The paper briefly outlines the care and after care work obtained in Bangalore and compared it with schemes elsewhere. Provisions were made to help needy patients with diet and special medicines. It was felt that this was the best that could be done for these patients in the absence of sufficient hospital accommodation. It was suggested that suitable employment be found not only for the arrested case but also for the sputum positive good chronic. For care of infants, institutional separation was adopted in Bangalore as familial boarding out may not work satisfactorily. Preventoria (open air schools) for older children was not feasible due to lack of sufficient finances. It was concluded that, in India, since medical work was state-managed, State aid should be forthcoming for TB, failing which, the TB work in the country would come to a halt.

The authors discuss the general problems in rehabilitation and after-care in TB in the US and offer some suggestions to solve them. Less than 10% of the estimated 65-75,000 tuberculous persons needing rehabilitation annually, actually received such assistance. The four major objectives of the TB Control Division of the US Public Service were: 1) Case finding, 2) Adequate treatment and isolation facilities for all patients, 3) After-care and rehabilitation, 4) Protection of the patient’s family against economic distress. The Director of the US Vocational Rehabilitation Services classified available programs into five categories: 1) Social Adjustment, 2) Training and guidance, 3) Financial assistance, 4) Physical restoration and, 5) Employment. Difficulty in defining concepts and scope of activities had impacted the progress of all the phases of rehabilitation. Three key factors in estimating the actual per patient cost of rehabilitation, the types of tuberculous persons who are rehabilitated and the types of rehabilitation programs offered to the tuberculous persons are presented in detail.

Various schemes to rehabilitate TB patients operating in England such as the Village Settlement concept where ex-patients live in settlements surrounding the sanatorium from which they have graduated, pioneered by Sir Pendrill Varrier-Jones at Cambridge, and in other countries are presented to focus attention on certain fundamentals and to stress that the attack on TB must be multilateral. Few Village Settlements have been developed in the past 15 years, as they only catered to a small proportion of the total tuberculous population. For countries such as India, it is considered impractical to embark on such large and expensive rehabilitation schemes. Rather, rehabilitation should focus on serving at least the basic needs of the patients. An important flaw in rehabilitation is the failure to test the results of treatment. There is a need for medical supervision of the patient while under treatment to ascertain whether he can maintain his physical condition in spite of gradually increasing expenditure of energy in exercise of various forms. Occupations for rehabilitation patients should be based on their physical capacity. A common and widespread effort by the State, industry and voluntary organisations is needed to bring TB under control.

The problem of rehabilitation of TB patients is not confined to medicine alone. The co-operation of other fields, psychology, sociology and economics must combine with medicine to obtain tangible, positive results. Sir Pendrill Varrier-Jones’s idea to bring work to the patient has had a salutary effect and is now recognised as the main method of rehabilitation. The most vulnerable period during which relapses occur are the first two years after the TB patient’s discharge. Hence, all patients discharged from institutions should be looked after for a further period of 2-3 years while making the patients feel they are being trained in some occupation. Colonisation or establishment of settlements for ex-patients serves this purpose. The advantages of colonisation are presented. The two main factors to be considered in rehabilitation after discharge are: 1) General principles with regard to the patient (which focus on the need to address the psychological fear and needs of the patient) and, 2) General principles with regard to the industries (which highlight the need for industry to be built around a worker) and taking various steps to protect the well-being, both physical and emotional, of the ex-patients. Making the services of ex-patients available for outside jobs and using machinery to the fullest extent in industries would resolve some criticisms leveled at settlements.

Pioneering and historical efforts on rehabilitation in TB are described briefly. Out of 92 rehabilitation institutions, 72 were located in the US, 6 in the UK, 1 each in S. America, India, Ireland and the rest in the European continent. The five necessary stages of a rehabilitation programme, according to Jacobs (1940) are: 1) Family understanding, 2) Re-education, 3) Post-Sanatorium training, 4) Stage of Convalescence, 5) Placements. Various approaches, focussed on the prerequisites to rehabilitation, the classification of tuberculous patients based on economic rehabilitation, when rehabilitation should commence, the recommended occupations for ex-patients are discussed. Five types of rehabilitation projects, described in detail, include: 1) In-sanatorium programs, 2) TB Colonies, 3) Sheltered Workshops, 4) Industrial Programmes, 5) Admission into a Colony. The suggested personnel, amendable to suit specific country needs include medical staff, Social Worker/ Public Health Nurse, Occupational Therapist, the worker in Physical Medicine, the Librarian, Education Adviser, Vocational or Rehabilitation Counselor. In the second part of this article, a comprehensive rehabilitation plan of the tuberculous in Delhi, a detailed calculation of the cost and suggestions to finance the plan are presented.

