis con-t r o l i s the B r i t i s h Columbia Taberculosis Society, the Provincial branch of the Canadian Taberculosis Society 0 It was founded in 1904 to enlist the services of the ordinary citizen i n preventive work, and to cooperate i n the treatment of actual cases. Funds are raised principally through the annual Christmas Seal campaign. The Society employs a full-time worker to handle the educational work of the division which includes the publication of an excellent series of pamphlets for patients, their families and the general public. Movies and library f a c i l i t i e s are also used i n the educational work of the Society. There i s a full-time rehabilitation officer who assists i n the retraining and job placement of patients. The Society has also f u l f i l l e d two other functions of a voluntary agency in the tuberculosis f i e l d , namely, research and demonstration of new a c t i v i t i e s . It has sponsored the development of survey work through the mobile X-ray vans which i t bought and presented to the Tuberculosis Division. In 1949 the Society built and equipped the Christmas Seal Institute at a cost of $500,000. The Institute provided up-to-date equipment for the more compli-cated surgical procedures i n tuberculosis which had not previously been a v a i l -able i n Canada. Br i t i s h Columbia Tuberculosis Control services compare favorably with 54 those i n the rest of Canada and i n many It i s now proposed to examine the patients and families i n the sample parts of the world, how these services were u t i l i z e d "by group. CHAPTER 3 Problems of the Tuberculous Patient as an Individual Tuberculosis i s a chronic reactivating disease requiring protracted treatment. There i s no means of foretelling how long i t w i l l take for a patient's lesions to become stabilized. Because of this, and i t s contagious-ness, tuberculosis necessitates a more complete dislocation of a patient's l i v i n g patterns than any other disease. Even i f the patient succeeds i n arrest-ing the disease, he s t i l l has to learn how to l i v e within the life-long l i m i t -ations i t imposes. This usually requires p a r t i a l or complete revision of his l i v i n g and working habits. The cure i t s e l f c a l l s for the subjection of the patient to a regime stricter and more all»embracing than that imposed by the sternest military discipline. This must be continued unremittingly for a much longer period of time than in most other illnesses. Even i f the patient follows the regime faithfully, there is no guarantee of cure — only the reasonable hope of recovery eventually i f he cooperates. There is also no guarantee that recovery w i l l mean that the patient can become completely self-supporting again. This may seem to be a gloomy view of tuberculosis, but i t i s a factual one; and these implications are sooner or later realized by most patients. The adjustments that the tuberculous patient must make are complex and leave no area of his l i f e untouched. The personal, family, social, economic and vocational aspects of his l i f e are a l l involved. What then, are the adjust-ments which the patient must make i f he i s to accomplish the cure? What are the problems he must face and overcome both in himself and in his environment? What 56 seems to be the factors determining success or failure? Acceptance of the. Diagnosis It may seem self-evident to state that the primary requisite for the successful treatment of tuberculosis i s that the patient must accept the diag-nosis and face his feelings about ito Yet many patients hinder the successful treatment of their disease for a considerable time, because they do not i n the f i r s t instance accept the diagnosis. To most patients the diagnosis comes as a shock* Even to those who anticipated the p o s s i b i l i t y there i s s t i l l , to most people, some degree of shock in having their fears verified, though to a few, the knowledge comes as a release. As Table 8 (page 57) shows, sixty-five per cent of the sample group did not suspect that they had tuberculosis. Many of the patients are of the opinion that nothing they have to undergo later compares with the shock of the i n i t i a l blast of hearing their diagnosis. It has been noted by many observers that, hypochondriacal and anxious individuals apart, patients who are familiar with tuberculosis usually adopt from the start a more courageous attitude than those who .know l i t t l e about ito "A person who knows what he i s up against and what he i s i n for i s at a definite advantage as compared with another who i s uncertain about his opponent1s strength".^ The responses of patients on learning their diagnosis varied widely, from hysterical behavior, to apparent apathy. The feelings which they ex-pressed ran the gamut''from anger, despair, guilt, humiliation, shame, resentment, anxiety,^ doubt, incredibility, helplessness, and depression, to open belliger-ency. ".A^small minority rejected the diagnosis completely and maintained this attitude. • , t 1, Wittkower, E., op. c i t . p. 21 57 Table 8, How Cases i n the Sample Group Came to be Diagnosed How Diagnosed People Living i n a Family People Living Alone Ho. P.C. 1. Following a hemorrhage 5 2 7 10 2. Consulted doctor because of i l l health 16 5 21 25 3. Diagnosed by the survey c l i n i c 38 13 51 65 ; (a) Mobile survey c l i n i c Industrial University General e.g.Department stores 3 2 6 2 (b) Stationary survey c l i n i c 1. Referred for routine X-ray from y.G.H.-O.P.D, from City J a i l from Army Recruiting Centre 1 1 1 1 2. Contacts of known cases reporting for checkup 3« Healed cases reporting for checkup 1 4. Self referred for checkup 9 3 5« Reason for referral not stated - apparently self referred 9 7 6. Tuberculosis accidently discovered when X-rayed for logging injuries 1 Total 59 20 79 100 1 ! 58 Mrs„ Q» Was very angry when given the diagnosis. She ranted and raved as to what she would do to the person who had infected her i f she could only get hold of him. She was referring to her husband, an ex«patient, about whose illness she had not known u n t i l after their child was born and he requested that the child he given the tuberculin skin test. Patient was estranged from her husband and l i v i n g i n common-law union with another man. Her father told her that her tuberculosis was a retribution for her way of l i f e . Patient denied she had a guilty conscience about i t . later, when her case proved terminal she described her condition as "a judgment". Mr. .7. Said i f the guinea pig test was positive i t was because the doctor had not scrubbed the germs from other patients o f f his hands before undertaking Mr. Y's test. Mr. J . Said he knew he had tuberculosis, but resented a l l suggest-ions that his disease was infectious. Some patients, while outwardly accepting the diagnosis, seemed lm» pervious to the recommendation that they begin rest treatment right away, to prevent the spread of the disease. This could, however, be due to the fact that many patients when told of their diagnosis hear the dread word "tuberculosis", and suffer a mental blackout. They are unable to absorb anything that the doc-tor says to them i n the way of further explanation. These people's f i r s t red-actions develop more slowly over a later period of time. Some patients try to erect a barrier against any intrusion of know« ledge about the nature of the disease. Mr. H. Did not wish to be told anything else about tuberculosis,, and what he should do about i t . He thought people were better off not knowing. Mr. 0. Took two bottles of cod l i v e r o i l and f e l t so much better that he returned to his logging camp convinced that he had cured his. tuberculosis. Most patients expressed some feelings of inferiority, inadequacy, and 59 a real fear of rejection, by those most important to them, Pear of loss of love, respect and status as a consequence of contagiousness was a strong com«=> ponent in the feelings of most patients. It was not confined to those patients with family attachments, Mr. S,' -was a 40-year old single man. He told the public health nurse, when she discussed with him the matter of examin-ation of contacts, that he would carry out the necessary precautions himself, but he did not want the family with whom he was l i v i n g to know of his disease. He was afraid they would ask him to leave i f they knew. He very much valued the congenial l i v i n g he had enjoyed i n their home for many years. Even patients who show l i t t l e apparent concern about their disease need to be helped, as this outward front i s often a defence against underlying anxiety and depression. Whatever a patient's i n i t i a l feelings are regarding his illness, he needs the release of bringing them out into the open. Indeed this i s an essential step i n treatment, because u n t i l he can do so he i s not ready to move on to proper orientation regarding the disease i t s e l f . It i s here that the patient can benefit from casework help. This i s one reason why a l l patients should be referred to the social worker as soon as possible after diagnosis. At this point, neither family nor friends can give the patient the release and support that a warm, accepting, professional relationship can. I n i t i a l reactions to diagnosis are followed by the emergence of a patient's basic attitude towards his il l n e s s . This i s , in the main, conditioned by his individual personality and l i f e experience, and usually corresponds to his previous pattern of meeting l i f e ' s d i f f i c u l t situations. The medical social worker here makes an important contribution to the treatment plan. As soon as possible following diagnosis she poses and' answers, as a result of her contact with the patient, the all-important questlonsj 60 What meaning does this illness have for this patient at this particular time? Why did he "become i l l when he did? Why did he "become i l l i n the manner he did? What is the goal of his "behaviour? What kind of person was he before he became i l l ? Does he view his il l n e s s as a punishment? Is he using his illness to punish somebody else? Does he view his illness as a welcome escape from res-ponsibility, or an unbearable situation? Does his i l l n e s s provide an accept-able and long-sought excuse to sink into dependency? Is he enjoying his i l l n e s s because i t makes him the centre of attention? Is he exploiting his illness to a neurotic pattern of l i v i n g so that i t becomes so much "stage property"? Hot u n t i l these questions have been satisfactorily answered can the treatment plan be geared to an individual patient's needs. It i s also important to know the facts about a patient's immediate social situation prior to diagnosis, as the two following cases i l l u s t r a t e s -Mr. B, Was a young man of 25, "Following his admission to the sanatorium i t was noted that he was extremely quiet and deliberately shut himself off from the other patients and the staff. The social worker learned that the patient and his fiancee had just set their wedding date when the patient received his diagnosis. He refused to see his fiancee again, without giving her any reason for so doing, Sherlearned of his hospitalization, phoned repeatedly, l e f t messages, food and flowers. Yet i t was a considerable time before ,the patient answered any of these overtures. Miss Z. Was a twenty year old single g i r l who was illegitimately pregnant when diagnosed for tuberculosis. She said later, "To be pregnant and to have tuberculosis too, was just beyond me". Consequently, patient made a very poor adjust-ment to sanatorium l i v i n g . She told nobody, not even her doctor or her family, of her pregnancy u n t i l her condition was self-evident. Problems in Orientation Orientation to tuberculosis i s always a highly individual matter. It cannot be accomplished on a mass instruction basis. Even factual information regarding the disease is'absorbed at different rates by different patients. 61 Their feelings about i t are s t i l l more varied. It i s a well-known fact that people tend to hear and interpret information selectively, according to the pattern of their psychological defense mechanisms. They unconsciously reject or misinterpret information which threatens or disturbs these patterns. From the practical point of view, what a patient considers important about his illness i s , i n the long run, more v i t a l than what the doctor knows to be important. The two following cases i l l u s t r a t e this fact© Mr, Q. Was a:married man with children. He resisted a l l efforts to orientate him to his disease. He was surprisingly ignorant of the most elementary facts about tuberculosis, and maintained stubbornly that patients were better off "knowing nothing". One day in the sanatorium he picked up a book which he read out of sheer boredom. What he read l e f t him so "scared and depressed1? that he had to do more reading to find out i f the prognosis was so serious i n a l l cases. He began to read and absorb everything he could lay his hands on regarding tuberculosis, and to carry out medical recommendations he had' previously ignored, - • Mr. C. Was a single man in his early forties, a known neurotic with hypochondriacal tendencies. He was forbidden to smoke be-cause i t caused him to cough excessively. He was resentful of the fact that other patients were allowed to smoke. He did not accept the doctor's explanation that i f smoking re-sulted in coughing spells i n them as i t did with him, then the others would be forbidden to smoke also, Mr. C. con-tinued to smoke, and told the doctor that he had read that smoking helps to cure tuberculosis, because "nicotine stops hemorrhaging", and "you should know that there i s a compara-tively low death rate among tuberculosis smokers compared to non^-ismokers". To the social worker the patient explained that he had to smoke, because "they." would not give him drugs© Problems in an individual patient's orientation depend largely on his personality structure and the kind of emotional d i f f i c u l t y he experienced prior to diagnosis. The social v/orker plays an indispensable role in helping the pat-ient work through any emotional patterns which are interfering with his acceptance of illness and treatment. She gives him an opportunity to think i t through and talk 62 i t out, thereby releasing his anxieties and misapprehensions. One area in which the medical social worker i s often called to give help i s that of helping a patient deal with his fears. "Fear" i t has been said, "can be a bigger black spot than the mark on the patient's lungs, and must be 1 brought out into the open", i f the patient i s to respond successfully to treat-ment. Fear of death is a very real one with many tuberculosis patients. Fear of suffocation i s also common. Fear of confinement i n an institution can prove an insuperable obstacle to treatment. Fear of the unknown, and fear of the future can negative medical efforts on the patient's behalf. Acceptance of Sanatorium Care The acceptance of sanatorium care i s an adjustment which most patients are called upon to make. Reactions to i t vary widely. When a patient enters a sanatorium he i n large measure gives up his right to self-determination. He no longer has the freedom of choice as to how he w i l l l i v e , what he w i l l eat, where he w i l l sleep, who w i l l share his waking and sleeping hours, or what a c t i v i t i e s he w i l l pursue. He gives up a great deal, and expects the gains to be corres-pondingly high. It i s only the importance of his ultimate goal - recovery of health - which as a rule, makes him tolerate such an unnatural existence. For this reason, the modern sanatorium must offer to the patient more than mere custodial care during the period of his infectiousness to others. The social worker's role in helping the patient accept sanatorium care i s an important one. He needs individualized help in overcoming his reluctance or even strong resistance to sanatorium l i f e . He needs preparing for the kind of l i f e into which he i s committing himself, 1, Dr. George Day, "Observations on the Psychology of the Tuberculous", The Lancet. Nov. 16th, 1946, p, 703. 63 The way that hospitalization is presented to him is important* I f he can he helped to accept i t positively as the "best preparation for his l i f e after recovery his adjustment to i t w i l l get off to a good start. It i s most important that he should he convinced that the sanatorium has something to offer him as an individual patient* The patient and his family are primarily inter-ested i n what the sanatorium can do for him and are not usually receptive to interpretation of i t s necessity as a public health measure. It has been said that, "The greatest discovery anyone can make i n a sanatorium i s , that a substantial number of people conquer their disease and make that conquest permanent... This overcomes the fear, that despite a l l that can be done for him, his case w i l l end fa t a l l y * . and that no man need remain forever slave to his previous habits and environment... that with patient and daily application, he can change his l i f e and his mind.*. The patient's motivation i n accepting sanatorium care also needs to be examined, as i t w i l l often give the key to how the patient w i l l use his period of sanatorium care* Mrs. K. Thought her family was trying to get r i d of her. Mrs. I. Did not think she could get better i n a sanatorium, but thought she owed i t to her family to go there* Mr. U. Was foreign born, and for him a tuberculosis hospital had different cultural connotations. He needed to be helped to understand that the sanatorium i s not a place where people are put away to die. When a patient refuses to enter a sanatorium his motivation for so doing should be examined?-1. Hudson, Holland and Pish, Marjorie. Occupational Therapy i n the  Treatment of the Tuberculous Patient. National Tuberculosis Association. The Livingstone Press, New York, 1944. p. 126. 