The financial burden borne by the various communities as a result of this migration cannot be exactly measured. As far as possible, however, the cost of all tuberculous activities in each of the cities was ascertained. The results show that the highest cost was in Phoenix, where the per capita yearly cost for each member of the community, men, women, and children, was $1.75 for the support and relief of the tuberculous. The financial burden in San Antonio was least. Colorado Springs, being a small community like Phoenix, carried a large financial burden, the cost per capita at that time being $1.00 per year.

Probably the saddest and most tragic part of the story was the inability to get adequate facts in regard to what happened ultimately to these tuberculous migrants. This is of the most vital concern, and a test of the community treatment of them. From the records it was found that 54 per cent were lost sight of, 13 per cent had died, 10 per cent were known to have moved out of the city, and only about one-fourth were known to be still in the city at the end of the year.

The enormous burden carried by the Southwest can best be evaluated by comparing the figures for these six cities with those of the city of Cleveland, in which a similar study was made. In the latter city with its facilities for caring for the tuberculous, only 11 per cent of all such persons reached by social agencies were non-residents (that is, had been resident in Cleveland less than two years).

No one who has traveled in the Southwest could be unaware of the magnitude of the problem. Every train carries an appreciable number of tuberculous, and the social and medical agencies in the cities are overtaxed to meet the pressing needs of these persons.

There can be no question that climate alone is not able to cure. The patient must have freedom from worry, rest, proper food, clothing and housing, as well as the effect of climate, to be successful in his quest. The indigent tuberculous is coming to the Southwest with none of these other necessary aids to cure. As a result, the deaths from tuberculosis in one county of Arizona constitute one-third of all deaths, and the tuberculosis death-rate of the state is over 300 per 100,000. It has therefore been the purpose of the National Tuberculosis Association and its affiliated state associations to attempt to keep these wanderers from a search which can only result in failure.

Many state tuberculosis associations, principally of the Middle West, have attempted to stem the tide by publishing folders with such titles as "Get Well in Indiana," or "Take the Cure in Michigan." In these folders they attempt to present the advantages of treatment at home with adequate care and freedom from worry as against an attempt at the cure in the Southwest without adequate funds. The National Tuberculosis Association also has in its publicity attempted to define these same advantages of treatment at home.

Whether this campaign of publicity had been successful in reducing the number of indigent tuberculous in the Southwest was made a matter of recent

study by the National Tuberculosis Association. It was thought that by comparing the figures obtained in the study of four years ago with present figures obtained on a strictly comparable basis it would be known whether the migration to this section was increasing, decreasing, or stationary.

Accordingly, two cities of the six formerly studied were selected for comparative purposes. These two were Phoenix and Colorado Springs. These were chosen primarily because of their smaller population, and because, accordingly, the ratio of the tuberculous to the general population was greater in these two cities.

The recent study shows that there has been a slight decline in the number cared for in Phoenix, amounting to approximately 9 per cent. But one must remember that between the two years, 1920 and 1924, there has been a 20 per cent decline in the death-rate and a corresponding decline in the incidence of the disease. Therefore one might expect that if the migration of indigents to the Southwest had kept pace only with the incidence of the disease there might have been a 20 per cent decline in the number found in those cities in 1924. As a matter of fact there was only a 9 per cent decline in Phoenix. Therefore we must conclude that instead of a decrease in migration there has been a relative increase.

While no definite study was made in El Paso, inquiry was made of the persons dealing with the migratory tuberculosis problem in that city and it was felt that there had been a slight numerical decline, although, as has just been pointed out, it amounts to an actual increase when viewed in the light of the decline of the disease itself.

But the most interesting fact brought out in the recent study is the very definite and decided increase in the number of indigent tuberculous in Colorado Springs. Between 1920 and 1924 there was an increase of 21 per cent in the number of indigent tuberculous cared for in that city. The former study included 385 persons; the latter one, 466.

In commenting on the results of the earlier study the writer said, "None of these cities has anything like adequate provision-medical, relief, or institutional-for caring for tuberculous persons, whether resident or non-resident." After four years that statement is still true. Colorado Springs, however, is probably better equipped to cope with the problem than any of the other six cities. And in addition it has less intolerance for tuberculous persons. It has definitely recognized the problem of the indigent health seeker and is taking all who come, the poor with the rich, and attempting to meet its obligations in this respect. It does not take news of that sort long to spread among health seekers, and it is undoubtedly on this account that the migration to Colorado Springs has increased so tremendously.

In Phoenix the policy for many years was to return, on half-rate charity tickets, non-residents whose residence could be established and who were tuberculous and liable to become a charge on the community. That policy

cost considerable money, but it relieved the community of a continuing burden. In Colorado Springs, however, this practice is seldom resorted to, and usually only in cases where the patient is willing to return.

We were interested to know whether these increases in migration in Phoenix and Colorado Springs had been attended by any major changes in the character of it. In recent years considerable has been written about the "gasoline gypsies," as they are picturesquely called. With the increase in facilities for purchasing cheap autos, many families are following the well-known slogan and seeing America first. For a time the health workers of the Southwest claimed that this was greatly increasing their burden, because many tuberculous persons were arriving in autos, in various degrees of dilapidation, accompanied by large families. However, it has been found by several studies that these migrants are not by any means in the majority, and that only about 30 per cent of them are tuberculous. They are therefore only a single phase of the problem and by no means the most important one.

The general character of the migration remains unchanged and confirms the accuracy and generality of the findings of the earlier report. As regards the proportion of men, the need for aid shortly after arrival, the proportion of the migrants who bring their families, the age groups, the percentages in the two years, 1920 and 1924, are practically the same.

