Research Article
Print
Research Article
Health education in France during the interwar period: an example of the fight against tuberculosis
expand article infoVirginie De Luca Barrusse
‡ University Paris, Paris, France
Open Access

Abstract

Since the 1890s, in Europe, as in the United States, the fight against social disasters has comprised public health education. In France, the prevalence of tuberculosis was of particular concern. Back in 1913, the mortality from this cause accounted for 12% of the total mortality. The war has worsened the epidemiological situation, urging representatives of the American philanthropic Rockefeller Foundation to take a number of actions. From 1917 to 1922, in parallel with the creation of dispensaries and sanatoriums, the Foundation conducted an informational and educational campaign. In France during the interwar period, this American experience served as a source of ideas for health education.

The purpose of this article is to study conditions for developing a health education policy and measures taken within the framework of this policy. The fight against tuberculosis serves as an example, since it enables understanding of how, alongside institutional innovations and introduction of prevention and care tools, a system of public health education is being created and developed. In particular, campaigns for distributing anti-tuberculosis stamps make it possible to trace how knowledge of hygiene principles was spreading in the population of France, simultaneously providing fundraising for the fight against tuberculosis.

Keywords

health policy, health education, tuberculosis, «tuberculosis» stamps

JEL codes: I10, I18

Introduction

Since the 1890s, in Europe and the U.S., the fight against socially significant diseases, including tuberculosis (TB), has included public health education (see only about tuberculosis: [Barnes, 1995; Bryder, 2002: 15-45; Teller, 1988; Bates, 1992; Tuberculosis Then and Now... 2009]). To control tuberculosis in France during these years, associations consisting mainly of doctors have attempted to spread knowledge about the principles of hygiene among the population [Guillaume, 1986: 82-88, 294-301]: they issued «Instructions», postcards and small brochures in which hygiene rules encouraged the right behaviours and condemned the wrong ones.1 Due to lack of funds, the circulation of these documents was limited, but as a result of this activity, an idea was born: to disseminate information so that people know about the risks of infection, and to provide means to prevent them. Tuberculosis was of particular concern because the incidence rates in France were disturbingly high. In 1894, the number of patients per 10,000 Parisians was estimated at 41.6, compared with 17.3 in London, 21.1 in Naples and 22.3 in Berlin. In 1913, tuberculosis mortality accounted for 12% of the total mortality in France, compared with 8.3% in Germany and 7.2% in England [Murard, Zylberman, 1996: 485].2

The First World War had further complicated the sanitary situation, which prompted the American philanthropic Rockefeller Foundation to undertake a series of actions [Viet, 2015; Murard, Zylberman, 2002]. Having already had experience in combating social diseases in other countries, the Foundation proposed a model for organizing the fight against tuberculosis in France. From 1917 to 1922, in parallel with the creation of dispensaries and sanatoriums, the Foundation conducted an intensive informational and educational campaign. In post-war France, the American experience was most welcome. When the Foundation ceased its activities in France in 1923, it was decided that «the fight against tuberculosis can be effective only when its defining principles are clear to everyone, when precautions are not only enshrined in laws, but also become habits for everyone. Only educating the population will help to achieve this result» [Bernard, 1923: 10-11].3

The purpose of this article is to study conditions for implementing the health education policy, as well as its tools in interwar France. Health education here refers to all efforts made to instill the principles of sanitation and habits of personal hygiene in the population. The fight against tuberculosis serves as a model, since it enables understanding how, together with institutional innovations, prevention and treatment structures, a health education system is being created and maintained. From our point of view, the campaigns for distribution of anti-tuberculosis stamps are particularly interesting, since they enable observing how information about hygiene principles is disseminated throughout the country, while simultaneously raising funds to fight the disease. What is the balance between the financial purpose of stamp campaigns and public health education? What remains of the sanitary enlightenment in the schemes that have been put into effect?

The article considers the American experience in the fight against tuberculosis in order to understand what results of the Rockefeller Foundation’s activities were preserved in France after the Foundation had left the country. Were the institutions created with the participation of the Foundation innovative for interwar France? What activities were carried out by those who were entrusted with anti-tuberculosis education? The authors will consider this mainly on the example of the anti-tuberculosis stamps campaigns, thanks to which the principles of hygiene has been spreading throughout France since 1925, and this included the most remote departments.4 The article is primarily based on the study of the archives of the Pasteur Institute, in which collections of the National Committee for the Fight against Tuberculosis are stored, as well as regional archives that make it possible to understand the dissemination mechanism of the model of health education, and, finally, visual archival materials precisely explaining what was demonstrated to the population as means of anti-tuberculosis education.

American Heritage

At the beginning of 1916, alarming signals about the growing prevalence of tuberculosis in France urged the International Health Department of the Rockefeller Philanthropic Foundation and the American Red Cross to send a TB prevention commission to Paris, which was often referred to as the Rockefeller mission (for the activities of the Foundation, see [Farley, 2004; Rockefeller Philanthropy..., 2003; Picard, 1999; Picard, Schneider, 2003: 106-124].

On July 23, 1917 the Mission began its work in Paris, declaring its purpose to «arouse public interest in the ideas of prevention and protection, disseminated among the population through an active campaign of public education and nationwide propaganda of knowledge about the causes, mechanisms of transmission, treatment and prevention of tuberculosis» [Bruno, 1925: 20]. To implement this activity, the American mission has organized several services, the functions of which it gradually transferred to the National Committee for National Defense against Tuberculosis (hereinafter – CNDT), which in 1920 replaced the National Committee for Assistance to Ex-Servicemen with Tuberculosis that had existed in France since 1916 [Murard, Zylberman, 1987].

To spread knowledge, the American mission used the same methods as propaganda in general: simultaneous use of mass media, which contributes to the fact that the scale of the problem becomes immediately apparent throughout the country; a variety of visual means and simultaneity of their dissemination. Posters were widely used in the campaign, because through a series of images they visualized the TB problem. Some posters used symbols and iconography, often borrowed from military propaganda; as shown in the poster of 1917: «The Boche Eagle shall5 be defeated, and so should tuberculosis»; in others, the image was accompanied by text. Every year, about 15,000 posters were displayed on the city walls, such as «Fight tuberculosis» (1920). Posters were also reproduced on postcards to ensure their faster distribution throughout the country. At the same time, short articles prepared by the American mission appeared in the Paris and regional press: «How a person gets tuberculosis» or «Tuberculosis at school». At the end of 1918, 24 different articles about tuberculosis were published in 33 newspapers, mainly regional ones.

