i i “Main” — 2003/12/20 — 17:33 — page 29 — #31 i i

Journal & Proceedings of the Royal Society of New South Wales, Vol. 136, p. 29–43, 2003 ISSN 0035-9173/03/020029–15 $4.00/1

‘The Celluloid Strip’ — Mass Screening for in New South Wales, 1950–1975

dr peter j. tyler

Abstract: Tuberculosis was a significant cause of mortality at the beginning of the Second World War when the technique of taking miniature X-ray photographs on movie film was introduced to Australia as part of the medical examination of men enlisting in the armed forces. Immediately after the war, the Anti-Tuberculosis Association of NSW expanded its existing diagnostic clinic in Sydney to provide a mobile X-ray service to country areas and industry. That experience provided a model for the subsequent national campaign which the Commonwealth Government funded to detect and treat the disease. Coincidentally, at the same time as the compulsory national screening program com- menced, the first effective therapy for the disease became available. drugs soon achieved results that long periods of rest in a sanatorium had never accomplished. Government funding was withdrawn after the incidence of tuberculosis diminished, so that by 1975 the ubiquitous X-ray caravans began to disappear from street corners around Australia. This paper describes the logistics of the mass screening campaign during the third quarter of the twentieth century, and the technological developments that made it possible.

Keywords: tuberculosis, camera, , screening, X-ray, Anti-Tuberculosis Association

The White Death, consumption, phthi- the Mycobacterium tuberculosis bacillus in sis, TB – by whatever euphemism it was 1882, medical practitioners realised that the known, tuberculosis was one of the most disease had a microbiological origin, and feared human diseases for at least three was not a hereditary affliction or punish- millennia. Despite the romantic deaths of ment for a dissolute lifestyle as previously operatic heroines like Mimi and Violetta, believed. Understanding the aetiology was the reality for most people was more stark. one thing; developing effective therapy that Lassitude and nightime sweating were early could overcome these germs was another symptoms of pulmonary tuberculosis, fol- matter. lowed by a chronic cough, loss of weight and a pallid complexion as the disease pro- In the late nineteenth century, the gressed, until the terminal stage when the favoured treatment was bed rest, fresh air victim was spitting blood. If the patient and a diet rich in saturated fats, preferably was the male breadwinner, most families taken at a sanatorium in a fashionable re- then faced destitution. sort on a ‘Magic Mountain’ in the Swiss Alps. For most people this was out of the When the German bacteriologist Robert question. In Australia, from the 1870s there Koch devised a technique to visualise were small private or charitable sanatoria

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 30 — #32 i i

30 TYLER

that catered for a handful of patients, but procedures such as reducing dislocations most sufferers stayed at home infecting the or fractured bones. Some also other family members who shared their bed recognised the potential of the technique or eating utensils. If a patient was too ill to for revealing abnormal pathology in the be cared for at home, or had no family, he or , particularly tuberculosis, but their she went to one of the State Asylums to die, more conservative colleagues were scepti- surrounded by the demented and insane. cal, claiming that their own experience en- It was 1911 before the NSW Govern- abled them to identify tuberculosis sufferers ment opened the large Waterfall Sanato- by physical examination and auscultation rium for Consumptives, and by this time of the chest through a stethoscope. Pathol- there were smaller establishments run by ogy tests did become routine, however, with the Red Cross Society and the Queen Vic- sputum specimens subjected to microscopic toria Homes on the Blue Mountains and in examination to determine whether the tu- the Picton area. Sanatoria were some help berculosis bacillus was present. in preventing the spread of infection, but In New South Wales, the first X-ray few of the patients recovered their health. equipment dedicated to the diagnosis and Various other treatments were tried. assessment of tuberculosis was installed at Koch himself developed Tuberculin, which Waterfall Sanatorium in 1929, to be fol- was popular for a period, and seemed to im- lowed shortly afterwards in 1930 by the prove the condition of certain patients. Less Anti-Tuberculosis Association of NSW at reputable practitioners advocated their own its chest clinic at Albion Street in Surry miracle cures, such as Spahlinger’s Serum Hills. Their Kelly-Koet apparatus was and the expensive, but ineffective gold ex- a Heath Robinson contraption by modern tract Sanocrysin. ‘Artificial sunlight’ en- standards, and of relatively low efficiency, joyed a vogue in the United Kingdom, but although at the time it was described as Australia seemed to have enough of the nat- ‘one of the most delicate instruments of its ural variety. Throughout this period, the kind in existence’. The radiologist could ex- incidence of tuberculosis in the community amine the patient directly through a fluo- was actually declining, which gave physi- rescent screen placed in front of the chest, cians an unwarranted sense of optimism or a large piece of specially-coated photo- about the treatments they were advocat- graphic film would be exposed in a light- ing. Nevertheless, in 1910 tuberculosis re- tight magazine, to give a life-size image that mained, after heart disease, the most com- could be processed and examined later. mon cause of death in New South Wales. The Anti-Tuberculosis Association of In 1895, Wilhelm R¨ontgen discovered New South Wales, later known as Commu- the remarkable powers of certain electro- nity Health and Tuberculosis Australia, had magnetic emissions to penetrate the human been founded by a group of influential con- body, and to visualise the internal organs cerned citizens in 1911 to grapple with the on a fluorescent screen. By the end of the misery caused by tuberculosis amongst the first decade in the twentieth, primitive X- impoverished residents of Sydney who could ray machines were installed in the main not afford private treatment. Many of the Sydney teaching hospitals for orthopaedic Association’s practices became a model for

