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TB Notes 1, 2000
A Glimpse at the Colorful History of TB: Its Toll
and Its Effect on the U.S. and the World
by Dan Ruggiero
Division of TB Elimination
In their 1969 book Tuberculosis, Lowell et al. tell us
that "Tuberculosis is an ancient disease with a lineage that
can be traced to the earliest history of mankind
In the last
millennium it has been universally distributed among all branches
of the human race."
Phthisis (from the Greek word 'to waste away'), scrofula (swellings
of the lymph nodes of the neck), the white plague (the TB epidemic
in Europe during the 18th century), consumption (progressive wasting
away of the body), TB (the presence or products of the tubercle
bacillus) are all words for tuberculosis marking a specific point
in history. Each has a significant connotation and meaning to millions
of people about a disease that has afflicted humans from the dawn
of history and continues to ravage mankind in large numbers. During
World TB Day 1999 it was reported that an estimated one billion
persons died of the disease worldwide during the 19th and early
20th centuries alone. This invisible enemy continues to challenge
man's knowledge and mock his efforts; the "Captain of the men
of death" continues to march forth leaving behind a trail of
human misery, economic chaos, and death. What is the origin of this
invisible predator that even today has been able to adapt and survive
by fending off the many remedies and cures that the best minds in
science have placed before it?
The tubercle bacillus, the organism that causes TB disease, can
be traced as far back as 5000 BC when archeologists found evidence
in human bones of the existence of TB. Evidence was found in ancient
Egyptian mummies which showed deformities consistent with TB disease.
Paleontologists have concluded that the disease must have been prevalent
in that part of the civilized world.
Image 1: Photograph showing evidence of TB in ancient human bone,
showing deformities consistent with TB disease.
Evidence of TB appears in Biblical scripture, in Chinese literature
dating back to around 4000 BC, and in religious books in India around
2000 BC. In ancient Greece Hippocrates mentions TB around 400 BC,
as does Aristotle, who talked about "phthisis and its cure"
(ca. 350 BC).
It was widely believed that European explorers, sailors, and the
settlers who followed Columbus to the new world brought with them
many infectious diseases, among them TB. However, paleopathologists
suspected that TB existed in the New World before 1492, based on
ancient skeletons and bones that contained lesions resembling those
caused by TB. Evidence to that effect was found in 1994, when scientists
reported that they had identified TB bacterium DNA in the mummified
remains of a woman who had died in the Americas 500 years before
Columbus set sail for the New World.
The TB epidemic in Europe that came to be called the "Great
White Plague" probably started in the early 1600s and continued
for the next 200 years. The epidemic reached its peak in western
Europe 12, and in the United States in the late 1700s and early
1800s. In early 19th century England, TB was so pervasive a killer
that it dwarfed other dreaded diseases like cholera and typhus.
So common and so little understood was TB that death from the disease
was accepted as inevitable. TB in the early 19th century may have
accounted for one third of all deaths. Death from TB was clearly
evident in the literature of the time in the writings of John Keats
(1795-1821) in the Ode to a Nightingale, of John Bunyan
(1628-1688) in The Life and Death of Mr. Badman, of Charles
Dickens (1812-1870) in Nicholas Nickleby, and of other
famous writers of the time.
In 1720, in his publication, A New Theory of Consumption,
the English physician Benjamin Marten was the first to conjecture
that TB could be caused by "wonderfully minute living creatures,"
which, once they had gained a foothold in the body, could generate
the lesions and symptoms of the disease. He continued that "It
may be therefore very likely that by an habitual lying in the same
bed with a consumptive patient, constantly eating and drinking with
him, or by very frequently conversing so nearly as to draw in part
of the breath he emits from the Lungs, a consumption may be caught
by a sound person
I imagine that slightly conversing with consumptive
patients is seldom or never sufficient to catch the disease."
For a physician living in such an early era, Dr. Marten showed much
Image 2:Photo of Dr. Robert Koch, who in 1882 presented to the
scientific community his discovery of the organism that causes TB.
In 1882, at a time when TB was raging through Europe and the Americas,
killing one in seven people, a German biologist by the name of Robert
Koch presented to the scientific community his discovery of the
organism that caused TB. It was called a tubercle bacillus because
small rounded bodies (tubercles) occurred in the diseased tissue
and were characteristic of the disease. Through his many experiments
with the organism, Dr. Koch worked on developing a cure for TB.
Koch was able to isolate a protein from the tubercle bacillus that
he tried as an immunizing agent and later as a treatment for TB;
in both cases it failed. However, the substance, now called "old
tuberculin," was to be later used as the screening tool (tuberculin
skin tests) for identifying people and animals infected with tubercle
A further significant advance came in 1895 when Wilhelm Konrad
von Roentgen discovered the radiation that bears his name. This
allowed the progress and severity of a patient's disease to be accurately
followed and reviewed.