The Mission’s commitment to spreading information about the fight against tuberculosis is noteworthy. So, it organized a travelling exhibition, which was widely advertised in the local press. From 1919 to July 1921, the exhibition visited more than a thousand towns and villages in 53 departments of France. The audience seemed to like it. A million adults and just as many children attended the lectures delivered as part of the exhibition, about six million leaflets and brochures were distributed free of charge [Williams 1922:45]. Children were the main target group for promoting a healthy lifestyle. In 1919, the play «Guignol de la santé» was written, it was devoted to health promotion; performances were held in a small mobile theatre. The script drew children’s attention not only to the danger of contracting TB, but also to the destructive effect of alcohol, another critical social problem [Bruno, 1925: 148-149]. These performances were attended by 67 thousand children in 30 departments of France.

The so-called «sanitary caravans» became the symbol of this system of sanitary education, covering even the most remote regions of France. Starting in March 1918, motorized groups consisting of a lecturer and a driver-operator travelled through towns and villages, demonstrating films and commenting them, as well as distributing leaflets. The arrival of the «hygienic tanks» or «medical tanks» (chars d’hygié or «tank-médecins»), as they were called by journalists, was prepared by a Mission’s representative, who met in advance with representatives of the municipalities and prefectures, religious figures; cooperation with local authorities was an important element of health education activities. Apparently, the population met these events with enthusiasm [Lefebvre, 1991]. The Mission distributed films produced in France, such as the films of the Mazo studio «Don’t spit on the floor» or «Recommendations for sweeping without dust», as well as the films of the Pathé and Gaumont studios «Wash your hands» or «Don’t drool your finger to turn pages», shot in 1918-1919 [Delmeulle, 2003]. Animated films were especially popular, particularly those created by animator Mr. O’Galop (pseudonym of Marius Rossiyon): «Tuberculosis threatens everyone», «Tuberculosis is contracted at the bar ...». These very short films were devoted, as a rule, to one idea, summarized in their title.

In regions, propaganda with the help of sanitary caravans was in full swing, contributing to the structuring of the anti-tuberculosis activities. In Hérault, a mostly rural department in the southwest, this coincided with the creation of the Regional committee for social hygiene in March 1921. The Committee was responsible for the fight against tuberculosis, creating dispensaries, mountain sanatoriums and outdoor schools, as well as supporting health education, as evidenced by an article in Le Méridional announcing the arrival of the American foundation:

«Representatives of the Rockefeller Mission have just arrived in Sète6 to assist in health education propaganda work conducted by the Regional committee for social hygiene. They started with activities in public and private schools, using the most modern and effective means: posters, leaflets, films, lectures. During this first propaganda campaign, which will be held among children from the 13th to the 20th of this month, they will also try to invited participation of all social groups in interesting public lectures, explaining everything we need to know about these important problems» [Le Méridional, March 9, 1921].

Thus, the Mission has become a driving force in organization of health education and its implementation at the local level. The innovative nature of its activities undoubtedly explains why it is closely monitored. Almost every day L’Eclair or Le Méridional publishes an article about the Mission’s visits to cities and towns. For instance, on March 15, 1921, Le Méridional reported a lecture that representatives of the Mission read to 600 children in Sète:

«The lecturer’s oratorical talent was able to attract and hold the children’s attention for an hour in a conversation on this serious topic [...]. Pieces of advice followed one after another: «Don’t spit on the floor,» «Let’s declare war on germs,» «Learn to be clean.» At the end of the lecture, the audience was shown two or three instructive and entertaining films. These conversations continued throughout the week, repeated three or four times a day, so that children from all schools could benefit from them» [Le Méridional, March 15, 1921]. «The children chant together: J’ai du bon soleil dans ma chambrette (I have nice sunshine in my room). This beautiful song, which is already being played on our streets, is designed to capture the main principles of a healthy and hygienic lifestyle in young minds» [L’Eclair, February 14, 1921].

On May 24, 1921, in Beziers, after the first lecture given to a large audience, including the local leadership, two films were shown, «a scientific one that made a great impression – about tuberculosis, its causes and consequences, and another one with pleasant and even entertaining symbolism.» One of the lectures, «Hygiene of childhood and hygiene of the home», was addressed to women. The celebration continued with a party and a Hygiene Ball and ended with screening a drama «The Force of Life» (La force de la vie), telling how «in Paris, one worker falls ill due to lack of exercise and fresh air. He returns to his native Corsica, where he restores his health thanks to fresh air. Then he returns to Paris, gets married and leads a healthy lifestyle» [Bruno, 1925: 159]. The audience, apparently succumbing to the charm of the film, left with hands full of brochures and postcards, which were distributed at the party free of charge [L’Eclair, May 25, 1921].

In addition to organizing large-scale events designed to attract attention of the public and impress them, the health education system supported by the Mission spreads new knowledge among the population. In lectures, excerpts from which are published, as well as in newspaper articles, information is given in order to disseminate medical knowledge about TB transmission and course of the disease. TB prevention education is aimed at making the hygiene rules a daily practice and breaking unhealthy or dangerous habits. TB prevention is carried out through adapting to the new «rituals». The methods of propaganda used assume that the knowledge which is to be assimilated, interpreted and applied is distributed in a population that has so far been unaware of this knowledge. There is no need to rely on the knowledge ordinary people possess or adjust it, rather new rules and habits based on new knowledge should be instilled. As Julia Csergo shows, in the case of personal hygiene, body cleanliness has become a general rule [Csergo, 1988: 31]. The new hygiene rules condemn and debunk certain habits that are no longer acceptable because of the risks they pose to others; do not spit, put your hand to your mouth when coughing or sneezing and wash your hands – all these gestures become signs of collective care, and they are not exclusive to France [Blom, 2007]. Violators are frowned upon, and deviant behaviour is deemed as spreading evil [Bourdelais, 2003: 24]. At the same time, health education does not distinguish between personal hygiene and social behaviour. Thus, the Rockefeller mission did not create the health promotion system that had already existed in France; the Mission provided for organization, technique and content.

