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TB Notes 1, 2000
Introduction
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
 
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

CDC and the American Lung Association/American Thoracic Society: an Enduring Public/Private Partnership

by Fran DuMelle, MS
Deputy Managing Director, ALA
and Philip Hopewell, MD
Associate Dean, Univ of California, San Francisco

The origins of the American Lung Association (ALA) and the American Thoracic Society (ATS) and of their collaborations with the CDC lie within the anti-TB movement of the late 1800s and early 1900s. The potential value of an organized voluntary society constituted of both physician and lay members was recognized in the late 1800s and marked by the founding of the Pennsylvania Society for the Prevention of Tuberculosis in Philadelphia in 1892. Twelve years later, in 1904, under the guidance of many of the luminaries of American medicine at that time Osler, Trudeau, Welch, Janeway, Knopf the National Association for the Study and Prevention of Tuberculosis (NASPT) was founded. Although the NASPT was largely composed of physicians and other health professionals (only two laymen were included on its first 29-member board of directors), its mission was public education and public policy, not clinical care or research.

Image 1: Early public health campaign: women disinfecting Syracuse sidewalks.

In 1918 the NASPT changed its name to the National Tuberculosis Association (NTA), a name it retained for the next 50 years. Because the organization was progressively involving itself in a broader range of activities, in 1968, after considerable discussion and debate, the name was changed to the National Tuberculosis and Respiratory Disease Association (NTRDA). After being burdened with this unwieldy name for 5 years, the NTRDA became simply the American Lung Association in 1973.

In 1905, a year after NASPT was chartered, a subgroup the American Sanatorium Association (ASA) was formed by physician members of NASPT who, for the most part, were directors of TB sanatoria. This group was focused on the science of TB and on the clinical care of patients with the disease. Although comprising initially only sanatorium-based physicians, the ASA subsequently became more inclusive, with membership open to all physicians and researchers in the field. In 1939 the name of the ASA was changed to the American Trudeau Society, honoring Edward Livingston Trudeau and recognizing the broader interests of the members. Finally in 1960 the name was again changed to the American Thoracic Society (ATS) in keeping with the evolution of the medical specialty area from pthisiology to pulmonology, including TB and the whole range of respiratory disorders.

The involvement of the ancestral ALA and ATS with organized TB control efforts in the United States began well before there was even a United States Public Health Service (USPHS), let alone a CDC. In fact, a major activity of the NASPT was promoting the establishment of public health departments with TB control programs in every community in the country. Lawmakers were urged to support such programs and to use taxes to make care for TB free to all patients. Thus, from its inception, the progenitor of the ALA had as its core mission advocacy for effective TB control and accessibility of clinical services for patients with the disease.

Among the factors recognized as limiting the ability to mount a countrywide TB control program were the lack of data describing the magnitude of the disease and the absence of any assessment of the availability of facilities for the care of patients with TB. The first of these voids was filled by an analysis conducted on behalf of the Charity Organization Society (COS) of the City of New York by Miss Lillian Brandt in 1903. This report, "The Social Aspects of Tuberculosis, Based on a Study of Statistics," compiled the data available for the US and presented in a systematic fashion both the scale and complexities of TB in the United States in the early 1900s.

Miss Brandt also provided the initial collection of data describing existing facilities and programs for patients with TB, "A Directory of Institutions and Societies Dealing with Tuberculosis in the United States and Canada." This survey, which served to highlight the dearth of facilities for TB, was jointly funded by COS and NASPT, and was the first project of the new society. Subsequent editions of the "Directory" were funded and published entirely by NASPT and provided the focus for the society's major advocacy program: to increase public funding for TB and to have TB control programs in all departments of public health. In 1916 the NASPT adopted a resolution stating that participation of the federal government in TB control is "desirable and necessary" and that the "proper federal agency for the purpose is the US Public Health Service." A bill providing that a division of TB should be set up in the US Public Health Service was introduced in the House of Representatives in 1916. This plan was not realized, however, until nearly 30 years later, in 1944.

In 1961 the federal government instituted the funding of state programs that were designed to support community-based outpatient care efforts, to shift TB control away from inhospital treatment. Funding increased progressively through the 1960s but declined precipitously in 1970 as federal support was shifted to block grants. By 1973 there were no categorical funds for TB control at the CDC. After several years' experience with block grants, it was clear that the states were spending few or none of these funds for TB control.

It was logical, therefore, that when the ALA opened its first full-time government relations office in Washington in 1980, among its first priorities was funding for TB control. In fact, the first victory logged by the fledgling office, under the leadership of long-time ALA and ATS employee Robert Weymuller and its legislative counsel Harley Dirks, was the Congressional authorization of the "Project Grants for Tuberculosis for Preventive Health Projects" (replacing block grants). This bill restored categorical funds for TB control to the CDC in 1980 after an 8-year hiatus. Following this success, the ALA/ATS proceeded with an intensive advocacy campaign to secure funding $1 million in FY1982, a significant amount in 1982 dollars. Throughout the 1980s the ALA/ATS continued to advocate for increased funding for the CDC, but it was not until 1993, after the resurgence of TB in the US had peaked, that funding increased dramatically.

The success in gaining increased funding for TB was facilitated by having in place the Advisory Council for the Elimination of Tuberculosis (ACET), an advisory group to the CDC that was specifically authorized by Congress as a result of ALA/ATS lobbying efforts. Among the first tasks of the ACET was the development of the Strategic Plan for the Elimination of Tuberculosis. This plan, plus the newly-created National Coalition for the Elimination of Tuberculosis (NCET), provided new energy and focus for the advocacy efforts, and funding levels grew to their current level of approximately $120 million by 1995.

