ADDRESS OF THE HONORABLE JOHN E. FOGARTY, MEMBER OF CONGRESS FROM THE SECOND
DISTRICT OF RHODE ISLAND, BEFORE THE NATIONAL TUBERCULOSIS ASSOCIATION
CONVENTION, PHILADELPHIA, PA., MAY 19, 1958.

It is most gratifying to be with you on this occasion. The annual
meeting of the National Tuberculosis Association is, I know, a most signifi-
eant occurrence in the nation's calendar of public health events.

In Washington where I serve, among other capacities, as chairman
of the committee of the House of Representatives responsible for the appro-
priations of the Department of Health, Education, and Welfare, I am kept
fully aware of your part in the progress that has been made in combatting
tuberculosis. The story of your Association is a splendid record of achieve-
ment against great odds. Indeed, I believe that your efforts as community
leaders and shapers of public opinion, and your vigorous cooperation with
State, local, and federal health agencies, have been largely responsible for
our present favorable position in the attack on a disease that has been a
scourge from the beginning of recorded time.

There is another area of interest which you and I share. I refer
to the field of medical research, including that aspect of medical research
that has to do particularly with the prevention and treatment of tuberculosis.

For more than 15 years I have derived great personal satisfaction
from being privileged to have a part in the formulation of our national pro-
gram for the conduct and support of medical research. I know the National
Tuberculosis Association has made many notable contributions to research in
its field of special interest--not only directly, through financial support
of productive projects, but also indirectly, through calling the public's
attention to research needs.

Through your rich relationships with the people--by means of your
special knowledge, your insight, and perseverance-~you build, in a real and

vital sense, a portion of the health structure of tomorrow. The voluntary
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tuberculosis worker clearly perceives what must be done, day in and day out,
to bring about the defeat of tuberculosis. He has the vision to see problems
that require inmediate action and to devise programs that will be uniquely
suitable for his community to undertake.

Above all others, the voluntary health worker, because of his close-
ness to the people, is most keenly aware of the feasibility and practicality
of plans for public health action. No one from Washington or anywhere else
can tell him what the people are ready for and what methods he must use to
achieve his goals.

Indeed, the pattern of future action in the control of tuberculosis,
as well as the course of total public health activity, depends in large part
on the understanding, the community acceptance, and the foresight of the local
voluntary health worker. His effectiveness, in turn, is determined by the de-
gree of his identification with the people of his community.

As one who is privileged to serve in the House of Representatives,

I have frequently had occasion to witness, to participate in, and to reflect
on the fundamental meaning of the democratic process, especially as it ap-
plies to the health and welfare of the American people.

Throughout the hearings on Federal health and welfare appropriations
over which I preside, I am always impressed by the deep humane concern of the
men and women who serve the people's purposes through the instrumentalities of
government. Repeatedly, it is made clear to me that if there is one character-
istic of American life that sets us apart from other nations, it is the way in
which our people give expression to their will and desire.

As a result of concerted citizen action, we have achieved in our
nation a proud record in public health and welfare.

This annual meeting is an excellent example of American democratic

action. Without such organization as yours, present achievements in the control
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of tuberculosis could not have been realized. Our strong federal, State, and
local official agencies could not have come into being and could not have grown
to their present stature without the united forces of citizen opinion and ac-
tion. Our American willingness to cooperate toward the achievement of desirable
goals, our people's generosity with money, time, and energy, have enabled us to
succeed in the control of a devastating disease like tuberculosis as they have
permitted us to prosper as a nation.

My work in Congress and my continuing concern for and interest in
public health problems permit me to believe that this morning I am among
allies. There is, therefore, no need for me to entreat you, to recruit, or
to justify. As citizens, we are in the same struggle. We work toward the
same end--the defeat of tuberculosis. And though you are experts and I am not,
we speak essentially the same language--one that bespeaks our desire to be free
from a lethal enemy of mankind.

I don't have to convince you of the seriousness of tuberculosis, nor
do I need to describe the almost miraculous advances that have been made toward
its conquest. Progress in solving the problems of tuberculosis is something
that we sense, even in the absence of statistical proof, as a reality, We do
not need constant reassurance to know that we are steadily approaching the
ultimate goal--the elimination of tuberculosis as a public health problem.
However, each step closer to that objective exposes new and challenging prob-
lems which demand solution. And if you, as leaders in a disease-control move~
ment that reaches every home in your States, are to reach that goal in the
foreseeable future, you must be convinced of the still urgent nature of your
mission. You must continue to demonstrate to the people the real need for
continuing, unrelenting effort.