Lucien Viborel: Project Manager

In April 1922, when the American mission was preparing its departure (planned from the moment of its arrival), it transferred the propaganda and agitation functions to the National Committee for Defense against Tuberculosis (CNDT) [Murard, Zylberman, 1987]. The service management was entrusted to Dr. Alexander Bruno, who, having been educated in France, practiced at the Roosevelt Hospital in New York; he was assisted by Lucien Viborel, who soon became project manager for organizing health education campaigns.

Lucien Viborel was born in 1891; in 1917 he became an employee of the American mission, then he was appointed deputy director of the CNDT Propaganda and Agitation department. In his own words, «this was the beginning of [his] career as an educator in the field of healthcare» [Viborel, 1954: 5]. In January 1924 the International Health Department of the Rockefeller Foundation offered him a scholarship to travel to the United States «in order to study methods used in this country in relation to social hygiene and actions to be taken to raise funds» [CNDT, letter dated January 3, 1924]. The CNDT Director , Dr. Arnaud, confirmed to the Director General of the Health Department, Dr. Russell, that «the extensive information collected [by Mr. Viborel] about your educational and financial propaganda organizations (organizations de propagande éducatives et financières), as well as about implementation of advertising campaigns, has greatly interested us, and by nature this information can be of great assistance to us and make our efforts more fruitful» [CNDT, letter dated January 3, 1924].7 This experience proved crucial, and upon returning from his trip in 1924, Mr. Viborel headed the CNDT Propaganda department. The following year, Jules Brisac, director of the newly created National Directorate of Social Hygiene, entrusted him with « implementing the educational programme of the National Directorate» [CNDT, Titres, Travaux...: 18].8 «From 1925 to 1935, when the National Bureau ceased to exist, I organized a campaign to support hygiene and fight against social diseases,» recalls Mr. Viborel. When budget cuts resulted in the Bureau liquidation, Mr. Viborel was instructed to «continue to direct and coordinate efforts to promote health education.» Mr. Viborel’s experience has spread beyond France after his appointment as Expert of the League of Nations at the International Institute of Educational Films, and in 1930 – as member of the international section of the League of Nations for Teaching and Social Education [CNDT, Titres, Travaux ...]. After the end of the war, Mr. Viborel became Director of the National Center for Sanitary, Demographic and Social Education under the Ministry of Health and Population.

Thus, in just a few years, Lucien Viborel has become the man behind healthy lifestyle promotion in France. He is credited with «great contribution to refining the concept of propaganda, turning it into a new science with its own doctrine, methods and tools» [CNDT, Nécrologie: 2]. In fact, Lucien Viborel has created theoretical foundations of sanitary propaganda [Viborel, 1936b, 1944, 1953] and popularized this idea, primarily through public education, since «ignorance is the main cause of our diseases» [Viborel, 1932: 309]. He defines sanitary propaganda as «the art of spreading, educating, in a word, popularizing the idea [...]. Its main purpose is, first of all, to make the population get into a habit of observing hygiene rules, because the main goal of propaganda is to provide deep and lasting protection» [Viborel, 1930]. He was inspired by the American methods, especially with regard to simultaneous implementation of several types of activities forming a «campaign». According to Mr. Viborel, the campaign «creates, defines, impresses, captures, enlivens and leads,» based on a combination of elements. «Efforts should be large-scale and diverse. Any means used in isolation is not a propaganda.» But it seems that Viborel’s method does not differ in any way from the sanitary propaganda carried out in the period between the First and Second World Wars in Western Europe, where a number of mass media were mobilized to help improve social hygiene [Lederer, Rogers, 2003; Perdiguero et al., 2005: 216-220]. In this sense, Viborel’s approach is quite common. The method focuses on cinema, the same can be said about the U.S., United Kingdom and Spain, where cinema is perceived as an excellent means of propaganda, since it is popular and has a certain emotional power [Viborel, 1923: 4; Viborel, 1932: 310; for a foreign example, see Perdiguero et al., 2007]. In addition, during the interwar period, cinema was put at the service of health education, resulting in mass production of documentaries [Murray Levine, 2010: 12-34; De Pastre, 2004; Zarch, 2002).]

Lucien Viborel continued implementation of the programme created by the Rockefeller mission. Throughout the interwar period, he has been seeking to develop an active and consistent policy, create favourable conditions for adopting new laws and provision of services to meet needs of the population. This policy was also aimed at developing individual prevention and care skills. Anti-tuberculosis stamp campaigns initiated by Mr. Viborel correspond to these aspirations.

A stamp: the flagship of the fight against tuberculosis

Campaigns for dissemination of anti-tuberculosis stamps have mobilized all means of propaganda to implement a comprehensive knowledge dissemination programme. The stamp was at the same time a «tool for health education» [Viborel, 1954: 28], a tool for fundraising and communication to promote the developed programmes. Therefore, its impact was observed at several levels.

The idea of issuing tuberculosis stamps originated in Denmark in 1904 and spread across the Atlantic in 1907. Here, as in Northern Europe, it was a great success [Mouret, 1994]. At the beginning of 1925, the Rockefeller mission updated the CNDT Propaganda department on theprogress of the American stamp distribution campaigns, although it is unknown whether any reaction from the CNDT followed. In October of the same year, the International Health Department of the Rockefeller Foundation provided CNDT with the first subsidy for a test launch of a stamp campaign in one of the departments. Meurthe-et-Moselle was selected as a pilot region because of its developed sanitary and social infrastructure, led by Dr. Jacques Parisot [CNDT, Titres, Travaux...: 18; Thévenin, 2002; Murard, 2008]. A month later, a new subsidy was allocated, designed to «support activities of the Propaganda department, especially those valuable in terms of public education, which will also be effective for increasing income of the National committee» [CNDT, Anti-tuberculosis stamp ..., 1925]. This subsidy made it possible to finance production of the number of stamps needed to launch the first campaign to distribute them in nine departments of France [ADH, Comment est né..., 1937]. Since 1927, the stamp distribution campaign has taken on a nationwide scale. Until the late 1970s, its organization was entrusted to the National Stamp Committee, established under the auspices of CNDT, which also organized international conferences on anti-tuberculosis stamps. Per Viborel’s initiative, the first conferences were held in 1930 in Paris, at the CNDT headquarters. Their purpose was to compare methods of conducting campaigns and their effectiveness.

