some reflections on the tuberculous in industry

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Some Reflections on the Tuberculous in Industry By MANN, Con s ultant Tuberculo sis Officer, West Riding C.C. of Iotkshire ; Tuberculosis Officer, Doncastei County B.C. For years the after-care attention meted out to post-sanatorium cases has been the Cinderella of the Tuberculosis Service. This has been due to a variety of reasons. In the main, the results were lessspectacular than those of the operating theatre and hence never achieved the same popularity in the lay mind; and again with a floating peace-time unemployed population of about 3,000,000-healthy labour was at a premium. There were a few outstanding pioneers like Sir P. Varrier-Jones, who saw the problem clearly and endeavoured to make some contribution to its solution. Undoubtedly, the establishment of Papworth Settlement was an immense advance on the threadbare schemes previously in vogue. It appreciated that dispensary, sanatorium and after-care were in essence complementary methods in the treatment of tuberculosis, and not merely unrelated and independent aspects of the problem. Further, it demonstrated that a large percentage of tuberculous subjects were fully capable of productive labour when utilizing modern industrial technique. However, even with the best leadership and intention such a scheme on a local basis, and in a competitive market could never hope to cope with a gigantic national problem. To-day there is a growing demand for a more progressive and rational attitude to this immensely important question. Man-power has assumed outstanding significance in our national life, and the fact that there are as yet untapped resources amongst tuberculous subjects has been acknowledged in recent statements of the Ministry of Labour. It seems clear that while this is not the ideal approach to the problem- that considerations of a national emergency rather than a sympathetic desire to effect a solution of the tuberculosis problem has been responsible for the recent ministerial pronouncements- -yet the experience gained can be effectively utilized in the future to place a possibly. makeshift and temporary scheme on a more rational and permanent basis. Therefore, it behoves us to assist the present measures in the fullest possible manner while appreciating their limitations, In a recent Ministry of Labour and National Service Circular, Local Authorities were advised to place the services of their Tuberculosis Officers at the disposal of the Local Employment Exchanges in the selection of negative and quiescent cases, who were in their opinion suitable for industry. This is for two reasons an important advance. Firstly, because it represents a national and not a local or philanthropic approach to the problem, and, secondly, because it establishes an effective liaison between the Labour Authorities and the Medical Officers. Unfortunately, the proposed scheme merely agrees to the employment of negative and quie scent subj ects, and thus limits the available candidates to a small fraction of the physically suitable tuberculous labour. The vast bulk of usefully employable tuberculous subjects- the 'middle case' with a positive sputum-is entirely omitted from consideration. It may well be argued that there is an unshakeable

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Page 1: Some reflections on the tuberculous in industry

Some Reflections on the Tuberculous in IndustryBy BERTRA~1 MANN,

Consultant Tuberculosis Officer, West Riding C.C. of Iotkshire ; Tuberculosis Officer,Doncastei County B.C.

For years the after-care attention meted out to post-sanatorium cases has been theCinderella of the Tuberculosis Service. This has been due to a variety of reasons. Inthe main , the results were lessspectacular than those of the operating theatre andhence never achieved the same popularity in the lay mind; and again with afloating peace-time unemployed population of about 3,000,000-healthy labourwas at a premium.

There were a few outstanding pioneers like Sir P. Varrier-Jones, who saw theproblem clearly and endeavoured to make some contribution to its solution.Undoubtedly, the establishment of Papworth Settlement was an immense advanceon the threadbare schemes previously in vogue. It appreciated that dispensary,sanatorium and after-care were in essence complementary methods in the treatmentof tuberculosis, and not merely unrelated and independent aspects of the problem.Further, it demonstrated that a large percentage of tuberculous subjects were fullycapable of productive labour when utilizing modern industrial technique. However,even with the best leadership and intention such a scheme on a local basis, and in acompetitive market could never hope to cope with a gigantic national problem.