To be sure, it is deeply satisfying to live and work in an era when,

for the first time in countless centuries, tuberculosis can be, and in this
Ao

country has been reduced to virtual impotence as a dealer of death. But there
is danger in such satisfaction, for it may weaken our awareness of the in-
escapable fact that tuberculosis still remains a mighty threat as a source

of prolonged illness, disrupted families, personal anguish and lost economic
productiveness.

As a layman who tries to keep informed in health matters and as a
Representative who is decply concerned about organized programs in the pre-
vention and control of tuberculosis, I am greatly encouraged, as you are, by
the continuing decline of the death and case rates. The Public Health Service
informs me that since 1939 the death rate has declined in the United States
from 47.1 per 100,000 population to 8.3 in 1956. Provisional figures show a
further decline for 1957.

Indeed, with every passing year fewer people die of tuberculosis;
illmess from the disease decreases in frequency and severity; and fewer chil-
dren and young adults are infected. The year 1956 is a milestone in the his-
tory of the attack on tuberculosis. In that year newly reported cases showed
a decline more precipitous than any in recent years. For the first time morbid-
ity exhibited a greater decline than mortality. Newly reported cases fell 10
percent below the figures for 1955; the death rate fell by 6 percent. It can-
not be said yet that this is a real breakthrough; but it does indicate a level-
ing off of the death rate, while reported cases continue downward.

Nevertheless, nearly 14,000 persons died last year from tuberculosis.
Sixty-nine thousand new, active, and probably active cases were reported to
health authorities. There are 250,000 active cases of tuberculosis in the
United States today plus 550,000 inactive cases that require public health
supervision and service. These active and inactive cases, old cases, and the
millions of infected people constitute a reservoir of disease that could reverse

the great advances of the past.
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Progress always presents new problems. At this very moment there
are approximately 300,000 tuberculous persons in this country who are not
in hospitals and who are in need of supervision and service. In most of
these cases, drugs must be administered and clinical services provided over
a period of 18 to 24 months after hospital discharge. However, studies con-
ducted by the Public Health Service show that a startling proportion of these
patients are not receiving adequate care and supervision. For the country as
a whole, there has not yet been developed a workable system whereby persons
with tuberculosis outside hospitals can realize the full benefits of modern
medical and public health resources. Now, and in the future, much of this
responsibility for providing and arranging the services needed by tuberculosis
patients outside hospitals will rest on State and local health departments.

However, if this disease is to be kept under control and the af~-
fected individuals restored to productive lives, these patients -- the poten~
tial sources of new disease--need drugs, continuing medical and nursing super
vision, and essential social and economic counsel. Only in this way will the
public as a whole, as well as these sick persons, receive the full benefits
of the great therapeutic gains of the recent past.

I have left to the last a discussion of research, because I wish to
place special emphasis on it as a predominant factor in the future of the
tuberculosis control movement.

Not many years ago it was not uncommon for authorities in the field
of tuberculosis to express the conviction that sufficient knowledge was already
available to make the eradication of tuberculosis a possibility within a few
generations if established control techniques were effectively applied. More-
over, interest in research was, until very recent years, limited to laboratory
investigations, and responsibility for it was largely centered in special in-

stitutions and groups. But today we see new support for research in tuberculo-
ae

sis and new evidence of widespread interest in epidemiological as well as
laboratory studies. Moreover, responsibility for research has been accepted
by a wide range of operating programs as well as by special institutions. A
most significant development, indeed, has been the growth of cooperative
clinical investigations which make use of multiple disciplines, staffs, and
facilities, thereby permitting nationwide research studies that include large
and diverse population samples.

I should like to cite two examples of such research now being car-
ried on by the Public Health Service or through projects supported by the
National Institutes of Health. They are: (1) the careful testing, by means
of controlled studies, of the effectiveness of isoniazid as a preventive, or
prophylactic, of tuberculosis; (2) the development of a vaccine that does not
have the disadvantages of BCG.