In France, an anti-tuberculosis stamp was not an ordinary postage stamp [Coutant, Jeff, 2010]. Indeed, a propaganda stamp with a simultaneous postal function, used in some countries, reached only a part of the population: «an ordinary postage stamp is not a means of propaganda, but merely a source of additional income» [ADH, Campagne du timbre..., 1927]. However, fundraising is not the only objective of the anti-tuberculosis stamp. The stamp, despite its small size, contains a message in the form of a picture and text. They relate to the rules of a «healthy lifestyle» (to use the name of the magazine published by CNDT). The text, for instance, could be: «Light» (1929), «Cleanliness (1930) or «Fresh air» (1931). Although the inscription on the stamp varies from year to year, one element remains unchanged: a red cross with two crossbars, which is used on all anti-tuberculosis stamps, both in France and in many other countries. In 1902, in Berlin, the representative of France at the International Bureau for the Prevention of Tuberculosis, Dr. Sersiron, suggested finding a symbol of unification: «The global fight against tuberculosis needs a banner [...], a sign of unity.» His proposal, the «double red cross», unanimously adopted, has created a recognizable and understandable image of the fight against tuberculosis, «a symbolic expression capable of arousing enthusiasm and maintaining it at the highest level of the Ideal» [Viborel, 1936a: 4]. In 1920 the International Union adopted this symbol.

Campaigns are held annually, and this regularity is important for the process of health education: «experience shows that an interrupted campaign is very difficult to resume afterwards» [ADH, Campagne du timbre..., 1927]. In addition, «in order to maintain the public’s favour,» a short-term sale of stamps is preferable to their permanently being on sale. Finally, «it is necessary that the campaign is simultaneously underway countrywide to create a broad propaganda movement throughout France that can only benefit everyone.» The end of the year to start the campaign has been selected because during this period there is most correspondence, making it possible to paste and distribute stamps; but it was also «the time of New Year’s gifts, when all hearts are open for good» [ADH, Campagne du timbre..., 1927]. In addition to selling the stamp for a month, one day in December was dedicated to fundraising in public places. Street fundraisers collected donations from people, in return handing over a fight TB badge – a double red cross [CNDT, Le timbre antituberculeux ..., 1965].

Since the very first campaign, the National stamp distribution committee has been publishing the «Week of the Anti-tuberculosis Stamp» newspaper (La semaine du timbre antituberculeux), which was supposed to provide cooperation between departmental committees, which in turn supervised activities of the municipal committees. The newspaper quotes prices for consumables, stickers, posters, leaflets and films, disseminates practical information, and also provides arguments in favour of selling stamps. For example, the issue dated December 15, 1927, recommended to remind customers about stamps: «Do not keep stamps in boxes, offer them to everyone, distribute life-saving stickers everywhere» [CNDT, La semaine du timbre..., 1927]. Following the results of each campaign, a leaflet was issued, which was then widely distributed. For example, in 1938, a leaflet of the «Cleanliness and Order» stamp explains that «this is a message of cleanliness. Cleanliness and neatness should be the first rule for everyone who wants to succeed in protecting against TB and preserving their health [...]. To buy and use the December stamp against tuberculosis means to ensure Health and Future of our People. This should contribute to the formation of healthy habits of cleanliness» [ADH, Dépliant de la 12 e campagne... 1938).

The Committee coordinates campaigns by mobilizing many media outlets. Posters on the walls announce stamp sales campaigns. During the first campaign for distributing «Sunshine Kiss» (Le baiser au soleil) stamps, a poem by Jean Rouveyr was read on the radio: «Donate! Your hand distributes health, just a small fraction for the sun, for fresh air, for children, for those who are slowly being devoured by the disease.» CNDT posters hung on the walls. For example, in 1934 one of them read: «It was after the organization of national campaigns of anti-tuberculosis stamps that the face of our country completely changed in terms of the fight against tuberculosis [...]. From 1881 to 1934, mortality from pulmonary tuberculosis in Paris decreased by 64%; mortality from all forms of tuberculosis decreased by 59.7%. This means that from 1881 to 1934 we were saving 7,500 human lives a year. In the fight against only one disaster, 7,500 human lives are saved per year! Tuberculosis is on the decline! Help us! Buy an anti-tuberculosis stamp and convince others to buy it» [ADH, Affiche du CNDT]. Gaumont newsreels also announced campaigns for releasing stamps on cinema screens. In 1923, they showed a feverish work of rotary machines in the printing house where the anti-tuberculosis stamp was printed [AA, Pour sauver des malades..., 1923]. On December 12, 1930, the chronicles of the news magazine of the Pathé film company announced the launch of the Cleanliness stamp: «Water is useful, water is beneficial, water is respected everywhere, is not the credit due to water for nature flourishing, with water touch our bodies gain new strength and everywhere it drives away what is unclean» [AA, Chronique philanthropique, 1930]. In 1934, newsreels recalled that «a terrible disaster generates pain and despair in many families» [8ème campagne du timbre..., 1934]. «Two sous for health» [AA, Actualités, 1934] is not too much. For many days, such messages followed one after another.

Comprehensive propaganda

However, in the field, organization of stamp campaigns, faces situations that required an annual adaptation of the previous experience in their implementation not only to the requirements of the local leadership, but also to the expectations of the local population. Thus, it is possible to observe what eventually remained of the ambitious health education programme at the local level.

On March 1, 1927, the President of CNDT addressed the prefects with a letter explaining why it was decided to hold the first national stamp campaign in 1927, following the convincing results obtained in the pilot departments; the letter payed a special attention to the funds that the campaign would raise. Distribution of the collected funds between the departments and the Committee was in favour of the departments, since 90% of the campaign proceeds were directed to the fight against tuberculosis at the local level [ADH, Lettre du président..., 1927]. In 1933, this share was increased to 95%.

