Tuberculosis: A Reflection of Political Institutions and Social Concerns in the United States

TUBERCULOSIS: A REFLECTION OF POLITICAL INSTITUTIONS AND SOCIAL CONCERNS IN THE UNITED STATES ALAN R. LEFF* and DONNA R. LEFFt Tuberculosis and man appear to have coexisted from the dawn of history [I]. This disease has mobilized the best and worst of man's resources as it has been institutionalized into the political process. The tragic tales of the initially innocent Mimi (La Bohème) and the morally tainted Violetta (La Traviata) have been preserved magnificently by their composers in dramas barely comprehensible to those born 100 years later. In his own tuberculosis, Eugene O'Neill found an allegory of his life—his mother's opiate addiction and his father's penury. In the play (Long Day'sJourney into Night), as in life, he was forced to seek treatment in a state institution rather than a private sanitarium, where recovery rates were reputed to be better. O'Neill's concerns probably were unfounded ; half of all patients entering all tuberculosis sanitariums died on first admission and half of those discharged (after 3—5 years) relapsed within the next 5 years. In the prechemotherapy era of tuberculosis treatment, the disease was regarded with the fear and superstition now reserved for cancer. Death was the expected outcome and isolation from the rest of society was mandatory to prevent spread (offering a painful model for the approach now advocated by some for patients having acquired immunodeficiency syndrome [AIDS]). Recovery was a divine and mysterious ordination that, like all such blessings, was subject to inexplicable change. Even today, there is little understanding of why some acquire tuberculous disease after many years of dormant infection (see below). Why, in some patients, are the clinical manifestations minimal, while in others they are multisystemic and rapidly lethal? ""Department of Medicine, University of Chicago. tMedill School ofJournalism and Center for Urban Affairs and Policy Research, Northwestern University, Evanston, Illinois 60201.© 1986 by The University of Chicago. AU rights reserved. 003 1-5982/87/300 1 -0504$0 1 .00 Perspectives in Biology and Medicine, 30, 1 ¦ Autumn 1986 \ 27 Out of fear as well as compassion, the tuberculosis sanitarium was fostered in the United States and abroad. Thomas Mann's Magic Mountain offers a sobering reflection of conditions in an institution where patients are sent both for recovery and for death. At their best, sanitariums were "resorts" for the ill. Care was optimal for the times. Splendid meals were prepared in an effort to overwhelm the anorexia that accompanied the cachexia of death. Government-run institutions varied substantially in quality. Indigenous to all such sanitariums was the second-class status of the patients. Equally indigenous was the politics, and the level of organization was remarkable. Some states established separate districts, creating tuberculosis governments with their own taxing power. Their domain was the multimillion-dollar tuberculosis sanitarium district and the patronage workers it employed. This led to the preservation of the sanitarium movement long after its obsolescence. An entire class of medical specialists (the phisthiologist) had to be preserved along with their political counterparts—bureaucrats who administered the sanitarium movement . The National Tuberculosis Association had to make a successful transition to the National Tuberculosis and Respiratory Disease Association and finally to the American Lung Association by broadening its appeal for public contributions (Christmas Seals) to other areas of lung disease (a problem later faced by its sister association, the March of Dimes [Easter Seals], with the discovery of the SaIk polio vaccine). However, even before its obsolescence, the public tuberculosis movement was rife with scandal and political manipulation. In 1916, Dr. Theodore Sachs, the founder of the tuberculosis movement in Chicago, took his own life after being accused of corruption. Since such acts of remorse remain highly uncharacteristic of Chicago politicians even today , it is not surprising that the charges were false allegations instigated by former Chicago mayor, William Hale Thompson. A major aspect of the disease has changed in the last 35 years. Prior to 1950, tuberculosis afflicted individuals from all walks of society. A list reads like a historical Who's Who (fig. 1) [2]. Today, tuberculosis has retreated to a largely indigent population in America [3]. The incidence of the disease may be confined to discrete...