Outbreak! Plagues That Changed History (9 page)

Western ideas about Romantic tuberculosis have parallels in Asia. In the eighteenth-century Chinese novel
The Dream of the Red Chamber,
the heroine, Lin Tai-yu, dies of TB at the moment her sweetheart marries another woman. In Japan, writers and some doctors called TB “lovesickness.” It was thought to be an illness brought on by longing or frustration that made people more intelligent and passionate. Love-starved daughters and diligent boys studying the Chinese classics were considered most susceptible. Tokutomi Roka’s
1898 novel
Hototogisu
(“Nightingale”) is about a young wife miraculously cured of her terminal tuberculosis when her beloved husband returns from abroad. This hugely popular book has been the subject of several films, many dramas, and a hit song. It is but one example of a Japanese literary genre that revolves around tuberculosis.

In Japan, tuberculosis was thought to be lovesickness.

Tuberculosis lost its romantic status once the true cause of the disease was understood. After the publication of Pasteur’s
Germ Theory of Disease
in 1880, researchers raced to discover one infectious microbe after another. In March 1882, after eight months of effort, Robert Koch finally isolated the TB bacterium. Consumption, it turned out, wasn’t hereditary at all. The Koch bacillus was a rod-shaped microbe that passed from person to person suspended in microscopic droplets of saliva from a person’s sneeze or cough. It could be avoided but not cured.

The bacterium
Mycobacterium tuberculosis

Confronted with this new knowledge, the middle class became obsessed with cleanliness, sure that TB microbes were lurking everywhere. Bodily fluids became scary, human smells repulsive (the search for effective underarm deodorants and antiperspirants starts here). Spitting, kissing, and even talking were now seen as bacteriological menaces. One story told of the tubercular worker who licked his fingers while he turned the pages of documents, spreading consumption far and wide. One British sign from that era reads, “Don’t Spit! It’s Disgusting and It Spreads Germs!”

In the United States, control of tuberculosis was first systematized in New York City. By 1900, Dr. Herman Biggs of the Metropolitan Board of Health had developed the basic procedures still used for the control of TB around the world. These included free sputum exams, mandatory reporting of cases, mandatory isolation and treatment of those infected, education of the public about the disease, and monitoring of living conditions. The methods were despotic by today’s standards, and the system concentrated on the poor, by now stigmatized and stereotyped as society’s primary TB carriers. Biggs proceeded from the notion that still animates all public health systems: the well-being of society is more important than private liberty. Since he was focusing on people with little political or economic clout, few objected. By contrast, the middle class and wealthy enjoyed private medicine, where the well-being of the individual comes first. The two systems, public and private, developed separately, in tandem.

Restrictions on the individual reached their apex with the creation of the sanitarium, an institution that totally cut off consumptives from society, sometimes voluntarily, sometimes mandatorily, sometimes for years, sometimes for life. If one was rich, a sanitarium might be a fancy seaside spa or a mountain resort. If one was poor, a sanitarium was little better than a prison. By 1950, over a hundred thousand sanitarium beds existed in the United States alone. Sanitarium doctors experimented with an amazing variety of therapies to try to treat TB. These included bed rest, fresh air, lung collapse, rib removal, exposure to heat, exposure to cold, exposure to sun, gold therapy, calcium therapy, iodine therapy, horse riding, the milk cure, the grape cure, the wine cure, and cod-liver oil. Dietary
therapies ranged from strict limits on what a patient could eat to stuffing them with nutritious food. For society, the main benefit was the removal of infectious individuals.

Before an antibiotic cure for tuberculosis was discovered, daily doses of fresh air were considered vital to preventing and treating the disease, even in the coldest weather.

Meanwhile, a new social reform movement, moral environmentalism, lobbied for better housing for the poor, public parks, public schools, hospitals, efficient waste disposal, sewers, water systems, street cleaning, and the regulation of markets, slaughterhouses, and restaurants. The idea was simple and owes much to Edwin Chadwick: improve the environment and you improve the person. The combination of control, isolation, diet, and improved living conditions worked. In 1828, TB deaths in England were about four thousand per million. By 1948, TB deaths in the United States had dropped to about four hundred per mil-lion. With the advent of antibiotics—drugs that could actually kill the tuberculosis bacterium—the American TB death rate dropped to its lowest ever: ninety per million. The tuberculosis decline among American minorities was not so steep. Indeed, in many developing nations, rates had not declined at all. Nevertheless, the mood was so optimistic that in 1980, a panel of experts convened by the U.S. Congress was called the Advisory Committee for the Elimination of Tuberculosis. In retrospect, this seems astoundingly naive.

