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TUBERCULOSIS

TUBERCULOSIS was the leading cause of death in the United States during the nineteenth century, responsible at times for as many as one of every four deaths. Although the death rate from tuberculosis steadily declined beginning in the mid-nineteenth century, it persisted as a major public health problem well into the twentieth century, when programs of public health education, disease surveillance and diagnosis, and the availability of antibiotics and vaccination helped to curb its incidence. After World War II, the death rate was only a small fraction of what it was a century earlier, but by the 1990s, the emergence of tuberculosis strains resistant to antibiotics and the connections between tuberculosis and AIDS again made it a significant health concern.

Before the late nineteenth century, various names—including consumption and phthisis—were used to describe the dry, persistent cough, throat irritations, chest and shoulder pains, and difficult breathing accompanied by emaciation that characterized pulmonary tuberculosis. The incidence of tuberculosis grew dramatically in Europe beginning in the eighteenth century, and although its incidence in the United States was less severe, it had grown into the leading cause of death in the United States by the mid-nineteenth century. Other than being slightly more prevalent in women than men, the disease respected no boundaries, afflicting Americans of all ages, races, ethnicities, and social and economic stations.

Tuberculosis in Nineteenth-Century Life

While sudden and dramatic epidemics of cholera, diphtheria, smallpox, and yellow fever commanded public attention, tuberculosis quietly became a regular feature of nineteenth-century American life. Healers diagnosed tuberculosis on the basis of its physical symptoms, but they were at a loss to offer a definitive cause or cure for the disease. For much of the nineteenth century, it was thought that tuberculosis was hereditary, and therefore, that it was noncontagious and could not be transmitted from person to person. It was presumed that there was some familial disposition that made a person susceptible to the disease and that the interaction of the inherited constitution with environmental or behavioral "irritations," such as rich diets, sedentary occupations, and cold, wet climates, brought on the disease. The remedies emphasized changing the irritants, whether to a mild or bland diet, to an active lifestyle with exercise, or to a residence that was mild and dry. Between 1840 and 1890, thousands of Americans with tuberculosis, particularly from New England, became "health seekers," moving to where they believed the wholesome, restorative climates would give them relief. These "lungers," as tuberculosis patients were colloquially called, moved first to Florida, and later to the West and Southwest, settling in the deserts and mountains of Arizona, California, Colorado, and New Mexico. One in four migrants to California and one in three migrants to Arizona during the second half of the nineteenth century went looking to improve their health.

During the 1830s, tuberculosis was responsible for one in every four deaths, but by the 1880s, the mortality rate had declined to one in every eight deaths. In major American cities, the death rate from tuberculosis at the end of the nineteenth century (200 deaths per 100,000 population) was essentially half of what it was a century earlier. Improvements in diets and in living conditions, along with natural selection and genetic resistance in the population, contributed to the declining rates. Even as the mortality rates from tuberculosis declined in the general population, it persisted as a significant health problem among America's growing immigrant population, most of whom lived in the crowded, dank, and dirty tenements of America's urban centers—living conditions that were ripe for the rapid spread of the disease. The incidence of tuberculosis became increasingly associated with immigrants and the impoverished and the overcrowded living conditions they experienced.

Tuberculosis in the Age of Bacteriology

In March 1882, the German bacteriologist Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacillus or bacterium that causes tuberculosis. But medical explanations attributing the cause of tuberculosis to heredity, climate, diet, lifestyle, poor ventilation, and other factors endured through the century and decades would pass before physicians were fully convinced that tuberculosis was contagious and could be transmitted between persons. The medical landmark of Koch's discovery accompanied the growing number of tuberculosis sanatoria being built in Europe and the United States after the 1850s and 1880s, respectively. The sanatorium movement emphasized a therapy regimen based on fresh air, proper diet, and rest, but they also served to remove and to isolate patients with tuberculosis from areas where they might infect others. Among the sanatoria were two founded by America's most prominent physicians of tuberculosis: Edward Livingston Trudeau established a sanatorium at Saranac Lake in the Adirondack Mountains of northeastern New York, and Lawrence Flick established a sanatorium at White Haven, in the Pocono Mountains of eastern Pennsylvania. Trudeau and Flick themselves suffered from tuberculosis, and learned of the benefits of an outdoor life in seeking a cure for their own afflictions. Trudeau's Saranac Lake sanatorium, founded in 1884, became a model for other sanatoria. Flick, believing that tuberculosis was contagious, advocated for a scientific approach to its diagnosis and treatment, as well as the registration of patients and the education of the public about the disease. In 1892, Flick founded the Pennsylvania Society for the Prevention of Tuberculosis, the first state organization in the nation devoted to the control and the elimination of tuberculosis. As other state societies against tuberculosis developed, Flick joined Trudeau, Hermann Biggs, William Welch, William Osler, and others to found in 1904 the National Association for the Study and Prevention of Tuberculosis (NASPT), the forerunner to the American Lung Association, which unified efforts, led public health education campaigns, and raised funds for research.

