History of the Union

The International Union Against Tuberculosis and Lung Disease (The Union) is very special in terms of its structure, membership and diversity of activities.

Origins of The Union: 1867–1914

Tenement nurse visits slums early 20th century. TB was endemic in these areas

1854: The first sanatoria opened as a new method of treating tuberculosis. These facilities relied primarily on rest, fresh air and good food to help patients fight off the disease.
1867: Tuberculosis was presented as a communicable disease at the first international conference of medical specialists convened in Paris.
1882: Dr Robert Koch of Berlin identified the Mycobacterium tuberculosis.
1887-90: The first TB dispensaries opened and the voluntary movement to provide information and control TB developed.
1888–98: Four conferences were held in Paris specifically addressing TB.
1899: The TB conference took place in Berlin, and, for the first time, official representatives from both governments and non-governmental agencies were present.
The developments of the previous 50 years all pointed to the need for a central agency to coordinate the dissemination of information about tuberculosis and the campaign against it.
1902: The Central Bureau for the Prevention of Tuberculosis was formalised in Berlin, and the double-barred cross was adopted as its symbol. This symbol is still used by lung associations more than a century later.
1904: Christmas seals were first produced in Denmark. The idea of using colourful stamps to raise money for TB came from a Danish postman, Einar Hølbell. Other countries quickly followed suit, and the stamps continue to be an important fundraising device today.
1902–14: Periodic international conferences systematically addressing clinical, research and sociological aspects of TB were held until the outbreak of the First World War in 1914.

The Union is established: 1920–1939

To agree on the means to fight TB, to make a consensus on the strategy,
to jointly apply the most effective weapons to combat this common enemy.
Pledge of the IUAT founders, 1920

1920: A conference on TB was convened in Paris in which 31 countries participated, including Australia, Bolivia, Brazil, Chile, China, Colombia, Cuba, Guatemala, Japan, Panama, Paraguay, Iran and Thailand, in addition to those of Europe and North America.
In an impressive procession, delegates one by one pledged “to agree on the means to fight TB, to make a consensus on the strategy, to jointly apply the most effective weapons to combat this common enemy”. Thus they established the International Union Against Tuberculosis (IUAT), which was conceived as a federation of national associations.
1920–1939: Ten international conferences were held.
1923: The IUAT Bulletin was launched to supplement the routine reports of the conferences. In this pre-war period, the Bulletin included administrative reports and compiled statistics – responsibility for which was later assumed by the World Health Organization. It also contained information on the strategy and policies for the fight against TB and results of numerous surveys on specific aspects of the disease and the campaign.
1940: The publication of the Bulletin continued until mid-1940. The final editions, before its interruption, contained the main reports to have been given at the 11th conference planned for Berlin in September 1939, the very month when the Second World War commenced.
1943: The antibiotic streptomycin was discovered and proved to be effective in treating tuberculosis, offering ushering in a new era in which TB would be curable with drugs.

Expansion and research: 1946–1961

1946: At the post-war reunion of the Executive Committee, the IUAT recommended the “establishment of a strong Division of Tuberculosis” to the planners of the future World Health Organization. Official relations with the WHO were then established which continue to the present time.
1950: The first post-war conference was held in Copenhagen, with the participation of 43 nations. It set the pattern for regular conferences in all parts of the world.
1952–59: Conferences outside North America and Europe were held in Brazil in 1952, India in 1957, and Turkey in 1959. During this period a series of international symposia were also held, usually in Paris. They addressed topical issues such as TB in Africa, strain variation in BCG, radiography for TB, new drugs and the role of voluntary agencies.
1952: In order to strengthen the administration of the growing IUAT, a full-time Executive Director was appointed. A system of quotas was devised for membership contributions, and over many years, the American Lung Association continually maintained a high quota share. Fees were also levied from individual members.
1953: Scientific committees were established that met annually for intensive discussion of the emerging strategy in the fight against TB.
1953: Latin America became the first region to organise. The regions were established in order to keep The Union close to where the needs are. The North America Region was the last to be created in 1978.
1958: The first international collaborative clinical trial for treatment of any disease was undertaken, with a total of 17,391 patients from 17 countries evaluated for drug resistance.
1960: A collaborative controlled clinical trial was launched in 1960 to evaluate the efficacy of chemotherapy in previously untreated patients.
In this period, the IUAT also contributed to annual international courses on TB control sponsored by the WHO in Istanbul, Prague, Rome and Caracas.

