(Electronic music)
- (Michael) What’s up, guys? Michael and his exceedingly fancy library here. Regardless
of how you’ve been feeling about the state of life under quarantine or semi quarantine,
chances are we’ve all had one shared experience: Confusion.
But among that confusion there is one consistent refrain: we just gotta figure something out
until there’s a vaccine. Once we get that sweet sweet attenuated, inactivated or modified
virus in our bodies, nothing will stop me from dining in at The Olive Garden.
But as much as I can’t wait to carbo-load unlimited lukewarm breadsticks with my fellow
pasta pass family, there is one thing this whole COVID crisis has revealed about how
we think about health. We, as a society, love to worship medicine. And, don’t worry, I’m
not here to hate on all the medical advancements that save millions of lives, but there is
one thing that gets lost in the mix: public health. And while this term has become a cool
new thing everyone gets to learn about during our plague-ridden apocalypse, I think there’s
a general sentiment that it’s just the thing you do until medicine catches up. And to figure
out why, in general, that’s an awful perspective, I want to talk about one of humanity’s most
lethal diseases: tuberculosis.
Welcome to this Wisecrack Edition on How to Stop a Plague
Now, for context - Tuberculosis is one NASTY-ass disease,
Fettucini-Alfredo-Left-Out-in-the-Sun-for- 48-Hours-Nasty. It is thought to have lept
from bovids (ie cattle or bison) approximately 17 thousand years ago and has clung to humanity
like a barnacle ever since. In its time, TB has killed as many as two BILLION people throughout
history, making it as evil as like 2.2 million Jonestowns? It’s airborne and can cause
symptoms in its host anywhere from weeks to DECADES after exposure. That’s right -- this
dipshit disease can hide in your body longer than the Simpson’s has been on TV - which
is to say, way to long
Like Covid 19, TB symptoms range from “asymptomatic” to “holy shit I’m dead.” In serious
cases, the TB bacteria replicates like within the lungs, causing pneumonia, coughs, night
sweats, chest pain and exhaustion. It can also catalyze such a drastic loss of weight
and strength that it appears to “consume” the afflicted patient, which is why it was
eventually dubbed consumption after striking the world with renewed fervor in the 18th
century.
TB surged in Europe and America at the onset of the Industrial Revolution, as historian
Frank Snowden explains in his book Epidemics and Society. At the time, it was also known
as “The White Plague” because of the way it drained all the human colors from your
face. The medical establishment understood basically nothing about the disease, presuming
it to be hereditary.
And because many famous artists contracted the disease, often writing or painting or
composing great works while seriously ill, TB became, and I’m not joking, kinda cool.
The disease itself was said to generate intoxicating effects that drove creativity - although as
scholar Matthew Gandy notes, widespread opiate addiction probably better explains this “mental
effervescence.” For women, the disease became associated with physical beauty and the emaciated
body, pale face, flushed-cheek look caused by TB became the height of fashion in some
places - women would basically stop eating or exercising and wear white face powder and
blush to cosplay as consumptives. That said, most victims of tuberculosis WEREN’T wealthy
poets, they were members of the urban poor. But we’ll get to that.
But as germ theory spread throughout the scientific community in the late 1800s, Tuberculosis
stopped being a cool rich person disease and started being something society wanted to
declare war on. It became viewed as a disease that punished the poor for their wretchedness.
Not only were people in overcrowded slums, tenements, prisons, and almshouses more likely
to become infected, malnourishment and pre-existing diseases put them at a much higher risk for
developing the life-threatening variety of TB. In some countries, a concurrent imperialistic
urge to maintain a strong military made tuberculosis, especially in crowded barracks and on the
front lines, a real existential danger.
This changed mindset helped give rise to what Snowden calls the “war on Tuberculosis”
from approximately 1880 to 1940, which relied primarily on various public health interventions
to prevent the further spread of the disease.
Here’s where it’s helpful for us to quickly distinguish between medical intervention and
public health. A medical intervention is basically everything you associate with going to the
doctor: getting a procedure done, being prescribed a medication, etc. Public health is everything
outside of that interaction. If getting a vaccine is a medical intervention, public
health is determining what vaccines people need, who to distribute them to, what new
vaccines to research, and educating people on the benefits of immunization.
And interestingly enough, long before TB treatment actually worked, TB rates plummeted, starting
in the mid 19th century, in Europe and America because of a combination of intentional and
accidental public health measures.
One such strategy was the rise of the international sanatorium movement, which advocated for isolating
tuberculosis patients at what were essentially fascist Club Meds. They were first conceived
of by a German physician, Hermann Brehmer, who experienced tuberculosis and healed in
the Himalayas. He credited his recovery to fresh air, climate and rest, and so started
a sanstorium to standardize such treatment. But the trend didn’t really catch on until
the 1880s, with the establishment of the first American sanstorium Little Red near Saranac
Lake in upstate New York, where patients were required to spend 8 to 10 hours a day outside
soaking up the fresh air They also had to abstain almost entirely from exercise and
eat a target of 4,000 calories a day to combat the consumptive effects of the disease. Believing
that negative emotions like shock or anguish stoked the illness, nurses censored patients’
mail to protect them from bad news. These sorts of rules varied from institution to
institution, but across the board they made for a highly-restricted life. At the same
time, it also effectively quarantined those who were contagious, which helped make a dent
in the spread of the disease. Getting into Little Red was a highly competitive process,
and many folks who were rejected moved to Lake Saranac anyway, so the town became a
sort of epicenter for TB treatment, like a shitty Disney World for the very ill. While
the “medical” intervention here is questionable, the strategy had the inadvertent public health
benefit of slowing further spread of TB.