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 31 — #33 i i

THE CELLULOID STRIP 31

other voluntary organisations and govern- Wunderly kept a pile of old medical books ment agencies throughout Australia. This nearby so patients of different sizes could paper refers mainly to the New South Wales stand at the correct height for the screen. experience because that can be regarded as Some practitioners were sceptical that such a microcosm of the later national campaign. a small image (36 mm x 24 mm) would be Early X-rays were a great help in con- useful, compared with the image on the firming a diagnosis of tuberculosis, but it conventional 17 inch by 14 inch (430 mm was a slow, inflexible and relatively expen- x 360 mm) sheet film. However, by view- sive procedure. With only a handful of ing the 35 mm negative through a suitable machines available, the technique could be magnifying viewer, experienced radiologists used only with high-risk groups. To illus- found that they could detect major abnor- trate this point, the Anti-Tuberculosis As- malities almost as easily as with the larger sociation recorded only 351 X-rays in its film. first year of providing this service in one New approaches to treatment were also of the poorest parts of Sydney, where there being introduced. The most common inter- was a high incidence of tuberculosis. It was vention was known as artificial pneumotho- 1937 before more than one thousand X-rays rax, where an incision was made in the chest were taken in a single year. By 1941 this wall to collapse a diseased . To main- had risen to almost three and a half thou- tain the collapse, nitrogen or compressed air sand, with 172 confirmed cases of tuber- was introduced into the pleural cavity. The culosis detected, a rate of one in twenty, theory behind this procedure was that a col- which was a rather disturbing result that lapsed lung, being relieved of its breathing was never equalled in the later mass sur- function, was given a chance to rest and re- veys. cuperate. Patients could still live reason- The obvious limitations of the early ably normally on the remaining active lung, technique stimulated researchers to look for but had to return to a clinic every six or a simpler, cheaper solution. In 1936, Dr eight weeks to have a ‘refill’ of the gas, a Manuel de Abreu in be- simple outpatient procedure. gan the first mass survey experiments with When the Second World War erupted, a camera using 35 mm cinema film. He the Australian military authorities decided mounted the camera in an enclosure be- that it was necessary to screen all recruits hind the fluorescent screen so that he could for tuberculosis before enlistment into the photograph the image, using a wide-angle armed services. This was intended not only lens and the faster film emulsions that were to weed out those who were unfit for ac- becoming available. After reading about tive service, but also to prevent transmis- these experiments, Dr Harry Wunderly im- sion of the disease to healthy personnel. Dr provised some equipment along the same Wunderly and others continued their exper- lines in his Adelaide consulting rooms in iments to convince the medical establish- 1939. A standard Leica camera was fixed ment that miniature radiography on 35 mm to a cardboard tunnel with adhesive tape. film was a viable technique. Within two Because the level of this home-made de- months, over 20,000 men had been exam- vice could not be adjusted, it is said that ined in this way, and 109 cases of active

