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the spread of this airborne disease and, as environmental conditions worsened, tuberculosis came to be the leading cause of death in Western Europe in the 18th and early 19th centuries (Dubos and Dubos, 1952).

What appeared to be a natural and inevitable decline in tuberculosis in Europe and North America caused many experts to think about the eventual eradication of the disease. Wade Hampton Frost (Frost, 1937) may have been the first to suggest the possibility of elimination of tuberculosis when he observed,

We need not assume that tuberculosis is permanently and ineradicably engrafted upon our civilization. On the contrary, the evidence indicates that in this country the balance is already against the survival of the tubercle bacilli; and we may reasonably expect that the disease will eventually be eradicated. (Frost, 1937)

Although World War II interrupted the decline in tuberculosis mortality rates and discussion of elimination, the idea was raised again as the number of active cases and the rate of mortality showed accelerated declines after the advent of chemotherapy. Palmer (1958) and Perkins (1959) independently issued calls for the eradication of tuberculosis. Recognizing the difficulty of eradication, the Arden House Conference Report of the United States Public Health Service called for “eliminating tuberculosis as a public health problem” in the United States (Communicable Disease Center, 1960; U.S. Public Health Service, 1944). This concept was repeated and defined as a case rate of less than 1 per 1 million population at the 16th International Conference on Tuberculosis (Canetti, 1962). Later, this definition was again used by the Advisory Council for the Elimination of Tuberculosis to define the goal for elimination of tuberculosis in the United States, with a target date set for the year 2010 (Centers for Disease Control, 1989).

Despite these calls and plans for eradication or elimination that would have required intensification of control efforts, the continuing decline in tuberculosis resulted, instead, in complacency and neglect. Rather than increasing resources to fund the efforts that would lead to elimination, tuberculosis program funding was progressively reduced and categorical funding was entirely eliminated from the Center for Disease Control budget in 1972.

The neglect of tuberculosis was also reflected in a laissez-faire attitude toward treatment of the disease. This in turn led to poor adherence to treatment and development of drug resistance.

There was also neglect at the international level that was fostered by a general attitude that all the tools were available and that all that was needed was their assiduous application. The failure to recognize that, internationally, tuberculosis was as much, if not more, of a political chal



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