Prof: Good morning.
 
You'll remember that last time
we talked about dividing
tuberculosis into two major
eras,
in terms of the way that it was
understood and experienced by
human society.
 
The first era we talked about
last time was what I chose to
call the age of consumption.
 
At that time,
only the lungs were known to be
affected by the disease,
as all other forms of
tuberculosis,
as it's now understood,
were then thought to be instead
different diseases.
At the time,
the theory of anticontagionism,
that by now is familiar to all
of you,
was still dominant,
and the tuberculosis patient
was deemed to be,
should we say,
blameless and harmless,
as he or she had a disease
thought to be primarily
hereditary.
The treatments in fashion were
still traditional remedies of
nineteenth-century medicine,
well familiar to you:
venesection,
or bloodletting;
poultices were applied,
and people were given
medications with an aim of
increasing their appetite,
to combat the wasting away;
creosote was administered.
We know it now primarily as a
wood preservative,
but it was, in fact,
in the nineteenth century,
one of the chief medications
used to treat tuberculosis;
and it was administered
sometimes internally,
sometimes by inhalation to
relieve the cough.
It was applied topically to the
larynx, to ease the coughing and
alleviate ulceration,
and sometimes there were
sub-mucosal injections.
 
Sometimes quinine was
administered,
with the strategy of lowering a
patient's fever.
And we've talked about gasses
that were administered to combat
the infection directly in the
lungs, sometimes carbolic acid
spray.
 
Opiates, like laudanum,
were sometimes given to relieve
symptoms,
and patients were advised to
travel to more salubrious
climates,
to visit the sea,
the mountains,
the dry American southwest,
the Mediterranean.
And then we moved on from that
period,
the age of consumption,
and saw the beginning of the
age--
as I'd like to call it this
morning--
the age of tuberculosis,
from around the 1880s.
 
And this was marked by a number
of factors that came together to
foster new attitudes,
new treatments,
and new public health
strategies to deal with
tuberculosis.
 
The first--and this man is by
now extremely famous to you,
and that's Robert Koch,
once again--
his theory of the germ theory
of disease,
and the discovery,
as you know,
of the bacterium that's the
causative agent in tuberculosis,
in 1882.
 
But that wasn't sufficient to
launch what we call the age of
tuberculosis.
 
In addition,
I would say that it was
influenced by international
politics;
a gathering of international
tensions, clashing imperialisms,
with colonial expansion.
 
Remember then that this is a
time when population growth was
held to be essential to military
strength;
indeed, to national survival,
to industrial production and
economic power.
 
This was the age when social
Darwinism was at its height.
And in that context,
tuberculosis was held to be a
real national danger.
 
It was an internal danger,
and because of that,
patients came to lose their
glamour.
They were no longer regarded as
creative, spiritual,
sexy and ignoble,
but were thought to be a danger
to health and to society.
 
So, that was a second--should
we call it the
social/economic/diplomatic
context in which tuberculosis
was situated.
 
And then there were
epidemiological studies that
went along in the period.
 
Public health became much more
cognizant, through statistics,
of the ravages of tuberculosis.
 
There were studies of its
transmission in society,
and knowledge,
statistically based,
now replaced anecdote.
 
And the implication was that
although tuberculosis did indeed
affect the elites of society and
the arts,
it was in fact
disproportionately a disease of
the poor,
of the "dangerous
classes"
and,
in the American context,
of unsavory,
impoverished immigrants,
a disease of Irish and
Italians.
 
And, so, tuberculosis slowly
becomes more stigmatized and
more shameful.
 
Well, the result of all of
these converging factors was
from about 1880 to 1940,
an age of tuberculosis,
certainly, but also a war on
tuberculosis,
with new strategies of public
health to combat what was seen
to be a major national and
international menace.
So, let's look at the weapons
in the new war in
anti-tuberculosis public health.
 
The first chronologically was
also the most distinctive,
and in some ways the most
interesting and creative,
and this was the establishment
of sanatoria--
or sanitaria,
if you prefer--which gave rise
to an international sanatorium
movement.
The prototype,
and the world's first TB
sanatorium, was founded in 1859.
 