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 32 — #34 i i

32 TYLER

tuberculosis detected – one in every 183 re- camera equipment from the Fairchild Cor- cruits. Manufacturers soon modified their poration in the USA. equipment so that a Leica or Contax minia- This duly arrived, but encountered a ture camera could be fitted, in addition to couple of unexpected hitches. Firstly, there the conventional large-film magazine. This was a waterfront strike in Sydney Harbour, paved the way for many images to be made and the wharf labourers refused to unload in quick succession on continuous film – ‘the the crates. This difficulty was overcome celluloid strip’ referred to in the title of this through some deft negotiation, when mem- paper. This experience prompted the Anti- bers of the Waterside Workers’ Federation Tuberculosis Association of NSW to acquire were promised the first screening survey us- similar miniature equipment for screening ing the new apparatus. Then, to the dis- the civilian population. may of the Association, when the crates One problem encountered with using were unpacked it was found that the equip- standard 35 mm cameras was that the film ment consisted of modified aerial photogra- had to be wound forward manually after phy cameras using 70 mm film, instead of each exposure. During a busy period, this the 35 mm size ordered. None of the exist- could result in inadvertent double expo- ing processing or viewing equipment could sures, or accidentally winding on more than use the wider film, but wartime exigencies one frame. Sometimes the film was fin- meant that returning the equipment and re- ished before the operator realised this. If placing it with the correct gear was likely to the frame numbers got out of sequence with be a lengthy and uncertain process. the patient record cards, the wrong person So the Anti-Tuberculosis Association would be recalled for further examination. decided to persevere with 70 mm film, and Furthermore, it was easy for the camera fo- adapted its other equipment to suit. This cus to shift during film winding, so that all size then became the de facto standard for subsequent images were indecipherable. all future mass X-ray screening in Australia, By 1942 the Anti-Tuberculosis Associa- as a result of a simple clerical error in an tion was in a position to conduct its first American factory. One advantage was that, mass industrial survey, when all 830 mem- being twice the width of the 35 mm film, the bers of the staff of Philips Electrical In- image provided better resolution, and made dustries came to the Albion Street Chest the radiologists’ task easier. After the war, Clinic for X-ray. Following the example when Philips returned to the market they of Philips, other factories, shops and gov- tried to promote a new film size – 40 mm, ernment departments began clamouring to but in Australia at least they were unsuc- be screened for tuberculosis. These sur- cessful. Later, 100 mm film was introduced veys were paid for by the firm taking part. for fixed, stationary installations, as an eco- Philips had a vested interest in this project nomical alternative to 17 by 14 inch sheet because they supplied the equipment, but film. as the war progressed, it became impossible Following the end of the Second World to source further supplies from Europe. To War, Australia enjoyed an unprecedented meet the growing demand, in 1944 the As- period of prosperity and confidence, with sociation ordered additional 35 mm X-ray a buoyant economy based on worldwide de-

