Was the First Public Health Campaign Successful? The Tuberculosis Movement and Its Effect on Mortality

May 17, 2017 • Research Briefs in Economic Policy No. 76
By D. Mark Anderson, Kerwin Kofi Charles, Claudio Las Heras Olivares, & Daniel I. Rees

In 1900, 194 out of every 100,000 Americans died of tuberculosis (TB), making it the second‐​leading cause of death, behind only pneumonia and influenza. Although an effective treatment would not be introduced until after World War II, the TB mortality rate fell dramatically over the next three decades. By 1920, it had fallen to 113 per 100,000 persons, and by 1930, it had fallen to 71 per 100,000 persons.

How was TB vanquished, or at least controlled, in the United States and other developed countries? Scholars have proposed several explanations, including better living conditions, herd immunity because of natural selection, reduced virulence, and improved nutrition. The introduction of basic public health measures (for example, isolating patients in sanatoriums and TB hospitals) is another potential explanation, but scholars have questioned whether such measures contributed meaningfully to the decline in TB mortality.

Drawing on newly digitized data from a variety of primary sources, the current study explores whether the TB movement contributed to the decline in TB mortality in the United States. The movement began with the establishment of the Pennsylvania Society for the Prevention of Tuberculosis in 1892 and gained momentum when the National Association for the Study and Prevention of Tuberculosis (NASPT) was founded in 1904. Spearheaded by voluntary associations composed of both laypersons and physicians and supported by the sale of Christmas seals, the U.S. TB movement pioneered many of the strategies of modern public health campaigns.

Between 1900 and 1917, hundreds of state and local TB associations sprung up across the United States. These associations distributed educational materials and provided financial support to sanatoriums and TB hospitals, where patients with active TB were isolated from the general population and, if lucky, could recover. In addition, these associations advocated, often successfully, for the passage of legislation designed to curb the transmission of TB, including requirements that doctors notify local public health officials about active TB cases.

Reporting requirements were a key feature of the campaign against TB. These requirements prevented physicians from concealing a diagnosis of TB from their patients and allowed local health officials to monitor TB patients, ensuring that they were taking precautions not to infect others.

In several states, “careless consumptives” could be forcibly committed to TB hospitals or sanatoriums, where they were not a threat to the health of their family and coworkers. When a TB patient died, municipalities and states often required that his or her premises be thoroughly disinfected. Although remarkable in its scope and intensity, the effectiveness of the U.S. TB movement has, to date, not been studied in a systematic fashion. Using municipal‐​level data from 1900 to 1917 from Mortality Statistics, which was published on an annual basis by the U.S. Census Bureau, we estimate the relationship between pulmonary TB mortality and the introduction of public health measures designed to curb the spread of the disease.

Our estimates, which control flexibly for common shocks and municipal‐​level heterogeneity, suggest that most anti‐​TB measures had no discernable impact on pulmonary TB mortality. Two exceptions to this general result stand out: requiring TB cases to be reported to local health officials is associated with a 6 percent reduction in pulmonary TB mortality, and the opening of a state‐​run sanatorium is associated with an almost 4 percent reduction in pulmonary TB mortality. These estimated effects are robust across a variety of specifications but can explain, at most, only a small portion of the overall decline in pulmonary TB mortality observed from 1900 to 1917.

This research brief is based on D. Mark Anderson, Kerwin Kofi Charles, Claudio Las Heras Olivares, and Daniel I. Rees, “Was the First Public Health Campaign Successful? The Tuberculosis Movement and Its Effect on Mortality,” National Bureau of Economic Research Working Paper no. 23219, March 2017, http://​www​.nber​.org/​p​a​p​e​r​s​/​w​23219.

About the Authors
D. Mark Anderson, Montana State University and IZA Institute of Labor Economics; Kerwin Kofi Charles, University of Chicago and National Bureau of Economic Research; Claudio Las Heras Olivares, Banco de Chile; and Daniel I. Rees, University of Colorado Denver and IZA Institute of Labor Economics