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TB Notes 1, 2000
History of the IUATLD
by Donald A Enarson, MD
and Annik Rouillon, MD
International Union Against TB and Lung Disease
68 boulevard Saint-Michel, 75006 Paris FRANCE
The International Union Against Tuberculosis and Lung Disease (known
to its members as "the Union") is the only international
voluntary organization dealing specifically with TB. It is very
special in terms of its structure, membership, and diversity of
Roots of the Union, 1867-1914
TB was presented as a communicable disease in the first international
conference of medicine specialists convened in Paris in 1867. Conferences
specifically addressing TB followed in Paris in 1888, 1891, 1892,
and 1898. The 1899 conference took place in Berlin and, for the first
time, official representatives from both governments and nongovernmental
agencies were present. The independent developments of sanatoria (1854),
the discovery of the bacillus (1882), the opening of TB dispensaries
(1887), the development of the voluntary movement (1890), and the
organization of periodic conferences called for a centralized agency
for coordination and communication. The Central Bureau for Prevention
of Tuberculosis was formalized in Berlin in 1902, and the double-barred
cross was adopted then as its symbol. Periodic international conferences
systematically addressing clinical, research, and sociological aspects
of TB were held until the outbreak of the First World War in 1914.
Establishment of the Union, 1920-1939
In 1920, a conference on TB was convened in Paris in which 31 countries
participated, including Australia, Bolivia, Brazil, Chile, China,
Colombia, Cuba, Guatemala, Japan, Panama, Paraguay, Iran, and Thailand,
in addition to those of Europe and North America. In an impressive
procession, delegates one by one pledged "to agree on the means
to fight TB, to make a consensus on the strategy, to jointly apply
the most effective weapons to combat this common enemy," thus
establishing the International Union Against Tuberculosis (IUAT) in
its present form. It was conceived as a federation of national associations
(130 by 1999). Ten international conferences followed until 1939.
In order to supplement the routine reports of the conferences,
a regular publication was commenced in 1923. In this prewar period,
the Bulletin included administrative reports and statistics (subsequently
compiled by WHO) as well as information on the strategy and policies
for the fight against TB and results of numerous surveys on specific
aspects of the disease and the campaign. The Bulletin continued
publication until mid-1940, the final editions containing the main
reports to have been given at the 11th conference planned for Berlin
in September 1939, the very month when the Second World War commenced.
Relaunching of the Union, 1946-1961
At the first reunion of the Executive Committee after the war in 1946,
the IUAT recommended to the planners of the future World Health Organization
"establishment of a strong Division of Tuberculosis." Official
relations with the WHO were then established which continue to the
The first postwar conference in 1950 in Copenhagen, with participation
of 43 nations, was followed by a series of conferences, with the
29th world conference in Bangkok in 1998, when 105 countries participated.
Conferences outside North America and Europe were held in Brazil
in 1952, India in 1957, and Turkey in 1959. During this period a
series of international symposia were also organized, generally
in Paris, addressing a variety of topical issues such as TB in Africa,
strain variation in BCG, radiography for TB, new drugs, and the
role of voluntary agencies, among others.
In order to strengthen the administration of the growing agency,
a post of full-time Executive Director was established in 1952.
A system of quotas was devised for membership contributions. Over
many years, the American Association has continually maintained
a high quota share. Fees were also levied from individual members.
In 1951, scientific committees were commenced and met annually for
intensive discussion of the emerging strategy for the fight against
TB. In 1953, regions were established in order to remain close to
where the needs are. In 1958, the first international collaborative
clinical trial for treatment of any disease was undertaken, with
a total of 17,391 patients from 17 countries evaluated for drug
resistance. This was followed by a collaborative controlled clinical
trial starting in 1960, to evaluate the efficacy of chemotherapy
in previously untreated patients. In this period, the IUAT contributed
to annual international courses on TB control sponsored by WHO in
Istanbul, Prague, Rome, and Caracas.
A global view 1961-1978
In 1961, at the suggestion of the Executive Director, Dr. Johannes
Holm, the Mutual Assistance Program was launched to encourage transfer
of technology, resources, and information from industrialized to newly
independent countries, through the agency of national associations
in the developing countries. This was followed by travelling seminars
in Africa and in Eastern and Middle East regions, and by field projects
in Mali, Sri Lanka, Peru, and India, among many others.
Image 1: A picture of the 1982 stamp from Benin marking the centennial
of the discovery of the tubercle bacillus by Dr. Robert Koch.
In this period, the scientific committees continued to focus on
the strategy for TB control. Some examples of the activities follow.
In 1961, two international collaborative studies evaluated the test
characteristics of 1,099 films read by 90 readers from 7 countries
and WHO. A subsequent study evaluated sputum smear microscopy. Starting
in 1965, an international collaborative study on tuberculin skin
testing evaluated 75,000 children in 21 countries. Further controlled
clinical trials addressed the issue of previously treated patients
and daily self-administered versus intermittent supervised regimens.
