HIST 234: Epidemics in Western Society Since 1600

Lecture 19

 - Tuberculosis (II): After Robert Koch


The cultural transition from the romantic era of consumption to the era of tuberculosis derived not only from the germ theory of disease and the triumph of contagionism over anticontagionism, but also from political considerations. Worries over population decline and growing working-class militancy were aggravated by what now appeared to be a social disease, or a disease of poverty. One of the strategies deployed against the disease was the sanatorium, an institution which was capable both of instructing patients in contagionism and in imposing a practical quarantine. Although the development of effective chemotherapy in the 1940s raised hopes that tuberculosis might be globally eradicated, these have unfortunately proven to be overly optimistic. Factors such as poverty and population displacement continue to favor the disease’s spread today, particularly in the Third World.

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Epidemics in Western Society Since 1600

HIST 234 - Lecture 19 - Tuberculosis (II): After Robert Koch

Chapter 1. The Age of Tuberculosis [00:00:00]

Professor Frank Snowden: 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.

Chapter 2. War on Tuberculosis: Sanatoria [00:05:58]

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.

Chapter 3. Pneumothorax and Dispensaries [00:30:23]

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 Bohème.

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 Défense 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.

Chapter 4. Vaccination and Antibiotics [00:39:23]

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.

[end of transcript]

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