6k Mrs. P. .A young married woman with far-advanced tuberculosis told the social worker that she could not enter the sanatorium because her husband did not wish her to. This proved to be correct, and concentrated efforts on the part of the doctor, public health nurse and social worker had to be exerted, before the patient's husband could be convinced of the value of sanatorium care for the patient. Miss 0, A young single woman, said she could not go to a sanatorium, as she would die of loneliness. The social worker learned that the patient had been abandoned by her own family and had lived with a foster family to whom she was very much attached. She reacted with extreme anxiety to any attempts to separate her from them, even temporarily. Miss L. A twenty year old woman, refused a bed in the sanatorium because her father and sister had both died in the sanatorium, and to ask her to enter the same hospital was tantamount to asking her to sign her own death sentence. Orientation to Sanatorium Living Having entered a sanatorium the patient needs help in u t i l i z i n g i t s services constructively. The atmosphere can assist or hinder the patient's ad-justment. Poor administration, niggardly budgeting, and indifferent staff mem-bers lead to low institutional morale, and intensify the inevitable periods of boredom, frustration, i r r i t a b i l i t y and mild depression which a l l patients feel from time to time, A patient entering hospital brings with him the omnibus of his l i f e experience, to which he has reacted i n his individualized way. He brings with him his feelings, motivations, prejudices, conflicts, defence mechanisms, pre-ferred modes of satisfaction, and preferred modes of reaction to d i f f i c u l t i e s . A l l of which w i l l manifest themselves'in the communal atmosphere of sanatorium l i f e . Even i f an institution i s ideally operated, most patients need consider-able help i n adjusting to this totally new way of l i f e . The medical social worker plays a v i t a l role i n assisting the patient in this area. 65 Acceptance of De-pendency The hardest thing for a sanatorium patient to do i s to rest. It i s i very d i f f i c u l t for any human being accustomed to the activity of daily l i v i n g to l i e quietly i n bed twenty-four hours of the day, especially i f he feels well, as many early tuberculosis patients do. No one on the sanatorium staff can make a patient rest. They can only make i t easier for him to do so i f he w i l l . In addition the bed patient must accept dependency on others, i n meet-ing the personal needs which he has been accustomed to attending to himself 0 The d i f f i c u l t y of accepting the dependency role i s often at the root of a pat-ient's violation of rest orders, especially when rest means complete bed rest. Those patients who cannot be helped to accept dependency without undue guilt and anxiety never u t i l i s e their sanatorium treatment effectively, and sometimes the battle ends only with the death of the patient. Jack S. Was aged 21 when a diagnosis "moderately advanced active tuberculosis" was made. He was the eldest son in a family of Yugo-Slav extraction. His father deserted, leaving his mother with four small children. Jack was always concerned about his mother and wondering how she was managing while he was in hospital.e» He had the greatest d i f f i c u l t y i n adjusting to sanatorium l i f e . He discharged himself from the sanatorium on "personal business" grounds. About this time he married. Later he was given a prison sentence for retaining stolen goods. Because of his condition he was transferred to hospital from j a i l . In hospital he boasted he had played baseball every day while in j a i l for t h i r t y -one months without any i l l effects, that he was coughing less, and had maintained his weight. He again signed him-self out when his wife deserted, leaving the younger of her two children on the doorstep of the Children's Aid Society. He then disappeared without trace, reappeared six months later, and went in the shipyards u n t i l a mobile X-*ray survey showed he had active tuberculosis. He became very hostile to the tuberculosis control authorities, saying i t was they who had caused'him to lose his job by reporting his condition to his employers. Later he had to be re-admitted to hospital as an emergency. He was much more cooperative than formerly. When he learned that bed rest was the only thing, he requested to be sent to Tranquille so that he could rest without any distractions. By this time, however, l i t t l e could be done to arrest the spread of the disease. Several months later he died. He was 26 years old. 66 Sanatorium l i f e inevitably reactivates a patient's conflicts regard-ing authority. Some patients d i f f i c u l t i e s i n this area manifested themselves i n refusal to follow sanatorium rules. Such patients were i n constant d i f f i -culty in their relationships with doctors, hospital personnel and other patients. Mrs. ?. was a case in point. She made herself very unpopular "by her habit of swearing violently i n the wards whether visitors were present or not, and by constantly making disparaging remarks about other patients. A consider-able minority of patients i n the group had similar d i f f i c u l t i e s , though not for the same reason. There were those patients whose basic h o s t i l i t y manifested i t s e l f i n poor precautionary technique, to the annoyance of both staff and patients. Mr. T's attitude was typical. He said i t was not altogether his fault that he got tuberculosis, so why should he be concerned about other people? There were those patients whose h o s t i l i t y found more subtle and i n -direct outlets and were thereby a plague to the administrator and the staff, and a source of discord among other patients, i n which they, the culprits, were never directly involved. Methods of non-cooperation i n the sanatorium are multiple and devious, and the sample group contributed their quota. Some patients made themselves very unpopular by being demanding of service. This i s due, usually, to some underlying anxiety, as illustrated i n the case of Mrs. B. Mrs. B. Became very hostile to sanatorium staff when her constant demands for service were not met. She accused them of neglecting her because she was not English. When the social worker talked with her, she learned that the patient's behaviour was related to the rejection she had experienced from her husband on account of her i l l n e s s . Some patients lack of cooperation was due to the fact that they had never really accepted the diagnosis. Mr. Y. was a case i n point. He admitted 67 that following his f i r s t discharge from hospital, he lived a "fast" l i f e "because he did not "believe he had tuberculosis,, When he had to be readmitted, however, he reconsidered his opinion and was much more cooperative. Psychiatrically, . this type of reaction i s said to occur in r i g i d egocentric individuals accustomed 1 privately to overvalue themselves and their opinions. The socialworker's help i n uncovering the motivating anxieties which affect a patient's outward .behaviour are a prerequisite to helping the patient to resolve them and improve his adjustment to sanatorium l i v i n g . There,are some patients who settle down to sanatorium l i f e exceedingly well, and offer no problems to staff or to other patients. The problems of, these patients come at a later stage i n i l l n e s s . When rehabilitation begins, extraordinary d i f f i c u l t i e s are often encountered i n getting them from the horizontal to the perpendicular. The Problem of Self--i3charge There comes a time in most patients 1 lives when reaction to the length 2 of hospitalization reaches flood level and they consider self-discharge. The following are typical remarks, (1) I'm tired of a l l this a.ow business, I'm going to try a quick cure 1 1. (2) "I'm getting tired of being i n hospital. I think I ' l l pick up better outside". (3) "They're not doing anything for me i n this hospital, anyway". (4) "A tuberculous patient's l i f e isn't worth a button, anyway. Why shouldn't I take a chance?'' 1, Hartz, Jerome. "Human Relationships i n Tuberculosis", Tuberculosis Control, Issue Bo. 56. Public Health Reports. U.S, Public Health Service. Vol. 65, October 6th, 1950. p. 1292 - 1305. 2, Wittkower, E. op. c i t . , p. 45, points out that i n his survey, of a total of 785 patients, comparison of various sanatoria showed that premature self -discharges are related to sanatorium morale; the incidence rate of premature self*_iseharges goes up when the sanatorium morale goes down and vice versa. 68 Sometimes impatience with sanatorium l i v i n g occurs because the patient feels so much "better than he is prepared to take a chance as far as complete recovery.is concerned. This reaction occurs most frequently following the ab-atement of acute symptoms, when the lesions are stationary, but certainly not well-healed. Yet the patient may experience a feeling of bodily well-being at this time which convinces him he is well on the road to recovery, and w i l l be better, off at home. It i s true that many patients control their disease at least temporarily without any form of treatment being administered. It i s equally true that of a l l patients who are sputum positive at diagnosis, a great many are dead within 1 ten to fifteen years regardless of the form of treatment administered. Although there are no reliable records of the post-sanatorium h i s -tories of the self-discharged as opposed to the medically discharged, i t i s known that there i s a marked correlation between length of treatment and survival 2 following treatment. When the patient i s going through this c r i s i s , the services of the medical social worker are often a determining factor in helping the patient reach the point where he can decide to continue with sanatorium care. In many hos-p i t a l s the medical social worker is routinely asked to interview a l l patients who are considering self discharge. This i s not with the idea of talking them into staying, but because i t i s hoped thereby to give the patient an opportunity to discuss his reasons for so drastic a step, and perhaps, with the social worker's help, arriving at other ways of coping with his problems. As Table 9 (page 69) shows, twenty-four per cent of cases i n the sample group signed themselves out of hospital, though fourteen per cent later returned 1. Myers, op. c i t . p. 395. 2. Hudson, Holland, op. c i t . p. 97. 69 Table 9 Acceptance and Non-acceptance of Hospitalization by the Sample Group Attitude to Hospitalization People l i v i n g in families People l i v i n g alone No. P..C. Accepted when f i r s t recommended 33 14 47 55 I n i t i a l l y refused but later accepted 7 l 8 l l Discharged themselves but later returned 7 3 10 14 Discharged themselves and refused to return 7 0 7 10 Persistently refused hospitalization 3 2 5 7 Suitable for care at home 2 0 2 3 Total 59 20 79 100 N.B. - Of those accepting hospitalization, 3Q$ were readmitted once, 16$ were readmitted twice, and 4$ were readmitted three times. to complete sanatorium treatment. This Table should be interpreted i n connection with Figure 5, page 70, showing length of hospitalization i n the sample group, which averaged eighteen - twenty-four months,, The reasons patients gave for self-discharge are illuminating:- Some of them seem t r i v i a l , but the medical social worker must remember that minor annoyances can be magnified into major ones in the a r t i f i c i a l atmosphere of the sanatorium. These the patient could take i n his stride i f he were well. The reasons patients gave for self-discharge can be tabulated as follows{-1. Was going to die. 2. Couldn't rest i n sanatorium. 3. To avoid surgery. 4. To settle marital a f f a i r s . 5. Dislike of hospital l i f e . 6. Was moved from a one bed to a ten bed ward. 7. Quarrel with room-mate. 70 n g a r e 5 Ee-gth of Hospitalization of the Sample ftwmp Sumter of cases 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Key O People living in families People living alone i s / 1 'ml'* under 6 mos* 6-12 mos. 12-18 mos. to 18*24 mos. <<> 2-3 3-4 yrs. yrs. .'.•vi #1 4-5 5-6 6-7 7-8 yrs. yrs* yrs. yrs, 1 lot known 71 8. Afraid room-mates might find out she had venereal disease* 9. Personal business - unstated. 10. Deaf mute patient, who was lonely. 11. Psychopathic personality. 12. To prevent stepson making a prior claim on dying husband's estate. 13• No reason given, 14. No reason given. The reasons given "by patients for self-discharge are not always the real ones, though some patients themselves are not always aware of this. Mr. L's case i s one in point. Mr. L. Was a forty year old married man. He discharged himself when he discovered that his wife was l i v i n g with another man. He divorced her and tried to get custody of their five-year old adopted son who had been placed i n a foster home. The social worker noted that the strongest element i n Mr. L's concern for the child seemed to be that he wanted to use the child as a weapon against his wife. Mr. L's real reason for self-discharge was thought to be his dislike of hospital l i f e and fear of active treatment, because he refused to return to hospital after he had settled his personal a f f a i r s . Facing Surgery Another major problem which the tuberculosis patient may have to face i s the prospect of submitting to some form of surgical procedure, possibly even major surgery. Very few patients recover on bed rest alone, and i f the various forms of pneumo thorax are considered as surgical procedures, i t would be true to say that most patients have to face at least "the n e e d l e S u r g e r y i s a c r i s i s situation, yet the patient's usual method of meeting crises w i l l not suffice here. In almost' any other c r i s i s there i s something that a person can actively do. In surgery there must be a letting-go of the w i l l ; a complete sur-render of one's l i f e into the hands of another. This can activate subconscious fears of death, suffocation or mutilation, of which the patient may not be aware, or may be unable to face unaided. The opinion of a psychiatric team i s that 5-"To understand and help the patient master these fears often requires detailed understanding of the psycho-dynamics of personality. We have observed that recovery i s f a c i l i t a t e d when patients get psychological help in preparation for 72 surgical treatment. The psychological trauma produced by recommendation for an operation produces tension states which are additional hazards to the surgical team. Adequate ventilation of the ideas and feelings associated with the tension w i l l tend to reduce i t , while neglect to do so often results in prolonged excessive pain and an extended period of invalidism".^ Even pneumo-thorax can arouse great anxiety. One woman patient i n the group was "so scared and i l l " following her i n i t i a l pneumo-thorax that she refused to have r e f i l l s . Needle phobia i s by no means uncommon especially among women patients. Sometimes refusal of surgery i s based on misapprehension as well as fear, as the case of Mr. P. ill u s t r a t e s . Mr. P. Was thirty-nine years old, married, intelligent and an accomplished musician. He had far advanced tuberculosis at diagnosis and thoracoplasty was recommended. He could not face this and discharged himself from hospital. His condition retrogressed and he considered re-admission principally for the sake of his family. He discussed his apprehensions with the social worker, and i t appeared that he was convinced that i f he re-entered hospital he would "wake ;up one morning to find a hole i n my side or a rib gone". Although the hospital authorities promised that no surgery would be performed without a patient's consent, Mr. P. did not consider that this was really hospital practice because "they compelled you to sign a statement on admission saying you would submit to anything they thought advisable. So you really have no choice about what i s done to you". Mr. P. expressed a fear of being maimed for l i f e or of dying while i n hospital. Whatever the reason for a patient's refusal of surgery, the medical social worker may be able to help him to "talk i t through" and reach a point where from his own convietion, he can carry through the doctor's recommendation. 1. Coleman, Jules V., Hurst Allan, and Horbein, Euth. "Psychiatric Con-tributions to the Care of Tuberculous Patients", Journal of American Medical  Association. Vol. 135. No. 11, p. 699 73 Wittkower, in his survey of a total of 785 patients i n many sanatoria, found that, while refusal of surgery may he due to many factors, i t i s most commonly, like premature self-discharge, related to low morale in the ward or sanatorium*, The impression he obtained was that doctors often f a i l to give patients sufficient information regarding the'nature and purpose of the operation, and to dispel their fears. Their own familiarity with the various surgical pro-1 cedures lead them to presume that the patient knows more than he actually does. Hence the patient's main source of information i s often other patients, who usually have a fund of knowledge, not a l l of which i s correct, hut which i s imparted gratis to prospective candidates for surgery* Economic Problems An i l l n e s s such as tuberculosis usually demands major adjustments in a family's economy. No matter how capably or willingly made, these entail eventually economic hardship and deprivation because of the chronicity of the disease. This can put an additional strain on family l i v i n g to the point of break-up. It has been observed, even in families where there has been insuf-ficient income over a long period, as well as d i f f i c u l t y in the management of i t , that chronic illness places additional burdens on the family's adjustment. Increased economic hardship is often the factor which t i l t s the balance i n an already precarious family equilibrium. The patient's reaction to the loss of his own earning power i s often a great problem i n i t s e l f . Where the patient is the head of the family his loss of economic independence affects other lives as well as his own, and this i s an additional source of worry and anxiety to him. Many patients have real conflicts over the loss,of their economic . status, fearing i t may lead to loss of a l l status within the family. The feel« 1. Wittkower, E., op. c i t . p. 47. 