But the movement then slowly
gathered momentum towards the
ends of the century,
and then continued down to
about the 1950s,
when antibiotics led to the
closing of the sanatoria,
and for a time a euphoric view
that tuberculosis was about to
be eradicated;
a view that unfortunately has
turned out not to be the case.
The founding father of the
sanatorium movement was a
German, Hermann Brehmer.
 
He was a physician,
and fell ill with
tuberculosis--not something at
all unusual--and expecting to
die, he traveled to take the
cure in the Himalayas.
To his surprise,
though, he recovered,
and he attributed his improved
health to fresh air,
climate and rest.
 
And he thought that he could
generalize that to treating
patients, and in 1859 he founded
the world's first sanatorium in
Silesia.
 
This was followed by Peter
Dettweiler, who founded,
in 1876, the second major
sanatorium at Falkenstein.
Despite those two examples,
the sanatorium idea didn't
really take off to become a
major movement until the 1880s.
And the decisive influence was
that of the American physician
who has,
through his offspring,
a Yale connection,
and that's Edward Livingston
Trudeau,
who lived from 1848,
and is well-known,
the Trudeau name,
to all of you as the
great-grandfather of Gary
Trudeau of Doonesbury fame.
 
Let me just--I have a
couple--that's Edward Livingston
Trudeau.
 
Let's remember a moment about
his life and how he came to play
a major role in the sanatorium
movement.
He was a physician educated at
the Columbia Medical School in
New York.
 
His brother had tuberculosis,
and he died of it.
He himself was diagnosed with
tuberculosis in the 1870s
and--this is a story that you've
heard more than one--he too
thought that he was going to
die.
But he followed medical advice
and went to an outdoor climate
to take the cure.
 
In his case,
his preferred destination was
the Adirondack Mountains,
and specifically Saranac Lake
in upper New York State.
 
At Saranac Lake,
which was at the time not a
town at all,
it was the wilderness,
and Trudeau spent his time
largely resting,
and he would hunt from fixed
positions in a canoe on Saranac
Lake,
or behind a blind.
And as far as possible,
he stayed outdoors.
Expecting to die,
instead he realized that he was
starting to feel better,
and he too attributed his
recovery to this fresh air and
rest;
and he too felt that this was
an experience that could be
generalized.
 
He became increasingly
interested in the medical
literature on tuberculosis,
and he read about Brehmer and
his sanatorium.
 
But in the 1870s,
there'd been little interest in
the medical profession in the
disease or in Brehmer's idea.
The 1880s, because of Koch's
major epoch-making discovery,
however, created an entirely
different and more susceptive
climate to the whole idea,
and Trudeau became an early
convert to the idea of
contagionism and the germ theory
of disease,
with specific reference to
tuberculosis.
 
So, in 1884--this is a statue
of Edward Livingston Trudeau at
Saranac Lake--he established
Little Red, which was the
beginning of the sanatorium.
 
This was in 1884,
which is the beginning then of
the establishment of a small
rest cottage,
Little Red, for the treatment
of tuberculosis patients.
This is a picture of Little
Red, the first building in what
becomes a much larger
sanatorium.
And that's a picture of the
inside of the sanatorium.
There were several ideas that
Trudeau embodied in the
sanatorium, and the first was
that the sanatorium was a means
of treatment.
 
And let's look at the treatment
ideas that Trudeau had in mind.
The first was what he called
the wilderness cure,
the one that he had experienced
himself;
that is to say,
that you should live outdoors
in all weather,
taking the cure on cottage
porches.
 
And, so, there was a document
called "The Rules for
Patients at the Sanatorium at
Saranac Lake,"
and it said the following:
"Patients are expected to
lead an outdoor life,
to remain eight to ten hours in
the open air every day.
 
Each patient is required to be
out of doors from 9:00 a.m.
to 12:45 p.m.,
and again from 2:00 p.m.
to 5:45 every day.
 
And sleeping out is considered
in no way to affect the
requirement."
 
So, the outdoor life was
compulsory.
Second was rest.
 
The patients at Saranac Lake
were to have no exercise.
A patient with a temperature of
99.5 degrees was allowed half an
hour of exercise a day;
and exercise included standing
up and getting dressed,
or walking to the refectory for
a meal,
and even getting in and out of
bed was thought to be exercise.
 