To-day there is a growing demand for a more progressive and rational attitude tothis immensely important question. Man-power has assumed outstanding significancein our national life, and the fact that there are as yet untapped resources amongsttuberculous subjects has been acknowledged in recent statements of the Ministryof Labour. It seems clear that while this is not the ideal approach to the problem­that considerations of a national emergency rather than a sympathetic desire toeffect a solution of the tuberculosis problem has been responsible for the recentministerial pronouncements- -yet the experience gained can be effectively utilizedin the future to place a possibly. makeshift and temporary scheme on a more rationaland permanent basis. Therefore, it behoves us to assist the present measures in thefullest possible manner while appreciating their limitations,

In a recent Ministry of Labour and National Service Circular, Local Authoritieswere advised to place the services of their Tuberculosis Officers at the disposal ofthe Local Employment Exchanges in the selection of negative and quiescent cases,who were in their opinion suitable for industry. This is for two reasons an importantadvance. Firstly, because it represents a national and not a local or philanthropicapproach to the problem, and, secondly, because it establishes an effective liaisonbetween the Labour Authorities and the Medical Officers.

Unfortunately, the proposed scheme merely agrees to the employment of negativeand quiescent subj ects, and thus limits the available candidates to a small fraction ofthe physically suitable tuberculous labour. The vast bulk of usefully employabletuberculous subjects- the 'middle case' with a positive sputum-is entirelyomitted from consideration. It may well be argued that there is an unshakeable

Page 2: Some reflections on the tuberculous in industry

March 1942 TUBERCLE 73

prejudice on the part of employers to the utilization of such potentially infectivematerial. Again, it is true that there is a deep-rooted bias in the minds of both theemployees and their unions against such a practice, in case the possibility of infectionmight occur. Such may be the case, yet there is nothing in the existing method oflabour recruitment in factory or workshop which precludes the entry of positivecases into industry. Very probably a goodly number of positive cases of the chronicfibrotic type has successfully passed the medical examination of the factory surgeonand has been admitted to industry. Furthermore, there are many factories, especiallyof the middle or smaller type, where no medical examination exists as a conditionof employment. Thus, at present it is clearly, if expressed in simple economic terms,to the advantage of the positive tuberculous subject to enter industry withoutdeclaring himself to be either tuberculous or infective. It does appear a ratherparadoxical situation, that whereas the Ministry of Labour have issued their circularwith the object of limiting infection, the non-existent or even cursory medicalexamination is quite incapable of attaining such an end. What is even more con­fusing is the repeated assertions of leading members of the War Cabinet that thefactory worker is in the front line and is performing as vital a service to the nationas the fighting services. Yet, whereas in the Navy or Air Force full-proof measureshave been taken to avoid the dissemination of the tubercle bacillus and in the Armya half-hearted approach has been adopted (absence of mass radiography)-no com­prehensive scheme of medical examination has been adopted to cater for the ever­increasing numbers of potentially infective workers who are flowing into the work­shops of Britain.

What immediate practical measures can be taken to extend the employment oftuberculous cases with the maximum protection to their fellow workers?

The Ministry of Labour and National Service has made it clear in several recentpronouncements that part-time employment is to be the 'New Order' in thefactories for married women with domestic responsibilities. Surely an extension ofsuch a scheme to include tuberculous subjects is the logical approach in the solutionof this problem? Not merely will it prove of undoubted assistance in the nationaleffort, but it would be an important 'grading' measure in the resumption by thetuberculous patient of normal working conditions. Furthermore, it cannot but havean extremely beneficial psychological effect on the tuberculous subject. The old dayswhen he constituted the rotting human vegetation on the industrial garbage heapwill have passed and he will have reassumed a value to his fellow citizens.

Such a scheme of part-time working would, however, imply an extremely lowstandard of living for the tuberculous subject and his family. For such a measure tobe practicable all wage earnings from part-time labour would have to be supple­mented from the Exchequer to full wage levels and a sliding scale adopted dependenton the periodic assessment of the working capacity of the tuberculous patient. Suchcapacity for work could best be estimated by the Tuberculosis Officer in' much thesame fashion as is now his practice for Navy Pensions.

There still remains the all-important problem of conquering the bias of theemployers and also the employees against the utilization of potentially infectivelabour. In this regard much can be done by its initiation (with adequate safeguards)into existing national industrial establishments and by intelligent propaganda.