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 33 — #35 i i

THE CELLULOID STRIP 33

mand for primary products like wheat and Sir Harry) Wunderly was appointed Com- wool. Having emerged victorious from the monwealth Director of Tuberculosis to deal conflict, there was a widespread feeling that with the apparently intractable problem of no goal was impossible to achieve. Some of reducing the damaging effects of tubercu- the people at the Anti-Tuberculosis Asso- losis on society. Dr Wunderly himself had ciation began to dream of an ‘X-ray plant been a tuberculosis sufferer who had spent on wheels’ that could provide a tuberculo- some time in sanatoria, both in Switzerland sis diagnostic service in major rural or ur- and Australia. His first task as Director was ban centres, as well as the existing facility at to investigate existing provisions. Over- the Chest Clinic in Surry Hills. Fundraising all, they were poor – ranging from fairly appeals organised by community groups in good in Tasmania, to being almost non- the Southern Tablelands yielded sufficient existent in Queensland, and not much bet- funds to translate that dream into reality. ter in New South Wales. Wunderly esti- A standard Sydney single-deck bus was ac- mated that there was a shortage of 3,200 quired, and fitted-out to the Association’s hospital beds for tuberculosis throughout specifications, with space for a ’s Australia, at a time when the total popu- consulting room, a photographic darkroom, lation was just over seven million. and storage for the delicate X-ray equip- Coincidentally, the long-awaited thera- ment in transit. On arrival at the selected peutic breakthrough was occurring at the location, the X-ray apparatus had to be re- same time, with the release of two new moved from the bus, assembled indoors and ‘wonder drugs’ that seemed to promise a connected to the electricity supply. cure for tuberculosis. One was the an- The first visit by the new mobile unit tibiotic streptomycin, developed by Sel- was to Goulburn in 1947, where over five man Waksman and his team of soil mi- thousand examinations were made. Par- crobiologists in the USA. The other was ticipation was voluntary, with a fee of five para-aminosalicylic acid (PAS), prepared shillings (fifty cents) charged to individu- through chemical manipulation of the as- als, or ten shillings (one dollar) for a fam- pirin molecule by Jorgen Lehmann in Swe- ily group. Patients were required to par- den. Although initial results for both thera- tially undress, stripping to the waist – not pies were very encouraging, it soon emerged an inviting prospect in a draughty country that in some patients there were serious side shire hall in mid-winter. Because of this, effects, or more disturbingly, a relapse of the separate sessions for men and women were disease. It was apparent that the bacillus held each day. Films were processed on the developed a resistance to these drugs unless spot and interpreted by the medical officer they were used in combination. Even then, who accompanied the mobile unit. about twenty per cent of patients were not In that euphoric spirit of postwar recon- cured. struction, one of the rare amendments to Isoniazid was synthesised in 1952 al- the Australian Constitution was achieved most simultaneously in both Europe and in 1946, when the Commonwealth gained America. This was more effective, had the power to legislate for the provision of few side effects, and was cheap to produce. medical services. Dr H. (later to become Once again, however, the tuberculosis bacil-

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 34 — #36 i i

34 TYLER

lus learnt to deal with the new drug, so was that the States should be financed chemotherapy took the form of a cocktail to engage in a program of early detec- of all three drugs. During the 1960s a num- tion through compulsory radiography of all ber of new preparations were developed, re- adults. This would be supplemented by placing both streptomycin and PAS, so that a massive expansion of treatment facili- modern triple therapy usually consists of ties, because existing hospitals had exten- these newer drugs. sive waiting lists. Finally, and despite ob- Thoracic surgeons were also becoming jections from Treasury, an adequate pension more adventurous in applying their wartime would be payable to tuberculous patients battlefield experience, and were removing while they were infective, to ensure that diseased portions of lung, or even whole they followed the prescribed therapy. These lungs, in selected patients. In other pa- principles formed the basis for the Com- tients, a lung was collapsed by removing monwealth Tuberculosis Act of 1948, and several ribs. These techniques stopped the the subsequent Tuberculosis Agreements spread of the disease, but could leave the under which the Commonwealth Govern- patient disfigured or disabled. As the effec- ment met all additional capital and opera- tiveness of chemotherapy became evident, tional costs incurred in tuberculosis control such radical surgery became unnecessary, by the States, on condition that the services so that the practitioners began to trans- were provided to the public without charge. fer their skills to the emerging discipline of New South Wales initially was wary cardio-thoracic surgery. about becoming involved, but eventually As Director of Tuberculosis, Dr Wun- signed the Agreement in November 1949. derly recommended measures for a con- The Anti-Tuberculosis Association of NSW certed national campaign to control the dis- was also invited to participate in the pro- ease. The concept of a common strategy gram because of its long involvement with had been agreed upon as early as 1911, , prevention and cure, but the First World War intervened before becoming the only non-government organi- any action was taken. Then, in 1925, a sation in Australia to be offered this priv- Royal Commission on Health recommended ilege. The Association formally became a that the States work together to deal with partner in April 1952, and twelve months tuberculosis, but this time the proposals later was ready to begin its intensive case- were thwarted by the Great Depression. So finding project. Six additional mobile X- the Wunderly Report of 1947 in some ways ray units were acquired to supplement the was a repetition of what the experts had two buses already in service, and extra staff been saying for nearly forty years, except were recruited and quickly trained to op- that this time the Government listened, erate this equipment. At the same time, and voted funds to begin a national cam- the Association’s new purpose-built Clinic paign, whose aim in Prime Minister Ben opened on the corner of Crown Street and Chifley’s words was ‘to reduce tuberculosis Foveaux Street in Surry Hills, partially to a problem of minor importance within funded by the Commonwealth. This Clinic two decades’. provided a comprehensive range of diag- The essence of the Wunderly scheme nostic and treatment services, including a

