July 1953 T U B E R C L E 197

been cut to free the lung, had the least complications and the A.P. maintained longest. In 5 ° cases with zones of atelectasis, best results were obtained by relaxing the adhesions by means of P.P. and dividing them at a later date when the atelectasis had cleared and the case stabilized.

I wish to express my thanks to Mr B. R. Billimoria, F.R.C.S.Eng., Consulting Sur- geon, and Dr R. B. Billimoria, Consulting Physician, Bel Air Sanatorium, for their friendly criticism and advice; and to the Superintendent, Major C. A. Watkins, for permission to publish these cases.

Principles and Results of Training and Employment at Papworth

By OWEN CLARKE (Based on a Paper read at a meeting of the British Tuberculosis Association in Leicester, April 17, 1953)

The clinical picture presented by pulmonary tuberculosis has changed very considerably even in the past decade, and tile great advances in diagnosis and t rea tment have resulted in a dramatic fall in the mortality figures: the notification rates have not shown a comparable fall. The consequence is that rehabilitation of the tuberculous is an in- creasingly important problem, which must be understood and practised if the efforts of the clinicians are not to be wasted.

To wander into the wide fields of this subject would be to enter a country so fascinating and so diverse that it could not be described briefly, but attention should be given to the outstanding example of this work in the whole world, the Village Settlement at Papworth. I f tile results there are good, the methods used should be a guide to other ventures, and although no one would claim that Papworth is the only answer to the problem, there is "no doubt that Papworth has made, and is making, a very important contribution to the happiness of men and women who have had tuber- culosis.

The purpose of treatment is to restore health, and thereby restore social and economic independence. There is, for ex- ample, little value either ethical, spiritual, or material in treating tuberculosis by such extensive surgery that a respiratory cripple results: it is often done, but such treatment is failure. But where is the difference if the

treatment is purely medical, and in the end the patient is economically a helpless cripple dependent - not indeed for his breath - but for his very food and comforts upon those whom he,should support?

State support, whether you call it insur- ance or welfare, is not the same as money in the pocket which has been earned by work, and whereas the one slowly undermines morale and saps the vitality of manhood, the other is an increasing stimulus to pride, self-confidence, and progress.

The purpose of Papworth, then, is to provide opportunity for men and women to regain economic independence, and the work is carried on with two quite distinct purposes in mind: (i) Training; (2) Settle- ment.

(I) Training.- The majority of men and women coming to Papworth do not require or hope for permanent settlement. Their aim is to build themselves up to a full day's work, to learn a suitable trade whilst doing so, and then to seek employment in their home area and rejoin the company of their family and friends. This usually takes twelve to eighteen months.

When it is realized that every man sent to Papworth is only sent because he could not previously find suitable local employment, such cases are seen to be a successful result of training. I consider that in many ways this group is more satisfactory even than those who settle permanently because they are

198 T U B E R C L E July 1953

restored to their own home life, and have regained the confidence in their health and skill which enables them to take their place in ordinar 3, jobs.

(2) S e t t l e m e n t . - B u t there are those to whom such progress is improbable. They are the older men, those w i t h family res-" ponsibilities who specially need a feeling of security, or those whose disease is such that they should not resume normal employment. For them the training is the same, but the offer of permanent employment and settle- ment is more attractive because it offers greater economic and social security, and freedom from anxiety.

Principles of Training There are five basic principles which are put into practice at Papworth:

(I) The amount of work must be strictly adjusted to the medical condition of the workcr.

(n) Thc typc of work must bc similar to that of ordinary industrics clscwhcre, and the product be sold in the ordinary markcts.

(3) Thc nature of the work must be kcpt suitable by thc maximum use of machincry, and the organization of factorics on standard production lincs.

(4) The quality of the work must always be cxcellcnt.

(5) Permancnt cmploymcnt and sccurity must be available for those who nced it.

These principles arc so important that thcy should be considered furthcr: if thc principlcs arc undcrstood the dctails will look aftcr themselvcs (Varrier Jones).

Firstly, the mcdical problem. Any man who is fit to be up all day and takc onc hour's exercise is fit to start three hours' work in suitable conditions (Trail), and when his physician thinks he has reached this stagc hc can be accepted at Papworth. In so many sanatoria, such a man will idle away about a year 'going through gradcs' until he is considcrcd fit for a full-time light job. That time should not be wastcd: it should be spcnt in gradually incrcasing work and training lcading to regular ¢mploymcnt.

'Regular employment' is the key to the other four principles.