In countries where TB is more or less under control, the state, assisted by voluntary agencies, provides complete care of TB persons. This service consists of medical, social, economic and industrial care of the sufferer, covering the whole period of his treatment, pre-sanatorium, in-sanatorium and post-sanatorium. In this country this service must be on a voluntary basis and for many years to come can only be adequately rendered by the TB Association and F.O.S.A.

The paper, read at the 7th TB Workers’ Conference, Bombay, 1949, presents the industrial worker’s view of and suffering due to the inadequate TB treatment and after-care facilities. The medical examination of workers in a cotton textile mill and a socio-economic survey of 1,300 women workers in a group of textile mills showed that the lower the earnings, the less was the weight of the workers and there was more sickness in the lower-paid workers of the unskilled groups compared to the better paid semi-skilled and skilled groups. When industrial workers were diagnosed with TB, typically, they were dismissed from work. If employers were willing to help diagnosed patients, then, the growing, inadequate hospital facilities were a major problem. The author cited his own published finding that the ghastly living conditions of 20,000 people (men, women and children) in the Matunga Labour Camp and in the one-room tenements underscored inadequate housing as the most important problem for industrial workers. This problem prevented the workers from being more efficient and productive, from maintaining good physical and mental health and from improving their standard of living. It also contributed to the spread of TB and other infectious diseases. While a positive step was taken by the Government by enacting the Employees State Insurance Act in 1946, three years later, it was yet to be enforced, invoking criticism for the Government’s apparent inaction. Seven suggested remedies for relief in the industrial areas and a discussion by various experts on the type of rehabilitation facilities to be provided, how and when to be made available to TB recoverers, are also included.

The paper reviews the social services offered to TB patients in Philadelphia, USA, in the hospitals, clinics, social agencies and the services of the rehabilitation facilities. From the review, it was evident that there was a lack of integrated medical and social planning in the city's TB control efforts, as observed in many practices of the agencies, either directly or indirectly involved in TB control work. A summary of these evidences is followed by recommendations confined to improving the medical social services and community social agencies.

The history of the concept of proper rehabilitation of the tuberculous is described and the principles of occupational therapy, rehabilitation and vocational training, with examples of their application, are outlined to serve as a possible guide to those who are considering setting up a new scheme for rehabilitation. The premise is that the patient’s psychological, physical, economic and social needs should be clearly understood to effect his/her complete rehabilitation. Rehabilitation is to be considered as an integral part of treatment. The principles described will need to be adapted according to the economy of individual countries which must develop schemes to suit the work available to their tuberculous patients.

The success of the entire treatment program for the patient with TB or other long-term illness lies not only with the attending physician and nurse but also with the occupational therapist. The human problems that can be benefited by occupational therapy can be physiologic, psychological or both. To be most effective, occupational therapy must offer a program of activity to meet the orders in the prescription and to help the patients overcome the deficient factors themselves. The range of activities used in occupational therapy is as broad as the needs and the interests of the patients (example, developing a scrapbook for one who has to have absolute bed rest; specific work-outs for those whose muscles have become flaccid; vocabulary building, spelling and arranging for studies within the intellectual capacities of young patients whose education was interrupted by illness), the facilities available and the ingenuity and the initiative of the therapist. Likewise, occupational therapy for young children helps them adjust to life in the hospital,, improve adverse, psychological reactions and reduces behavioural problems. For adolescents, their interests are directed toward vocational training and often, actual training is initiated in the occupational therapy programme. Occupational therapy can dramatically shorten convalescence and improve the degree of recovery in patients.

To determine whether the patient who has had TB needs training for a better job any more than those who have not had TB, 150 newly diagnosed TB cases at the Mayo Clinic, Minnesota, USA, were analysed. It was found that the ages, gender and occupations of the patients were such that only one, a miner, would need vocational rehabilitation after treatment, although others might be taught skills so as to earn more money afterwards. Finding that this group of 150 patients were not representative of all the tuberculous persons in the US or even in Minnesota, a series of 279 patients admitted to the Mineral Springs Sanatorium in Minnesota, for the first time during five years (1952-1956), were analysed. Of these patients, 152 were males and 127, females. All were 16 years old or more. Eighty-nine of the females were housewives and 8 were maids, 7 were office workers, 5 had retired, and the rest had varied blue-collar occupations. While many of the women might have benefited from vocational rehabilitation to obtain better-paying jobs, rehabilitation was not needed to prevent relapse of the disease in any case. Of the 152 males, 25 were retired and 30 were farmers. Ninety were skilled workers. There were 14 unskilled laborers and 3 whose work exposed them to silica. These last 3 were the only ones in need of vocational rehabilitation, from a medical standpoint. From these results, it was concluded that vocational rehabilitation, which was limited in availability, should be reserved for those physically disabled citizens who actually have medical indications for vocational rehabilitation.