74 ing of "being a "burden on one's family i s a problem with which many patients wrestle long and hard "before they come to peace within themselves,, There were many examples in the group of patients resenting their wives going out to work to support the family and of patients reluctantly accepting par t i a l or complete support from adolescent or married children. Anxiety regarding economic a f f a i r s has a two«*fold result in tubercul-osis. "First i t prevents the patient from achieving the rest that i s the corner stone of the treatment. It i s impossible for most patients not to worry about how their families w i l l manage when they are no longer able to provide for them. If a patient feels that his family is suffering deprivation as a result of his i n a b i l i t y to provide for them during his i l l n e s s , he i n fact shares their de-privation, though he may outwardly be comfortably ensconsed i n a well equipped sanatorium, complete with a l l modern conveniences and three square meals a day. I f he feels that his family, i n accepting social assistance i s being reduced to subsistence level, this i n i t s e l f may be a continuous source of resentment and inner conflict. His anxieties may mount so high that he discharges himself from hospital or returns to employment before he i s medically f i t . There were, several examples of the latter reaction among the males in the group. The second effect of economic insecurity and deprivation i n a family i s that i t intensifies any emotional problems which existed before onset of i l l -ness, or which have arisen because of i t . Social and emotional needs are so inter-related that they are inextricably interwoven in daily l i v i n g . One of the greatest d i f f i c u l t i e s a patient may encounter during his illness i s facing the necessity of having to accept social assistance for himself and family. It i s an anomaly of our social system that we equate productivity with economic productivity, so that a person who becomes economically inadequate 75 loses not only his own self-sufficiency "but also the respect of society, and often, along with i t , his own self respect. While i t i s true that theoretically, illness i s an acceptable form of dependency i n our culture, the receipt of social assistance carries with i t i n practice a social stigma and a tacit impli-cation that there i s some inherent defect i n a person who i s unable to provide for himself and his family. This attitude can be a great blow to the patient and his family. Of the sample group forty-five cases accepted social assistance, thirty at diagnosis and fifteen during convalescence. The accompanying table shows the economic status of those who did not accept social assistance. It i s signi-ficant that about half of the non-acceptors were married women patients who were supported by their husbands. In almost a l l cases when the patients were bread-winners or single persons they had to accept social assistance. Table 10. Economic Status of Patients who did not accept Social Assistance 1. Married women supported by husbands 2. Single people who preferred to accept help from relatives. Refused social assistance, though elig i b l e and no other v i s i b l e means of support,„ Accepted diagnosis, but continued working....... 5. Refused to accept diagnosis and continued working.. 6. Newly diagnosed, liv i n g on savings. Total 16 6 2 4 4 2 34 The mixed feelings of many patients are well illustrated by the case of Mr. T),, 76 Mr.".-. A single man, an orderly i n a tuberculosis hospital, had Just returned from a t r i p to his home country when he learned of his diagnosis. He told the social worker that his friends would take care of him u n t i l his admission to hospital and they did not wish him to apply for assistance, A few weeks later, he applied for social assistance. Complaints of the inadequacy of social assistance i n terms of daily economic management v/ere almost universalv i n the group. Mr. E's case i l l u s t -rates the general group feeling. ..Mr.. E.. Was very i l l on" admission and required thoracoplasty from which he made one of the quickest comebacks the medical staff had ever witnessed. He considered rehabilitation r e a l i s t i c a l l y . He did not think he would need social assistance except for a short while after he l e f t hospital. He expressed real fear about his a b i l i t y to l i v e on social assistance. He said that patients were having breakdowns and requiring readmissions because they could not manage on social assistance. He wondered i f the same thing would happen to him. He thought this was poor economy on the part of the Government. He resented having to report a l l his proceeds from his occupational therapy products*; He thought this destroyed a man's i n i t i a t i v e . In spite of these f e e l -ings he remained friendly to the social assistance worker and to the occupational therapist. A small minority refused to accept social assistance though obviously i n need. This refusal to "accept charity" was not confined to the older people. Some young people preferred to borrow from relatives or be supported by their families. Problem of Separation from "Family, and Changed Family "Relationships Long separation from his family, both physical and psychical, is one of the hardest problems the patient has to face. His diagnosis brings this home to him forcibly when he i s told that he must not kiss or caress his wife and children, and with this painful edict goes the lurking fear of the effect that long separation w i l l have on his family relationships, especially marital and parent-child relationships. 77 The following cases show some,aspects,of the problem. . . . - \ Mrs. A. Was a twenty-five year old married woman. She was concerned about her husband not writing regularly. : She thought he was probably interested i n other women. He had always been attracted to the opposite sex. But she wasn't going to worry like another patient who had died when her husband started divorce proceedings. Then relenting, she f e l t sorry for him, too because he would "go wild i f he didn't have female company", and she had been in hospital for three years. But she intended to speak to him severely when he came at Christmas. Her underlying fear was that he might go home to Russia and leave her with the child. But the house was in her name, and was the only security she had. Mrs. Q, Complained that her husband was very jealous. A male pat-ient had lent her a radio and her husband accused her of in f i d e l i t y because of this. She complained she gets l i t t l e change apart from the radio, for when her husband v i s i t s her he just sits silent. When she t e l l s him l i f e i s not very satisfactory to her, either, he laughs and says a l l she has to do i s sign on the dotted l i n e . Mrs. X. Was twenty-six years old, married, with two children i n a foster home. She f e l t she was neither needed nor missed at home. Her family ignored her, her husband comes once or twice a week, "depending on his mood". Her father, didn't like hospitals and wouldn't v i s i t . Brother just writes. She got no food or flowers like other patients did. Problem of Substitute Care for Children This i s usually a very acute problem where the mother i s the patient and there i s no suitable or available person to act as mother substitute. The income level of these families usually precluded a b i l i t y to pay for full-time or even part-time housekeeper service. There i s no community agency providing homemaker care on a free basis or on a sliding scale according to family income for indefinite periods. The Family Welfare Homemaker Service cannot undertake to 1 provide the service indefinitely in cases of chronic i l l n e s s . 1. Since the survey was made the Federal Government provided a f i s c a l grant i n 19^9 for a p i l o t project of this nature. The Metropolitan Health Committee administered the grant and the Family Welfare Bureau supervized the placement of twenty-five Homemakers in homes where the mother was a tuberculosis patient. This service was highly successful and much appreciated by the families concerned. However, i t was discontinued i n 1952 when the Federal grant ceased. The Provincial and local authorities, i n spite of much campaigning by the Health and Welfare agencies, did not undertake financial responsibility for i t s continuance. 78 Consequently, placement of young children outside their families had' to "be considered "by a number of families i n the group. In ten cases children were cared for "by relatives. Also a number of husbands were willing to under-take extra responsibility to enable school-age children to remain in the home when the mother was i n hospital or convalescent. Three children were placed i n the Preventorium. Fifteen others were placed i n foster homes, either through Children's Aid Society or i n private foster homes found by their relatives. Some families refused to consider placements even when no other plan was feasible. Placement planning for children always activates mixed feelings i n the parents, as the two following cases show, Mrs. K. Was a twenty-three year old married woman who had minimal active tuberculosis and was on bed rest at home. Placement of the child was not a new experience for her as she had once previously boarded him out so she could go out working. She consented to his placement i n a foster home after she became i l l . Becoming pregnant again, she expected the c l i n i c doctors would recommend an abortion. When they did not, she said that i f she was well enough to go through with a pregnancy she was well enough to look after her other child, whom she removed from the foster home. Then she looked after both children unaided except by her husband. Mr. y. Was a twenty-three year old married man, very immature emotion-a l l y , and regarded his baby son as a r i v a l for his wife's affections. When he learned his diagnosis they were l i v i n g i n one small room. As the patient was sputum positive i t was recommended that he take a hotel room pending admission. He wanted his wife to place the child and come to Tranquille to be near him. He phoned his wife regularly from Tranquille u n t i l the doctor cut down the calls; so he sent wires. The wife, equally immature, was indecisive about continuing the marriage, as he had never supported her. Both seemed to look upon the boy as a burden. She asked Children's Aid Society to place the child while she sorted out her a f f a i r s . Problems Created by lack of Family Cooperation Lack of family cooperation can create manifold problems for the patient i n the management of tuberculosis. Though an extreme case, Mrs. M's well i l l u s -trates this. 79 Mrs. M«, Was a twenty-three year old married woman who was readmitted following a breakdown attributed to excessive exercise and worry over marital a f f a i r s . Said she had to exceed her exercise because husband objected to her staying in bed and his having to look af£er her. He had also begun to drink and got i n with a bad crowd. He made love to his g i r l friend in front of his wife, but "didn't know why, as he respected his wife" 0 Doctor, public health nurse and 'social worker fail e d to help him understand tuberculosis, but the latter, learned that his mother had been a chronic invalid. He resented having had to do many menial household tasks as a boy. Following a reconciliation the husband's behaviour persisted, which greatly depressed patient. Her doctor stated that she needed "to want to get well". Her condition improved enough so that she could be discharged. This time, however, she went to relatives. Problems in Preparing to Leave the Sanatorium Environment It i s a paradox that though most patients have great d i f f i c u l t y i n adjusting to sanatorium l i f e i n the beginning, they almost a l l have some reluct-ance towards leaving. A patient being "built up for discharge" has mixed f e e l -ings. He i s glad to be through the period of bed rest, but he has some qualms about his a b i l i t y to resume his l i f e outside the sanatorium. He wonders about the acceptance he w i l l get from his family. He knows, too, that one purpose of the "building up" phase i s to evaluate how well his lesions w i l l stand up under increased activity, and he may therefore fear a reactivation of his disease. To quote from the psychiatric team again:-"Various suspicious and rebellious tendencies may appear at this time and patients may accuse the institution of rushing them i n order to give their beds to incoming patients.i.... It i s at this time that somatic complaints often assume a dramatic quality..,.. The somatic complaints should be treated as well as the underlying fears, and not coldly dismissed as psychological." 1. .'Coleman, Jules V., et a l . op, c i t . p, 699» 80 Problems in the Rehabilitative Phase of the Illness There must be a complete change in the patient's psychologic attitude i f he i s to adapt himself successfully to the next phase of illness — the rehabilitative phase. Until this time i t has been demanded of him that he assume a role of complete dependency. Now i t i s demanded that he assume his independence again. Though he may ardently desire to do so, i t i s not without d i f f i c u l t y that he shakes off the comforting protection that sanatorium l i f e offers him. One young g i r l , following discharge, said she would not mind break-ing down again, as she missed a l l the g i r l s so much. It i s not surprising, perhaps, that the most common d i f f i c u l t y in this period of illness i s reluctance to take the recommended increase in a c t i v i t y . Persistent and unresolved d i f f i c u l t y i n this area i s often a sign of gross maladjustment in some area of the patient's l i f e . The medical social worker can often be very helpful to the doctor in helping both him and the patient focus on what are the factors in a particular patient's personality which make the l i f e of an invalid preferable to the satisfactions of normal living, or what i t i s in his l i f e situation that he cannot face returning to. -.Once this i s discovered, the medical social worker can also help i n evaluating the capacity of the patient to work through his d i f f i c u l t i e s , or the degree to which he can be helped to develop the capacity to cope successfully with such obstacles, whether in himself or i n his environment. A small minority who from a medical point of. view are extremely d i f f i c u l t to treat, are those patients for whonc tuberculosis seems to serve the purpose of gradual suicide. Their wish to die i s sometimes unconscious, sometimes consciously, stated. What-ever i s done from the treatment point of view, they get worse instead of better. As one doctor puts i t , "A malign fate seems at work". There are also those people who might be described as the "passive" 81 personality type; the ones who have given up trying i n every area of l i f e and sink "back into an acceptance of chronic invalidism.which defies a l l attempts to help them re-establish a more constructive pattern. There seems to be no point at which the doctor or social worker can get a foothold. Some patients are aptly described as: "increasingly disturbed patients who manage to achieve some precarious kind of equilibrium with severe pulmonary disease but remain chronically i l l for years. They rarely become ambulatory, and i f they do, are soon back i n bed for years after an immediate and severe relapse. As personality types these patients tend to be introverted, withdrawn people who use their severe tuberculosis to guarantee care and affection for themselves. They seem to pay scant attention to their disease, yet manage to be the most discussed therapeutic problems i n the sanatorium over long periods of time. They would probably be frank schizophrenics i f their emotional needs were not somehow being precariously met by the care and sympathy they always manage to get for themselves In the sanatorium", 1 A l l these types of reaction were represented i n the sample group0 Most patients, however, given adequate individualized help, can come through this phase and move on to the practical aspects of discharge planning. At this point the help of the medical social worker and the family case worker can be invaluable. Convalescence Convalescence i s considered the most important phase of tuberculosis, because during i t the patient makes the transition to normal l i v i n g . It i s the phase during which most breakdowns occur, usually within six months of leaving the sanatorium. Physical aspects of l i v i n g conditions are important and must not put undue strain on the patient. 1. Hartz, Jerome, "Human Eolations i n Tuberculosis", Tuberculosis Control  Issue Ho. 56 of Public Health Reports, U.S.A. Federal Security Agency. Vol. 65, October 6th, 1950. p. 1303. 