By the turn of the twentieth century, as the presence of the tubercle bacillus rather than the physical symptoms became the basis for diagnosis, the new understanding of what caused tuberculosis and how it was spread brought important changes in public health and the medical care of patients. The goal of Progressive Era public health work against tuberculosis was to improve social conditions

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and to control the behaviors that fostered the disease. Health departments instituted education campaigns that used films, posters, and lectures to dissuade individuals from practices that spread germs, such as spitting and coughing. In addition to maintaining clean, well-ventilated homes, the use of nonporous building materials such as metals, linoleum, and porcelain was encouraged over wood and cloth, which could harbor disease-causing germs. Public health officials inspected and fumigated dwellings that posed health risks, required physicians to report cases of tuberculosis, and forcibly isolated individuals who did not seek treatment. New diagnostic tests such as the tuberculin skin test and radiological examinations were used in mass screenings for tuberculosis, and new surgical therapies involving the collapse or partial section of the lungs were introduced. Infected individuals were required to seek treatment through a sanatorium or through a dispensary that engaged in disease surveillance and patient education.

Tuberculosis after World War II

The result of the far-reaching and aggressive public health campaign was that the incidence of tuberculosis, which had been steadily declining since the 1870s (when the mortality rate exceeded 300 deaths per 100,000 population), fell to unprecedented low levels by the 1930s (when the mortality rate fell below 50 deaths per 100,000 population). Disease mortality fell even lower (to 10 deaths per 100,000 population in 1954) after the development of an antibiotic, streptomycin, by the microbiologist Selman Waksman in 1943. Although other countries in the 1950s instituted vaccination campaigns using the Bacillus-Calmette-Guérin (BCG) vaccine, it was not adopted for wide use in the United States as public health programs emphasized the identification of patients exposed to the bacillus rather than universal vaccination against the disease.

Between 1954 and 1985, the incidence of tuberculosis in the United States declined 75 percent, and by 1989, public health officials confidently predicted its eradication in the United States by 2010 and worldwide by 2025, believing it would no longer pose a public health threat. These expectations were dashed as a worldwide pandemic of tuberculosis began in 1987 and the World Health Organization declared that tuberculosis posed a global emergency in 1993. The displacement of populations through immigration and political conflicts; the emergence of drug-resistant strains; the high rates of incarceration, homelessness, and intravenous drug use; the prevalence of mass air travel; the collapse of medical services in eastern Europe; the persistence of widespread poverty; and the progress of the AIDS pandemic, in which tuberculosis emerged as an opportunistic infection, all contributed to a worldwide public health crisis. By 2002, the World Health Organization reported that tuberculosis was the leading infectious killer of youth and adults and a leading killer of women, and that a third of the world's population was infected with the tuberculosis bacillus. In response, nearly 150 countries, including the United States, agreed to adopt the Directly Observed Treatment Short-Course (DOTS) system in which countries would promote public health programs of case detection, standardized treatment regimens using multiple drugs, patient surveillance to monitor compliance, and the forcible detention of noncompliant patients. Once thought to be on the verge of eradication, in 2002 it was not known if and when the worldwide incidence of tuberculosis would return to levels experienced only a half century before.

BIBLIOGRAPHY

Bates, Barbara. Bargaining for Life: A Social History of Tuberculosis, 1876–1938. Philadelphia: University of Pennsylvania Press, 1992.

Ellison, David L. Healing Tuberculosis in the Woods: Medicine and Science at the End of the Nineteenth Century. Westport, Conn.: Greenwood Press, 1994.

Feldberg, Georgina. Disease and Class: Tuberculosis and the Shaping of Modern North American Society. New Brunswick, N.J.: Rutgers University Press, 1995.

Lerner, Barron H. Contagion and Confinement: Controlling Tuberculosis Along the Skid Road. Baltimore: Johns Hopkins University Press, 1998.

Ott, Katherine. Fevered Lives: Tuberculosis in American Culture since 1870. Cambridge, Mass.: Harvard University Press, 1996.

Rothman, Sheila. Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in America. New York: Basic Books, 1994.

Ryan, Frank. The Forgotten Plague: How the Battle against Tuberculosis Was Won—And Lost. Boston: Little, Brown, 1993.

Teller, Michael. The Tuberculosis Movement: A Public Health Campaign in the Progressive Era. New York: Greenwood Press, 1988.

D. George Joseph

See also Epidemics and Public Health.