Another important development was provided by the French bacteriologist
Calmette. Together with Guerin, he used specific culture media to
lower the virulence of the bovine TB bacterium, thus creating the
basis for the BCG vaccine still in widespread use today.
TB in America during the colonial period was accepted as a scourge
of humanity that was common to the poor and rich alike. The first
available mortality figures from Massachusetts in 1786 indicated
300 deaths per 100,000 population. The peak mortality figure reached
in New England was 1,600 per 100,000 in 1800. With the industrial
development, the epidemic traveled to the Midwest in 1840 and to
the West in 1880. Though the disease occurred in blacks at a lower
rate than in whites before the Civil War, the increase was massive
among blacks after the war, when emancipation and urbanization created
an ideal atmosphere for transmission of TB. The American Indians
and Alaskans were the last American populations to become affected
by the TB epidemic.
At the turn of the century it was estimated that 10% of all deaths
in the United States were due to TB. By 1904 the TB death rate for
the United States was 188, by 1920 the rate was 100 per 100,000,
and by 1955 the rate had decreased to less than 10 per 100,000 people
The TB sanatorium movement, which was started in Germany by Dr.
Hermann Brehmeris in the 1850s, did not take hold in the United
States until after 1884. Edward Livingston Trudeau, a physician
who recovered from TB disease, started a sanatorium in Saranac Lake,
New York, based on the European model of strict supervision in providing
fresh air and sunshine, bed rest, and nutritious foods.
Image 3: Photograph of a small building - "Little Red,"
first cottage for tuberculosis patients at Trudeau Sanatorium.
As infection control measures took hold in large urban centers
of the country, TB patients who could not be treated in local dispensaries
were removed from the general population and placed into sanatoriums.
Soon a great movement was underway to build TB sanatoriums. By 1938
there were more than 700 sanatoriums throughout the United States,
yet the number of patients outnumbered the beds available.
For those households in which the adults could not be placed in
a sanatorium, children were removed from infected parents and placed
in preventoriums that were created for children.
A milestone in the history of TB control in the United States occurred
in the autumn of 1893, when the New York City Board of Health called
on Dr. Hermann Michael Biggs, the Chief Inspector of the Division
of Pathology, Bacteriology, and Disinfection, for a report on TB.
In the report, Biggs stated that TB, which was responsible for more
than 6,000 deaths in New York City in 1892, was both communicable
and preventable. Some of the recommendations made to the Board in
his report were the need to
- educate the public of the dangers that the disease posed to
the person and his/her contacts,
- properly dispose of and immediately destroy sputum or the "discharges
from the lungs" of individuals with disease,
- have all physicians of pulmonary cases report such cases to
the health department,
- have health inspectors visit the families where TB exists and
deliver proper literature and take specific measures to disinfect
the areas as may be required,
- obtain and submit sputum specimens to the laboratory for analysis,
- create a consumptive hospital to care for indigent patients.
The Board adopted most of the recommendations made by Biggs, including
the creation of "The Consumptive Hospital." These recommendations
created a storm of controversy among the medical community. Many
private doctors objected to the mandatory reporting, believing that
it violated physician-patient confidentiality. Because of the resistance
from the medical community, reporting practices were not fully implemented
for several years. In the end, Biggs' recommendations to the Board
and their implementation in New York City created the model for
TB control programs that was emulated by other health departments
across the country and laid the groundwork for a campaign called
the "War on Consumption."
Image 4: Photograph of patients sitting outside - With no drug
therapies, past TB patients like these in 1953 were isolated in
During the first part of the 20th century, great emphasis was placed
on improving social conditions and educating the general public
about good hygiene and health habits. If you went to public school
anytime between 1900 and 1930, you got the TB message, which said
essentially that spit is death. In hospitals it was common to see
signs that read "Spit Is Poison." Notices were plainly
printed in public places and government buildings that stated "Do
Not Spit on the Floor; To Do So May Spread Disease."
In the 1920s, when fresh air and bed rest did not secure improvement
in the patient's condition, physicians sometimes performed surgery
or collapsed one of the lungs (pneumothorax). During this time there
were many other "sure-cure" remedies being advertised
by many firms and physicians.
Image 5: Picture of an old advertisement - During the early 1900s,
there were many "sure-cure" remedies being advertised
by many firms and physicians.