A very interesting phase of the study was the fact that the sources of migration to Colorado Springs had changed very slightly; Missouri, Kansas, Illinois were first, second, and third in rank according to the number of their residents sent to Colorado Springs in 1920, and they had the same order and rank in 1924. Oklahoma, Kentucky, and Indiana were fourth, fifth, and sixth in 1920, and had the same rank in 1924 with a slight change in the order.

There is a different story in Phoenix. The states which led in the number of their residents sent to Phoenix in 1920 were, in order, Illinois, Ohio, New York, Pennsylvania, and Missouri. In 1924 New York and Pennsylvania have dropped out of the picture and their places have been taken by Michigan and Oklahoma.

While the fatality rate among all known cases may not be a particularly significant figure, it is of interest to note that in Phoenix in 1924 there was one known death in every six known cases; in 1920 there was one known death to every seven cases. In Colorado Springs in 1920 the ratio was one death to every seven cases, and in 1924 one death to nine cases.

In Colorado Springs there seems to be no large group of foreign-born among the non-resident tuberculous, while in Phoenix the situation is complicated by nearness to the Mexican border and the consequent Mexican colony among which are many tuberculous. They constitute about one-eighth of the tuberculous population. In Phoenix tuberculous negroes are more in evidence than in Colorado Springs, perhaps because in the former city a hospital for negroes has recently been established, to which tuberculous negroes are admitted.

Along with the increase in migration to Colorado Springs has gone a corresponding increase in the financial burden carried. In 1920 the amount spent for the tuberculous in Colorado Springs was approximately $32,000; in 1924 it was nearly $41,000.

In Phoenix the estimated total expenditures for tuberculosis in 1920 was $51,000, most of which was in out-door relief administered by the county supervisors. The amount spent in 1924 probably fell short of that by a few thousand dollars.

As before, there was the same story of emergency relief and the passing from ken of the patient, costing the community much financially and receiving no lasting benefit.

What of the future? We have seen that all the publicity efforts have not succeeded. The migration of the tuberculous to the Southwest is increasing. In Phoenix there has been a 9 per cent decline between 1920 and 1924, while a 20 per cent decline was taking place in the country at large between the two years.

In Colorado Springs an increase of 21 per cent in the migration took place between the same two years. Both communities are trying to meet their needs in this respect to the limit of their respective abilities. Colorado Springs is second in rank in the country in the per capita amount raised by the Federation of Social Agencies. Phoenix had a hard time this year to meet its budget for very necessary social work. Financially they are at their wit's end.

Colorado Springs is still advertising its climate and may expect a considerable increase in its tuberculous population. Are these cities going to be able to meet this increasing and continuing burden? If so, how? If not, what is to be done about it?

THE RESPONSIBILITY OF STATE AND MUNICIPAL AUTHORITIES AND TO THE MIGRANT CONSUMPTIVE

Jessie D. Lummis, Executive Secretary, Tuberculosis Society,

Denver

In our discussion of the responsibility of the state and municipal authorities to the migrant consumptive it is important that we consider an aspect of the problem as it affects our western and southwestern communities.

It is not alone the consumptive individual who is the confirmed wanderer, the unstable individual whose fetish is climate but who gives no climate a chance to work its proclaimed magic for him, who makes up our migratory tuberculosis case. The case with a vast number of ramifications has been assembled for us throughout all our years of settlement and development and is still being assembled. This has been in no way more clearly illustrated than it was to me just recently by a few figures collected from the past year's work in the nutrition classes conducted by the Denver Tuberculosis Society.

In these demonstration classes conducted in public and parochial schools in Denver 450 children were given a complete physical examination during the year. With the exception of four rooms of first-grade children, where the entire room was examined, the group was composed of underweight children-some seriously underweight, as we call those 7 per cent or more below the standard weight-table measurements, some in the borderline, between the 7 per cent and the standard line. Of the total number examined, 18 per cent, or nearly onefifth, came from homes in which there was tuberculosis. In one group composed only of seriously underweight children who had come into the nutrition class for no other reason than that they were underweight, 40 per cent were tuberculosis contacts; in another group, 34 per cent; in still another, 25 per cent.

The migratory tuberculosis case for the West has the individual migrant consumptive as its first phase only, and from this first phase it gathers momentum as time goes on with the greater need evident, in these communities made up in such large measure of health seekers, of much more health education work among the children, many more preventive measures, in the effort to safeguard the health of the community, than in the average city or town. I feel that this aspect of the situation must be understood before the subject can be appreciated by the public at large-before the agonizing cry of the western and southwestern communities for adequate recognition of a situation that they are helpless to meet will really be heard.

A few illustrations will, I think, best put the situation before you. My first example is one that I do not class with the regular migrant group, but it so well illustrates the appeals that come to our communities constantly, and the way the burden grows with the real migrant as only a part of it, that I want to give it to you. The other two illustrations are perhaps typical, if the case of one individual or family with all its different complications and angles can be typical of another.

Mr. Blank has been in a western sanatorium for a number of months. He has been improving slowly but steadily. He became ill with tuberculosis several years ago and during an extended period of treatment all the family savings were used up. Finally the wife secured a position and has been able through her earnings to care for herself and the two children and to keep her husband in the sanatorium. A sanatorium in the West was strongly recommended by the physician in charge and the change from East to West was made. Husband and wife are of exceeding culture and refinement. There is great devotion between them and they felt recently that they must see each other. By extraordinary effort the wife was able to arrange for the care of the two children in the East and to save sufficient for the trip West. A day or two after her arrival the husband noticed a slight cough, which she made light of, insisting that it was due to nervousness. He persisted in his urging that she have an examination, with the result that she finally consented and active tuberculosis was found. The physician in telling me the story said, "We had the definite findings yester