82 The emotional environment to which a patient returns i s also important. The family need help i n readjusting the l i v i n g patterns they have developed i n the patient's absence* They must also understand that he is not a, completely well person,, -The patient's feelings about returning home are usually mixed. He i s on a r i g i d rest schedule which he must follow i f he i s to maintain the gains he has made i n the sanatorium. It i s very d i f f i c u l t for one person in a family to adhere to a schedule when nobody else in the house i s bound by i t ^ especially i f there i s no privacy. Many patients i n the sample group did not have a room of their own where,they could take their day-time rest. It should also be remembered that:-n...while i t i s true that self-centered and introspective individuals are usually unduly concerned about their health, i t i s equally true that chronic sickness tends to make a person self-centred and introspective. The two following cases indicate the problems vrhich can occur follow-ing discharge.. Miss J . Was a twenty year old single g i r l who returned to her family. Her mother, a confirmed neurotic, indulged Miss J. who exceeded her exercise, and complained that she could not rest in the small apartment which her mother, sister and brother shared. She and her mother were being supported by the brother, whom patient f e l t resented her presence and her ill n e s s . Miss S. Was a twenty-two year old single g i r l , one of a family of five children. The parents had separated many years before, j and the patient was l i v i n g with her mother and siblings vrho contributed to the family income. She had her own room, nicely decorated, with a new bed-room suite bought especially for her. She spent considerable time at leather work and knitting. .She assured the public health nurse that she was carrying out c l i n i c instructions f a i t h f u l l y . Her mother, however, said that the patient was hard to handle. She 1. Wittkower, op. c i t . p. 22 83 swore at her mother and sometimes refused to speak for two or three days. She c r i t i c i z e d her mother for keeping a male hoarder whose payments helped the family income, hut the mother did not like to ask him to leave because of patient's attitude. Mother suspected.daughter of v i s i t i n g her father down town, and patient was talking of going to l i v e elsewhere. Mother thought she would he better boarding with g i r l s her own age. Also said daughter was often out late. Patient had a boy friend and became engaged but her lesions broke down and she was readmitted to hospital, A patient who i s not well enough to manage on his own, and accepts c i t y boarding home care also has problems in adjustment. During the past ten years at least five or six tuberculosis boarding homes have been opened and ut-i l i z e d by City Social Service Department for tuberculous convalescents. The operators of a l l except one requested to be relieved of their boarders within six months to two years. This was not primarily because of fear of infection but because of practical d i f f i c u l t i e s in daily management and discipline. The one boarding home which has been in existence fifteen years, owes i t s success largely to the personality of the landlady who has the knack of handling tuber-culous convalescents. The patient who is discharged to a room of his own must be careful to strike the balance between too much and too l i t t l e exercise. The problems of this group are discussed further i n Chapter Five, as these patients are a special community problem. Some of the patients in the group had "flareups" i n their condition following discharge. For purposes of this study, "flareup" i s defined as a reactivation of the disease in patients who had become well enough to leave hosp-i t a l but had not yet been c e r t i f i e d f i t for f u l l time light work, Flareups occurred in eighteen per cent of the total sample group, in the ratio of ten men to four women, most commonly within the f i r s t six months following discharge. Only two of the flareups followed self discharge from hospital, though their occurrence might have been anticipated i n a l l but three of the fourteen cases. 84 , "because the patients were grossly exceeding their exercise orders. It i s interesting to note that while flareup was much more common i n patients l i v i n g i n family settings, "breakdown, that i s recurrence of disease in those who had "been c e r t i f i e d well enough to undertake f u l l time light work, was much more common i n the group living, alone, Flareup was often related to a too active social l i f e on discharge, while "breakdown was most commonly related to return to unsuitable employment', Rehabilitation It i s d i f f i c u l t to estimate the precise point at which the reha b i l i t -ation of a patient begins. In a sense, rehabilitation begins with diagnosis. Actually, treatment and rehabilitation proceed together. In the restricted sense, rehabilitation begins when the patient has reached that point in his il l n e s s where he can begin to take an active part i n the plan to restore him to community l i v i n g as self-supporting as possible. The standard definition of r e h a b i l i t -ation i s that drawn up at the Hational Conference on Rehabilitation at Washing-ton, U, S. A, i n 1942: "Rehabilitation i n tuberculosis i s the restoration of tuberculous persons to the f u l l e s t physical, mental, social, vocational, and economic usefulness of which they are capable". It i s often possible to commence vocational re-training while the patient i s i n the sanatorium. As a preliminary or concurrent measure, some form of occupational therapy i s usually recommended. Its function i n a sanatorium is many-sided. It helps to maintain the morale of patients, i t helps them to occupy time usefully, i t may cultivate new interests which can later be turned into a part-time source of income, and i t can help provide training for a more suitable type of work. Occupational therapy i s , however, an adjunct to vocational tr a i n -ing, not a substitute for i t . A good deal of occupational therapy i s craft therapy which does not appeal to those patients who may not have the interest or 85 s k i l l to produce work of marketable standard. Vocational re-training may involve academic educational courses, "but should never "be limited to these. It i s often possible for a patient to com-plete the required high school grades while in hospitaL Hot t i l l later can he undertake technical, industrial re-training© In addition, the patient's work capacity needs to be evaluated medically and his work tolerance tested. He also needs the opportunity to develop confide cnce in himself and his capabilities. These conditions are usually found in sheltered workshops and i n very light occupations. A minority of patients in the sample group wished to return to their former jobs which were medically suitable. The majority, however, could be divided into two large groups* - f i r s t , those who because of their medical condition w i l l never be more than p a r t i a l l y self-supporting. This group requires specialized retraining, plus selective placement in sheltered workshops of some kind. The second group are those whose prognosis is good, and who can be com-pletely selfrsupporting but who are unable to return to their former work be-cause of i t s unsuitability. Casework service to patients in the f i r s t group i s directed towards helping them make a constructive adjustment to their d i s a b i l i t i e s . The second group often need help i n accepting the change-over to sedentary employment. It i s not to be presumed that most patients w i l l welcome the idea of sedentary work merely because they realize i t is i n their best interests. Many patients who have lived a l i f e of action and who suffer from what has been called "cultural poverty", have neither the capacity nor the inclination for sedentary work, as the following cases show0 .Mr. A. A young man in his early twenties, had been a logger before his i l l n e s s . He returned the sheet the Rehabilitation 86 officer gave him completely blank. He said there was nothing i n i t for him. He was ruined anyway. He wasn't going to do anything for the rest of his l i f e , he would rather have no job than a light job. It was no use planning for a future that for him wasn't there. It was a toss-up whether he would return to the woods and have a good time and then return to the hospital to die. The woods held more appeal than any light job, even though the light job helped him to l i v e to be 100 years old. Mrs. 1. Did not want any rehabilitation course. A l l her previous plans had had to be cancelled so i t was better to l i v e from day to day. She understood she should not return to her former employment, but she would wait and see -•something would perhaps turn up. The patient's emotional readiness to undertake any specific form of rehabilitation training i s the requisite without which no plan can succeed. The role of the medical social worker i n evaluating the patient's weaknesses and strengths i n terms of a b i l i t y to use retraining f a c i l i t i e s and helping him work through his feelings regarding the whole area of rehabilitation i s a pro-fessional job demanding the highest in casework s k i l l s . Rehabilitation i s not completed t i l l the patient i s restored to the community again as f u l l y self-supporting as possible. This implies the existence of a job-^placement program. Because such f a c i l i t i e s do not exist in sufficient measure i n Vancouver, the tendency in the sample group was for patients to re-turn to their former jobs. As these usually involved the things which are occupational hazards for the ex-tuberculous*- heavy manual labor, irregular hours, night work and exposure to extremes of temperature, i t i s not surprising that the percentage of breakdowns in the group was high, as Figure 6 (page 8?) shows. For purposes of this study, a "breakdown" is defined as a recurrence df active disease i n those whose lesions had become sufficiently well healed previously, to allow them to undertake f u l l time light work, on medical recom-mendation. Breakdown occurred i n eighteen per cent of the total sample. But i f 87 the sample group of those l i v i n g alone is considered separately forty-five per cent of the people l i v i n g alone suffered a "breakdown, as compared with a cor-responding figure of ten per cent for those l i v i n g i n a family setting,, In five cases out of the total breakdown group, a breakdown was unex-pected, as the patients' lesions were apparently well healed, and they were f o l -lowing a moderate regime. The remainder (over half of the group) were following a mode of l i f e unsuitable to an ex-tuberculous patient, usually because of unsuit-able employment. Patients need to remember that having had the disease imposes some limitations on them which they must observe for the rest of their l i v e s . Though a patient may recover his health, he s t i l l retains the bacillus within his t i s -sues. No matter how well-healed lesions may appear to be this does not exclude the poss i b i l i t y that the b a c i l l i he carries within him may be stirred into activity again by anything which lowers, his powers of resistance. Therefore, for the rest of his l i f e , he should observe moderation i n l i v i n g habits. I f he does, the chances are that he w i l l maintain his health and conserve the gains made at such a cost to himself, his family and the community. 31GUBE -6 Incidence of Breakdown in the Sample Group Number of cases KEY >ple a family j j People l i v i n g i n People l i v i n g alone M - Men W - women ! w M Breakdown within 1 - 6 mos. 6-12 1 - 2 3-4 5 - 6 7 - 8 8- 9 9 - 1 0 mos. yrs. yrs. yrs. yrs. yrs. yrs. following resumption of light work CHAPTER 4. The Family and Tuberculosis Tuberculosis i s an illness whose impact affects a patient's entire family* Their understanding and cooperation are essential i n the successful management of the disease, l i k e the patient, his family must be will i n g to ac-cept major readjustments i n l i v i n g patterns as a result of the disease. Changes in family roles are inevitable, whether the patient be the father, mother or single adult, husband or wife. The family must be prepared to accept constructively the consequences which the long absence and incapacitation of a family member entails. Some family members may have to assume the absent patient's role as parent or breadwinner. They must accept a reduction i n l i v i n g standards with the resulting readjustments. At the same time they must maintain high standards of nutrition, for their own and the patient's sake. They must be prepared to accept their part in the treatment plan and take responsibility for the daily management of the patient's illness while he is home, Family problems existing prior to the illness are usually intensified, while others may arise as a result of i t . A l l these are important ingredients i n the emotional atmosphere surrounding the patient, and their presence or lack may play a great part i n determining the nature of the adjustment he makes to his illness, his eventual degree of recovery and the success of his rehabilitatory efforts. Without family support the patient finds fate's blow even harder to take. The situation of the patient with no family presents, ipso facto, even greater d i f f i c u l t i e s , . Family attitudes varied as much as did those of the individual patients. 89 ..Mrs. V. Received the public health nurse p o l i t e l y but resisted a l l suggestions that her son had tuberculosis. Mrs. C. Was cooperative regarding X-rays for herself and family, but did not want her roomers, who shared the household f a c i l i t i e s , to know of her son's diagnosis. Mr. M. Mr. .M. thought his daughter would die from the disease anyway and "would just as soon see her go now as l i v e l i k e an invalid for the rest of her l i f e " . In some families there was a real fear of infection which fear the patient was made to feel. In others there was a f a t a l i s t i c attitude; or complete unconcern. Sometimes a family refused X-ray checkup, or would ignore precaution-ary techniques. The following case illustrates this attitude. Mr. P. Was a married man with three children. He drove a city gar-bage truck. His wife who had severe tuberculosis, discharged herself from the sanatorium following the f i r s t stage of thoracoplasty and refused to return for the completion of the surgery. She was sputum positive, and told the public health nurse she did not practice precautionary measures as she thought i t a lot of "tommy rot". When the public health nurse discussed checkup examinations with Mr. P., he stated he was not worried about infection of the children or himself. "If you are going to get i t , you can get i t by walking down town" he said. "With a l l the precautions they took i n hospitals a lot of nurses got i t " . There was as much tuberculosis walking round Vancouver as there was in his own home. Besides, "one that's got i t i s one that you don't need to be afraid of". He didn't believe i n "taking dirty stuff from a cow and putting i t into a child's body". He thinks his wife would be dead now i f she had stayed in hospital, and after a l l , she doesn't need to worry about the housework. Undoubtedly, Mr. P. took excellent care of the children. He prepared their school lunches and put them in the f r i g i -daire for next day; was a good cook, handy with a needle, bought a washing machine and worked i t , and tried to get a suitable woman to do the heavy work. Problems of Dally Management when a Patient i s Home A l l patients, whether they accept sanatorium care or not, are home for considerable periods of their i l l n e s s , including the two most crucial ones from 90 the patient's standpoint —namely, when he i s awaiting admission to the san-atorium and when he i s convalescent* . Family attitudes at these times are specially important* The period when a patient is awaiting .admission i s an extremely d i f * f i c u l t one for "both him and his family* The recommendation "Admit" i s inter-preted to mean immediate bed rest. If the patient i s sputum positive, the task of looking after him is doubly d i f f i c u l t * In order that the patient be given the required care, the home must be turned into a rainature hospital. The B r i t i s h Columbia "Handbook on Tuberculosis" states thatj-1. Patient must have a room to himself i f at a l l possible* 2* A l l excess and stuffed furniture to be removed* 3* Patient's linen and towels to be kept separate and disinfected with l y s o l solution or soaked i n boiling soapy water before putting with family wash (ambulatory patients to use their own towels always)* 4. Dishes and cutlery to be boiled i f possible after each use or washed in boiling soapy water, and rinsed in clear hot water. I f this i s conscientiously carried out, there is no need to keep the dishes separate. 5* Blankets, comforters, pillows should be frequently hung in moving a i r , outside i n the sun i f possible* 6* Outer clothing, suits, dresses and topcoats are to be protected by careful conscientious use of the paper handkerchief* . Any spotting which does occur i s to be carefully cleansed with soap and water and the clothing hung in moving a i r . A l l outer clothing should be hung i n the fresh a i r frequently* Pressing with steam whenever possible i s also effective. 7* Damp dusting to be done daily* 8* Home to be thoroughly and frequently a i r e d * 1 9* Asceptic techniques i n the home should follow as closely as possible -that followed i n insti t u t i o n s . 2 The d i f f i c u l t y of carrying out the necessary precautionary techniques i s greatly intensified by the extremely unsatisfactory housing conditions In which many of the families i n the group lived. Apart from those l i v i n g alone i n housekeeping or sleeping rooms, there were twenty eight patients l i v i n g i n houses, 1. Hatfield, op. c i t . p« 89. 