Shortly after the establishment of the state of Israel, 501 tuberculous patients were sent to the Rehabilitation Center for TB patients at Neve Chaim. Many of these tuberculous patients had arrived sick and destitute, had gone through the concentration camps, and, the torture, hunger and fear had seriously undermined their health. Their conditions, therefore, made treatment more complicated. The aim of the Center was to restore the patients’ self-respect and make each one a tax-paying citizen through environmental treatment, individual approach and vocational training. When necessary, the medical treatment was continued to ensure the patients’ eventual discharge. Vocational training was started at about the same time as the medical rehabilitation. In selecting a trade for the patient, the person’s inclinations, the educational level, results of psychotechnic tests, the medical condition and trades for which there were openings in the labor market were all taken into consideration. The average course ran 10 1/2 months and, on completion, the trainee took the General Federation of Labor Examination. Details of the medical data of the patients, their economic and social problems, discharge problems, non-rehabilitated patients, Programme B added to the general rehabilitation programme to help effect the rehabilitation of patients in the last stages of medical treatment and, follow-up studies to determine the medical, vocational and social status of each patient, are elaborated. The follow-up observations, which ran for more than six years, showed that 80% of the patients succeeded in becoming absorbed into their communities as normal, healthy citizens. Similar measures to rehabilitate the tuberculous are recommended to be carried out in hospitals and out-patient clinics and the need for a widespread public information campaign is underscored.

The real economic loss to industry, from the prevalence of TB, is greater than the estimated cost of Rs. 200 crores and 90-100 crore man-days (1961). This is because some tuberculous workers get examined in an advanced stage, implying many unsatisfactory work days, and, some workers resume work before they are fit implying shorter hours worked. With some exceptions, the majority of the patients can receive ambulatory treatment. The author quotes several studies confirming that the regulation of physical activity was an important factor in management of the patient during illness and convalescence. The functional respiratory tests were important as a preliminary rehabilitation measure and as a control of the progress of such rehabilitation. There must be graduated movements and varied exercises in rehabilitation, with the kind of exercise being dependent on the clinical form, the phase of the disease, age, gender and occupation of the patient.

According to Carr (1959), TB patients were classified as 1) Curables, 2) Incurables. Those included in the former group are: a) Retired people, and b) Those able to return to their former occupation; Those included in the latter group are: b) Those with no former occupation, and d) Those unable to return to their former occupation because of the risk of relapse or impairment of respiratory function. The kinds of rehabilitation activities for patients in these different categories are described. The two main types of rehabilitation facilities are: 1) Village settlement, 2) Modified existing site (by combining favorable medical factors, early case-finding and intensive follow-up, with favorable social circumstances, adaptable employment). The set-up in the Philips industries in Holland is described to illustrate that the adoption of the second type of facility resulted in marked lowering of TB mortality.

The need for the rehabilitation of the tuberculous has been recognised for many decades, especially, by those engaged in the treatment of TB. A good deal of work has been done in the West in this line as manifested by the Papworth Village Settlement and the Preston Hall Rehabilitation Center in England, the Spiro Works in London and the Altro Workshops in New York. Though such colonies or settlements were attempted in a few places in India, as yet, no large scale concerted efforts have been made, probably because of the overwhelming pressure for treatment of the seriously sick and infectious. Due to the expansion and effectiveness of domiciliary treatment with the use of new anti-bacterial drugs, the village settlement type of rehabilitation is now redundant in India. The groups that need most help are the chronically ill who are still excreting Tubercle bacilli despite prolonged treatment and, those who have had lung resection and need to learn a different occupation because of reduced lung capacity. One rehabilitative measure is to have training given for cottage industries for the handicapped tuberculous and some of their family members. It is suggested that the Government should provide the necessary inducement and encouragement to non-official bodies who are better suited to provide physical and mental rehabilitation for the above patients. Suggestions are made for the involvement of the TAI in various ways to assist the TB control programme.