In 1902 at the first International Conference on Tuberculosis held
in Paris, Dr. Gilbert Sersiron suggested the adoption of the Cross
of Lorraine, used by the Knights of the First Crusade, as the symbol
of a new movement, a crusade for good health against sickness and
death, and against TB. The double-barred cross was adopted as the
international symbol for the fight against TB. This symbol was later
adopted in 1904 in the United States by the forerunner of the American
It was not until the turn of the century that private voluntary
groups in the United States joined the fight against TB. In April
1892, Dr. Lawrence F. Flick organized the first American voluntary
anti-TB organization, the Pennsylvania Society for Prevention of
Tuberculosis. The organization was instrumental in helping organize
free hospitals for poor consumptive patients in Philadelphia. In
1902, Dr. S. Adolphus Knopf of New York was one of the men responsible
for the movement that launched the Committee on the Prevention of
Tuberculosis of the Charity Organization Society of New York City.
The aim of the committee was to disseminate information that TB
was a communicable, preventable, and curable disease. The Committee
advanced the movement for hospitals, sanatoriums, and dispensaries
for consumptive adults and children. As a result of his focus on
the need for a national TB association, in 1904 a voluntary health
agency was organized under the National Association for the Study
and Prevention of Tuberculosis, later renamed the National Tuberculosis
Association (NTA) and now known as the American Lung Association.
To fund the activities of the many local affiliates, the Association
adopted a method that was originated in Denmark in 1904 by Einor
Holboll, a Danish postal clerk, who sold Christmas Seals. In 1907,
many TB sanatoriums had sprung up all around the country; most were
small and makeshift. One in Delaware was in such urgent need of
funds that it was going to have to close unless $300 could be raised.
Dr. Joseph Wales, one of the doctors working at that sanatorium,
contacted his cousin, Emily Bissell, to help raise the money. Emily
was a welfare worker in Wilmington, Delaware; she was also active
in the American Red Cross and had fund-raising experience. After
reading an article about the Christmas seals in Denmark, she created
a design, borrowed money from friends, and had 50,000 Christmas
seals printed. The seals were sold for a penny each at the post
office. She worked hard to make the campaign a success, personally
presenting the idea to all sorts of groups and officials, including
the Philadelphia North American newspaper, emphasizing
how buying Christmas seals would help children and adults with TB.
The idea took hold, and by the end of the holiday season, $3,000
had been raised — 10 times the amount she had set out to raise.
By 1946 at least 10 million people were purchasing seals or giving
to the Christmas seal fund. The Christmas seal campaign was so widely
advertised on buttons, milk caps, postcards, school booklets, billboards,
book marks, rail and bus passes, etc., that it permeated many aspects
of social life. The National TB Association said at that time that
"No nationwide program has rested for so many years on so broad
a base made up of millions of small gifts."
Image 6: Photograph of Emily Bissell - Emily Bissell started the
U.S. Christmas Seal campaign to raise funds for TB sanatoriums
Then, in the middle of World War II, came the final breakthrough,
the greatest challenge to the bacterium that had threatened humanity
for thousands of years: chemotherapy.
Image 7: Photo of baseball game promotion - The Christmas seal
campaign was so widely advertised that it permeated many aspects
of social life.
In fact, the chemotherapy of infectious diseases, using sulfonamide
and penicillins, had been underway for several years, but these
compounds were ineffective against Mycobac-terium tuberculosis.
Since 1914, Selman A. Waksman had been systematically screening
soil bacteria and fungi, and at the University of California in
1939 had discovered the marked inhibitory effect of certain fungi,
especially actinomycetes, on bacterial growth. In 1940, he and his
team were able to isolate an effective anti-TB antibiotic, actinomycin;
however, this proved to be too toxic for use in humans or animals.
Success came in 1943. In test animals, streptomycin, purified from
Streptomyces griseus, combined maximal inhibition of M.
tuberculosis with relatively low toxicity. On November 20,
1944, the antibiotic was administered for the first time to a critically
ill TB patient. The effect was almost immediate and impressive.
His advanced disease was visibly arrested, the bacteria disappeared
from his sputum, and he made a rapid recovery. The new drug had
side effects — especially on the inner ear — but the fact remained,
M. tuberculosis was no longer a bacteriological exception;
it could be assailed and beaten into retreat within the human body.
A rapid succession of anti-TB drugs appeared in the following years.
These were important because with streptomycin monotherapy, resistant
mutants began to appear within a few months, endangering the success
of antibiotic therapy. However, it was soon demonstrated that this
problem could be overcome with the combination of two or three drugs.
