In the early 20th century, tuberculosis was the leading cause of death. Tens of thousands of people wasted away as a result of the white plague. Sanatoriums offered fresh air, bed rest, regular meals, and gradual exercise, but with the discovery of streptomycin in 1944 a new era of effective treatment for tuberculosis began. Aminosalicylic acid was added in 1949 and isoniazid in 1952. Early preparations of isoniazid had stimulant effects. Lerner notes that "pictures of formerly gravely ill patients dancing in the halls" contributed to isoniazid's reputation as a wonder drug.
Tuberculosis is a chronic disease with important medical, social, civil-liberties, and public health implications. The history of tuberculosis reflects the prevailing social thought of the times. In the early 20th century, tuberculosis was thought to be caused by both medical and social factors. Osler wrote in 1894 that "it was important to consider not only the seed [the bacillus], but also the soil [the patient] when analyzing why a given patient had become tuberculous." It was argued that unless poor living conditions, poor working conditions, and poor nutrition were addressed, medical treatment alone would not be sufficient to treat tuberculosis successfully.
Barron Lerner sets his social history of tuberculosis in the post-World War II era in Seattle, among the population of "Skid Road." Seattle attracted single, unskilled laborers to work in its seasonal industries. Unable to support themselves adequately, they spent the winters in the taverns, flophouses, and missions surrounding the area. Skid Road was known for its high rates of alcoholism and tuberculosis. Residents with tuberculosis often did not complete their prescribed treatment. At the end of World War II, a vacant military hospital was deeded to Seattle, allowing for the expansion of the Firland Tuberculosis Sanatorium. Now having an adequate number of beds, Seattle launched a herculean program that screened 398,309 Seattle residents with chest x-ray films during a three-month period in 1948. The effort identified 402 patients with tuberculosis who were admitted to Firland.
In the 1950s, important work by Thomas Holmes, a staff psychiatrist, set the tone at Firland. Social factors were thought to be important risk factors for tuberculosis. Holmes, along with Joan Jackson, a medical sociologist, began studying Skid Road alcoholics with tuberculosis at Firland. Alcoholism was considered a medical illness, and treatment of it was considered essential. In-house staff services were provided, on-site Alcoholics Anonymous meetings were held, vocational rehabilitation was provided, and psychological support was offered.
Drawing on historical examples, including the incarceration of more than 30,000 prostitutes in federally funded institutions during World War I to prevent the spread of venereal disease, the state of Washington adopted a quarantine policy for patients with tuberculosis. In 1949, Firland established Ward 6, a locked detention ward. Firland went on to have the most aggressive policy of involuntary detention in the country. By the 1960s nearly half of all Skid Road alcoholics at Firland spent at least two weeks in Ward 6. Patients were detained without a legal process and could be held indefinitely. They were locked up for disciplinary problems, even if they did not have active disease. Beginning in 1965, a local judge held monthly sessions at Firland to hear complaints from patients held in Ward 6. At the same time, news of successful, supervised, twice-weekly outpatient treatment of tuberculosis came from Denver. This type of treatment heralded the demise of Firland and tuberculosis sanatoriums throughout the United States.
Firland closed its doors in 1973. In the early 1980s there was a resurgence of tuberculosis associated with the human immunodeficiency virus (HIV), a rise in homelessness, and the dismantling of programs to control tuberculosis, especially in New York City. Tuberculosis was once again thought of as a social disease, and housing for the homeless and drug treatment for the addicted were considered necessary for its treatment. Directly observed therapy was used, and practitioners became skilled in tracking down infected persons in bars or Skid Road areas to ensure that treatment was completed. Unfortunately, after successful treatment, such persons were still homeless, still had HIV infection, and were still impoverished.
Although this social history of tuberculosis in the post-World War II era is concerned mainly with Seattle, Contagion and Confinement has universal relevance. This book will appeal to a broad spectrum of health care professionals, including pulmonologists, infectious-disease specialists, public health officials, and those interested in the relation between poverty and tuberculosis. It is exceedingly well referenced and uses primary sources extensively. It provides a chronology of the historical events that led to the rise and fall of the tuberculosis sanatorium and the abuses of civil liberties in the name of public health. There are corollaries between the history of the treatment of tuberculosis and the HIV epidemic and current efforts in some states to require reporting of persons infected with HIV. Some fear that the next step could be the quarantine of "recalcitrant" patients with HIV disease.
Reviewed by Daniel Wlodarczyk, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
"Lerner's excellent, thoroughly researched, clearly-formulated book deals with the experiences of tuberculosis (TB) control in Seattle, Washington, during the post-World War II period, especially at the Firland Sanatorium, but the implications speak to TB prevention, and, indeed, to transmissible disease prophylaxis in general." -- Peter Baldwin, Journal of the American Medical Association
"Contagion and Confinement has universal relevance. This book will appeal to a broad spectrum of health care professionals, including pulmonologists, infectious-disease specialists, public health officials, and those interested in the relation between poverty and tuberculosis. It is exceedingly well referenced and uses primary sources extensively." -- Daniel Wlodarczyk, New England Journal of Medicine
"Contagion and Confinement provides a window into changing public health priorities, emerging medical technology, persistent problems found on the Skid Road, and the complicated and ever-present tension between individual rights and the public's health." -- Carolyn G. Shapiro-Shapin,Social History of Medicine
"Insightful analysis." -- Booklist