It might be possible to segregate the infective 'middle case' as a group in aseparate workshop in an immense factory. Alternatively, a small factory with

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74 TUBERCLE March 19+2

a capacity of approximately one hundred employees might well be manned exclu­sively by infective subjects. There are certain dangers in the acceptance of theformer thesis, that there is a passionate hatred on the part of cases to be isolated andsegregated from their healthy workmates. Yet, this is surely far better than theexisting practice where virtually no control exists in the appointment of new, andpossibly infective 'hands' to an establishment. The management in such a factorvcould, with the assistance of the Industrial Medical Officer, investigate the pro­vision of canteen, hostel and rest-room facilities. In many cases where 4-6 hourshifts would be employed some of those welfare arrangements would probably proveto be unnecessary. It may well be shown, if either of those schemes were adopted, theproductivity in terms of man-hour labour, especially in highly skilled tasks, mightprove to be as high in the tuberculous subject as in the healthy workman. Such,indeed, has been the experience in the U.S.S .R.

Further, there are a considerable number of physically lighter tasks which couldbe performed just as satisfactorily by a tuberculous subject with a 60 to 80 per centworking capacity as by a normal healthy adult. There appears, therefore, no logicalreason why such man-power readjustments should not become a definite nationalpolicy. Indeed, a similar sifting of personnel already exists in the Services, wheretroops are allocated tasks they are most satisfactorily able to discharge, viz. physicallyfit clerical workers are being redrafted to front line regiments, and Cg front linetroops are being allocated less strenuous du ties.

There are , however, certain basic conditions which not to admit or fulfil wouldbe to doom any scheme to a premature failure .

Information about tuberculous disease or previous treatment at a sanatorium ordispensary should be made compulsory for all persons entering industry. This is thepractice at military medical boards and there appears no legitimate reason why thisshould not be incorporated into the civilian industrial life of the country. Such ameasure would ensure the control of infection in the interests of the health of thecommunity. Naturally, such a course will occasion opposition. It will be argued thatthis represents an encroachment on the freedom of the individual; however, freedomwould be an intolerable institution if it permitted an individual indisc,riminately toinfect with disease his fellow creatures.

An extremely strong case can be made out in view of the recent extension of theDefence Orders making the treatment of scabies compulsory in the interests ofnational health. The extension of such a Defence Regulation to incorporate tuber­culosis should prove a relatively simple legal measure.

A further difficulty is that such a compulsory measure might well be consideredto prejudice the earning capacity of the tuberculous subject after the presentemergency has passed. It is thus incumbent on the Ministry to prepare a compre­hensive scheme for the subsidy of part-time labour coupled with a pledge that suchinformation as is obtained will not be used against the subject 's interests.

It would be palpably absurd to pretend that such measures alone would resultin the absolute control of tuberculosis. As has been indicated by many authors andhas been shown following mass radiological surveys, there are many people whosuffer from 'symptomless' tuberculosis. These are to be found amongst the industrialas well as other sections of the community. Hence, the exclusion of known infectivecases would, like the partial closure of a cavity, limit, though not eliminate, tubercu­losis in the factory. It must be clearly recognized that just as complete closure of a

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March 194-2 TUBERCLE 75

cavity is essential to obviate further extension of disease; similarly, examination of allindustrial workers in and entering factories is necessary for the complete control ofphthisis in the workshop.

Mass radiography alone can solve this problem. This too will occasion opposition.The T.U.C. has, however, recently enunciated its stand on this question, which,broadly speaking, endorses the policy of the National Association for the Preventionof Tuberculosis. Their attitude will in a large measure govern the reception thisproposal receives from the employees.

At such an early stage it is hardly necessary to elaborate the methods of classi­fication of cases. Clearly it would be unwise to place all individuals exhibiting someradiological opacity into the tuberculous group, and segregate them in specialworkshops or factories alongside infective cases. The criterion will have to dependlargely on the degree of infectivity of each individual case, when detected by massradiography. There are immense possibilities in such a scheme which have beenstressed by many workers, and which hardly require further elaboration in anarticle of this character. It must, however, be clearly indicated that a comprehensivepolicy of the type outlined cannot but playa significant role in the early diagnosisof tuberculosis, and in the prevention of the dissemination of the bacillus. Further, itutilizes the potential tuberculous labour in the national interests in the most carefuland discriminating fashion. Graduation of work could well become the corner stoneof not merely the ideal sanatorium life, but also the routine measure of ordinaryworking life.

Finally, it must be confessed that the suggested proposals bristle with difficulties.Mistakes too will inevitably arise in the translation of theory into practice, but thereare such immense possibilities that might emerge from the present embryonicscheme that we should not hesitate to stimulate its growth and development byevery means in our power.