Studies of isoniazid as a prophylactic, conducted by the Public
Health Service in cooperation with the National Tuberculosis Association,
showed such promise among laboratory animals that trials of the drug as a
preventive of tuberculosis in human beings have been organized and are now
going forward in numerous commmities throughout the country.

In initial project, involving mcre than 2,700 children in 33 pedi-
atric clinics in the United States, Puerto Rico, Mexico, and Canada, tested
the effect of isoniazid in preventing complications of primary tuberculosis.
The first results from this work show that during the twelve months these
children have been taking isoniazid, at least 80 percent of the major com-
plications of childhood tuberculosis were prevented. On the basis of these
findings, health agencies and private physicians are provided with a new,
well-confirmea method of control that can be applied now.

To complement this knowledge, further research is required to de-

termine whether this protection continues for an extended period after the
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drug is discontinued and whether similar protection can be given other popula-
tion groups under different conditions. Therefore, studies among close con-
tacts of newly discovered cases of tuberculosis are being carried out. Trials
have already begun in about 40 communities and institutions in 16 states. Ad-
ditional groups are being added to this research project monthly. A peak
workload on this research will probably be reached in fiscal year 1959.

The second aspect of research--the development of a vaccine--has
become a subject of increasing interest to me. The experts tell me that we
need a vaccine which may be given to everybody regardless of his reaction to
the tuberculin test; one which is, of course, not only safe but without reac-
tions of any consequence; one preferably consisting of killed micro-organisms;
and one which produces a solid immunity. If and when such a vaccine is avail-
able, mass immunization of the entire population may have top priority in the
tuberculosis control program.

Research now going on under the auspices of the National Institutes
of Health and elsewhere gives some promise that such a vaccine may ultimately
be realized. But, of course, it is too early now to make predictions. The
development of a vacciné, as you well know, is a long, laborious, arduous
task. You may be assured, however, that this work will have my abiding in-
terest and persistent support. Perhaps, in some future year not too far dis-
tant, you may again invite me to attend your annual meeting, and I may then
be able to discuss with you a great achievement in the field of tuberculosis
vaccination. Let us hope.

There are many other areas of action and fact-finding that might
well engage our attention this morning, but their proper forum is in your
discussion sessions and scientific meetings. I want merely at this time to
salute you for past work ably done and to express my deeply felt wishes for

the future.
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Despite the magnitude of your achievements, the job that remains
to be done is enormous.

It is easy to formulate a hundred unanswered questions in the field
of tuberculosis control--those of poverty, malnutrition, mental and emotional
imbalances, unhealthful and crowded housing, industrial health hazards--all
of these plead for your attention and action insofar as they contribute to
continuing illness from tuberculosis.

Although tuberculosis has diminished in force as a lethal enemy of
mankind, it will remain a threat as long as the tubercle bacillus continues to
infest the human body. The history of tuberculosis demonstrates again and
again the insidious resourcefulness of this bacillary organism.

We all know that the mortality rate alone does not reflect the
social menance of tuberculosis. Indeed, it is through prolonged destructive
illness that tuberculosis takes its social and economic toll. To be sure,
it is a task of prime magnitude to save people from untimely death. But the
way to prevent these deaths is to fight tuberculous disease. The incapacitat-
ing character of tuberculosis, the broken homes, the loss of productivity con-
stitute the essential challenge. Even were there no deaths from tuberculosis,
its devastation as a long-term illness would demand our utmost vigilance.

I know that you will go on to even greater achievements if you are
eareful not to cling to things that are finished. We all must be willing to
accept changes and face new challenges with unremitting vigor and unflagging
imagination. Moreover, you must never lose sight of the irrefutable fact that
the success of the voluntary movement in tuberculosis control depends upon a
broad base of citizen cooperation, support, and action.

You must fight complacency on all sides and refute the smug assump-

tion that in tuberculosis little remains to be done. No thinking person can
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be complacent in the face of the long list of unfinished business, not only
among tasks not yet undertaken but also among tasks not yet done well enough.
Yes, there is still much to do. Citizens, now as in the past, will
tackle new challenges with the resolute vigor that has always characterized
American democratic action. But let us, however, remember that all our
future public health work depends not only upon organizational functioning
put also upon the kind of public interest and understanding that tuberculosis

associations have persistently stimulated and maintained.