So, there was very little that
you were allowed to do.
The third thing that was part
of the sanatorium regimen at
Saranac Lake--
and I'm choosing Saranac Lake
because this was the model
sanatorium that really became
the ideal for an entire
international movement;
thousands of sanatoria were
founded on this model.
The third treatment idea was a
solid substantial diet,
to combat the consumption,
if you like,
the wasting away of the body,
and to build resistance.
In pursuit of that goal,
patients at Saranac Lake had
four compulsory hardy meals a
day,
with milk served in between,
with a strong emphasis on meat
and carbohydrates.
 
The goal was for the patient to
consume 4,000 calories a day.
Another point about the
treatment regimen is that the
sanatorium was what we might
call a total institution.
Unlike the old idea of taking
the cure, at the sanatorium at
Saranac Lake patients were under
constant vigilance.
That was one of the reasons
that you kept them on the
porches;
on a porch you were constantly
in view.
 
And visitors were strictly
regulated.
The patients' mail was
censored, the idea being that
they should be sheltered from
distressing news and emotional
shocks--
those were not conducive to
recovery.
 
The rules, therefore,
stipulated that you weren't
allowed,
as a patient at Saranac Lake,
to discuss your disease,
even with fellow patients at
the sanatorium.
 
The rules also stated that
there was to be no alcohol or
tobacco;
that there was to be no
socializing for more than an
hour a day;
and there were to be no indoor
visits from members of the
opposite sex.
 
You also--I'm not sure of the
medical purpose of this,
but these rules were enforced
by expulsion.
If you violated the rules,
you couldn't stay.
And the rules also said that
you couldn't practice profanity.
You weren't allowed to gamble.
 
Those were part of the cure as
well.
And the next idea of this was
segregation;
that is, I'm not meaning racial
segregation now,
I mean isolation.
 
There were individual rooms,
with porches,
where patients were always out
of doors.
This is the polar opposite of
crowded conditions in tenements
that were thought to be the
great means of spreading the
tuberculosis epidemic.
 
And Trudeau carried out--there
was an island.
If you visit Saranac Lake,
you'll notice that there is an
island which is called fondly
Rabbit Island,
in the center,
where Trudeau,
during his self-imposed exile
for the cure,
had gone hunting and so on.
 
But he also conducted an
experiment on Rabbit Island,
and the experiment
consisted--I'm not sure what you
think of the robust scientific
quality of it,
but it certainly convinced
Edward Livingston Trudeau
himself.
 
He took, I think,
ten rabbits onto Rabbit Island,
and five of them were allowed
to live free in good outdoor
conditions.
 
The other five were put in
artificial facsimiles of
tenement conditions;
that is, they were confined to
insalubrious,
unsanitary, crowded cardboard
boxes.
 
And at the end of a certain
period,
Trudeau noticed that the five
confined rabbits had died of
tuberculosis,
and the other five,
who were leading the hardy
outdoor life,
were a good advertisement for a
sanatorium and the outdoor cure.
Well, let's take a little tour
of this sanatorium.
And we saw it started at Little
Red, in very humble beginnings.
But then I say this was the
total life.
This was the library.
 
As you got better,
you were allowed to do a little
bit more,
and you could progress to the
point where you'd be allowed the
strenuous exercise of reading
books in the sanatorium library.
 
There was also the idea that
this would be an educational
experience,
and you would take back skills
and knowledge that would be
essential to you after you had
been discharged from the
sanatorium.
And this is the workshop where
you would learn skills or a
craft that you could exercise.
 
Remember that you might still
be something of an invalid,
and it would be important that
you would have those sorts of
skills that you were capable of,
a craft that you could carry
out.
 
There was the chapel at the
sanatorium.
Here is one of the pure
cottages;
and you'll note a proliferation
of porches at Saranac Lake.
And these are more of the
buildings.
This is the central
administration.
And here we actually see
patients doing what they did
most of the time at Saranac
Lake,
and this is taking the cure in
the horizontal position and
being watched.
 
You were also educated to use
this little fashion accessory,
which is your sputum cup.
 
In other words,
your sputum was thought to be
extremely dangerous and
contagious,
and therefore you were not to
spit on the ground but in this
little cup.
 