In July 1927, the Hérault Prefect began organizing a committee in the department, following the model recommended by CNDT [ADH, Le timbre antituberculeux...]. Local figures who could be contacted immediately agreed to take part in the fight against tuberculosis. Several associations informed the Prefect that they were ready to cooperate in the fight against tuberculosis, for example, Association of the Disabled with Lung Injuries [ADH, Lettre de la fédération nationale ..., 1927]. On October 7, 1927, the first meeting of the Committee was held, at which the secretary presented his mission: «We have the directives of the National committee, but they are broad enough to let us freely move forward in accordance with our ideas and decisions, following mutual discussions and an exchange of views, complying with the spirit of those directives.» He recalled principles the Committee should be guided by: «In the minds of those who promote it, the stamp is indeed a means of creating resources, but above all it is a means of propaganda and public education in terms of health» [ADH, Rapport sur l’organisation ... 1927]. The Regional Committee ensured cooperation with local committees organized in municipalities. A real organization has been created in the form of a pyramid. Contacts between local offices and the Regional Committee were frequent including: exchange of information, up-to-date sales data, reports, monitoring of actions taken, innovations, etc. Each local committee brought together representatives of the municipality. On January 28, 1928, the Mayor of Marcelan informed the Prefect that he had created a local committee consisting of members of the city council, teachers, several doctors and pharmacists, a parish priest, chief tax inspector and the secretary of the Mayor’s office: «The members of the Committee, each in their community and professional spheres, were spreading the idea of selling the stamp and its deep humanitarian purposes in order to get the population interested in making large purchases» [ADH, Lettre du maire..., 1928]. For each new campaign, these committees were formed anew, however their activities were far from ideal. Right from the second stamp campaign in Hérault, the Regional Committee reported conflicts in local committees, for example, in Castries; in Montpellier the local committee was inactive. Personal rivalries, conflicts over the methods of work used, and especially over revenue management in local committees were not uncommon.

Concurrently, the Regional committee publishes articles in local newspapers calling for goodwill [ADH, Lettre du préfet..., 1936]. It appeals for support to sports groups and associations, in particular, football or bullfighting fans, to mutual aid societies... The Committee hangs up posters that say «Buy an anti-tuberculosis stamp» and offers to hold radio conferences. Dance halls and theater halls are also widely used in the campaign. Musicians are asked to remind the audience during the concert: «Buy an anti-tuberculosis stamp.» «No means should be neglected. As experience shows, the crowd mentality requires that the product to be sold be in fashion. In order for our vignette to become fashionable, it is necessary that the phrase announcing the sale of stamps become a kind of leitmotif that cannot be ignored. Therefore, intensive advertising everywhere and by all possible means is the basis and a guarantee of success. A well-advertised stamp should be a success» [ADH, Rapport sur l’organisation..., 1927].

During the second campaign, 6 thousand large and 11 thousand small leaflets were distributed in the department. Conferences were organized with the subsequent screening of films: «education in the field of anti-tuberculosis propaganda with the help of cinema is perhaps the most effective means, or the most popular one among people to say the least» [ADH, Rapport moral ..., 1928-1929]. Programmes on the campaign topic were broadcasted on the radio. Contests for the best window display design mobilized shop owners. In 1934, the Montpellier merchants’ union organized such a competition in favour of the stamp’s campaign. The lottery offered generous prizes: a luxury car, a refrigerator, and a fur coat. Diplomas and medals were provided for young people. However, «according to the unanimous opinion of school principals, young people are not attracted by medals and diplomas, regardless of how beautiful they are. Therefore, it is necessary to take into account modern tastes, especially sports» [ADH, Rapport moral ..., 1935]. And next year the prizes included cameras, balloons, dolls, pens and even airplane flights!

Stamp distribution campaigns heavily relied on school [Guillaume, 1986: 201] where they were part of a set of measures to combat other social vices, alcohol abuse in particular [De Luca Barrusse, 2013].9 Teachers were actively involved in this campaign.

Manual for Primary School Teachers (Manuel général de l’Instruction primaire) published articles recommended by the National Committee for stamp dissemination [Mouret, 1994]. The manual included topics for essays, dictation, lesson plans about tuberculosis and ways to prevent it. But above all, it was the children who were the target group of the anti-tuberculosis campaign, because they were entrusted with selling stamps in their community [Mouret, 1994]. A small manual was written for schoolchildren, which told how to address their loved ones. «Not sticking anti–tuberculosis stamps on letters and parcels means committing a crime against your neighbour. Here’s what a student should know before offering to buy a set of stamps. He should make it clear that «he is not an intrusive petitioner, he serves the purpose of social solidarity» [Viborel, quoted by Mouret, 1994]. For each new campaign, schools received an illustrated booklet on the topic of the year so that the teacher could provide the best support to students. The report on the morale of the 1934-1935 campaign states that «at school, the stamp is bearing fruit not only in terms of financial results, but also in moral terms, because it teaches children a lesson in altruism and solidarity and it teaches them to love a healthy outdoor life in order to protect themselves from the social scourge of tuberculosis» [ADH, Rapport moral..., 1935]. Indeed, it was in schools that the mobilization was most active: «Schoolchildren are the best propagandists» [ADH, Rapport moral..., 1928-1929]. A real competition was organized among children: they had to sell as many blocks of stamps as possible [Guillaume, 1986: 201]. The success was outstanding. In 1927, 3.5 stamps were sold per inhabitant, in 1928 – 4.4.; In total, 181,538,425 stamps were sold that year.

Fundraising in a competitive environment

The stamp is a fundraising tool. CNDT’s profit-sharing guidelines at the local level remain unchanged. The funds collected during the campaigns were priority directed to prevention: vaccination of newborns, placement of children in rural areas, in preventoriums, in summer recreation camps, admission of TB patients to medical institutions and creation of hospital beds [ADH, L’œuvre féconde..., 1934]. As in other countries in Europe and North America, children were the subject of special attention and special care.10 Among the projects subsidized by the National Committee was, for instance, the Granche project; under this project children living in households with TB patients were resigned to foster families [Becquemin, 2005]. In the Hérault Department, discussions on the use of revenues from the stamps sale show that the preference was also given to associations for child’s protection.