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 35 — #37 i i

THE CELLULOID STRIP 35

twenty-bed hospital wing. ing campaign, the mobile units began work- The new fleet of mobile units bene- ing a twelve-hour day, 9.00 a.m. to 9.00 p.m. fited from the experience gained in pre- from Monday to Friday, and sometimes on vious years, and the improved equipment Saturdays. The staff attached to each unit then available. Compact 70 mm camera X- normally worked in two shifts of three peo- ray apparatus fitted comfortably into an ple. They were multi-skilled, and rotated eighteen-foot caravan that could be parked the radiography, clerical and reception du- in front of a prominent public building such ties every hour. An experienced team could as a railway station or town hall. Patients easily X-ray 800 people a day – better than could remain fully clothed, so there was one a minute. A mobile unit might be tour- no need to schedule separate sessions for ing country regions for up to three months, women and men. Film cassettes were re- followed by a three-month stint in subur- turned to the Association’s headquarters in ban areas. This was a lifestyle which did Crown Street for processing. There, each not suit everybody, although some of the photographic frame would be examined sep- young operators relished the opportunity to arately by two specialist radiologists, and move away from the parental home in the if there was disagreement about interpreta- less permissive era of the 1950s. tion, a third opinion was sought. Many incidents and tribulations accom- Some of the earlier technical problems panied these efforts. Mobile units had to had been overcome. Special cameras with traverse rough country roads, cross flooded fast, short-focus lenses having minimal op- rivers, cope with heat, dust, and torrential tical aberrations were available. Large ca- downpours, yet still provide X-ray services pacity film magazines were fitted, holding in a remote town on the advertised dates. up to 400 frames instead of the 36 on a stan- An advance party had previously visited the dard 35 mm cassette. More importantly, area to arrange a site for the van, electric- motorised film advancing mechanisms were ity connections, and publicity. They also linked to the X-ray control panel so that had to enlist teams of volunteers to help synchronisation was maintained, and the X- the survey proceed smoothly. Members of ray could not be taken unless there was Red Cross, Country Women’s Associations, film in the gate for the next exposure. Rotary Clubs and Boy Scouts were amongst Later still, the patient record card was pho- the many recruits who assisted with clerical tographed on the same frame, to avoid mis- work. identification. It was almost foolproof, but Every person examined received a re- a careless operator could still put the wrong sponse from the Association within three record card in the reader, or forget to take it weeks. For most people, this was merely out between patients. Furthermore, an ac- a card to advise that no abnormality ex- ceptable result depended ultimately on the isted. If further investigation was needed, quality of the film processing. Careless han- the person received a notice to attend the dling or exhausted chemicals could degrade Association’s Clinic or a major regional hos- the image. pital for a larger X-ray and other tests to To cope with the enormous demand for confirm the diagnosis. In later years, the chest X-rays generated by the mass screen- service was improved by equipping a sepa-