So, the education of patients
then, in contagionist theory,
was a part of the experience.
 
They were issued with sputum
cups, with handkerchiefs.
Spitting was strictly forbidden
at Saranac Lake,
on pain of expulsion,
and patients had severe
instructions to suppress their
coughs whenever possible,
and to cover their faces when
they did.
So, Saranac Lake then was not
just for its own patients.
It was also conceived of to
spread the idea of the
sanatorium as a model.
 
And Trudeau--and this was one
of his great assets,
he was really skilled at
publicity--he became a full-time
agent for his own humanitarian
project.
Well, the Saranac Lake
Sanatorium then was a place of
treatment and a place of
education.
It was also a place of
scientific research,
featuring the science of
tuberculosis.
At Saranac Lake,
Trudeau founded the world's
first laboratory devoted to the
study of tuberculosis,
and Koch's techniques of
microscopy,
that Trudeau so much admired,
were followed and taught.
Medical students were taught
staining,
the culturing of bacteria,
diagnosis,
and there was a six-week course
for already qualified physicians
for an internship,
if you like,
in the Saranac Lake laboratory
and at the sanatorium.
And there were courses for
nurses as well.
Well, what were the results?
 
Trudeau himself was very
optimistic that this institution
had positive results for the
health of his patients.
He argued that normally an
active case of tuberculosis was
almost universally fatal,
but Trudeau,
by contrast,
claimed that he achieved a
recovery rate of about thirty
percent.
And, so, he adopted,
for Saranac Lake,
a little slogan of his own,
which was "cure sometimes,
relief often,
and comfort always."
So, those were parts of the
mission of the Saranac Lake
Sanatorium.
 
We should also see it though as
an instrument of public health,
based on the idea of the
isolation of the contagious.
Trudeau estimated that each
tuberculosis patient in a year,
if he or she continued to live
in an urban environment,
would on average infect another
twenty people.
So, we could see the sanatorium
as a kind of quarantine.
And its particular idea was
that this was to remove working
people, and people of modest
means.
In other words,
this first American sanatorium
was a work of philanthropy.
 
Patients, at most--there was a
sliding scale of expense,
and patients were charged at
most half the cost of their stay
and their treatment.
 
And the endowment of the
sanatorium--
because Trudeau was very
effective at gaining approaching
donors and getting financial
support for this idea--
and, so, the endowment of the
sanatorium made up the
difference.
 
So, there was a considerable
number then of patients with no
funds, who were subsidized by
the institution.
Well, this went on as well--we
can see a relationship between
tuberculosis also and,
should we say,
economic development,
in that the sanatorium became
the centerpiece also for the
development of a town--
that is, Saranac Lake as a
town--which was based on
tuberculosis.
 
And Edward Livingston Trudeau,
in fact, was also the mayor of
the town.
 
Well, initially those--we
should remember that if you
think getting into Yale was
difficult for you,
getting a place at the Saranac
Lake Sanatorium,
if you had tuberculosis,
was even more difficult.
There was a rate of about 2,000
people applying for every place.
And, so, the city,
or Town of Saranac Lake,
sprang up as a place where
people could be taken care of,
who weren't admitted to the
sanatorium itself.
In other words,
the town was filled with
cottages,
with boardinghouses with cure
porches,
and the local board of health,
of the town,
supervised and regulated what
went on in these cottages.
 
There were district nurses who
gave advice and monitored
conditions.
 
And there was a Bureau of
Information in the town,
to assist patients to find
suitable arrangements.
And then there were so-called
reception cottages,
for patients so ill that they
would be rejected by the
sanatorium, and by the
boardinghouses even.
One of the features of the
sanatorium--
it's difficult at Saranac Lake
to determine the effect,
because there was considerable
triage among those who were
admitted.
 
And one of the features of it
was that Trudeau didn't wish to
take people into the sanatorium
whom he considered so ill that
nothing more could be done for
them.
He wanted people who would
actually benefit from his cure.
So, in that sense,
the statistics were a little
bit massaged by the fact that
the most serious cases of
tuberculosis didn't figure in
them.
Well, the idea of the
sanatorium spread,
and spread rapidly.
 
It wasn't long before every
state in the nation had a
network of sanatoria.
 