2. Hatfield, op. c i t . p. 87 <, 91 and thirty one i n suites,, Those l i v i n g i n houses were "better off as regards sanitary f a c i l i t i e s , "but at least half of the houses had defective heating equipment and food storage f a c i l i t i e s . Very few of the suites were self con-tained. In most, "bathroom and to i l e t f a c i l i t i e s were shared, and i n some, k i t -chen f a c i l i t i e s were shared too. Quite apart from the fact that there was over-crowding according to the standard of "one person per room, excluding the kitchen and "bathroom", i t i s significant that o f - a l l the f i f t y nine patients, i n only eleven cases was i t possible for the patient to have his own room* Overcrowding Apart from the opportunities overcrowding offers for the spread of infection i t can cause emotional conflicts of various kinds due to lack of privacy for any family member; i t can make i t impossible to show adequate res-pect for the rights of others; It engenders resentment when one's rights are interfered with; i t fosters uncongenlality between family members;.it helps to cut off young people from normal social relationships; It i s the most potent single factor i n the continuation of deleterious l i v i n g habits; i t prevents concessions which must be made to the patient because of his ill n e s s ; i t can impose a tremendous strain on both patient and family, from which there is.no release when there i s no privacy. I t i s quite true that people react to unsatisfactory l i v i n g conditions i n a variety of ways, but most people i n the sample group expressed some degree of frustration with their l i v i n g accommodation. Children It i s dangerous to expose children to an open case of tuberculosis because i t i s impossible to control the amount of infection the child receives. There i s no way of foretelling a child's resistance level, and the chances of developing a progressive f a t a l Infection are much greater among exposed children 92 than among non-exposed children* ^ for this reason tuberculosis patients are expected to separate them-selves from their children at least during the period they are infectious 8 Dif-f i c u l t -as this may he for the tuberculous parent and the remaining parent, i t i s * most d i f f i c u l t for the child. An entire thesis could he devoted to the effects on parental tuberculosis on children. One brief glimpse of this can be i l l u s t -rated by the case of Mrs. U, Mrs. U. Mrs. TJ's children were placed in a foster home when she went to hospital. She discharged herself while s t i l l sputum positive; directly against doctor's orders. She contacted, one of the children in the foster home, and he visited her on the sly when he went to the public library. The ten year old boy admitted kissing his mother many times.. The step-father invited him to v i s i t them oftener, but the boy knew he was doing wrong, though he did not like to disappoint them. When the parents visited the boy at the foster home, the foster mother asked the mother not to come again, as she considered 'the mother a very sick woman. Effects of Tuberculosis on Family Relationships Many families i n the group successfully weathered the stress and strains on relationship caused by the patient's illness, but many others did not, Ho matter how great their concern for the patient a relative doe6 not always have the ego strength to assume a new family role. Mrs. Z's case illu s t r a t e s this, Mrs. Z. Learned that her husband had far-*dvanced tuberculosis when he was X-rayed for a logging injury. She gave him good care i n the home, but n u l l i f i e d this by periodic drinking bouts, which later caused him to discharge himself from the hospital through worry over her after she came to v i s i t him in an intoxicated condition. Later he refused an available bed because one day's notice did not give him time to make financial arrangements for her. Her dependency needs con-tinued to be an undue strain on the patients. Sometimes, though a wife may competently assume the breadwinner's role, there are underlying dissatisfactions which can have serious repercussions on 93 the marital relationships, as Mrs. B's case shows0  Mrs. B» Was a forty year old woman at the time of her husband's diagnosis,, They had a five year old daughter,. He was chronically i l l for seven years but refused surgery, though his condition slowly retrogressed,, She gave him excellent care and cooperated f u l l y i n the treatment plan. Finding Mother's Allowance not enough she went out to work. After seven years she asked for a divorce, saying she was having to neglect her child, i n order to make a l i v i n g . Also, she knew another man who wanted to marry her. Her husband, who had known him previously, said he approved of him and was glad that his daughter would have a good home, as there was : not much chance of recovery for him. He admired his wife's frankness i n the situation. Later, he became well enough to be discharged and married a g i r l over twenty years younger than himself. Economic Problems Created or Intensified by the Illness Economic hardship i s another.great d i f f i c u l t y which the family of the patient has to face. Almost a l l families i n the group complained of the d i f -f i c u l t i e s i n this area. Without exception, those who accepted social assistance found i t inadequate. Some of them borrowed from friends or relatives to supple* ment i t . No matter how cooperative a family was or how great their strength, continued economic problems sapped them eventually. This i s well illustrated i n the case of the P. family. Mr. P. Was a thirty-nine year old married man with a four year old daughter when he was diagnosed minimal active tuberculosis. Though cooperative his condition did not improve. His wife, happy, intelligent and understanding, moved to a small farm holding i n Kamloops to be near him.. She took care of a l l heavy work and household duties while he made the furniture by hand. He wished to take vocational training for light work. Later he had to be re-admitted to Vancouver hospital for a reactivation of his lesions. Finally they bought a float house, the inside of which they fixed up splendidly. Mrs. P. made the rugs, curtains, chair-covers and kept everything always bright and ;clean. They had no taxes and well water cost them $1.00 per month. Mrs. P. collected and,sawed driftwood which kept the house always warm and dry. He spent much time fishing from the float. But after several years the P's, in spite of r i g i d budgeting and 94 making their own clothes and household furnishings, and collecting their fuel, could not li v e on Mother's Allowance, so Mr So P. worked as a domestic, "but only intermittently as they could get no reliable person to look after the small g i r l . On his discharge Mr. P. took care of the child while Mrs. P. worked in a cannery. But the doctor ordered a cutting down of his household duties as being excessive. Consequently, Mrs. P. worked on the night shift, or from one to five p. m. only. Mr. P. spent one hour per day on a bookkeeping course, which they had to finance themselves because of her earnings. They continued to save a l i t t l e each week, as they did not wish to be l e f t homeless i f industry took over their water-front spot and made their property valueless. They also paid for music lessons for the child. Mrs. P. continued as cheer-f u l as ever. But Mr, P. became depressed after eight years of illness, his lack of improvement and in a b i l i t y to take his share of domestic responsibility. Inadequacy of Social Assistance Set at Subsistence Levels If we expect to obtain the patient's' fullest cooperation i n the treat-ment plan we owe i t to him to take proper care of his family while he i s incap-acitated. It might be argued that the tuberculous group in British Columbia i s in a privileged position as regards public welfare allowance, ThiB i s undoubt-edly true but even with the extras they are allowed, i t i s s t i l l d i f f i c u l t for a patient and his family to manage adequately over the long period of the patient 1 i l l n e s s . Basic social assistance rates make no allowances for the provision of such essentials as cleaning and to i l e t a r t i c l e s , clothing repairs, shoe repairs, household replacements such as brushes, pans, crockery, linen. It makes no allowance^ whatever, for those "semi^luxuries" which have become almost neces-s i t i e s in modern liv i n g , and which do so much i n preserving patients' sense of well-being — such things as newspapers, radio, tobacco, cosmetics, permanent waves, movies and the occasional b a l l game. The heat and light allowance might be made to stretch i f the family used one room only, eat only one hot meal a day, and went to bed early. If there i s an infectious or sputum productive patient i n the home i t i s practic-95 a l l y impossible for a family or patient to have a l l the hot soapy water required to carry out the precautionary techniques regarding dishes, linen and clothes, and stay within the fuel allowance. The British Columbia Social Assistance Act states that assistance should be given according to need, and according to the standards set. These standards, however, are set at subsistence levels. Cur society i s s t i l l i n -fluenced by the philosophy that social assistance levels must be placed as low as possible to act as a deterrent against people l i v i n g on social assistance any longer than necessary. It i s considered that assistance at higher than sub-sistence levels would undermine people's characters and make permanent paupers out of them. These views s t i l l persist regardless of our experience in depres-sion years which provided irrefutable evidence that most people normally desire a fuller l i f e than that provided by bare existence, and that most people want to work when the opportunity offers. It i s the frustration caused by enforced idleness which eventually makes some social assistance recipients unresponsive to normal satisfactions, thus resulting in what we have come to c a l l "pauperization" of the individual. Besides, as every social worker knows, the work-ahy are not made worke 0. -conscious by*deterrent social assistance rates. Their*s i s a social sickness which goe^ s much deeper, and for which that kind of punitive "therapy" i s entirely ineffectual. Another argument unfailingly raised whenever social assistance levels are discussed i s that the normal standard of l i v i n g of such as those in the sample group barely reaches subsistence level, anyhow, Tet available evidence indicated that most people i n the group were in the borderline income brackets and would not have fallen to subsistence levels had not illness pushed them over the edge. It i s true that there was a small percentage of chronically destitute. 96 people i n the group, hut from the point of view of tuberculosis control i t i s our responsibility to raise such people to a better standard of l i v i n g in the economic scale i f only as a public health measure, quite apart from the broader question of their rights as human beings* There are, as Dr. Wade Hampton Frost reminds us, two conditions favour-ing the spread of tuberculosis, intimate exposure and poverty* Family Attitude to Convalescence i s C r i t i c a l for Patient A l l patients spend the greater part of their convalescence i n the home* Family attitudes are especially important at this time. The patient needs to be handled understandingly but normally, and with due regard for his physical l i m i t * ations* The family, like the patient has to make major adjustments i n this phase of the patient's i l l n e s s . They have had to devise new patterns of family l i v i n g during the absence of the patient. Now they must revise them and make a place for the returning patient© Casework help at this point i s often a great f a c i l -itator of the readjustment process for both family and patienW The onus for non-cooperation i s not always on the family, for i n some cases the returning patient refuses the family's proffered assistance. There were cases where the family offered the patient a home, yet saw their offer rejected i n favor of a city boarding house. In some homes there was constant f r i c t i o n over the patient's refusal to follow rest and exercise orders. There was much evidence to justify the view that convalescence i s the most trying time for the family as well as the patient* Problems of Families where more, than one Member is Tuberculous One tuberculous patient i n a family creates a, burden, but more than one patient i n a family has a devastating effect on the whole family structure. The case of the A. family is presented as an il l u s t r a t i o n . The A. Family. Consisted of parents and six children, the eldest of whom was sixteen. Mr. A. was diagnosed and accepted hospital-97 ization. In the following year Mrs. A. contracted tuber-culosis and was hospitalized. She worried about her children in foster homes. In the opinion of the public health nurse, the family was considered to be somewhat lax regarding pre-cautionary techniques, and housekeeping standards were not high. Nevertheless, family bonds were strong. There was always a well-kept vegetable garden and chickens as additional food supplies, and as time went on the family purchased modern home appliances, as for example, a washing machine. On discharge the father took unsuitable heavy work digging ditches which was a l l he could get. The eldest daughter contracted the disease, was hospitalized and made a good. recovery, following which she took a stenographic course. The youngest daughter had a healed primary complex. Because his work was too heavy the father reapplied for social assistance t i l l he could get lighter work. This was refused because of the earnings of the two eldest sons, the younger of whom l e f t home to go logging, where he got i n with a "bad" crowd, started drinking and gambling. He was ashamed of the family history of tuberculosis, tried to conceal i t and neglected to report for X-ray checkups though feeling i l l . He contracted debts of over two hundred dollars which his sister repaid, The eldest son .supported the family, though planning to be married himself„ When reporting for his routine X-ray checkup, the eldest boy was diagnosed as mod-erately advanced active tuberculosis. The younger boy f i n a l l y consented to X-ray and was found to have far advanced active tuberculosis. Both boys entered hospital. The younger hoy died there. Mrs, .A, was distraught and refused to let the youngest son take a paper route for fear he would break down too, "I give them good meals, good clothes and a good home, yet one by one they get i t " . While in Tranquille the eldest son learned that his father was working in a foundry because the family had been granted only reduced social assistance on the grounds that the daughter was earning. He became bitter, saying that he had been pro« mised that his people would he looked after i f he entered hospital. A l l he asked was that his father be helped to get lighter, more suitable work, so that social assistance would not be necessary for his family. Evaluation of factors determining successful management of the disease There i s no accepted index of success or failure in the management of ill n e s s . Yet examination of the case histories i n the sample group shows that the degree of cooperation of the patient and his family are of paramount imports 98 ance, and might he said to he the greatest single factor influencing success or failures A patient's cooperation i s affected by many things. The most important determinant i s what i s commonly called emotional maturity. This i s a complex thing. It i s most frequently found as the by-product of a happy l i f e experience meeting a l l areas of need i n the formative years. Its hallmarks are the problem-solving attitude towards l i f e , freedom from undue mental conflict, the a b i l i t y to be guided by r e a l i t y principles and long term values, capacity to love someone other than one's self, good work adjustment, and a l l the other characteristics of the well-adjusted person. In almost every case i n the sample group where the patient was unco** operative, there was conspicuous absence of emotional maturity. Those patients who managed their tuberculosis successfully, usually showed evidence of. maturity in other areas of l i v i n g . The importance of this i n relation to medical social work and to social services i n general cannot be overemphasized* CHAPTER 5, In our modern world, community organization of welfare services i s , or should be everybody's business. But ih our complex, pressured way of l i f e i t i s easier to leave i t to the other fellow. Even with the cooperation of patient and family, the tuberculosis control program i s ineffectual without the understanding and cooperation of the general public. "The battle against tuber-culosis, n as Osier once said, " i s not a doctor's a f f a i r ; i t belongs to the entire public"? From the health and welfare view point, tuberculosis presents the most d i f f i c u l t administrative problems. Because of i t s communicability, i t involves a multitude of social implications which no other disease presents to the same degree. Ojoarantine regulations cannot be established or enforced as in other communicable diseases, because i t i s impossible to estimate the time interlude between infection and the onset of the acute disease. Some patients, i n spite of willing cooperation and long periods of sanatorium treatment, remain sputum positive a l l their lives, so that for them quarantine regulations are tantamount to l i f e imprisonment, 1. "Anybody dealing with tuberculosis", says Rich , " i s impressed by the great frequency with which i t i s impossible to trace the source of infection, and the number of people who have open lesions without knowing i t . " Out of the sample group thirty-four per cent could name a known contact, 1. Rich, op. c i t . p. 896. In his footnote (1019) Rich quotes one observer, Zalle, who could not find the source of infection i n 71$ of a group of adults, which Rich considers a reasonable average. 