In 1968, a survey evaluated adverse reactions to BCG vaccination,
with over 10,000 events analyzed. Also in 1968, A Technical Guide
for Sputum Smear Microscopy was published; the 5th edition of this
guide was published in 1999.
In 1965, the Tuberculosis Surveillance Research Unit was established
under Dr. Karel Styblo. It developed an index to evaluate infection
and its trends, clarified the natural history of the disease (including
transmission probabilities and risk factors), and estimated the
impact of control measures. In 1969, in collaboration with the then–Communicable
Disease Center of the United States and seven member countries in
Eastern Europe, an international trial of preventive chemotherapy
for fibrotic lesions of the lung in 25,000 individuals was commenced
and was evaluated over 5 years of follow-up. In 1973, it was proposed
that the mandate of the IUAT be extended to include other lung diseases.
However, the name of the organization was not changed to reflect
this extension until 13 years later.
In 1975, Dr. Halfdan Mahler, Director General of WHO, publicly
acknowledged the crucial role played by the IUAT in the fight against
TB. In early 1976, 18 NGOs (nongovernmental organizations) responded
to IUAT's invitation to consider jointly the role which NGOs may
and should play in primary health care (PHC) programs. The resulting
position paper was presented at the joint UNICEF/WHO International
Conference on PHC in Alma Ata in 1978.
Image 2: Picture of a stamp from Burundi commemorating the fight
Image 3: Picture of a stamp from the Republic of Korea depicting
a community x-ray campaign for TB.
Modeling the global fight against TB, 1978-1991
In 1978, in response to a request from the Minister of Health of Tanzania,
the IUAT proposed the establishment of a National TB Program under
the direction of the government and with support and coordination
of the IUAT. This proposal was the basis of a new program of Technical
Assistance of the IUAT and became the basis in 1979 for the first
edition of the TB Guide. Such assistance eventually extended to nine
low-income countries and became the basis of the current DOTS Strategy
of the WHO.
In 1981, the IUAT became the first organization to adopt a policy
that its meetings be designated "non-smoking" conferences.
In 1982, the Koch centenary was celebrated at the 25th conference
in Buenos Aires, where the Koch Medal of the IUAT was awarded to
Drs. Johannes Holm and Wallace Fox. That same year saw the establishment
of World TB Day on March 24 each year, following a proposal by the
Mali Association. In 1984 the IUAT was officially registered with
USAID, a very rare privilege for a non-US agency. The IUAT officially
changed its name in 1986 to the IUATLD to reflect the inclusion
of other lung diseases in its mandate. In 1987, a delegation from
the IUATLD visited WHO to encourage it to consider the problem posed
for TB by the emergence and spread of HIV infection that had been
noted in the collaborative projects.
In 1989, the Burden of Health Study carried out by Harvard University
was pivotal in demonstrating the cost-effectiveness of the IUATLD
model, which was instrumental in convincing planners and policymakers
to adopt the strategy as a part of the general health services.
A global fight, 1991-present
The principles of the model National TB Program, outlined on the occasion
of the retirement of Dr. Styblo in 1991, were subsequently enumerated
as the "DOTS" Strategy, promoted as the official policy
of the WHO. In that year, the international TB training course of
the IUATLD was first held in Arusha, Tanzania, to illustrate the principles
of the model program. From 1993 to 1996, the training and technical
support activities of the IUATLD were extended from a largely African
base to represent every region of the world. In 1996, the IUATLD entered
into a formal agreement to provide training fellowships with support
from the International Fogarty Foundation.
By 1998, field activities involved 10 countries in the Eastern
Region, 5 in the Middle East, 10 in Africa, 15 in Europe, 8 in Latin
America, and 2 in North America. The network of courses in management
included Tanzania, Benin, Nicaragua, and Viet Nam, and the courses
on research methods included Turkey, Kenya, South Africa, Mexico,
Chile, Argentina, Brazil, Peru, Malaysia, and China. During this
period, more than 1 million patients with TB were cared for in the
context of the collaborative programs of the IUATLD. In 1998, the
IUATLD joined with the WHO and other international partners to form
the "Stop TB" Initiative in the hopes of extending the
model to all countries of the world.
These activities were made possible thanks to funds entrusted to
the Union from richer associations and by governments of a number
of affluent countries.
Characteristics of the IUATLD
The distinguishing qualities of the IUATLD, besides its universality,
its spirit of solidarity, and its tolerance, are its continual striving
for quality and its independence. Thanks to these, it provides the
international community with an invaluable asset, namely, its pioneering
role in devising and encouraging or testing innovations. It provides
a neutral platform for international collaboration, exchange of information,
friendship, mutual esteem and education, and a reduction of prejudice.
It maintains not only a program of scientific conferences and publications
but also a program of action for health in the community, comprising
technical assistance, education, and research. Dr. Gro Harlem Brundtland
outlined the future in the following statement to the 51st session
of the World Health Assembly in Geneva in 1998: "We must reach
out to the NGO community. Their reach often goes beyond that of any
official body. Where would the battle against leprosy, TB, or blindness
have been without the NGOs?"