And some of them were
specialized: some for the
indigent, that is,
the poor;
some for women;
some for African-Americans.
Abroad, there were also
sanatoria, the most famous in
Switzerland,
in Davos--you can read about it
in Thomas Mann's The Magic
Mountain--
and that was clearly a
sanatorium that wasn't
subsidized but was,
in fact, for the social elite.
So, there were also sanatoria
of various types,
for various social classes and
social groupings.
There were also distinctions
within the movement in the
sanatorium idea.
 
In England, for example,
they shared the idea of the
importance of the outdoor life,
diet and surveillance,
but they differed in that they
thought that the kind of rest
regimen that Trudeau had in mind
was counterproductive,
and that this would ruin
working people,
who would get used to a life of
idleness.
So, in England the sanatoria
instead practiced what was
called graduated exercise,
and instead of the rest
treatment we have the work
treatment.
And those of you who are skiers
know that the slopes are given
color codes: your black
diamonds, your blue and your
green, for example.
 
Well, at the British sanatoria,
there were walks for the
patients,
and they were also color coded
according to difficulty and how
much it was going to make you
breathe.
 
And inmates then--as you got
well, you were encouraged to
take walks of progressive
difficulty.
In the inter-war period,
there were some additional
innovations in the treatment of
tuberculosis.
One was--this is still before
the age of antibiotics,
you see--and one was a surgical
approach.
And this was practiced at
Saranac Lake as well,
the idea being to extend rest
to have real,
total rest of the lungs.
 
This was termed artificial
pneumothorax;
and that means that air was
injected,
or another gas,
like nitrogen,
into the pleural cavity to
collapse the lung,
or the lungs,
by subjecting it or them to
external pressure.
 
The procedure was developed in
the 1890s, and came into vogue
after World War I,
especially in this country.
Very invasively,
some surgeons even decided to
make the collapse permanent by
removing patients' ribs to
paralyze the diaphragm.
 
Let me show you--this is a
patient undergoing pneumothorax,
the artificial collapse of the
lung.
And this is a diagram of the
pneumothorax apparatus.
The remark of one surgeon was
this, in a burst of surgical
optimism.
 
He said, "Physicians have
treated tuberculosis for 2,000
years, and without effect.
 
It's time now for us surgeons
to show the way."
The analogy was that of the
resting of a broken limb in a
cast.
 
Unfortunately,
however, statistics seemed to
indicate that the results were
deeply disappointing,
and the procedure was almost
totally abandoned by 1940.
Fortunately,
however, there were other
weapons in the war on
tuberculosis.
One was another institution,
in addition to the sanatoria,
and that's the dispensaries.
 
In cities to which patients
returned,
after discharge from hospitals
and sanatoria,
they needed follow-up care,
and the dispensaries were
designed to provide that in the
community.
They also taught hygienic
education,
reminding patients that even
after discharge from the
sanatoria,
they still weren't allowed to
spit,
and they should cover up their
faces when coughing or sneezing,
and they should tell everyone
in their families to do the
same.
So, these were,
in part, health education
facilities.
 
They also performed what we
might call social work services.
They helped recovering patients
to find jobs that were suitable
for their condition.
 
Sometimes they provided loans
or cash grants,
or food to tide patients over
while they attempted to get back
on their feet,
after a prolonged period of
being unemployed.
 
There were also--these were
joined by campaigning voluntary
associations.
 
And, so, we see a proliferation
of what we might now call NGOs.
In England was the National
Association for the Prevention
of Consumption and Other Forms
of Tuberculosis,
founded in 1898.
 
And there were similar
associations in France,
Germany, Belgium,
Portugal, Canada,
Denmark, Sweden,
Russia, Japan,
Norway, Australia.
 
And in our country there was
the National Tuberculosis
Association, that's now called
the American Lung Association.
And I wonder if you could guess
who its first president was?
Well your friend,
Edward Livingston Trudeau.
I said he was a propagandist of
genius.
The mission of these
associations again was to
educate the public about the
disease,
to help teach people in how
they could protect themselves
from it,
and also protect those around
them.
 
And they spent a lot of time
attacking the social
construction of tuberculosis
from the first half of the
nineteenth century;
that is, the romantic idea of
tuberculosis.
 