100 excluding the three cases where there were occupational exposures through work in tuberculosis hospitals* Doctors estimate that by the time a tuberculosis case has gone unrecognized unti l the far advanced stage, the person has infected at least five other people* On this basis the group would be responsible for the infection of about 150 people. Figure 7 illustrates the incidence of sputum-positive patients in the sample group. At least sixty—four per cent of the group had positive sputum at some time during their illness, twenty-five per cent of these were sputum-positive at diagnosis. Therefore the community in its own interest and the patient's, should take responsibility for tuberculosis control services* Figure-7 Showing Incidence of Sputum Positive Cases in the Sample Group KEY ESQ Families with children Families without children People living alone Scale - 1mm. *»1 case TOTAL 64$ I Positive Sputum at Diagnosis I 11$ 3? Positive Sputum Later B.B. - Positive sputum rate i n people living in families ~ 66$ Positive sputum rate i n people l iving alone — 64$ Essentials cf a Good Tuberculosis Control Program The first problem which the disease presents to the community is responsibility for an adequate program of case-finding. This can only be done through the provision of a complete range of diagnostic services, free and avai l -101 able to a l l * The most important diagnostic tool i s mass radiography of large numbers of apparently healthy people* This has the additional advantage that a high percentage of cases w i l l be discovered i n the early stages* Presuming that there are enough beds, this should result i n patients being admitted to sanatoria while the disease i s s t i l l i n the minimal stage. The stage of the disease at which most patients are admitted to hospital i s , say 1 some authorities, "the most important.single factor i n prognosis". The next essential of an adequate tuberculosis control program i s the development of adequate treatment f a c i l i t i e s , both medical and social. These have already been outlined i n an earlier chapter* Tuberculosis control programs are judged by such standards as required ratio of beds to deaths, ratio of known cases and deaths, and the stage of disease at which most patients are admitted to and discharged from hospital. According to these reliable guides the B r i t i s h Columbia Tuberculosis Control Pro-gram ranks high. But even i f a community has the required ratio of beds to deaths this i s not sufficient i f there i s s t i l l a waiting l i s t for sanatorium beds. Some authorities believe there should be a bed for each case of tuber-culosis regardless of the stage of the disease. Nor i s i t economical to cut down on the waiting l i s t by discharging patients, whose disease i s quiescent, sooner than would be medically advisable under more favorable conditions, to make way for those i n the more acute stages of the disease* The only real test of the.adequacy of the community's tuberculosis services i s that a l l the required services are readily available following diag-nosis, or at the point i n treatment that they are required* 1* Chadwick and Pope. op. c i t . p. 73* 102 A Tabercul68l8 0ontrol Program Operated In a Social Milieu. Hot a SociaT Vacuum Ho tuberculosis control program, however complete i t s medical services, <•')..< can be effective unless adequate aneilliary social services exist i n the com-sanity. It i s not generally realized that the patient's a b i l i t y to benefit f u l l y from medical care depends primarily on two things f i r s t , his adjustment to his disease, and secondly, the f u l l e s t possible resolution of the social problems influencing his i l l n e s s . Without social services the social aspects of tuber-culosis cannot be treated. These are so important that tuberculosis has been called "a social disease with medical implications% The costs of these services must be borne willingly by the community. It was estimated that in 1952 i n B r i t i s h Columbia, the average cost of a- tuber-culosis case was $14,000, including money spent on the patient's family as well as on his medical care. Understandably, f i s c a l policies play an important part in tuberculosis control, but i f they are allowed to determine the quality and. quantity of tuberculosis control services then the whole community i s the loser i n the long run. Better services mean that more patients w i l l get well i n less time, and more w i l l stay well. <, Responsibility for Rehabilitation Services Another problem for the community i s the development of adequate rehab-i l i t a t i o n services, the lack of which i s a great weakness i n the B r i t i s h Col-umbia tuberculosis control program. Having spent.$14,000 on one case, common sense dictates that a l l possible steps be taken to prevent spending another $14,000 on the same person, which occurs unfortunately, through the lack of adequate rehabilitation services. Another aspect of this lack of service shows in the fact that eighty per cent of those released from sanatoria as cured die 1 within ten years. Evidently, the bacillus i s not solely to blame. 1. See address given by Dr. Myrom C. Weaver at the annual general meeting of the Vancouver Preventorium, 1952. •->;'£• 103 Adequate rehabilitation services include vocational retraining and job placement programs, and also sheltered workshops for those unable to com- ' pete i n the general labor market. To be therapeutically sound, the workshop program w i l l always need some degree of subsidization.< But the costs of main-taining patients i n hospital and on social assistance after breakdown are higher than the costs of enabling patients to earn their l i v i n g as far as they can. The psychological gain for patient and his family are incalculable. Responsibility for Preventive Measures In practice, treatment and prevention cannot be divorced. Early isolation of Infectious cases, and X-ray follow up of contacts, are as much preventive as therapeutic. A high level of public hygiene i n general w i l l assist the specific tuberculosis control measures. Per many years tuberculosis research workers have, carried on exten-sive experiments to find a method of producing a significant degree of immunity without.producing progressive disease. Innoculation with Bacillus Calmette-Guerin i s the closest approximation to this yet discovered. Since i t s develop-ment i n Prance i n 1908 by Galmette and his associate Guerin i t has been widely used i n Prance and Germany for infants, and i n Scandinavia for student nurses. Other countries were less receptive of i t , though Britain, Hew Zealand, U.S.A. and Oanada have a l l begun to use i t recently. .1 Authorities d i f f e r regarding the merits of B.C.G., though i t s advo-cates claim that the vaccine produces a r t i f i c i a l l y what the individual would have got by a small primary infection, thus protecting against a massive i n -1. Dr. C. J . Seckwith, President of the Canadian Tuberculosis Association said at the Annual Meeting of that society i n 1952 that most disease could be eliminated i f a l l were vaccinated, and that the negative reactor i s four times more susceptible than the positive. Bich, op. c i t . p. 810, i s inclined to think i t i s advantageous i n many cases, though bad for a minority - which would put i t in the same category as small pox and diphtheria vaccinations and i n -noculations. 104 faction later on. Some authorities hold that the effect of our present tuber-culosis control policies in deferring primary infections u n t i l adolescence and early adulthood may be undermining the resistance of the race, and paving the way for future increase i n the severity of the disease. Problems of the Tuberculous Patient who Lives Alone One quarter of the patients i n the sample group were unattached men l i v i n g alone. This group presents special problems to the community. Many authorities believe that this group i» the real crux of the spread of tuberculosis i n a community. It was interesting to note that i n the sample group f i f t y per cent of those l i v i n g alone were in the far advanced stage of tuberculosis at diagnosis as compared with twelve per cent i n the rest of the group. This might seem to confirm the view that this group consists mainly of the dregs of society - the vagrants, the alcoholics, the mental defectives, the drug addicts and others. It i s true that there was a minority of such people among the group l i v i n g alone, The majority, however, were men who had good work records i n unskilled labouring jobs, and did not become public charges t i l l they contracted tuberculosis. It was often just as d i f f i c u l t for these men to ad-just to a reduced income at social assistance level as i t was for patients who had families. These patients are often judged to be among the least cooperative patients because their background and Lack of family ti e s make i t d i f f i c u l t to rehabilitate them. As regards the sample group, there was no evidence to sup-port the theory that such people are i n general less cooperative patients. If there is a higher incidence of breakdown in this group, i t should be remembered 1, Bich, op. c i t . p. 797, cites the opinion of Cobbett, an English observer who stated this in his book "The Pause of Tuberculosis», Cambridge University Press, London, 1917. p» 86 105 that this group encounters exceptional d i f f i c u l t i e s i n convalescence and re- ' kahilitation. While It i s interesting to speculate on the emotional compon-ents of the illness i n this usually close-mouthed, lone-wolf type of individual who for various reasons have severed their family'ties, i t does not necessarily follow that their psychological conflicts and personal problems are necessarily more sever© than those of patients l i v i n g i n family settings. The patient who returns to l i v e i n a room of his own i s "beset by d i f -f i c u l t i e s unless he i s lucky i n his landlord or friends* Few i n the group were lucky i n these respects and most of them found that the combination of unsuit-^ able housing and looking after their physical needs meant overdoing their exer-cises* There are not enough boarding homes to take care of a l l the patients, and the patient without housekeeping f a c i l i t i e s , though he gains i n rest, loses financially by eating a l l or most meals i n restaurants; and the "tuberculosis extras" soon go the same way* Eating out can also interfere with exercise schedules especially i f stair-climbing i s involved* Mr. I i ' s case was typical. Mr. X. Was a single man l i v i n g i n a hotel room. He complained that his allowance was not enough and he had to borrow small amounts from friends, but this he could do no longer. The City Social Service Department advised him to save by cooking his own meals. He said he had no cooking utensils but was told he should apply for them through the Bad Cross Society. This episode upset him and changed his previous friendly relationships with the Department* It i s to be noted that people l i v i n g alone do not benefit from the social assistance concessions to tuberculous patients to idle same extent as > patients l i v i n g i n family settings* The maximum amount of social assistance for a patient l i v i n g alone never exceeds the current cit y boarding home rate, which at present Is $55*00 a month. . 106 Almost without exception this group had the choice of returning to unsuitable heavy jobs and thereby risking a breakdown, or remaining on social assistance, because of lack of vocational training and job placement f a c i l i t i e s . This group presents a special community problem, but not a l l the d i f -f i c u l t i e s arise from within the group i t s e l f . Their degree of cooperation can not be f a i r l y judged v/hen there i s no suitable rehabilitation program geared to their specific needs. The Uncooperative -Patient - a Challenge to the Community It may be thought that a community has f u l f i l l e d a l l i t s responsib-i l i t i e s i n tuberculosis control when i t has set up a program which finds, treats, and rehabilitates tuberculosis sufferers, and provides as many preventive measures as is humanly possible. But i t i s one thing to have a good program and another thing to get the people who need i t to u t i l i z e the program con-structively. No tuberculosis control program can be considered apart from the people for whom i t i s intended. It i s appropriate at this point to discuss the community aspects of. the problem of "the uncooperative patient", that much-maligned misfit who would be better described as "misunderstood" or 0mishandled,,• A considerable number of the group could be cla s s i f i e d as uncooperative. The following cases are representative. Mr. 0. Was a cheerful l i t t l e alcoholic who was always going to reform but never quite got round to i t . Whenever he was in hospital his lesions healed well, but he never stayed long enough to complete his cure. He was sure to be found in one of three places — i n hospital, i n j a i l for shop-l i f t i n g , or with a bootlegger family with whom he lived and fought with in the intervals when he was not in an institution. Mr. H. Was a married logger who drank heavily. He had two children, and liked the ladies. After contracting tuberculosis he 107 t e r r i f i e d his wife by his complete lack of concern for his own and his family's protection* She contracted the disease and died, and relatives took the children, though Mr* E. retained legal guardianship* He was discharged from hospital for repeated violation of sanatorium rules* He thought he was "putting one over" on the doctors because his X-ray showed improvement even while he wa drinking heavily* Though sputum positive he ate in restaur-ants, and when he got hopelessly i n debt he decided to re-enter hospital. He said he did not want to be cured. He was better off on social assistance. Obviously, i n both these cases the primary problem was not tubercul-osis. This was also true i n the case of Mr. v., whose lack of cooperation stemmed from mental d i s a b i l i t y or mental i l l n e s s . Mr. V* Was a forty year old single carpenter, who refused to believe he was i l l . He told the social worker he had "passed" his X-ray and the doctor said he was cured. Actual-l y his diagnosis was "moderately advanced tuberculosis". He usually l e f t his room early i n the morning, wandered down town a l l day, often insufficiently clad, and returned to his housekeeping room late at night. He showed marked schizoid tendencies but refused psychiatric examination* As he was not committable there was nothing the doctor or social worker could do* Intellectual a b i l i t y does not necessarily mean patient cooperation, as the case of Mr. F. shows* Mr. F. Was a University student, married, and was a contact of his brother who had signed himself out of hospital and taken his cure at home. Though a far advanced active case, Mr. F. refused hospitalization and told the public health nurse he was under the care of a private physician, though i t was known that he did not attend his doctor regularly* His D.V.A. grant was suspended for a time because he would not follow medical recommendations; but as his wife was working, they were able to get along financially. His condition improved enough to allow him, eventually, to attend University part time* For i s a person who i s a community problem in one sense necessarily so in the management of their tuberculosis, as the case of Miss W. shows. Miss W. Was an unmarried mother with four children, three of whom 108 were the product of her l i a i s o n with a married man. She had been i n receipt of social assistance since the birth of her f i r s t child. She would not accept employment as she considered her place was at home with her children, to whom she gave excellent care. She was a cooperative patient and soon began to make a good recovery. When she was to be hospitalized a male friend, a cook on a transcontinental train who had wished for some time to marry her, came forward and offered to support the children and maintain a home for them i n Vancouver, which he did. The H. family were a community problem long before the onset of their tuberculosis. The combination of interior and exterior pressures i n this family were so great, that to them, their tuberculosis was almost incidental. Certain-l y they a l l treated i t as an H e t cetera". From their viewpoint, the community was not interested i n helping then u n t i l they became infectious to other people. H. family Were Doukobors from the prairies, who had a hard time finding l i v i n g accommodation during the war years. Mr. H. was jail e d for drunken driving. Mrs. H. complained of intermittent non-support, and summonsed him for assault. Mr. H's mother lived with them, and apart from being the source of much family s t r i f e , was also believed to be the source of the family's tuberculous infection, but she always refused to be examined. When given his diagnosis, Mr. H. refused hospitalization t i l l he could find his family a home, then said they could not possibly exist on social assistance, so he would have to keep on working, which he did, u n t i l his death. When Mrs. H. was diagnosed, she denied she had the disease, later also refused hospitalization, because she could not bear to be parted from her children, (with whom she was alternately over-strict and over-indulgent) and also because "those who give i n and go to bed die". The eldest married daughter took her child from the prevent-orium, following her own return from hospital. The eldest son, a juvenile delinquent, was continually in and out of j a i l , and was also diagnosed. Another daughter, of border-line intelligence, was also delinquent. The youngest daughter had a primary infection. The whole family of nine lived i n two rooms in a converted store, the only accommodation they could find. Their a t t i -tude was that eighty per cent of the children i n the neighbourhood had tuberculin positive skins, so why pick on them? Besides, Tuberculosis Control had known for a long 109 time that their l i v i n g quarters were unsatisfactory, but nobody had done anything about i t * Perhaps the department would l i k e to loan, them the $500 necessary to purchase the $50 worth of furniture i n the only other place they could find which would take children? Devising an Approach to the uncooperative Patient In every community today, there are adults who are not mature emotion-a l l y . As children, they did not, owing to stresses of various kinds within their families, receive the love, understanding and security so necessary to balanced emotional growth* Many among them belong to families who have become, in the accepted parlance, "pauperized". Over the years, as their troubles mount, and their real needs go un-met, their attitudes crystal!ze into that anti-social behaviour not expected from adult human beings and which i s unacceptable to their fellow men. While i t i s possible to isolate them for treatment of their tuberculosis, i t i s ut-terly impossible to isolate them for their anti-social behaviour. For good or e v i l , they are part of our social and economic body, and their social i l l - h e a l t h affects the whole social body* "For the good of the whole, as well as for that 1 of the sick individual, we must provide remedial treatment for the sick part". When such people are stricken with the bacillus i n addition to a l l their other d i f f i c u l t i e s , most of them w i l l be uncooperative patients. It could not be otherwise. From both the medical and the community point of view, they w i l l remain uncooperative and thereby a potent source of the spread of infection, u n t i l our services are strong enough and ample enough to meet a l l their legitimate needs. 