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History of the Union
DONALD A ENARSON* AND ANNIK ROUILLON**
*Director of Scientific Activities (Union,
Paris)
**former Executive Director of the Union
The International Union Against Tuberculosis
and Lung Disease (known to its members as "the Union") is
the only international voluntary organisation dealing specifically with
TB. It is very special in terms of its structure, membership and diversity
of activities.
Roots of the Union: 1867-1914
TB was presented as a communicable disease in the
first international conference of medicine specialists convened in Paris
in 1867.
Conferences specifically addressing TB followed in Paris in 1888, 1891,
1892 and 1898. The 1899 conference took place in Berlin, and for the
first time, official representatives from both governments and non-governmental
agencies were present.
The independent developments of sanatoria (1854), the discovery of the
bacillus (1882), the opening of TB dispensaries (1887), the development
of the voluntary movement (1890) and the organization of periodic conferences
called for a centralised agency for coordination and communication.
The Central Bureau for the Prevention of Tuberculosis was formalised
in Berlin in 1902, and the double-barred cross was adopted then as its
symbol. Periodic international conferences systematically addressing
clinical, research and sociological aspects of TB were held until the
outbreak of the First World War in 1914.
Establishment of the Union: 1920-1939
In 1920, a conference on TB was convened in Paris in
which 31 countries participated, including Australia, Bolivia, Brazil,
Chile, China, Colombia, Cuba, Guatemala, Japan, Panama, Paraguay, Iran
and Thailand, in addition to those of Europe and North America.
In an impressive procession, delegates one by one pledged "to agree
on the means to fight TB, to make a consensus on the strategy, to jointly
apply the most effective weapons to combat this common enemy", thus
establishing the International Union Against Tuberculosis (IUAT) in its
present form. It was conceived as a federation of national associations
(there would be 130 by 1999). Ten international conferences followed until
1939.
In order to supplement the routine reports of the conferences, a regular
publication was commenced in 1923. In this pre-war period, the Bulletin
included administrative reports and statistics (subsequently compiled
by the WHO) as well as information on the strategy and policies for the
fight against TB and results of numerous surveys on specific aspects of
the disease and the campaign.
The Bulletin continued publication until mid-1940; the final editions
before its interruption contained the main reports to have been given
at the 11th conference planned for Berlin in September 1939, the very
month when the Second World War commenced.
Relaunching of the Union: 1946-1961
At the first reunion of the Executive Committee after
the war in 1946, the IUAT recommended to the planners of the future World
Health Organization the "establishment of a strong Division of Tuberculosis".
Official relations with the WHO were then established which continue to
the present time.
The first post-war conference in 1950 in Copenhagen, with the participation
of 43 nations, set the pattern for regular conferences in all parts of
the world. (At the 32nd World Conference on Lung Health, held in Paris
in November 2001, 107 countries participated.) Conferences outside North
America and Europe were held in Brazil in 1952, India in 1957, and Turkey
in 1959.
During this period a series of international symposia were also organised,
generally in Paris, addressing a variety of topical issues such as TB
in Africa, strain variation in BCG, radiography for TB, new drugs, and
the role of voluntary agencies, among others.
In order to strengthen the administration of the growing agency, the post
of full-time Executive Director was established in 1952. A system of quotas
was devised for membership contributions, and over many years, the American
Association has continually maintained a high quota share. Fees were also
levied from individual members. In 1951, scientific committees were commenced
and met annually for intensive discussion of the emerging strategy for
the fight against TB.
In 1953, regions were established in order to remain close to where the
needs are. In 1958, the first international collaborative clinical trial
for treatment of any disease was undertaken, with a total of 17,391 patients
from 17 countries evaluated for drug resistance.
This was followed by a collaborative controlled clinical trial starting
in 1960, to evaluate the efficacy of chemotherapy in previously untreated
patients. In this period, the IUAT contributed to annual international
courses on TB control sponsored by the WHO in Istanbul, Prague, Rome and
Caracas.
A global view: 1961-1978
In 1961, at the suggestion of the Executive Director,
Dr Johannes Holm, the Mutual Assistance Programme was launched to encourage
transfer of technology, resources and information from industrialised
to newly independent countries, through the agency of national associations
in the developing countries.
This was followed by travelling seminars in Africa, Eastern and Middle
East regions and field projects in Mali, Sri Lanka, Peru and India, among
many others.
The scientific committees continued, in this period, to focus on the strategy
for TB control. Some examples of the activities follow. In 1961, two international
collaborative studies evaluated the test characteristics of 1,099 films
read by 90 readers from seven countries and the WHO. A subsequent study
evaluated sputum smear microscopy. Starting in 1965, an international
collaborative study on tuberculin skin testing evaluated 75,000 children
in 21 countries.
Further controlled clinical trials addressed the issue of previously treated
patients and daily self-administered versus intermittent supervised regimens.
In 1968, a survey evaluated adverse reactions to BCG vaccination, with
over 10,000 events analysed, and a Technical Guide for Sputum Smear Microscopy
was published. Its 5th edition appeared in 1999.