They stressed,
in pamphlets and in lectures,
that tuberculosis was neither
romantic nor poetic.
One pamphlet wrote--and I think
it laid it on a bit a heavy--
it said, "TB is a coarse,
common, vulgar disease,
bred in foul breath,
in dirt and squalor.
The beautiful and the rich
receive it from the unbeautiful
and from the poor."
 
I think we're a million miles
away from La
Boh�me.
 
In any case,
the idea then was to frighten
people in order to reform their
habits.
And these associations produced
pamphlets.
They sponsored lectures.
 
There were traveling exhibits.
 
Later on there were films and
radio broadcasts,
newspaper articles.
 
And the propaganda blanketed
schools and hospitals,
offices and shops,
factories, town halls,
billing places,
public squares,
city walls,
bulletin boards at schools and
universities.
 
And particular targets were the
habit of spitting and
alcoholism.
 
You would've noted,
not too many years ago,
that if you boarded a bus,
say in Paris or in Rome,
that the back of the bus would
have a sign
D�fense de
crecher;
"no spitting"
in French.
Or Vietato sputare,
in Italian.
Spitting was really something
that this campaign heavily
focused on.
 
In addition,
there were other messages:
the outdoor life and exercise.
 
It wasn't unrelated that this
was the time when the Scout
movement gets going,
to give people outdoor
experience, so that they'll be
more healthy.
It sponsored playgrounds at
schools,
and parks in cities and urban
areas,
and also the movement funded
research in the basic sciences
related to tuberculosis.
 
So, that was part of this
campaign, the war on
tuberculosis.
 
In addition,
there were government measures.
One was a campaign--I said that
a secondary way in which
tuberculosis was spread was
through milk.
And, so, in this period we see
the attempt to screen herds,
to prevent diseased milk and
meat from reaching the market,
and it was the time when the
pasteurization of milk took off
as a practice.
 
Tuberculosis also,
by states, municipalities and
nations, was made a notifiable
disease.
The pioneer here was New York
City in 1897.
Manchester in England followed
suit in 1899,
and then there was a cascade of
other places where physicians
were obligated to report cases
to the authorities.
Now, a result--this clearly is
a positive thing in that public
health depends on accurate
information and you can only get
information through statistics.
 
So, I don't want to argue that
this was anything but positive.
Except, as many positive
measures have,
it also had a small undertow;
in other words,
this increased the fear of the
disease.
People feared being reported,
because they might lose their
jobs.
 
They would lose all standing in
the marriage market.
They might be shunned by
anxious friends,
neighbors and relatives.
 
Another idea was vaccination,
and this was followed from
1925--
well 1908, in particular,
but especially after 1925--
with the BCG first,
and vaccination with attenuated
bacteria thereafter,
not with a very successful
result.
But this was part of the policy
as well.
And then there was mass
screening through radiology and
the tuberculosis skin test.
 
Well, how effective was the war
on tuberculosis with this set of
tools used to combat the
disease?
Interestingly,
I think one could argue that
the war on tuberculosis really
gathered speed,
not at the very height of the
tuberculosis epidemic,
when there was the most
suffering, morbidity and
mortality.
 
The decline probably began
spontaneously somewhat earlier,
maybe reflecting the sanitarian
movement,
and improved urban living
conditions,
improved wages and diet,
improved housing;
things that were done
spontaneously,
and led to a recession of the
disease by those sorts of means.
But everyone agrees that
sanatoria and isolation did
reduce infection;
that dispensaries and TB
campaigning organizations
provided those at risk with
means to protect themselves.
 
So, they undoubtedly did have
an important effect on
tuberculosis,
and we can see a decline in the
disease in the early decades of
the twentieth century.
But the real massive decline
began in what we might call the
antibiotic era,
from 1940 to 1980,
roughly.
 
Here a major event,
a new magic bullet,
was devised by Selman Waksman
in 1943, at Rutgers University;
that is, the development of
streptomycin.
And the first patient to be
treated with it,
tuberculosis patient,
was 1944, when a critically ill
TB patient made a full recovery,
what seemed truly a miracle
cure.
 