A man wants to do a man's job. There is little pride for a man in achieving temporary skill in ladies' handicrafts, and although knitting, crochet-work, and doll-making may occupy idle hours in bed they are not the basis of financial independence. But to do the same work as is done in factories else- where is to walk along the road to self- confidence, pride in craftsmanship and independence.

For that reason Papworth concentrates on such industrial processes as coach-build- ing, furniture-making, printing, etc., and sells its goods in the markets of the world.

When advocating the maximum use of machinery, a more controversial point is raised but the employment of unfit labour can only be successful if it is arranged so that temporary absences and short hours do not disorganize production too seriously. It is easy to provide work by subsidy, but that is not rehabilitation: that is charity, and however commendable for certain pur- poses, it is not the correct way to stimulate and lead a man to ultimate independence.

During training, and preferably after- wards also, the tuberculous worker stands a much better chance in a factory where the routine is organized and other shoulders can carry the burden of responsibility and worry.

I know this seems to be flouting the best traditions of the pig-keepers, poultry-keepers and other smallholders, but although such jobs are excellent in themselves they are not best suited for .this purpose because of the remorseless regularity of them. There is nothing more insistent than the clamour of hungry hens on a wet morning, and the luxury of home produce can only be earned the hard way, in wind and rain, on good days and bad, in sickness and in health. It is as relentless as matrimony, and as binding, with the same gloomy and inevitable sugges- tion that death ~411 be the end-result.

The one-man business, whether dealing with livestock or in a trade, is fundamentally

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unsound because there is the constant remorseless pressure of work which prevents relaxation. All those small traders whose jobs are thought to be so suitable for tuber- culous people suffer from this fact: the watch- makers, shopkeepers, jewellers, cobblers, and so on must work hard to build up the reputation upon which their livelihood depends; and they then find themselves working harder still in order to cope with trade which they themselves have stimu- lated. Success can be very satisfactory, but sickness or even holidays are a nightmare. At first extra work piles up: but if the absence is too long work soon falls off and the very livelihood is gone. For these tradesmen, their reputation is vital, yet it depends on that vaporous asset-goodwill , so easily blown away by the first slight winds of adversity.

In modern conditions of life there are perhaps only two professions in which a man can work in his own time, and call his soul his o w n - t h e priesthood "and crime. Un- fortunately the Ministry of Labour will not recognize either for their training schemes.

And finally, quality of work. From the economic point of view it is plain common sense that if a man's output is limited he must be trained to produce fine goods: only qualitycan gainhim economic independence. And from the point of view of the rehabilita- tion those who have suffered a long and demoralizing illness, the production of fine- quality goods is the best stimulus to morale. And morale is the foundation stone upon which independence is built.

Programme of Training As soon as a man has made his choice of work he starts work for three hours daily, resting in bed in the afternoon.

The amount of work done is controlled only by the medical staff, and is increased to five, six, seven, eight hours as thq patient improves.

The Ministry of Labour make their usual training grant until the time of colonization, when the grants are stopped and the man is offered permanent employment at agreed

Union rates of pay. The Papworth scheme differs from other Ministry of Labour schemes because it does not plan a short intensive full-time course, e.g. six months at six hours a day. The duration of training may last up to three years, so that the amount of daily work can be left to the discretion of the medical staff uninfluenced by financial considerations. This wise and trusting con- cession has enabled a government scheme to be given the flexibility and humanity which grows from friendly co-operation between clinician a n d the independent industrial leaders. Tuberculosis is not a stereotyped disease and cannot be handled by official memoranda or rigid official programmes.

On colonization, a man is accepted by the Unions for membership, and thereby ac- quires the status which is normally only granted after five to seven years' apprentice- ship. The Unions thus play their part in helping the permanent employment of the tuberculous, but there is obviously a corres- ponding obligation to ensure that the standard of training and work is high, and that men are not accepted as colonists until they have reached this standard. It is not ahvays the medical condition which pro- longs training.

Tile Ministry of Labour Training scheme first applied to Papworth in April I948 , and in the first four years 346 trainees were accepted. The second half of this paper will show the progress of this number, as judged by colonization, relapse, absentee rate, and duration of training, and it will be seen that the figures compare very favour- ably with ordinary industry.

But any discussion of rehabilitation must ahvays bear in mind the central figure of the working man who has had one to two years' treatment and then finds himself unable to get work, afraid for his wife and children, and spurned by his former colleagues. Only too often the hand which is held out to help during sickness is extended as a barrier when re-employment is required.

(To be conchtded)