Although there were some attempts at providing guidance on TB control
measures through publication and conferences, the federal control
of TB did not occur until the mid-1940s, when the 1944 Public Health
Service Act (Public Law 78-410) authorized the establishment of
a TB control program. On July 6, 1944, the Surgeon General established
a Tuberculosis Control Division in the Bureau of State Services
of the Public Health Service (PHS). Doctor Herman E. Hilleboe was
appointed medical director of the new division. The Public Health
Service provided supplemental fiscal support to state and local
health departments for TB control activities through formula grants
and special grants-in-aid. These grants were to assist states in
establishing and maintaining adequate measures for prevention, treatment,
and control of TB and focused greater attention on the need for
In 1947, the PHS organized and supported mass x-ray screening in
communities with populations greater than 100,000. Over a period
of 6 years more than 20 million people were examined; the program
ended in 1953. The mobile x-ray vans continued to be used in the
communities into the mid-1960s. It was common use to show well-known
figures such as Santa Claus posing for x-ray pictures, stimulating
the population's compliance with being tested.
Image 8: Photograph of Santa Claus - In 1947, the U.S. organized
mass x-ray screening campaigns in large cities; it was common to
show well-known figures such as Santa Claus posing for x-rays.
A new era was advancing with the introduction of TB drugs, resulting
in a declining morbidity. The mainstreaming of TB treatment to general
hospitals and local community clinics reduced the need for and dependency
on sanatoriums. In 1959 at the Arden House Conference, sponsored
by the National Tuberculosis Association and the U.S. Public Health
Service, recommendations were made for mobilizing community resources
and applying the widespread use of chemotherapy as a public health
measure along with other case-finding activities under the control
of public health authorities. With the natural decline in disease
and the introduction of chemotherapy in the 1940s and 1950s, TB
disease started to take on a dramatic decline in the United States.
Morbidity declined at a rate of about 5% per year until 1985, when
22,201 cases were reported in the U.S. for a case rate of 9.3 per
100,000 population. By 1970, only a handful of sanatoriums still
remained in the United States and by 1992 there were only four TB
hospitals with 420 beds providing care.
Between 1953 and 1979, along with the declining morbidity came
declining funding from state, local, and federal agencies responsible
for TB control. The cutback in TB control programs across the country
left a dismantled and frail public health infrastructure, too weak
to ward off the emergence of a new epidemic wave that was brewing.
Little did the experts know that a new illness that was first observed
among gay men in New York City and San Francisco (HIV/AIDS) would
have a dramatic impact on TB morbidity.
The mid-1980s and early 1990s saw an increase in TB morbidity.
It was not long before the country started to see TB and HIV coinfections
as well as cases with multidrug resistance. Facilities with poor
or no infection control measures experienced numerous nosocomial
outbreaks, and there were high death rates in hospital wards and
correctional facilities throughout the country.
The unprecedented media coverage of TB, a disease barely noticed
for more than 20 years, gave rise to increased funding by state,
local, and federal agencies for TB control activities. With the
infusion of funds came the task of rebuilding a national infrastructure
to control TB and the introduction to TB control programs of a concept
that was old, yet new: that of directly observed therapy (DOT),
in which the TB patients ingest or take their therapy in the presence
of a health care worker.
Image 9: Cover of Newsweek - The unprecedented media coverage of
TB gave rise to increased funding for TB control activities.
As the numbers of TB cases continue to decline in the United States,
nearly half of the new cases reported are occurring in people who
have immigrated to the United States. In 1998, of the 18,361 cases
reported in the United States, 7,591 or 41.3% occurred in foreign-born
persons. Most of these persons came to the United States from countries
where TB is still endemic (e.g., Mexico, the Philippines, Viet Nam,
China, and India). While the United States continues to bring its
TB problem under control, it must be realized that the United States
is not an island unto itself, isolated from the rest of the global
In 1993, the World Health Organization declared TB a global emergency.
Approximately 8 million new cases and 2-3 million deaths occur each
year around the world from TB. In an effort to reduce TB morbidity
and mortality worldwide, we must share our expertise, successes,
and failures, if we are to move toward national and global TB elimination.
We have the power to relegate this ancient enemy to the confinement
of laboratory vials and store it in a deep freeze. As we journey
into a new century and a new millennium, we will face new opportunities
and challenges and write new chapters in the history of TB. Will
we learn from the past? Will we develop and use new technology to
the utmost efficiency? Will we utilize our resources prudently,
and share information with our neighbors? Will we devote our energies
and talents to the elimination of our common enemy? How long will
it take us to accomplish our goals? How many more lives will be
sacrificed to TB? The answer to those questions rests in each of
us who works in TB control.
In 1956, the Minnesota Tuberculosis and Health Association encouraged
school children to be Knights of the Double-Barred Cross and to
to do everything
to overthrow the enemy,
TB." Are we willing to take the same pledge today?