Technical assistance programme begins: 1961–1978

1961: At the suggestion of the Executive Director, Dr Johannes Holm, the Mutual Assistance Programme was launched to encourage transfer of technology, resources and information from industrialised to newly independent countries, through the agency of national associations in the developing countries. This was followed by travelling seminars in Africa, Eastern and Middle East regions and field projects in Mali, Sri Lanka, Peru and India, among many others.
1961: The scientific committees continued to focus on the strategy for TB control. Two international collaborative studies evaluated the test characteristics of 1,099 films read by 90 readers from seven countries and the WHO. A subsequent study evaluated sputum smear microscopy.
1965: An international collaborative study on tuberculin skin testing evaluated 75,000 children in 21 countries. Further controlled clinical trials addressed the issue of previously treated patients and daily self-administered versus intermittent supervised regimens.
1966: The Tuberculosis Surveillance Research Unit (TSRU) was established under Dr Karel Styblo, Director of Scientific Activities. It developed an index to evaluate infection and its trend, clarified the natural history of the disease (including transition probabilities and risk factors) and estimated the impact of control measures
1968: A survey evaluated adverse reactions to BCG vaccination, with over 10,000 events analysed, and a Technical Guide: Sputum Examination for Tuberculosis by Direct Microscopy in Low-income Countries was published. Its 5th edition appeared in 2000.

Dr Karel Styblo developed the principles that evolved into the DOTS strategy

1969: In collaboration with the United States Communicable Disease Center and seven member countries in Eastern Europe, an international trial of preventive chemotherapy for fibrotic lesions of the lung in 25,000 individuals began and was evaluated over 5 years of follow-up.
1973: A proposal was made to extend the mandate of the IUAT to include other lung diseases, but this idea was not adopted until more than a decade later.
1975: Dr Halfdan Mahler, Director General of WHO, publicly acknowledged the crucial role played by the IUAT in the fight against TB.
1977: Spanish became the third official language of The Union.
1978: 18 non-governmental organisations (NGOs) responded to the IUAT’s invitation to consider jointly the role that NGOs could and should play in primary health care (PHC). The resulting position paper was presented at the joint UNICEF/WHO International Conference on PHC in Alma Ata in 1978.

Groundwork laid for DOTS strategy: 1978–1991

1978: In response to a request from Tanzania’s Minister of Health, the IUAT proposed the establishment of a National Tuberculosis Programme under the direction of the government and with the support and coordination of the IUAT. This proposal was the basis of a new IUAT programme of Technical Assistance. The IUAT’s technical assistance programme was eventually extended to nine low-income countries and became later on the basis of the WHO's DOTS strategy.
1978: Based on its experience in the field, the IUAT produced the first edition of Management of Tuberculosis: A guide for low-income countries. The 6th edition is now in preparation.
1982: The Koch centenary was celebrated at the 25th conference in Buenos Aires. The Koch Medal of The Union was awarded to Executive Director Dr Johannes Holm and the British doctor who pioneered the concept of home care for TB in India, Dr Wallace Fox.

Dr Robert Koch identified the cause of TB

1982: World TB Day was established, following a proposal by the Mali TB Association, constituent member of The Union, and is now celebrated each year on March 24 – the day Dr Robert Koch identified mycobacterium tuberculosis as the cause of TB.
1984: The IUAT was officially registered with the United States Agency for International Development (USAID), a very rare privilege for a non-US agency.
1986: The growing and expanding organisation officially changed its name to the International Union Against Tuberculosis and Lung Disease (IUATLD).
1987: An IUATLD delegation visited the WHO to encourage it to consider the problem posed for TB by the emergence and spread of HIV infection, which had been noted in collaborative projects in the field.
1989: The Burden of Health Study carried out by Harvard University was pivotal in demonstrating the cost-effectiveness of The Union model. This was instrumental in convincing planners and policy makers to adopt the strategy as a part of the general health services.

DOTS used to address global TB emergency: 1991–2001

1990s : Fueled by the global HIV/AIDS epidemic, the incidence of tuberculosis increased dramatically, catching both wealthy and poor countries unprepared.
1991: The principles of the model National Tuberculosis Programme were outlined on the occasion of the retirement of Dr Karel Styblo. These principles formed the basis of what was later known as “DOTS”.
1991: The International Tuberculosis Course was held in Arusha, Tanzania for the first time to illustrate the principles of the model programme.
1992: Dr Nils E Billo, MD MPH, became Executive Director.

1993: WHO declared TB a global health emergency.
1994: Recognising the threat to lung health caused by tobacco use, The Union became a founding member of the International Non Governmental Coalition Against Tobacco (INGCAT and housed its secretariat for several years. INGCAT gave voice to its members throughout the development and implementation of the Framework Convention for Tobacco Control (FCTC), the world’s first public health treaty, which became law in 2005.
1995: The Union model for delivering TB services became branded “DOTS” by the World Health Organization and promoted as the official strategy for international TB control.