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 36 — #38 i i

36 TYLER

rate mobile unit for taking large X-rays, and monwealth Government. this unit visited many of the smaller centres As the campaign continued, better about three weeks after the initial screen- equipment became available. The most no- ing, accompanied by a travelling medical of- table improvement was the introduction of ficer who would follow-up doubtful cases. the ‘Odelca’ mirror camera. This was based With the rapid expansion of the ser- on the principle of the Schmidt camera used vice in 1953, it was clear that the Anti- in astronomy, where a spherical mirror is Tuberculosis Association of NSW would used instead of a lens system to form the op- never be able to mobilise sufficient resources tical image. Although this is a rather bulky to cover the whole population with regu- device, it is much faster and gives better lar surveys. The Division of Tuberculo- sharpness over the full field. sis within the NSW Department of Health Although the Wunderly Report recom- gradually developed its own facilities for mended that every person over the age community X-ray surveys, based closely on of fourteen should be required by law to the Association’s model. To rationalise the present for X-ray examination, at first both itinerary, the Association agreed to take New South Wales and Victoria were reluc- responsibility for the northern and north- tant to implement the sanction of fines for western areas of New South Wales, while non-compliance. Their stance seemed vin- the Department took care of the remain- dicated in the first survey, where it was der. Similarly, municipalities in the Sydney common in many areas for 85 per cent of metropolitan area were shared between the the adult population to present for X-ray. two agencies, with the State’s population In some western towns of New South Wales, divided in the ratio of one-third to the As- the number of X-rays exceeded the official sociation, two-thirds to the Health Depart- population statistics. Presumably, people ment. were travelling long distances from outlying The procedures and equipment that had settlements. been developed by the Anti-Tuberculosis On the other hand, the fact that the re- Association of NSW also provided a model maining 15–20 per cent of the population for the compulsory campaign in other were not being examined was a concern, be- States, where the service was conducted cause it was likely that a proportion of these solely by the respective State Health De- knew or suspected that they may have tu- partments. For three months, NSW sta- berculosis, and consequently avoided the X- tioned some of its mobile units in Mel- ray examination. bourne to provide a pilot scheme for Initially, the results of mass screening the Victorians. Ultimately, there were were impressive, as the notifications of new about thirty chest X-ray caravans working tuberculosis cases in Metropolitan Sydney throughout Australia. Surveys in Federal show (Figure 1). The number attend- Territories such as the Northern Territory, ing usually declined when the mobile units A.C.T., Nauru and Christmas Island, were made return visits two or three years later, conducted by the Anti-Tuberculosis Associ- probably because people became apathetic ation of NSW, under contract to the Com- after being cleared on their first X-ray.

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 37 — #39 i i

THE CELLULOID STRIP 37

1000,000

1400

ys 800,000 1200 Number surveyed X-ra

of 600,000 1000 er

b 800 diagnosed 400,000 Num 600

Cases diagnosed Cases 400 200,000 200

1953/551955/571957/591959/611961/631963/65 Survey Period Figure 1: Successive TB surveys in the Sydney metropolitan area.

In 1956, the State Government yielded clinicians would be prone to classify doubt- to Commonwealth pressure, making X-rays ful cases as tubercular, particularly with compulsory, and imposing a fine of £20 for their own continued employment at stake. failing to attend when the mobile X-ray Subsequent testing would have confirmed units visited a proclaimed district. A fur- which patients were infected, but the statis- ther penalty of two pounds a day could be tics were not adjusted. incurred for every day that elapsed before Overall, the campaign detected only one the defaulter presented for an X-ray. A few case of tuberculosis for every 1,300 X-rays ‘show trials’ took place to convince the pop- taken. However, this rather small statistical ulace that the government was serious. average overlooks the marked discrepancy In the twenty-five years between 1950 in cases between different areas. For ex- and 1975, the Anti-Tuberculosis Associa- ample, there was one positive diagnosis for tion took eleven and a half million chest every 350 X-rays taken at the Crown Street X-rays, using about 900 kilometres of film Clinic. This difference is explained by the – a very long ‘celluloid strip’. As a result fact that many of those presenting at the of the surveys, 8 854 new cases of tubercu- Clinic already had symptoms and were re- losis were detected, as well as many inac- ferred by their private doctor, or they were tive cases. To these figures we must add contacts of known tuberculosis patients. the parallel efforts of the NSW Department What these statistics do not reveal is of Health. The totals may be a little ex- that many other serious abnormalities were aggerated, because there could have been detected at the same time, particularly a certain amount of over-diagnosis, as the heart conditions or . By 1959,