The creation of NCET harkens back to the early days of the ALA and its activities in community organization. NCET was formed at a time when TB cases were increasing and there was rising concern about drug resistance, yet public apathy and Congressional inaction continued. The goals of ALA in fostering the creation of NCET were nearly identical to the goals of the NASPT almost 90 years earlier: increasing public awareness of TB and advocating for adequate public funding of control programs. As noted above, NCET played an important role in the intensified response to the resurgence of TB in the 1990s. In 1998 NCET reevaluated its role and structure and is focusing on advocacy at the state level for funding and for ensuring an appropriate legal framework for TB control, while not abandoning it national activities.

Image 2: An illustration from Huber the Tuber, a book about tuberculosis written and illustrated by H. A. Wilmer, MD, and published by the National Tuberculosis Association in 1942.

Both the ALA and the ATS have concerns with international, as well as domestic, TB control concerns that are consistent with the traditions of the organizations, with current epidemiologic realities, and with the increasing international focus of the CDC. Soon after its founding, the NASPT became involved in international activities, hosting the sixth International Congress on Tuberculosis in 1908. True to its origins, the ALA currently is an important constituent of the International Union Against Tuberculosis and Lung Disease (IUATLD). Additionally, the ALA and the ATS are founding partners of the Stop TB Initiative, together with the CDC, the World Health Organization, the World Bank, the IUATLD, and the Royal Netherlands Antituberculosis Association. The Initiative is a global partnership to accelerate TB control worldwide and in part is a product of the successful efforts of the ALA/ATS in advocating for funding of international TB control through the US Agency for International Development.

At the first annual meeting of NASPT in 1905, two committee reports were read, "Early Diagnosis" and "Clinical Nomenclature." These reports, which served to define the state of the art on one hand and standard terminology on the other, set the pattern for future activities of both the NASPT and ASA. The Society's journal, the American Review of Tuberculosis (subsequently the American Review of Tuberculosis and Pulmonary Disease, then the American Review of Respiratory Disease, and now the American Journal of Respiratory and Critical Care Medicine) was first published in 1917. The first issue carried an article, "The Classification of Pulmonary Tuberculosis," which was the first of an ongoing series of statements entitled "Diagnostic Standards and Classification of Tuberculosis" (first so-named in 1920). The "Diagnostic Standards" document continues to provide important guidance to TB control efforts in the US. The most recent revision has just been completed.

In addition to the "Diagnostic Standards," the early ATS developed expert opinions, presented in the form of committee reports, on various clinical, research, and public health aspects of TB. Obviously, because there was no TB control agency within the federal government until 1944, when the Division of TB Control was established, these reports were not collaborative ventures but were, nevertheless, intended to guide the public health aspects of TB. Although persons employed in various federal agencies were members of some of the committees, there was no official USPHS representation (at least none identified in published committee reports) until 1943 when, in the "Report of the Committee on Tuberculosis Sanatorium Standards," it was noted that a Dr. Sharp was representing the USPHS. Additional involvement of the ATS with the Division of Tuberculosis Control was noted in the "Report of the Committee on Postgraduate Medical Education" in 1946. Dr. Herman Hilleboe, the first director of the Division, requested suggestions for the training of medical officers in TB control and asked for the committee to review courses that he had outlined.

In the same year the Committee on Rehabilitation (of patients with TB) reported that the USPHS, the NTA (and ATS), and the Federal Office of Vocational Rehabilitation would jointly provide a team to study rehabilitation programs in the US. Also in 1946, the NTA and ATS, together with the USPHS and the American Hospital Association, developed an informational package describing how hospitals should conduct mass radiography screening ("Report of Committee on Tuberculosis Among Hospital Personnel"). These sorts of collaborations continued on a more or less informal basis through the 1950s and early 1960s. In the 1960s there were several instances in which the ATS specifically endorsed USPHS reports (the US Public Health Service Task Force Report on Tuberculosis Control; the USPHS Recommendations on the Use of BCG Vaccine in the United States.)

It was not until 1971 that the first formally acknowledged joint ATS/CDC statement was published (Preventive Treatment of Tuberculosis: A Joint Statement of the American Thoracic Society, National Tuberculosis and Respiratory Disease Association and the Centers for Disease Control). Since that time joint statements have also been published on BCG vaccines (1975), eradication strategies (1978), short-course chemotherapy (1980), TB control (1983), treatment and prevention (1986, 1994) and diagnostic standards and classification of TB (1990). Currently, there are three joint statements: "Diagnostic Standards and Classification," and "Targeted Testing and Treatment of Latent Tuberculous Infection," both of which have been revised recently, and the "Treatment of Tuberculosis" that is now undergoing revision.

Although the historical and ongoing collaborations between the ATS and the CDC are exemplified most clearly by the formal joint statements, the interactions go well beyond these activities. Staff of the Division of Tuberculosis Elimination are active and valued members of the ATS, participating especially in the programs of the Assembly on Microbiology, Tuberculosis, and Pulmonary Infections, and assuming leadership roles in many of the Assembly's undertakings. Likewise ATS members, both as Society representatives and as individuals, are regular participants in a variety of CDC activities, including serving in advisory roles, contributing to training courses, and conducting program evaluations (often organized by state ALAs).

It is striking to note the degree to which the current collaborations of the ALA and the ATS with the CDC Division of Tuberculosis Elimination are consistent with the goals and activities of their forebears and adhere to traditions established early in the lifetimes of the organizations to support and advocate for scientifically sound, publicly funded, government-based TB control.

 


Released October 2008
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