1, Govan, Elizabeth "Public Assistance i n Modern Society", Canadian  Welfare. Vol.'xxviil Ho. 1, May 1952, p, 5 110 r The attitude of the general public to these people i s characterized "by lack of understandings I t i s sometimes d i f f i c u l t to remember, as Charlotte Towle reminds us that "Parents who f a i l have frequently been f a i l e d ... that 1 we give as we are given to ... and that none of us can give from a vaccuum". One of the problems facing the community i s how to bring about a change of at-titude towards these people. It w i l l not become about by chance. Public edu-cation regarding community responsibility for such social i l l s i s only part of the answer. It i s fundamentally related to the much deeper question of how we can equip people for the complexities of l i v i n g in modern democratic society. To answer that question i s the great challenge to our c i v i l i z a t i o n . There i s no short cut to making uncooperative people cooperative. The process is as slow as nature's healing of tubercular lesions, and almost as un-certain. We cannot make them cooperate in the treatment of their disease. We can only make them want to, through meeting their basic needs i n other areas of l i v i n g . I f we wish them to accept their community responsibilities, we i n the community must respect their fundamental rights as human beings. The community must recognize the fact that some people have been so bruised by l i f e that they cannot be reached. They might be said to be suffering from "inoperable social cancer". They are socially irreclaimable and we must accept responsibility for them as we do for the chronic tuberculosis patient who cannot overcome his disease. But to those who can respond, and to those who come i n the future, the community has a different responsibility. We must provide for them the requisite services to assist them to build up in their formative years those human relationships which are the root of their inner s t a b i l i t y and security 1, .Towle, Charlotte, "Common Human Heeds", Public Assistance Report Ho, 8 U.S.A. Federal Security Agency; Social Security Board, Washington. 1945, P» 6? I l l as individuals, and the foundation of socialized and considerate "behaviour towards their fellows. We w i l l thus create for the community citizen assets as against citizen l i a b i l i t i e s . Chapter 6. Tuberculosis Control in the Future. Cohclusions and Becommendations In reviewing present success i n our battle with the bacillus, we cannot escape the question:- "Are we doing a l l we can, within the present limits of our knowledge, to control and eventually eradicate tuberculosis?" Pasteur once said that i t i s within the power of man to cause a l l germ diseases to disappear from the earth* Some eminent medical authorities at the beginning of this century prophesied that by 19^0 tuberculosis would be an almost extinct medical curiosity i n western c i v i l i z a t i o n * And indeed, i n the opinion of two eminent present day authoritiesj-n Sufficient knowledge i s already available to make the erad-ication Of tuberculosis a po s s i b i l i t y within a few generations i f the established techniques are effectively a p p l i e d * . T h e heavy t o l l taken by tuberculosis economically and socially for centuries can be reduced to a minor public health problem i n one generation, and eventually eliminated altogether by putting into practice the knowledge we have of i t s epidemiology and treatment".^ It i s evident that achievement of this goal i n Br i t i s h Columbia would necessitate improvements i n practically a l l aspects of the existing tuber-culosis control services. Becommendations regarding. Medical -Services The standard of medical services i n tuberculosis control i n B r i t i s h Columbia i s extremely high, yet existing deficiencies negate many of the v positive features. One of the most important i s the shortage of sanatorium 1* Chadwick and Pope, op. c i t . p. v i i and p. 100 113 teds* At the time this survey was made the new Pearson Memorial Hospital, opened in March, 1952, had not "been "built. Though i t was hoped, and was act-ually stated in the press, that this unit of 264 beds would more than compen-sate for the shortage, this expectation has not been realized i n practice. It has s t i l l not enabled tuberculosis control.to meet the crucial practical test of immediate admission following diagnosis. Therefore, according to the best standards, there is s t i l l a bed shortage which should be remedied. There i s also a shortage of trained personnel, especially medical personnel i n the tuberculosis f i e l d . This i s partly due to lower salaries i n Government medical appointments, as compared with the income which medical personnel can obtain i n private practice. At present the appointment of Medical Director of Taberculosis Control i s not on a full-time basis, as i t should be i n a comprehensive program for tuberculosis control. Higher salaries are a necessity i f tuberculosis control work i s to attract top people i n the medical profession. Recommendations regarding Nursing Services B r i t i s h Columbia i s one of the few provinces to include a course i n tuberculosis nursing i n the curriculum i n recognized Schools of Nursing. It might be expected that interest i n the tuberculosis f i e l d would thus be aroused, but there i s s t i l l a shortage of tuberculosis nurses. But there has always been, except i n a few privileged spots i n the world, a chronic shortage of nurses of a l l types i n hospitals. Remedial measures to overcome this defic-iency should be. directed towards improving conditions i n the nursing profession as a whole. Recommendations regarding legislation and hospitalization . Existing B r i t i s h Columbia legislation allows for compulsory removal 114 1 of proven infectious cases of tuberculosis to hospital, hut does not provide any authority for keeping them there. They are free to walk out the same day i f they so wish, Also, as long as the bed shortage continues, i t i s somewhat ludicrous to insi s t on hospitalization of the uncooperative when there i s a waiting l i s t of patients. Consideration should be given as to the po s s i b i l i t y of amending pre-sent legislation to allow for the protection of the community from the proved non-cooperative sputum-<positive patient while at the same time protecting the rights of the cooperative sputum-positive patient for whom compulsory hospital-ization for the duration of his infectiousness to others would be tantamount to l i f e imprisonment. A l l such legislation would have to be used extremely cautiously. There would also have to be some decision as to the position of those patients who had not acquired British Columbia residence according to the "Residence and Responsibility Act", because after a l l , from the public health point of view, the non-resident i s as infectious to the community as the resident. Tree hospitalization for tuberculous patients i s recommended. At the present time, the Office of the Collector of Hospital Revenue decides whether a patient and his family shall pay hospital rates i n f u l l , i n part, or be exempt. While i t i s quite true that many patients can pay a l i t t l e , the chron-ic i t y of the illness i s usually such a drain on the family resources that the advisability of depleting them further i s to be questioned. Often by the time the patient reaches rehabilitation, there i s l i t t l e l e f t to help re-establish the family according to i t s former standard of l i v i n g . Observers i n U.S.A. have noted how often even small payments which the family agrees willingly to 1. See "Regulations to the Control of Communicable Diseases Act", 1945, p.p. 15-16, King's Printer, Victoria, B. C. 1945* 115 pay in the •beginning "become an intolerable "burden as the illness drags on* Recommendations Regarding Building of Hospitals Hear Urban Centres It i s .recommended that future institutions for the treatment of tuber-culosis should be built closer to the larger urban cetres. Since i t i s acknow-ledged that i n the treatment of tuberculosis, no one climate i s superior, there seems to be l i t t l e j ustification for straining the fabrics of family l i v i n g further, and intensifying the pain of separation for tuberculous patients and their families. Recommendation Regarding.Mass Radiography Inauguration of a public education program to encourage annual radio-graphy of a l l residents of the province i s recommended as an implementation of the existing case-finding program* Compulsory X-ray's at six monthly intervals for a l l food handlers i s recommended* This could be made a condition of employ-ment as i t i s at present for hospital employees* Recommendation Regarding general Use of B..C..G* ' At present, the use of B.C*S* innoculations i n B r i t i s h Columbia i s confined to certain specialized groups. A program of public education,,would assist public acceptance of i t as a general preventive measure, which might be extended to other groups in the population, and might eventually become accepted on the same basis as innoculations against other infectious diseases. Recommendations Regarding Medical Research It has been previously stated that the control of tuberculosis i s within our grasp i f we apply the technical knowledge already available. It may therefore seem somewhat incongruous to place extension of medical research high on the l i s t of p r i o r i t i e s i n tuberculosis control. Yet in the f i n a l analysis, we do not yet know what makes people get tuberculosis, nor how to cure them when they do. The most we can do, even with a l l our modern medical techniques, 116 i s to assist by a r t i f i c i a l means the "body's natural defences to overcome the disease. There i s as yet np specific cure for tuberculosis, no substitute method for nature's slow way of healing tubercular lesions. U n t i l there i s , we can-not expect to reduce the long protracted period of incapacitation which tuber-culosis now causes, Recommendations Regarding Psychosomatic Orientation i n Schools of Medicine The adoption of the psychosomatic approach i n Schools of Medicine i s recommended so that medical students become oriented to this method of study and treatment of their patients by the time they become practitioners, and can thus more adequately f u l f i l l their responsibility to treat "the whole man". Some medical men today vizualize that i n the medical practice of the future the general practitioner w i l l come into his own again. He w i l l however have undergone a metamorphosis, from which he w i l l re-emerge with pivotal im-portance i n the whole structure of medical services. He w i l l be the practitioner trained i n the basic speciality of "human biology" - that i s , the study of the human personality and human relationships - and w i l l c a l l i n as his technical assistants the various specialists who today outrank him. Recommendations. Regarding.Public Health Services Public Health services in British Columbia are of a high standard, though naturally not so well developed i n the rural areas as i n urban centres. One would, however, l i k e to see an enlargement of concepts i n this area to i n -clude what has been called "social medicine", that i s : -"The idea of medicine applied to the service of man as socius, as fellow or comrade, with a view to a better understanding of and more durable assistance to a l l his main and contributory troubles which are inimicable to active health and not merely to removing or alleviating a present pathology. It embodies also the idea of medicine applied in the service of societas, or to the community of men, with a view to lowering,the i n c i d -ence of a l l preventable disease, and raising the general level of human fitness." L, This i s a quotation from an address given by Professor Ryle of Exford University on the social aspects of medicine, which the writer came across i n a pamphlet, which has since been lost, . 117 Recommendations Regarding Medical Social Work The role of the medical social worker in combating tuberculosis i s a v i t a l one. She i s the medium through which the to t a l i t y of services available to the patient are individualized to meet his particular needs. Through her associates in the public and private welfare agencies, the patient and his family are helped with other social d i f f i c u l t i e s . It i s recommended that a l l tuberculous patients be referred to the - medical social worker as soon as possible after diagnosis. Ho matter how stable the individual, tuberculosis involves such major adjustments in l i v i n g for the patient and his family, that there must be few indeed who would not benefit at least supportively from the services of the medical social worker. Though an individual patient or family may not be able to u t i l i z e a casework relationship constructively, the social history information which the medical social worker obtains during her contact with the patient and his family i s of great diagnostic and therapeutic value. Indeed the findings of the "social laboratory" are just as important as the findings of the chemistry laboratory i n the treatment of tuberculosis. It i s recommended that at least one member of the social service staff in tuberculosis hospitals be a qualified group worker, so that there can be experimentation i n the value of group therapy for tuberculous patients. This has already proved successful i n other chronic illnesses. One tool which has been particularly effective i n rehabilitation work has been the use of psycho-drama, in which patients enact dramatically, either impromptu or from prepared scripts, situations they are l i k e l y to encounter on leaving hospital, within their families, i n seeking employment, and in social relations i n general. Group discussion afterwards, guided by the worker, has been of proved therapeutic value to many patients i n helping them to face the r e a l i t i e s of such situations . and their feelings about them. 118 It i s also recommended that i n order to enable the medical social worker to function f u l l y i n a medical setting, namely, to participate i n the treatment process, and not merely to gather social history information and to help with environmental problems — there should be regular consultation with psychiatric staff regarding d i f f i c u l t cases. The medical social worker would then be able to help more effectively those seriously disturbed patients where her role i n the treatment team though distinct from the psychiatrist's cannot be performed except in collaboration with him. It i s also recommended that experimentation be undertaken with pro-grams for the extension of medical social services into the home. There has been some interesting pioneer work in this f i e l d i n U.S.A., especially at 1 Montefiore Hospital i n New York. There i s great need for improvement i n methods whereby medical care programs are adapted to the medical needs of people,in our present-day society* Provision for medical social work research i s also recommended. The f i e l d of teleology has been very much neglected by medical social workers. They can make a significant contribution to medical care when they can answer more sc i e n t i f i c a l l y than at present, not only the question?, "Why did this person become i l l when he did?", but also the equally important questions: "Why did he get better when he did, and what were the mechanisms concerned i n his recov-ery"? It i s f u l l y realized that the implementation of these recommendations regarding medical social work w i l l be costly. Individualization of services i s always costly, but less costly than non-individualization* 1. See Field, Minna and Schless, Bessie, "Extension of Medical Social Service into the Home", i n the Journal of Social Case work Vol. XXIX No. 3., March, 1948, p. 94 119 Recommendations regarding Social Assistance Regulations Success of tuberculosis control from the social point of view depends i n large measure on adequate public welfare programs. Of prime importance i s the social assistance program. What constitutes adequate assistance i s d i f -f i c u l t to define. Experience has shown that attempts to do so without regard to a family's existing standards of l i v i n g are l i k e l y to be unsuccessful. It i s important i n dealing with the tuberculous group to help the family maintain some semblance of the standards to which they, were accustomed before the disease struck. The special concessions allowed to tuberculous patients under the • British Columbia Social Assistance Act represent an attempt to do this, but to jadge from the experiences of the people in the - sample group, they f a l l consid-erably short of their intended aim. They w i l l continue to do so, in the opinion of the writer, u n t i l we broaden the concept of public assistance to include a sliding scale of additional financial and social privileges above bare sub-? sistence level, which w i l l be available for individuals and families according to their specific need. It i s also recommended that there be further extension of social assistance i n the form of boarding homes for convalescent patients. Experience elsewhere has shown that the cottage type of unit, preferably managed by ex-tuberculous patients, are the most successful. A. minor revision in social assistance regulations which i s recommended i s payment of travelling allowances for a patient's immediate relatives for purposes of v i s i t i n g patients i n tuberculosis institutions, at least twice a year. It i s the function of public welfare agencies to strengthen their clients. "Valid public welfare services" i t has been aptly said "can only be given i n a society and i n an administrative setting 120 which i s receptive to social work aims, "by workers who have the s k i l l s to provide the services that conserve the strengths and develop the capacities of the citizen group which the agency serves."