Contagion and Confinement: Controlling Tuberculosis along the Skid Road (review)

Barron H. Lerner. Contagion and Confinement: Controlling Tuberculosis along the Skid Road. Baltimore: Johns Hopkins University Press, 1998. xv + 243 pp. Ill. $42.50.

The rise of drug-resistant tuberculosis is frequently reported in our newspapers, popular periodicals, and television broadcasts. For example, a recent issue of the New York Times Sunday Magazine (30 May 1999) included a stark essay entitled "A Brutal Cure" by Lisa Belkin, which documented the tuberculosis of one Laotian immigrant-student named Toon Choummanivong that required the surgical removal of his lung. One telling full-page photograph of Choummanivong's face, obscured by a "protective" surgical mask, superbly expressed the all-too-common conflation of fear of disease and of the foreigner. How will we approach the myriad public health and medical problems brought on by the recrudescence of a disease that most physicians in practice today have little experience with or desire to treat? Matters become especially problematic when we consider the socioeconomic, educational, and cultural disadvantages of the average patient with tuberculosis in the United States: the poor, the immigrant, and the socially disenfranchised. The unhealthy addition of illicit drug and alcohol use to this scenario only makes medical and public health interventions more complicated.

In order to address these issues, Barron Lerner, an internist and historian at Columbia University, suggests that public health policymakers and medical professionals need to study the history of the disease during the twentieth century, especially before the advent of antituberculosis chemotherapy, in order to understand tuberculosis as both a medical and a social disease. His discussion focuses on the institutional history of the Firland Tuberculosis Sanitarium in Seattle, Washington, and its treatment of alcoholic, recalcitrant patients during the years 1945 to 1973. A major goal of this research is to investigate how "aggressive pub-lic health policies designed to protect the community from tuberculosis--specifically, forcible quarantine and detention--influenced both the medical and social strategies for combating the disease" (p. 5).

Perhaps the book's greatest strength is its microhistory approach to the in-depth study of one tuberculosis sanitarium in a region of the United States that has not been given enough attention by medical historians--the Northwest. In this well-written monograph, Lerner describes the people who staffed the Seattle Department of Public Health and the Firland Sanitarium and the patients who were treated there, at times under intolerable conditions. Like Judith Leavitt, Charles Rosenberg, Nancy Tomes, and several other historians of public health and quarantine, Lerner reiterates the delicate dance of bargaining and negotiation that often occurred among the sanitarium staff, public health workers, and a "subset of extremely unreliable, uncooperative Skid Road patients" (p. 8).

A closing chapter reflects on the return of tuberculosis in the 1990s, and on the changes in public health policies that have been developed especially for those patients who are noncompliant and may have several other problems to contend with, such as homelessness, poverty, and drug and alcohol abuse. One modern method Lerner is especially enthusiastic about is the so-called DOT, or directly observed therapy, where outpatients take their medications directly under the observation of an outreach worker. Yet even this method, as the author warns, has its negative aspects: if patients do not comply with the DOT protocols, they "can expect a series of increasingly restrictive measures that may ultimately culminate in detention" (p. 174). Lerner approaches but ultimately cannot answer (as none of us can) the major question that plagues all quarantine measures: how does one protect the health of the public against the recalcitrance, for whatever reason, of the individual who refuses treatment, without violating that individual's civil liberties? The balance sheet of pros and cons in quarantine efforts, alas, changes all too quickly with each new epidemic.

One minor problem with Lerner's discussion of quarantine and isolation for tuberculosis is that he does not consider other diseases for which quarantine was...