Since the stamp was a fundraising tool, it was important to publicize the contribution and results of activities at the national level, because «everyone should be able to realize that his efforts were not in vain, and should know how the anti-tuberculosis stamp was able to alleviate so much suffering» [ADH, Timbre antituberculeux..., 1928]. CNDT was also regularly calling on the Hérault Prefect to share results of the stamp sale without delay, since «publishing these data and listing purposes the raised funds are intended for, is the finest of all methods of propaganda» [ADH, Timbre antituberculeux ..., 1928]. Every year, based on the reports of the regional committees, CNDT publishes results of the national campaign and lists subsidies provided to anti-tuberculosis organizations in a brochure called «Fruitful work of the anti-tuberculosis stamp» (L’œuvre féconde du timbre antituberculeux). CNDT also publishes a ranking of departments according to their contributions, which is undoubtedly done to give role models. In addition, several films are shot every year at the request of the Сommittee. Most often, the funded film companies convincingly present the results achieved through the sale of stamps. Films show life in a sanatorium or preventorium, a typical day in the life of a convalescent. «It is by using this method of propaganda that the population will understand importance of the struggle we are waging and will generously support the anti-tuberculosis stamp» [ADH, Instructions concernant...]. In 1936, the news bitterly reported: «There are times when human charity fights against death for many lives; the tuberculosis stamp enables maintaining sanatoriums and dispensaries, how many human lives has this little vignette already saved?» [AA, Actualités, 1936]. From the following year and at least until 1939, the newsreels show preventoriums built thanks to collective efforts to conduct a new campaign [AA, Actualités, 1938a, 1938b, 1939].

However, activities of the stamp campaigns were gradually fading. At the end of the 1930-1931 campaign, in conditions of the economic depression that has begun, the Hérault Regional committee states: «it should be noted that the public looks to be through withpurchasing anti-tuberculosis stamps [...]. The mayors of several rural communes expressed their desire to halt stamps sale since it is the communities rather than individuals who are responsible for achieving the campaign goals, and asked to include additional allocations to fight against TB in the state and regional budgets» [ADH, Timbre antituberculeux..., 1930-1931]. Some communes announced that they will not participate in the next campaign. Schoolteachers also expressed concern about mobilizing resources needed to sell the stamp. «It would be terrible to see (the work of the stamp) come to naught due to fatigue of the society» [ADH, Timbre antituberculeux..., 1930-1931]. The Prefect of the Hérault Department warned the Minister of Health about this fatigue and the risk of declining sales of stamps. On June 22, 1931, the Minister replied that «the purpose of issuing an anti-tuberculosis vignette is not only to provide charities with additional funds, but also to raise public awareness about tuberculosis [...] For this reason alone, it’s worth supporting» [ADH, Lettre du ministre..., 1931]. The Minister’s answer is clear: the stamp campaign is not only a fundraiser, but also an educational activity.

Indeed, many stamps have been competing with one another. Success of the anti-tuberculosis stamp encouraged other associations to launch their own campaigns. For example, in 1932 The Federation of Merchants issued «To help the unemployed» stamp (L’aide aux Chômeurs); in 1938, following the Society for Promotion of a Healthy Lifestyle, the Society for Sanitary and Moral Prevention – an association for preventing sexually transmitted diseases – issued a stamp «For Salvation of the People» (Pour sauver la race) [De Luca Barrusse, 2013]. CNDT, represented by its president André Honnorat, was concerned about this competition: «By tiring the public with too frequent requests, we are running the risk of reducing revenues from the stamp sale « [Tronchet, 2009: 380].11 CNDT has several times demanded a monopoly on the stamp from the Minister. Such competition was clouding the outlook for the anti-tuberculosis stamps campaigns, while the number of calls for generosity grew the local resources of various associations were being depleted, as they were constantly mobilized for «good deeds». Therefore, although revenues are always high, they fluctuate from year to year [CNDT, Le timbre antituberculeux, bilan annuel...]. The anti-tuberculosis stamp has withstood the competition. The stamp success is undoubtedly ensured by its historical roots, as well as by the campaigns through which it has gained fame.

Conclusion

When in 1958 Lucien Viborel summed up results of the fight against tuberculosis, he called the stamp campaigns the most convincing element of the project and its greatest success: «Resources provided by the anti-tuberculosis stamp campaigns and used in accordance with the reasonable programme have significantly contributed to the creation of numerous means of controlling TB, from dispensaries and visiting nurses to sanatoriums and sanatorium hospitals, including an entire range of measures from BCG vaccine immunization and investments in prevention to preparation for treatment, treatment itself and subsequent rehabilitation» [CNDT, Titres, Travaux...: 25]. However, campaigns were not limited to fundraising; their activities were also measured by health education: «their impact has initiated and sustained a decrease in TB mortality, and this was the result of the psychological impact of the campaigns to distribute anti-tuberculosis stamps» [Viborel, 1954: 28]. This opinion was shared by many. In particular, professor Claude Bernard, Head of CNDT, who in 1934 confirmed: «comparing the mortality curve from pulmonary tuberculosis [...] we clearly see that the mortality rate from this form of tuberculosis is decreasing faster than the overall mortality rate, especially since vigorous efforts have been taken in France in this area. Tuberculosis has abated in France and it is mainly due to an undoubtable and invaluable victory of the educational campaign of the anti-tuberculosis stamp» [CNDT, Titres, Travaux...: 26]. Based on statistical data on mortality due to causes related to the period of the stamp introduction, J. Wallen and F. Mele estimated that mortality from TB ranged between 19.4 and 23.0 per 10,000 population at that time. In 1935, it was already 12.5-14.6 per 10,000 [Vallin, Meslé, 1988]. The decline is obvious, and it coincides with an intensive campaign of health education, but the effect of the stamp should not by downplaying impact of the structured health policy based on a network of institutions (see, for example, the tuberculosis system created in the Lyon region [Dessertine, Faure, 1988]).

This level of health education has been achieved through gradual implementation of actions that contribute to strengthening individual and collective health. This has contributed to the formation of the idea that hygiene is a common capital. Education against the scourge of tuberculosis is health promotion; the goal is to make health both an individual value and a collective asset that must be preserved and maintained. In addition, health education provides information about existing institutions, preventive medical services, and treatment programmes. Thus, it is promotion of both health and health policy.

In particular, the stamp distribution campaigns had a double impact: raising awareness of the risks associated with tuberculosis and awareness of the current policy. The goal was to engaged people in supporting national efforts to combat tuberculosis and to involve people of all ages in this activity. Success of the stamp distribution campaigns and a parallel reduction in TB mortality rates have validated the chosen policy. Thus, the Third Republic has built a health policy based on the American model. Lucien Viborel’s long tenure as head of the structures responsible for health promotion and also linked to education explains sustainability of the model, despite the changing institutional context.

Appendix

Figure 1.