^ The implications for B r i t i s h Columbia are programs aimed at improving community understanding of social work, and the employment of more f u l l y trained soeial workers i n public welfare. Recommendations Regarding Behabilitation Services Inauguration of government sponsored rehabilitation programs for the tuberculous i s recommended. The weakness of the present rehabilitation services i n B r i t i s h Columbia seem to the writer to v i t i a t e much of excellence of existing medical and social services i n combating tuberculosis. There is need for the development of adequate vocational retraining programs for discharged sanatorium patients: an educational program to soften up employer—employee resistance i n the employment of handicapped people; practical help i n developing work opportunities and locating suitable employ* ment. The work of the Special Placements.Branch of National Employment Services and the British Columbia Tuberculosis Society i s excellent but extremely limited i n relation to existing needs. The task i s too great for voluntary agencies to meet the needs unaided. One of the greatest obstacles to effective work in the rehabilitation f i e l d i s the lack of a universally accepted definition of what constitutes light work. While both the patient and his doctor know very clearly what is involved i n " f u l l time light work", the same cla r i t y does not exist on the labour market. Time and again, a patient has undertaken what i s cl a s s i f i e d as light work on industrial f i l e s , but which proves i n practice to be too arduous for an ex-tuberculous patient. 1. Brown, Luna Bowdoin "Responsibility of the Public Agency for Strength-ening Its Clients", Journal of Social Casework. Vol. XXIX No. 7, July, 1948,p.255 121 1 It i s also recommended that the B r i t i s h system he adopted, whereby •very employer of twenty or more persons i s required to employ a quota of d i s -abled persons, amounting to at least three per cent of his labour force. Also, under the B r i t i s h plan of "designated employment", future, openings in certain occupations such as car park attendant and elevator operator, may be reserved for disabled people* It i s also recommended that an adequate sheltered workshop program be developed and subsidized from public funds. Such projects may range a l l the way from the work colony, where severe tuberculous chronics can l i v e i n village 1 settlements with their families, as i n Papworth village i n England, to non-residential workshops where.patients can work from one to six hours per day, depending on their capacity* Dr. Myrom C, Weaver, Dean of the University of British Columbia School 2 of Medicine, recently suggested that ex-tuberculous patients form a self-help group similar to Alcoholics Anonymous, to help i n their own rehabilitation* This i s a recommendation well worth implementing* The a r t h r i t l c s of B r i t i s h Columbia have already formed their organization, and according to recent re-ports, are finding the project well worth while* Recommendations Regarding Subsidization of Work of Voluntary Agencies Services of voluntary agencies are strained to capacity by the needs created by chronic i l l n e s s . They cannot answer a l l requests for their services unless there is some public subsidization of those aspects of their work which, i n our modern society, are primarily a community responsibility, rather than 1* If properly run, there i s l i t t l e danger of spread of infection i n such projects. In Papworth, England, i n thirty-two years, not one child born there to tuberculous patients has developed pulmonary tuberculosis. 2. In his address at the Annual General Meeting of the Preventorium Society, 1952. 122 that of a private agency. It i s recommended that the Family Welfare Bureau Homemaker Service "be enlarged through public funds, to enable the agency to place and supervize home-makers in families where the mother i s tuberculous, or suffering from any other chronic incapaciting i l l n e s s . Placement of a child outside his family because of chronic illness should be considered only as a last resort, and should not be dictated by financial considerations only. Implementation of the foster day care program i s recommended to provide day care for the children of working fathers where the mother i s incapacitated, so that,full time placement; of a child during the illness of his mother, i s avoided except where absolutely necessary. Private agency services to tuberculous people without family attach-ments should be strengthened. It i s specifically recommended that a program similar to the British "Meals on Wheels"- be adopted. At present there i s no private agency which could undertake i t without subsidization from public funds. If such a program were inaugurated,' convalescent tuberculous people l i v i n g alone would have a hot cooked meal brought daily to their homes by mobile canteens for which they would pay according to their means. This could be the greatest single measure i n enabling this group to come through their convalescence suc-cessfully. Recommendations. Regarding Primary Basic Public Welfare Measures Because of the inter-relatedness of tuberculosis and major social problems, no program of tuberculosis control i s complete without adequate^ pror v. vision in the national economy for those basic public welfare measures neces-sary to meet the primary needs of human beings in our society. These include: - a comprehensive social insurance such as that out-lined by Dr. L. C. Marsh in his report on Social Security for Canada: f u l l 123 employment policies; a health services scheme which w i l l make medical care available to a l l according to need; government subsidization of low rental 1 housing projects. The provision of such a comprehensive health and welfare scheme i s held back principally by two obstacleBo The f i r s t i s expense. The cost of such services may indeed appear prohibitive from the f i s c a l point of view. However, that depends on whether the long or short term view i s taken. There can be no disputing the fact that i t costs the community more, in the long run, to tolerate tuberculosis than to wipe i t out. In terms of human unhappiness. and incapacitation, i t may well be that the present cost to the community i n not providing these services i s actually greater than the cost of providing them. The second great stumbling block is current philosophy. It i s s t i l l a commonly held view that the provision of adequate social security measures would result i n the undermining of the moral fibre of a population. Social workers are often accused of favouring the removal of a l l d i f f i c u l t i e s from people's l i v e s . But none of us can avoid conflict and pain. The tragedy i s that those people who have had i t meted out to them i n overabundant measure often*become unequal to the undertaking of mature responsibilities i n the adult world. Freud once said that " i t is the duty of medicine to make the patient strong enough to face the inevitable suffering of l i f e " . The same i s true of social work and social security. If we are really concerned about people, we w i l l provide the services to enable them to cope with the complexities of modern liv i n g , not as has been said, "as a sentimental move, but as a basic 1. See Report on Social Security for Canada, prepared by Dr. L. C. Marsh for the Advisory Committee on Reconstruction, Ottawa, King's Printer, 1943 124 1 need for personal stability and social order". According to the Human Eights Charter of the United Nations* "Everyone has the right to a decent living; to work and advance his well-beingj to health, education and social security.• • There shall be equal opportunity for a l l to participate i n the economic and cultural l i f e of the community". We have not yet implemented this i n our culture. The l i f e histories of the people described i n this study are ample proof of this. Most of them ask noth-ing more than the very thing the charter describes. It may he, as F. D. Eoosevelt said, that the twentieth century w i l l come to be dubbed hi s t o r i c a l l y as the "century of the common man", because of the improvement i n his lot which i t has witnessed. It i s equally possible that posterity w i l l judge our century by our tragic omissions i n the f i e l d of human betterment in view of the extent of our sci e n t i f i c enlightenment and technical achievements. Such tremendous power w i l l never be used to the ad-vantage of mankind as f u l l y as i t might be u n t i l men understand themselves:-"The c r i t i c a l , empirical attitude of the natural sciences must now be extended to the study of personality and to the social sciences i n order to achieve the same mastery of individual and social behavior which we have acquired over the forces of inanimate nature".^ It i s the great challenge and the great privilege of the profession of social work to assist i n this great undertaking. Prevention and control of tuberculosis i s inescapably linked with the raising of the general level of well being of a l l peoples, to which the profession of social work is dedicated. Human experience had already shown repeatedly that i n dealing with tuberculosis, half way measures w i l l not do. 1. See H i l l , Eeuben, "Are We Expecting Too Much of Families"? Journal  of Social Casework. Vol. .XXXLl No. 4. April, 195L P» "'±53 2, Alexander, Franz, "Our Age of Unreason, a Study of the Irrational  Forces i n Social L i f e . . J . .33. Lipplncott Go. New York, 1942, p. 22 125 "In order to get at the roots of tuberculosis, i t . i s necessary to understand where i t s springs arise. Prom some crater i n the depthB of society, among the most wretched poverty, misery, unemployment and inbecility, the fountain of tuberculosis infection i s thrown up through the community, and seizes upon a l l who are susceptible. U n t i l these social e v i l s can be got under control, we shall never be quite free of tuberculosis. U n t i l then, we shall not deserve to be." 1. Olsen, H. C., The Fight against Tuberculosis i n Bernholm. Acta Tuberculosis Scandinavia. Supp., 11, 19^3 126 Appendix A BIBLIOGRAPHY GOVERNMENT PUBLICATIONS Annual Reports of the Division of Tuberculosis Control, Provincial Board of Health Report on Social Security for Canada, prepared for the Advisory Committee on Reconstruction by Dr. Leonard C. Marsh King's Printer Victoria, B.C.,1945-1951 King's Printer Ottawa, 1943 BOOKS Alexander, Franz Bankoff, M. D. Chadwick, H.D. and Pope, A.S. Denning, Dorothy Dunbar, Flanders English, O.S. and Weiss, E. . Hatfield, W. H. Hodgson, V. H. Hudson, Holland and Fish, Marjorle Lovell, Robert G. Marsh, Leonard C. Our Age of Unreason: A Study of the Irrational Forces i n Social Life J . B. Lippincott Co., New York, 1942 Conquest of Tuberculosis Macdonald and Co., London, 1944 The Modern Attack on Tuberculosis The Commonwealth Fund, New York, 1942 Home Care of Tuberculosis National Tuberculosis Association, New York, 1943 Psychosomatic Diagnosis Harpe Bros., New York, 1943 Psychosomatic Medicine W. B. Saunders Co. Philadelphia, 1943 Handbook on Tuberculosis King's Printer, Victoria, 1944 Handbook on Tuberculosis for Public  Health Nurses. National Tuberculosis Association, New York, 1942 Occupational Therapy i n the Treatment of  the Tuberculous Patient. National Tuber-culosis Association, New York, 1944 Taking the Cure; The Patient's Approach to Tuberculosis, Macmillan and Co., New York, 1948 Rebuilding a Neighbourhood: Report on  a Demonstration Slum Clearance and Urban  Rehabilitation Project in a Key Central  Area i n Vancouver. The University of Briti s h Columbia, Vancouver, 1950 Maxwell, James Myers, J, Arthur Pattison, H. A, Pinner, Max Rich, Arnold R. Sapirstein, M. B. Segal, Jacoh Smillie, Wilson G. Towle, Charlotte Ustvedt, Hans Jacoh Wittkower, Erie ARTICLES AND PAMPHLETS Axelrad, B. K. Bellack, Leopold Berle, B. Be 127 The Care of the Tuberculous Patient in the Home,, Hodder and Staughton, London, 1943 Tuberculosis Among Children and Adults Chas. C. Thomas, Springfield, Illinois, 1938 Rehabilitation of the Tuberculous Patient The Livingston Press, New York, 1942 Pulmonary Taberculosis in the Adult Chas. C... Thomas, Springfield, Illinois, 1945 The Pathogenesis of Tuberculosis Charles C. Thomas, Springfield, Illinois, 1944 Emotional Security. Crown Publishers, New York, 1948 , . . Pulmonary Tuberculosis. Oxford University Press, Oxford, 1939 Public Health Administration, Macmillan Co., New York, 1941 Common Human Needs. United States Government Printing Office, Washington, 1945 Pulmonary Tuberculosis and Its Treatment John Bale, London, 1942 ~~° A Psychiatrist Looks at Tuberculosis. National Association for the Prevention of Tuberculosis, Loudon, 1949 "Some Aspects of the Treatment of the Emotional Problems of the Tuberculous11, Newsletter; American Association of Psychiatric Social Workers, Spring, 1946 Vol. 15., No. 4 "Psychiatric Aspects of Tuberculosis11, Journal of Social Casework. Vol. 31» No. 5., May, 1950, p. 183 - 189 "Emotional Factors in Taberculosis; a Critical Review of the Literature", Psychosomatic Medicine. Nov., 1948 p. 366 - 373 128 Bloom, Sophia Bloom, Sophia Bowers, Swithun Brooks, Mary S. Brown, Luna Bowdoin Coleman, J.V., Hurst, Allan and Horhein, Ruth Day, George Egypt, Ophelia Field, Minna and Schless, Bessie Field, Minna Forster, A> M. and Shepard, C. E. Frost, W. H 0 "Community Wide Chest X-ray Survey Part III: Social Work", U. S. Public Health Reports.' Vol. 66 Feb. 2nd, 1951.pp. 139 - 156 "Some Economic and Emotional Problems of the Tuberculosis Patient and His Family", (reprinted from) TJ. S. Public  Health Reports.: A p r i l 2nd, 1948 "The Nature and Definition of Social Casework", Journal of Social Casework Vol. 30, No. 10 Dec. 1949. p. 4 l? "Psychology of the Tuberculous Patient" Journal of Social Casework, Vol. 29, No. 2. Feb. 1948, p. 57 "Responsibility of the Public Agency for Strengthening i t s Clients", Journal of  Social Casework. Vol. 29, No. 7, July 1948,pp. 255 - 260 "Psychiatric Contributions to the Care of the Tuberculous", Journal of the American Medical Association, Vol. 135» No. 11 Nov. 15th, 1947.PP. 699 - 702 "Observations of the Psychology of the Tuberculous", The Lancet, Nov. 16th, 1946, pp. 703 - 706 "Helping a Tuberculous Patient to Face Surgery", Journal of Social Casework. Vol. 32, No. 3 . , March, 1951, pp. 119 - 125 "Extension of Medical Social Services into the Home", Journal of Social Casework. Vol. 29, No. 3., March, 1948, pp. 94 - 99 "Family Sessions; a New Cooperative Step i n a Medical Setting", Journal of Social  Casework. Vol. 3 0 . , No. 10. Dec. 1949, p. 417 "Abnormal Mental States in Tuberculosis" American Review of Tuberculosis, Vol. 25 No. 324, 1932, pp. 324 - 333 "Age Selection of Mortality from Tuberculosis i n Successive Decades", American Journal  of Hygiene. Sect. A:30 91-96 Nov., 1939 Frost, W. H. "How Much Control of Tuberculosis", American  Journal of Public Health. Vol. 27.1, 1937 129 Govan, Elizabeth Harper, F. B. Hartz, Jerome Hartz, Jerome Hi l l , Reuben Hudson, Holland Maedonald, Norman Miller, pauliae Nitzberg, Harold Olsen, H. C. Schultz, I, T. Teague, R. E, and Taylor, R» "Public Assistance in Modern Society", Canadian Welfare. Vol. 28, No. 1, May 1952, pp. 5 - 8 "Surgical Treatment of Tuberculosis", Hospital Progress. Vol. 30, No. 5, May 1949, p. 146 "Human Relationships in Tuberculosis", U. S. Public Health Reports. Vol. 65, Oct. 6th, 1950, pp. 1292 - 1305 "Tuberculosis and Personality Conflicts" Psychosomatic Medicine, Jan. 1944, pp.17 - 22 "Are We Expecting Too Much of Families", Journal of Social Casework. Vol, 32, No. 4, April 1951, PP. 153 - 155 "Six Traffic Signals in the Rehabilitation of the Tuberculous", Journal of Rehabilitation Vol. 12, No. 1, 1946, pp. 17 - 19 "The Social Aspects of Tuberculosis", The Almoner. London, Vol. 2, No. 7, p. 148 "Medical Social Services in a Tuberculosis Sanatorium", U. S. Public Health Reports Vol. 66, No. 31, Aug. 3rd, 1951 and No. 36, Sept. 7th 1951 "Rehabilitation of the Tuberculous - A Casework Process" Journal of Social Casework Vol. 31, No. 2, Feb. 1950. pp. 61-64 "The Fight Against Tuberculosis in Bornholm" Acta. Tuberculosis Scand. Supp. 11, 1943 "The Emotions of the Tuberculous* a Review and an Analysis" Journal of Abnormal Psychology Vol. 37, No. 260, 1942 "Study of Tuberculosis Control in Philadelphia" P. S. Public Health Reports. Vol. 65, No. 9M March 3rd, 1950, pp. 267 - 279 

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