A study conducted in Cleveland, Ohio, is presented which explores the characteristics and rehabilitation problems of a metropolitan tuberculous population. The study was based on a random sample of 384 adult Cleveland city residents, drawn from the TB medical case register. On the basis of the findings, four sub groups of patients were identified. Three of these-the “family isolates,” the “anomic”, and the “otherwise ill”-were shown to be highly disadvantaged socio-economically, and to have especially reduced potential for successful rehabilitation. The fourth group-the “normals”-were also disadvantaged, but had much higher rates of successful rehabilitation. The problem of unemployment emerged as one of the most serious besetting the tuberculous patient. The patient’s age, lack of previous skills, the stereotyped image of the tuberculous and contemporary theories of work suitability frequently militated against his/ her successful rehabilitation. Recommendations include changes in the institutional structure to provide a more supportive institutional environment for the patients and, provision of basic skills in conjunction with a program of specific vocational training.

The decrease in the death-rates and morbidity noted in Poland and throughout the world now makes it practicable to apply, on a wider scale, the complex rehabilitation procedures which involve medical, social and vocational aspects. Nevertheless, TB continues to cause numerous individual difficulties (example, unemployment, insufficient wages, instability of marriage), attributable to incomplete stabilisation and the diminished efficiency of patients and convalescents. The task of rehabilitation is the removal or diminution of such difficulties. The distribution of patients according to rehabilitation requirements in Poland is illustrated and described.

The correct evaluation of the action against TB can be effected when the outlook of the patient is considered from many aspects based on follow-up examinations. To create an objective evaluation of the follow-up examinations, a list of the most essential parameters with 3 point values, very good, sufficient and insufficient, with 5, 3 and 0 points respectively, was compiled. Several evaluative criteria were listed under the six main parameters: 1) The clinical state, 2) state of physical efficiency, 3) employment, 4) regaining the possibility to earn, 5) regaining psychical balance, 6) regaining independence. Summation of the point values indicated the final evaluation of the medical and social results for each patient. Cases where the parameters were used for evaluation are described. The unsuccessful results of treatment and rehabilitation procedures are revealed through three other case histories. The positive measures indicated that 71.5% of the patients undergoing rehabilitation in the Rehabilitation Center in Otwock, Poland, successfully regained ability to work in a new profession. The evaluation was found effective in analysing patients’ present state and for future prognosis.

There is still some need for rehabilitation of certain groups such as the chronically ill and the drug-failure patients. TB continues to afflict the various low-income groups. As the joint family system is fast disintegrating in India and longevity is increasing, people are to rely on their own resources, especially, when other family members are reluctant to bear the burden of the incapacitated person. None of the sheltered workshops or the colony established near Tambaram in the second Five- Year Development Plan have succeeded because the light industries or handicrafts started at each center were few and people could not find jobs after the training. The problem of rehabilitation is likely to arise among the unemployed and poor, urban population than among the rich or in the rural population. The practical solution to this problem is to get ex-patients trained in small, industrial/ vocational establishments near their homes to avoid difficulties such as daily travelling for long distances. Suggestions have been made to add certain trades to those that are offered for rehabilitation purposes. It is also recommended that social workers, with the doctors, should review the possibility of rehabilitation for every patient soon after the start of treatment to prepare the patient to adjust psychologically to the changed condition and for training.

The objective of the study was to improve the financial condition of poor TB patients during and after the full course of treatment. Out of 1,472 suitable patients, 972 socio-economically poor and disabled TB patients from rural and urban areas were admitted to the Vocational Rehabilitation Center in Dhaka, Bangladesh. They were divided categorically and given vocational training in different areas based on their aptitude, education and socio-economic conditions. The progress of training of each patient was assessed every month. The details of the training given in different fields with the results of final assessments are presented in a table. After the final assessment of progress of training, the disease status and the provision of work facilities, 905 out of 972 patients received certificates. 67 patients did not receive certificates because they were far advanced cases and did not progress well after treatment. Those unsuccessful patients with minimal lesions left the hospital before completing their training. Based on the findings, it was concluded that control of TB could be achieved through effective treatment and provision of vocational training to patients so that they could complete the full course of treatment, earn money and properly rehabilitated.

TB patients do not go to the TB clinic for treatment for fear of social boycott from their friends and relatives. Therefore, there is a need to create community worker groups to impart health education and create confidence among patients and the population. Such groups, formed at one each for one hundred thousand persons, could encourage the patients to seek treatment and assist in providing the needed medication. Creating rehabilitation centers to help affected families add to their earnings and fund-raising are suggested measures to control TB.