Poster of 1934

Figure 2.

«Healthy life» poster, November 1927

Figure 3.

CNDT poster, 1936

Reference list

  • Barnes D (1995) The making of a social disease. Berkeley.
  • Bates B (1992) Bargaining for life: A Social History of Tuberculosis, 1876-1938. Philadelphia.
  • Becquemin M (2005) Protection de l’enfance et placement familial. La fondation Grancher. De l’hygiénisme à la suppléance parentale. Paris.
  • Bernard L (1923) Préface à Dr. Jullien, La tuberculose envisagée au point de vue social (Paris, 1923), pp. 10-11.
  • Bourdelais P (2003) Les épidémies terrassées. Une histoire des pays riches. Paris.
  • Bruno A (1925) Contre la tuberculose. Paris.
  • Bryder L (2002) Below the Magic Mountain. Oxford. Pp. 15-45.
  • Coutant L, Steff P (2010) Les campagnes du timbre antituberculeux français du 20e siècle, 1ère partie 1925-1944. Paris.
  • Csergo J (1988) Liberté, égalité, propreté. La morale de l’hygiène au XIXe siècle. Paris.
  • De Luca Barrusse V (2013) Population en danger! La lutte contre les fléaux sociaux sous la Troisième République. Bern.
  • De Pastre B (2004) Cinéma éducateur et propagande coloniale. Revue d’histoire moderne et contemporaine 51(4): 135–151.
  • Delmeulle F (2003) Contribution à l’histoire du cinéma documentaire. Le cas de l’encyclopédie Gaumont. Lille.
  • Dessertine D, Faure O (1988) Combattre la tuberculose. Lyon.
  • Farley J (2004) To cast out disease. A History of the International Health Division of The Rockefeller Foundation. Oxford.
  • Frioux S, Nourrisson D (2015) Propre et sain ! Un siècle d’hygiène à l’école en images. Paris.
  • Guillaume P (1986) Du désespoir au salut: les tuberculeux au XIXe et XXe siècles. Paris.
  • Lederer S, Rogers N (2003) Media / In R.Cooter, J.Pickstone (eds), Companion to Medicine in the Twentieth Century. London. P. 487-502.
  • Lefebvre T (1991) Les films diffusés par la Mission Américaine, de prévention contre la tuberculose (Mission Rockefeller, 1917-1922) // 1895, revue d’histoire du cinéma 11 : 101-106. https://doi.org/10.3406/1895.1991.987
  • McCuaig K (2000) The Weariness, the Fever and the Fret, The Campaign against Tuberculosis in Canada, 1900-1950. Kingston.
  • Mouret A (1994) L’imagerie de la lutte contre la tuberculose : le timbre antituberculeux, instrument d’éducation sanitaire // Cahiers du Centre de Recherches Historiques 12. https://doi.org/10.4000/ccrh.2734
  • Murard L (2008) Social Medicine in the Interwar Years. The Case of Jacques Parisot // Medicina nei secoli 20(3): 871–890.
  • Murard L, Zylberman P (1987) La mission Rockefeller et la création du Comité national de défense contre la tuberculose // Revue d’histoire moderne et contemporaine 34(2): 257-281.
  • Murard L, Zylberman P (1996) L’hygiène dans la République. La santé publique ou l’utopie contrariée. Paris.
  • Murard L, Zylberman P (2002) Les fondations indestructibles : la santé publique en France et la Fondation Rockfeller. Med Sci 18(5): 625–632.
  • Murray Levine AJ (2010) Framing the Nation. Documentary Films in Interwar France. London.
  • Nourrisson D, Freyssinet-Dominjon J (2009) L’école face à l’alcool (Saint-Etienne, 2009)
  • Perdiguero E, Ballester R, Castejon R (2005) Mass-media and health informations campaigns in Spain (1920-1936) / In: ITEMS Networks, Medicine, Health and Society in Europe: Trends and Prospects. Coimbra. P. 216-220.
  • Picard J-F (1999) La fondation Rockefeller et la recherche médicale. Paris.
  • Picard J-F, Schneider W (2003) From the Art of Medicine to Biomedical Science in France / In: W. Schneider (ed.), Rockefeller Philanthropy and Modern Biomedicine. Indianapolis. P. 106-124.
  • Rockefeller Philanthropy and Modern Biomedicine. International Initiatives from World War I to the Cold War (2003) / W.Schneider (ed.). Indianapolis.
  • Teller M (1988) The Tuberculosis Movement: A public Health Campain in the Progressive Era. Chicago.
  • Thévenin E (2002) Jacques Parisot (1882-1967): un créateur de l’action sanitaire et sociale. Nancy.
  • Tronchet G (2009) André Honnorat ou l’hygiène par l’exemple (1910-1940). In: La promotion de la santé à travers les images véhiculées par les institutions sanitaires et sociale / Actes du colloque sur l’histoire de la protection sociale, Arles, 16-21 avril 2007. Paris. P. 371-387.
  • Tuberculosis Then and Now: Perspectives on the History of an Infectious Disease (2009) / Condreau F., Worboys M. (eds), Kingston.
  • Vallin J, Meslé F (1988) Les causes de décès en France de 1925 à 1978.
  • Viborel L (1923) Propagande: propagande par le film // La vie saine 3: 3-4.
  • Viborel L (1930) La technique moderne de la propagande d’hygiène sociale. Paris.
  • Viborel L (1932) L’effort de propagande d’hygiène sociale par le cinématographe en France// Revue internationale du cinéma éducateur 4 : 309-315.
  • Viborel L (1936a) Le timbre antituberculeux instrument d’action médico-sociale. Paris.
  • Viborel L (1936b) Les méthodes de propagande. Rennes.
  • Viborel L (1944) L’éducation sanitaire, science d’action. Tours.
  • Viborel L (1953) L’éducation sanitaire, manuel pratique et précis technique. Tours.
  • Viborel L (1954) La prodigieuse histoire du timbre antituberculeux. Paris.
  • Viet V (2015) La santé en guerre, 1914-1918. Une politique pionnière en univers incertain. Paris.
  • Williams L (1922) La fondation Rockefeller pour la lutte contre la tuberculose en France // Revue du Musée Social 2: 45.
  • Zarch F (2002) La caméra sanitaire / In: D. Nourrisson (ed) Education à la santé XIXe-XXe siècles. Rennes, 83-90.