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 38 — #40 i i

38 TYLER

such pathologies already exceeded the de- agnosed, costing somewhere in the vicin- tection of new cases of tuberculosis. These ity of $5,000 for each case notified. Sub- were referred to private practitioners or sequent treatment costs presumably would public hospitals for further investigation have been much greater, and treatment. In retrospect, this part of It was becoming obvious that the law the campaign may have been more signif- of diminishing returns applied. Indeed, it icant for the long-term health of the pop- seemed that Ben Chifley’s ambition to re- ulation than identifying the relatively few duce tuberculosis to a minor problem within tuberculosis cases. two decades had been achieved, so it is not Because the number of tuberculosis surprising that the Commonwealth Govern- cases was declining, a rationalisation of the ment led by Malcolm Fraser decided to re- mass radiography program in New South voke the Tuberculosis Agreement with the Wales took place in 1971. The NSW States, taking effect from the end of 1976. Department of Health withdrew from the In retrospect, this may have been a prema- statewide surveys, and transferred its mo- ture decision, occurring just as an increas- bile X-ray units to the Anti-Tuberculosis ing number of ‘boat people’ refugees from Association, together with some of the op- the war in Vietnam began settling in Aus- erational staff and funding to continue the tralia. Tuberculosis was endemic in their program. To further reduce costs, the in- homeland, and they brought a new locus terval between surveys extended to an av- for the disease to their adopted country. erage of five years. The minimum age for Of course, the way remained open for the compulsory X-rays was raised from twenty- State authorities to finance their own con- one to twenty-five years, with an increase to trol programs, but they were reluctant to thirty-five years soon afterwards. divert funds from other responsibilities. At first, nobody asked publicly whether The apparent success of the Australian the benefits justified the cost of the national Tuberculosis Campaign is confused by the campaign, but the reality is that it was a fact that streptomycin and similar thera- very expensive exercise. The total Com- peutic agents were introduced almost con- monwealth expenditure on the program be- currently with the commencement of the tween 1950 and 1977 was $361 million, campaign. Effective treatment that could which of course would be many times that be administered at home or in a hospi- sum at today’s prices. In 1977, the Anti- tal outpatient department quickly rendered Tuberculosis Association published for the many of the new sanatoria and chest hospi- first time the actual costs incurred in pro- tals redundant. Certainly, the mass screen- ducing each 70 mm diagnostic film image. ing surveys still played a useful role in case- In the metropolitan area this amounted to finding, identifying patients who could be eighty cents per head, but in regional ar- referred for prompt treatment. In doing so, eas it was twice as expensive, at $1.64 per potential sources of infection were removed head. The difference was due to travel and from the broader community. accommodation costs for staff. From nearly However, it would be presumptuous to a quarter of a million X-rays taken in that claim that the lowered incidence of tubercu- year, only 55 cases of tuberculosis were di- losis in Australia was due to the implemen-

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 39 — #41 i i

THE CELLULOID STRIP 39

tation of a compulsory, nation-wide screen- age disposal in the late nineteenth century ing program, for the decline in notifica- were accompanied by heightened awareness tions commenced long before the campaign of personal hygiene. Increased prosper- (see Figure 2). With some fluctuations, the ity led to better housing and nutrition. trend had been declining steadily for a hun- Smaller families resulted in less overcrowd- dred years. This fact poses some interest- ing. These elements combined to reduce ex- ing questions. We cannot attribute all of posure to risk, and possibly generated im- the decline to improved treatment, because proved resistance to the disease. It is also effective chemotherapy did not arrive until conceivable that there has been a reduction the late 1940s, so it must be due to other in the virulence of the bacterium during this causes. A number of possible factors have period. Chemotherapy did make an impact been identified, but it is difficult to appor- on the death rate, although this also had tion the relative significance of each. Retic- been improving steadily since the Great De- ulation of pure water and efficient sewer- pression.