In 1966, the Tuberculosis Surveillance Research Unit was established under
Dr Karel Styblo. It developed an index to evaluate infection and its trend,
clarified the natural history of the disease (including transition probabilities
and risk factors), and estimated the impact of control measures.
In 1969, in collaboration with the United States Communicable Disease
Center and seven member countries in Eastern Europe, an international
trial of preventive chemotherapy for fibrotic lesions of the lung in 25,000
individuals was commenced and was evaluated over 5 years of follow-up.
In 1973, an extension of the mandate of the IUAT was proposed to include
other lung diseases, which was to result in a change of name to Union
in 1986. A programme for this was commenced in 1975.
In the same year, Dr Halfdan Mahler, Director General of WHO, publicly
acknowledged the crucial role played by the IUAT in the fight against
TB. In early 1976, 18 non-governmental organisations (NGOs) responded
to the IUAT's invitation to consider jointly the role which NGOs may and
should play in primary health care (PHC). The resulting position paper
was presented at the joint UNICEF/WHO International Conference on PHC
in Alma Ata in 1978.
Modelling the global fight against TB: 1978-1991
In 1978, in response to a request from the Minister
of Health of Tanzania, the IUAT proposed the establishment of a National
Tuberculosis Programme under the direction of the government and with
the support and coordination of the IUAT.
This proposal was the basis of a new IUAT programme of Technical Assistance,
and became the basis in 1979 for the first edition of the Tuberculosis
Guide. Such assistance eventually extended to nine low-income countries
and became the basis of the WHO's current DOTS strategy.
In 1981, the IUAT became the first organisation to adopt a policy that
its meetings be designated "non-smoking" conferences. In 1982,
the Koch centenary was celebrated at the 25th conference in Buenos Aires,
where the Koch Medal of the Union was awarded to Drs Johannes Holm and
Wallace Fox.
That same year saw the establishment of World TB Day on March 24, following
a proposal by the Mali Association. In 1984, the Union was officially
registered with USAID, a very rare privilege for a non-US agency. In 1987,
a delegation from the Union visited the WHO to encourage it to consider
the problem posed for TB by the emergence and spread of HIV infection
that had been noted in the collaborative projects.
In 1989, the Burden of Health Study carried out by Harvard University
was pivotal in demonstrating the cost-effectiveness of the Union model,
which was instrumental in convincing planners and policy makers to adopt
the strategy as a part of the general health services.
A global fight: 1991- present
The principles of the model National Tuberculosis Programme,
outlined on the occasion of the retirement of Dr Styblo in 1991, were
subsequently enumerated as the "DOTS" strategy, and promoted
as the official policy of the WHO. In that year, the Union's international
TB training course was held in Arusha for the first time, to illustrate
the principles of the model programme
. From 1993 to 1996, the training and technical support activities of
the Union were extended from a largely African base to represent every
region of the world. In 1996, the Union entered into a formal agreement
to provide training fellowships with support from the International Fogarty
Foundation.
In 1998, the Union joined with the WHO and other international partners
to form the "Stop TB" Initiative in the hopes of extending the
model to all countries of the world.
A Clinical Trials Programme was established by the Union in 1998 to evaluate
two 8-month regimens of chemotherapy in the treatment of newly diagnosed
pulmonary tuberculosis, one of which consists of an intermittent intensive
phase of chemotherapy.
The rationale for the study is to establish the efficacy of a treatment
regimen that is substantially less costly, in terms of both medications
and personnel requirements for administration. Patient enrolment and follow-up
will encompass a total of 5 years.
By 2002, field activities involved eight countries in the Eastern Region,
two in the Middle East, 23 in Africa, 14 in Europe, 8 in Latin America,
and 2 in North America. The network of courses in management included
Tanzania, Benin, Nicaragua and Vietnam, and the courses on research methods
included Turkey, Egypt, Kenya, South Africa, Mexico, Chile, Argentina,
Brazil, Peru, Malaysia and China.
During this period, more than 1 million patients with TB were cared for
in the context of the collaborative programmes of the Union. These activities
were made possible thanks to funds entrusted to the Union from richer
associations and by governments of a number of affluent countries.
Characteristics of the Union
The distinguishing qualities of the Union,
besides its universality, its spirit of solidarity and its tolerance,
are its continual striving for quality and its independence. Thanks
to these, it provides the international community with an invaluable
asset, namely its pioneering role in devising and encouraging or testing
innovations.
It provides a neutral platform for international collaboration, exchange
of information, friendship, mutual esteem and education, and a reduction
of prejudice. It maintains not only a programme of scientific conferences
and publications, but also a programme of action for health in the community,
comprising technical assistance, education and research.
Dr Gro Harlem Brundtland outlined the future in the following statement
to the 51st session of the World Health Assembly in Geneva in 1998:
"We must reach out to the NGO community. Their reach often goes
beyond that of any official body. Where would the battle against leprosy,
TB or blindness have been without the NGOs?"
Reproduction of any Union documents for
commercial purposes is strictly prohibited.
Conditions of use
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