Other sources of information

Audiovisual Archives (AA)

Actualités (1934) Diffusé le 29/11/1934. Archives Pathé Gaumont.

Actualités (1936) Diffusé le 9/12/1936. Archives Pathé Gaumont

Actualités (1938a) Diffusé le 7/12/1938. Archives Pathé Gaumont

Actualités (1938b) Diffusé le 28/12/1938. Archives Pathé Gaumont

Actualités (1939) Diffusé le 21/12/1939. Archives Pathé Gaumont

Chronique philanthropique (1930) Journal d’actualité Pathé, 50 secondes, noir et blanc, sonore. 1ère diffusion 12/12/1930.

Paris. 8ème campagne du timbre antituberculeux (1934) Journal d’actualité Gaumont, 39 secondes, noir et blanc, sonore. 1ère diffusion 30/11/1934.

Pour sauver des malades. La campagne du timbre antituberculeux est ouverte (1923) Journal d’actualité Gaumont Journal Eclair, 30 secondes, noir et blanc, muet 1ère diffusion 1/12/1923.

Archives of the Department of Hérault (ADH)

Affiche du CNDT. AD Hérault, 5 M 158

Campagne du timbre, réponse à quelques questions posées au Congrès de Lyon, le 12 avril 1927. AD Hérault, 5 M 158.

Comment est né le timbre antituberculeux (1937) La Vie Saine, novembre.

Dépliant de la 12e campagne du timbre antituberculeux (1938) AD Hérault, 5 M 158.

L’Eclair du 14 février 1921. AD Hérault, 5 M 157.

L’Eclair du 25 mai 1921. AD Hérault, 5 M 157

Le Méridional du 9 mars 1921. AD Hérault, 5 M 157.

Le Méridional du 15 mars 1921. AD Hérault, 5 M 157.

Instructions concernant l’efficacité de l’effort par le cinématographe, dactylographié, non daté. AD Hérault, 5 M 158.

L’œuvre féconde du timbre en 1933, édité par le CNDT (1934) AD Hérault, 5M158

Lettre de la fédération nationale des blessés du poumon au préfet, le 29 novembre 1927. AD Hérault, 5 M 158

Lettre du 23 novembre 1920 du préfet au directeur de l’assistance et de l’hygiène publique.AD Hérault, 5 M 157.

Lettre du maire de Marseillan au préfet le 28 janvier 1928. AD Hérault, 5 M 158.

Lettre du ministre de la Santé au préfet, le 22 juin 1931. AD Hérault, 5 M 158.

Lettre du préfet à aux rédacteurs en chef (modèle de courrier) le 15 novembre 1936. AD Hérault, 5 M 158

Lettre du président du CNDT aux préfets, le 1er mars 1927. AD Hérault, 5 M 158.

Rapport moral de la campagne de 1934-1935 du timbre antituberculeux, le 10 mai 1935. AD Hérault, 5 M 158

Rapport moral sur le timbre antituberculeux, 1928-1929. AD Hérault, 5 M 158, grand cahier.

Rapport sur l’organisation des comités dans l’Hérault, 27 juillet 1927. AD Hérault, 5 M 158.

Timbre antituberculeux, campagne 1930-1931, compte rendu moral. AD Hérault, 5 M 158.

Timbre antituberculeux, rapport moral 1927-1928 adressé au Comité national le 15 février 1928. AD Hérault, 5 M 158.

Archives of the Pasteur Institute, CNDT Foundation (CNDT)

Courriers relatifs au transfert des services. Archives Pasteur, CNDT 14.

Echange de lettres entre le Dr. Williams et Léon Bourgeois, le 3 mai 1920. Archives Pasteur, CNDT 14.

La semaine du timbre antituberculeux (1927) 1ère année 17: 5.

Le timbre antituberculeux. Archives Pasteur, CNDT 17. Historique, dactylographié, 14 janvier 1965.

Le timbre antituberculeux, Bilan annuel, cahiers de tenue des recettes. Archives Pasteur, CNDT 17

Le timbre antituberculeux, Instructions générales pour l’organisation de la campagne du timbre antituberculeux, Organisation de la propagande, organisation de la publicité. Archives Pasteur, CNDT 17

Lettre d’Alexandre Bruno au Pr. Léon Bernard, le 22 octobre 1918. Archives Pasteur, CNDT 14.

Lettre de Gunn à L. Bernard, le 20 octobre 1917. Archives Pasteur, CNDT 14.

Lettre du 3 janvier 1924 de S.M. Gunn au docteur Arnaud, directeur du CNDT. Archives Pasteur, CNDT 14.

Nécrologie. Archives Pasteur, CNDT 8. Dossier Viborel.

Timbre antituberculeux, Lettre au docteur Arnaud émanant de l’IHB, le 19 novembre 1925. Archives Pasteur, CNDT 17.

Titres, Travaux et Activités de Lucien Viborel, dactylographié. Archives Pasteur, CNDT 8, Dossier Viborel.

Information about the author

Virginie De Luca Barrusse, PhD, HDR, professor at the Institute of Demography, University Paris 1 Panthéon Sorbonne. E-mail: Virginie.Barrusse@univ-paris1.fr

1 The first «Instruction for the population: what you need to know and how you can protect yourself from tuberculosis» was published in 1888.
2 Boche is a contemptuous nickname of the Germans in France.
3 Sète, a port city in the department of Hérault
4 This case of transference is not a single one: in Spain, Julio Bravo-Sanfelier, who plays an important role in health promotion, also makes an educational trip to the USA [Perdiguero et al., 2007: 80].
5 For the actions held in schools, see [Frioux, Nourrisson, 2015]; in particular, about alcohol – [Nourrisson, Freyssinet-Dominjon, 2009].
6 For Canada, see, for example: (Mc Cuaig 2000: 157-178).
7 Honor’s letter to Dr. Evro dated January 3, 1939, quoted by [Tronchet, 2009].
8 The Rockefeller Foundation stands at the origins of the office creation. Until 1929, three-quarters of its budget was of American origin.
9 No matter how high these estimates of contemporaries are, they are certainly underestimated.
10 Professor Leon Bernard was at that time president of the National Committee for the Fight against Tuberculosis.
11 The issue of stamps, suspended in 1940-1944, was resumed in 1945.