And this led,
immediately after World War II,
to a confident expectation--and
we'll see this repeated in a
number of different fields and
with regard to a series of
diseases,
the idea that worldwide
eradication was just around the
corner.
And there was--in fact,
it was fueled by a constant
decline, from the 1950s to the
mid-1980s in tuberculosis.
In the USA, there was a
seventy-five percent decline.
There were 80,000 cases in 1954;
20,000 only in 1985.
And the government confidently
predicted eradication by
2010--something that you know
didn't happen--and worldwide by
2025.
 
Unfortunately,
a troubling problem rapidly
emerged.
 
First there was monotherapy,
that is, streptomycin,
and soon it happened,
it was discovered,
that bacteria were becoming
resistant to it.
For a time the problem was
overcome by combination
treatments;
two, three medications at once,
instead of monotherapy.
 
Isoniazid was developed in
1952, rifampicin in 1963.
But then the problem increased
with multiple-drug-resistant
tuberculosis.
 
And in 1985,
there was a halt in the
decline;
1986 and '7 a slight rise;
and after 1987,
a rise in the United States,
but even more troubling,
a pandemic in Eastern Europe,
Southeast Asia and Sub-Saharan
Africa.
Indeed, in 1993,
the World Health Organization
took the step,
for the first time,
of proclaiming the TB pandemic
a world emergency,
and warned that the disease
might spiral out of control.
Today there are perhaps
worldwide some 8,000,000 people
who develop active infections
every year, and a million,
over a million people die.
 
Well, what are some of the
factors in this resurgent
emergency?
 
One, of course, is poverty.
 
Tuberculosis thrives in the
conditions promoted by poverty,
and worldwide the nations with
the highest incidence of TB,
not by accident,
are those with the lowest gross
national product.
 
If we look at the United
States, we can confirm this
picture,
in that seventy percent of
cases in the United States occur
among racial and ethnic
minorities;
forty percent among immigrants
from abroad,
or what we might call marginal
groups: intravenous drug users,
prisoners, the homeless,
people in nursing homes for the
elderly,
or people with compromised
immune systems due to HIV/AIDS.
Remember, of course,
that in an era of air travel
our country isn't an island and
can't reduce its own burden of
tuberculosis without also
dealing with the global
emergency.
 
There were other factors that
have fed into this upsurge:
the displacement of people due
to war, or economic disaster,
or environmental catastrophes.
 
Remember, of course,
that refugee camps are
wonderful for propagating
tuberculosis.
And then there's the HIV/AIDS
pandemic, and the upsurge in
malaria.
 
Both of those diseases are
immunosuppressive,
and both act as powerful
substrata for the emergence of
tuberculosis.
 
Indeed, TB is the leading
immediate cause of death among
AIDS sufferers.
 
Tuberculosis is the perfect
opportunistic disease.
Then there's the problem of the
emergence of drug resistance
that we referred to,
and that has fed the pandemic.
High rates of incarceration
feed the pandemic;
that's been clearly
demonstrated in Russia,
the former Soviet Union,
and in our own country.
And in Russia,
the collapse of medical
services in Eastern Europe.
 
And then, of course,
there's the availability of
mass air travel.
 
Well I just wanted to close
with the fact that we're then in
the midst of this world
pandemic.
And I wanted to say also that
there are a number of issues
about tuberculosis,
historically and medically,
that still need to be worked
out.
It's not understood what
factors cause it to pass from
the dormant state to an active
infection.
It's not known why in some
people it's a fulminant disease,
but in others a slow,
wasting process.
It's not known why it chooses
to invade certain tissues and
organs, rather than others.
 
It's not really clear why in
the middle decades of the
nineteenth century it
disproportionately affected
women,
whereas from the late
nineteenth century it tended to
favor men.
And it's not entirely clear
what were the factors that
caused this major recession of
the disease between the 1890s
and 1985;
although we've dealt with quite
a number of them:
spontaneous economic advance;
improvement in living
conditions;
government and NGO campaigns;
the reporting of the disease;
the sanatorium movement;
and then finally the
development of antibiotics.
 
So, that's the tuberculosis
story, from the age of
consumption down to where we are
today;
which today we find ourselves
in a very problematic condition
with regard to what has been
this terrible upsurge of a
disease that defeated the
confident expectation that it
would soon be eradicated.
 
 
 