Once TB was no longer a terror, tuberculosis control systems deteriorated. In the United States during the 1980s, sanitariums were shut down or converted into hospitals. Public health programs were defunded. Salaries stagnated for personnel responsible for monitoring and treating TB. Funding for poverty programs was slashed. Mental hospitals were emptied, pushing people unable to care for themselves onto the street or into crowded homeless shelters. In 1992, the Soviet Union collapsed and with it the expensive TB control program of SanEp, the Russian empire’s unwieldy state health system. Revolution in Africa and Central America ensured that people there with tuberculosis got partial treatment or no treatment.

Under such conditions, many TB patients took only enough antibiotics to feel better but not enough to eradicate all the TB germs in their bodies. They killed off the weak bacteria, allowing the strong ones to reproduce and make them sick again. The next time they took the antibiotic, it didn’t work. The strong microbes were
resistant.
These resistant TB bacteria spread around the world in the bodies of refugees fleeing their crumbling societies. In 1993, the re-emergence of tuberculosis caused the World Health Organization to proclaim a global TB emergency. Today nearly two billion people on earth may host the tuberculosis bacterium. Over the next decade, ninety million will develop active TB. Eventually thirty million will die.

Tuberculosis, once the most Romantic of illnesses, is now the deadliest disease on earth. Controlling the bacterium is the twenty-first century’s greatest public health challenge.

World War I extinguished ideals of chivalry that since medieval times had cloaked battle in a nimbus of glory, honor, and sacrifice. In this, the world’s first truly industrial war, battle was revealed not as a righteous conflict but as a riot of slaughter. Most of the efficient mass killing machines we are familiar with today got their start here: tanks, long-range artillery, machine guns, aerial bombardment, submarines, and poison gas. In the horrific trench warfare that characterized this struggle, tens of thousands of soldiers lost their lives to win a few feet of ground. Tens of thousands more died to win it back. The war had many names, including “the Great War” and “the war to end all wars.” President Woodrow Wilson’s favorite was “the war to make the world safe for democracy.” Poet Robert Graves called it “the sausage machine,” because “it was fed with live men, churned out corpses, and remained firmly screwed in place.” From 1914 to 1918, over fifteen million people died, nine million of them in combat.

In the last months of the war, however, a new killer appeared, far more efficient than anything devised by man. It was Spanish influenza, the single largest epidemic of the twentieth century, if not world history. As with normal flu, people who caught this illness became lethargic, feverish, and achy. But instead of recovering, many of those who were infected by this strain of influenza then progressed to a deadly pneumonia that filled the lungs with bloody froth. Oxygen was sucked from the tissues, turning the skin a sickly purple before the victim died, gasping for air.

Spanish flu had another fatal peculiarity. Most flu epidemics kill the very young or the very old. This disease, however, was most lethal among those it was most likely to encounter on the battlefields of Europe: twenty-to-thirty-year-olds. Of the one hundred thousand American soldiers who died in World War I, forty-three thousand died from the Spanish flu. Total U.S. flu deaths were about half a million. Globally, death toll estimates range from twenty million to one hundred million people. Up to twenty million may have died in India alone. In some of the isolated aboriginal populations in Alaska and the Pacific, nearly everyone perished.

“The Purple Death” didn’t just kill huge numbers of people; it shaped world events. The epidemic was a major player in the final battles of World War I and had a role in the shaping of the Versailles peace treaty. It totally overwhelmed the ability of even the best-prepared governments to care for the living and bury the dead. It catalyzed the creation of today’s global influenza surveillance system and the cycle of annual autumn flu shots. Most important of all, scientific research into the nature of the Spanish flu uncovered something totally new and unexpected that would revolutionize medicine: the first antibiotic.