80

60 Cases notified opulation p

40 100,000 er p 20 Mortality rate Rate

0 1900 1920 1940 1960 1980 Year Figure 2: Incidence of TB in NSW.

The campaign continued at a reduced evitable that mass screening of whole com- scale after Commonwealth funding was munities would soon cease. Government withdrawn, but from 1979 it was no longer health authorities decided that tuberculo- compulsory, although people over thirty- sis detection in future would concentrate five were still encouraged to have regular X- on high-risk sections of the community. In rays. Under these circumstances, it was in- 1981, the Health Commission of NSW gave

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 40 — #42 i i

40 TYLER

the re-named Community Health and Anti- graphic surveys. Tuberculosis Association six months’ no- The ubiquitous X-ray caravans then dis- tice that it was terminating its arrangement appeared from street corners around New with the Association to provide mass radio- South Wales.

A Mobile Xray Bus at Mudgee. The original mobile X-ray units travelled in a converted Sydney bus, which included space for a photographic darkroom and a radiologist’s con- sulting room. The large X-ray machines of this era had to be unloaded from the bus and set up in a building, usually the local Town Hall.

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 41 — #43 i i

THE CELLULOID STRIP 41

Improvements in equipment resulted in shorter exposure times and better images. This illustration is of an Odelca mirror camera installed in the Sydney clinic of the Anti- Tuberculosis Association. Similar gear was used in mobile units towards the end of the national campaign.

An Anti-Tuberculosis Association mobile X-ray unit. These large caravans were placed in prominent suburban locations for periods from a few days to several months. Each caravan included a small office for registering the client’s personal details, as well as the miniature X-ray equipment.

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 42 — #44 i i

42 TYLER

Processing the Celluloid Strip Miniature X-rays consisted of 400 separate images on a single length of 70 mm photographic film - ”the celluloid strip”. Films were returned from the mobile units to a central location for processing. Here technicians are inspecting a film before it is handed to the medical staff for diagnostic examination.

This is a poster announcing a forthcoming visit to country towns by a mobile X-ray unit. The slogan ‘No Charge - No Undressing’ indicated a notable change from the early days of mass population surveys, when a small charge was levied, and clients had to strip to the waist. There were still some restrictions on the type of clothing that could be worn.

i i

i i i i “Main” — 2003/12/20 — 17:33 — page 43 — #45 i i

THE CELLULOID STRIP 43

ACKNOWLEDGEMENT D.J. Stevens, ‘Evolution of X-ray equip- ment for tuberculosis case-finding pro- The author acknowledges the co-operation grammes in Australia’, Medical Journal of Community Health and Tuberculosis of Australia, 23 November 1968, pp. 931- Australia (CHATA) in providing access to 5. research material used in this paper. R. Taylor, M. Lewis & J. Powles, ‘The Aus- tralian mortality decline: cause-specific mortality 1907–1990’, Australian and REFERENCES New Zealand Journal of Public Health, 1998, Vol.22, No.1, pp. 37–44. Anti-Tuberculosis Association of NSW P.J. Tyler, ‘No Charge – No Undressing’, (now CHATA), Annual Reports. chata, Rose Bay, 2003 (in press). T.C. Boag, ‘Community-wide chest X-ray H.W. Wunderly et al., ‘Miniature radiogra- surveys in Australia’, Medical Journal of phy and mass X-rays’, Medical Journal of Australia, 10 July 1971, pp. 74–8. Australia, 4 September 1948, 2, p. 268ff. R.M. Porter & T.C. Boag, The Australian Tuberculosis Campaign 1948–1976, The Menzies Foundation, Melbourne, 1991. Dr Peter J. Tyler A.J. Proust (ed), History of Tuberculosis in Consultant Historian Australia, New Zealand and Papua New Peter J. Tyler Associates Guinea, Brolga Press, Canberra, 1991. 2/3 Annandale Street, F.B. Smith, The Retreat of Tuberculosis Darling Point NSW 2077 1850–1950, Croom Helm, London, 1988. Email: [email protected]

i i

i i