The five principles or elements of the “DOTS” (Directly Observed Treatment, Short Course) strategy are:

• government commitment
• standardised treatment and directly observed treatment
• a controlled consistent supply of high-quality drugs
• use of sputum smear microscopy for diagnosis
• accurate recordkeeping

“Short Course” refers to the length of the treatment regimen.
1993–1996: The tuberculosis training and technical support activities of The Union were extended from a largely African base to represent every region of the world.
1995: The Asthma Division was established with the objective to apply The Union model for the delivery of TB services as a model for asthma management in low- and middle-income countries.
1996: Management of Asthma: a guide for low-income countries published. This guide was subsequently revised and expanded; the second edition appeared in 2005 as Management of Asthma: a guide to the essentials of good clinical practice.
1996: The Clinical Trials Division was formed. It has conducted two major multicentre international trials, Study A and Study C, as well as other research projects.
1996: The Child Lung Health Division was created to improve health care services for children with pneumonia and other acute respiratory infections, TB, HIV-related lung disease and asthma.
1996: The Tobacco Prevention Division was established to develop practical strategies for tobacco control in low-income countries and to disseminate this information through technical assistance, education and applied research. Its technical guide on tobacco control, published in 1998, was the first to target the issues faced by low-income countries.
1997: International Journal of Tuberculosis and Lung Disease was founded. The monthly peer-reviewed journal continued the work of disseminating the latest research begun by the IUAT Bulletin in 1923.
1998: The Union joined with the WHO and other international partners to form the “Stop TB” Initiative, which later became the Stop TB Partnership.
2000: Child Lung Health Project in Malawi began. By 2005, it had reduced the pneumonia case fatality rate for children under 5 by 54.8 percent.
2001: The HIV Department was established to address the growing TB-HIV co-epidemic.
2001: The Health Policy Research Unit was formed to research what influences the formulation and implementation of policies relating to lung health.

Growth and consolidation: 2002-2010

2002: The Board of Directors voted to change the short name of the organisation from the acronym “IUATLD” to “The Union”.
2002: The Union was active in 57 countries and more than 1 million patients with TB around the world were cared for in the context of the collaborative programmes of The Union.
2002: The Union’s income jumped from just over 5 million euros in FY 2001 to 8 million euros in 2002. By the end of FY 2007, it was up to 25.4 million euros.
2003: The Fund for Innovative DOTS Expansion Through Local Initiatives to Stop TB (FIDELIS) project was launched. Over 5 years, 53 case-finding projects in 18 countries were funded through FIDELIS.
2004: The India Resource Centre (IRC) opened in New Delhi, the first of what has grown into a network of region and country offices. The IRC is now known as The Union South-East Asia Office.
2004: The 5-year Laboratory Strengthening Project began to establish a network of expert laboratories to support and monitor the work of national tuberculosis programmes in low-income countries and help them achieve and maintain external quality assessment (EQA) standards.
2004: Results of Study A were published in The Lancet. Study A was an international multicentre trial comparing an 8-month regimen of chemotherapy for treatment of newly diagnosed pulmonary tuberculosis with a 6-month regimen, containing Rifampicin in the second phase of treatment.
2004: The Union launched the Asthma Drug Facility so that good-quality, essential asthma medicines could become accessible and affordable in low- and middle-income countries
2004: Management courses were offered for the first time to build skills and strengthen the leadership and business acumen of TB programme managers. The series became known as the International Management Development Programme in 2007.
2005: The Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS (IHC) programme began in Myanmar. Between 2005–2008: it became operational in Benin, Zimbabwe, the Democratic Republic of Congo and Uganda.
2006: The Union became a partner in the Bloomberg Initiative to Reduce Tobacco Use co-managing the grants programme, tobacco control management courses, establishing regional resource centres and managing other components of this $125-million initiative.

The Union Logo

A new Union logo was adopted in 2007.

2006-7: The Eastern Region divided into the Asia-Pacific Region and the South-East Asia Region to better serve this large diverse region. The Scientific Sections were restructured to align with the Scientific Departments: Tuberculosis, HIV, Lung Health and Tobacco Control.
2007: With the increasing incidence of multidrug- and extensively drug-resistant tuberculosis, The Union stepped up its technical assistance, research and training efforts in this area.
2008: TREAT TB, a five-year cooperative agreement with USAID and other partners, was funded for up to US$ 80 million.
2008: The Union continued to expand its regional network; 10 region and country offices were operational in China, Egypt, India, Mexico, Myanmar, Russia, Uganda, UK, USA, and Zimbabwe.
2008: With 98 constituent and organisational members and more than 2,600 individual members, federation of The Union represented a formidable network of knowledge and experience.
2009: Research Department was established comprising the Centre for Strategic Health Information and Operational Research, the Clinical Trials Division and the Health Policy Research Unit.
2009: The Board of Directors adopts a new vision for The Union: health solutions for the poor. They also update the mission: The Union brings innovation, expertise, solutions and support to address health challenges in low- and middle-income populations
2009: The 40th Union World Conference on Lung Health is scheduled to be held in Cancun, Mexico on 3-7 December. The World Conference has become the largest annual lung health meeting focused on the issues in low- and middle-income countries.
2010: The Union will celebrate its 90th anniversary throughout the year.

The distinguishing qualities of The Union, besides its universality, its spirit of solidarity and its tolerance, are its continual striving for quality and its independence. Thanks to these, it provides the international community with an invaluable asset: a pioneer in devising, encouraging and testing innovations in the delivery to health services and a neutral platform for international collaboration, exchange of information, friendship and mutual esteem.

-- Dr Annik Rouillon, (Executive Director, 1978-1992) and Prof Donald A Enarson (Director of Scientific Activities, 1991-2007; Senior Advisor, 2007-present)