Typically after spending time healing at the sanatorium, patients would then return to
their urban homes. From there, they would rely on dispensaries, or medical centers that
provided both medical care and public health strategies, like offering monetary loans or
helping patients find work. Importantly, these dispensaries, along with a slew of NGOs, also
offered community hygiene education, warning against the dangers of sneezing without covering
your nose, and obsessing a little bit over the comparatively less risky act of spitting.
Concurrently, starting around 1840, and admittedly a little ethically questionable, was the segregation
of the poor suffering from TB into workhouses. And it’s widespread movements like this
that really helped contain the disease from further spread. As scholar Matthew Gandy notes,
“before the infectivity of the disease was understood, British workhouses admitted ever
greater numbers of consumptive patients,” continuing “the issue then… is not the
effectiveness of treatment but the impact of containment on rates of infection.”
Another social campaign about the spread of cow TB led to the screening of herds for the
disease and the now-ubiquitous practice of pasteurizing milk. At the same time these
public health efforts intensified, improvements in nutrition, urban housing, and the proliferation
of more hospitals were concurrently fighting TB.
While public health was kicking TB’s ass, what new treatments were doctors concocting?
Just a little thing called artificial pneumothorax, which basically collapsed and paralyzed the
patient’s lungs, which they thought would allow them to heal like a broken bone in a
cast. Needless to say, this DID NOT WORK. A vaccine was debuted in 1921, but it was
“mired in controversy” because it a. Was not totally effective and b. Doesn’t protect
against all forms of TB. By the time antibiotics for TB came around, reported cases of TB had
already plummeted across Europe.
Of course, even on the public health front, there’s a debate about what stopped TB.
According to some, including historian Thomas McKeown, TB was stamped out by a cocktail
of social and economic interventions. He points especially to improvements in nutrition, which
strengthened people’s immune systems, thus making them less susceptible to its ravages.
Other scholars pushed back on this interpretation, leading to a battle between “nutritionists”
or those who credit the decline of TB to better human RESISTANCE against the disease - via
improved nutrition, water and overall standard of living, and “contagionists,” or those
who stressed the reduced SOURCES of infection, due to a variety of public health interventions.
Contagionists believed that the decline in TB was due to successfully identifying and
quarantining afflicted patients vis-a-vis sanatoriums as well as broader public health
campaigns with dispensaries and NGOs.
Regardless of what you believe, it’s super important to note that it was some form of
public health efforts, and NOT medical intervention, that effectively combated this disease for
decades - effecting change in everything from workplace safety regulations to improved sanitation.
Sometimes, the “public health” part isn’t even intentional, Robert Koch suggested that
even housing design could influence how infectious the disease could be.
You might be asking: So what? We’ve got drugs now! Housing design be damned. And I’m
only a few clinical trials away from getting my breadstick on. After the antibiotic revolution
began in the 1940s, doctors believed declared the war on infectious disease to be won. It
was declared a dying field in the 1950s, and med students were discouraged from studying
it. But it’s precisely because we declared victory so confidently that we’re all f***ked.[
Let’s just start with something you might have heard of: antibiotic resistance. In 1943,
Selman Waksman developed streptomycin, an antibiotic that, when tested on a TB patient
led to full recovery. According to Snowden, this monotherapy, or treatment via one rock-solid
drug, really seemed like a “miracle cure.” However, doctors soon realized that the TB
bacteria was becoming resistant to the meds, so folks who underwent treatment were becoming
sick again, and what’s more, were now immune to the only real treatment. So doctors developed
two new medications: soniazid in 1952 and rifampicin in 1963 to supplement it and began
treating patients with all THREE. Thanks in large part to these discoveries,
TB declined for decades, up until the mid 1980s, and everyone expected that the disease
would be eradicated by 2010. So we’re in the clear, right? Not so fast, you rascally
optimist! TB eventually became resistant to all three medications and that’s when the
shit was about to really hit the proverbial fan.
Nowadays, the research laboratory is the focus of public health, rather than social or economic
efforts. As an article in the American Medical Journal notes, “departments of public health
shed sanitation, housing reform, and even hospital care.”
And now, Tuberculosis is back. In 1985, TB cases stopped declining. Over the next two
years, rates started RISING in the US and blossomed into a full on pandemic in Eastern
Europe, Southeast Asia and Sub-Saharan Africa. By 1993, the WHO declared tuberculosis a “global
emergency.” So much for eradication. Remember how people living in poverty were particularly
at risk for TB?
Within the US, those most likely to be afflicted were traditionally marginalized and impoverished
folks - such as those who are homeless or in prison. What’s more, the emergence of
HIV created a brand new class of people who were more susceptible to the bacteria.
One really illustrative example can be seen in New York City, which served as an epicenter
of an outbreak in the 80s. The city had experienced a fiscal crisis in 1975 that led to severe
budget cuts, which caused the “dismantling of health, public safety, and social service
infrastructures; and the deterioration of living conditions for vulnerable populations,”
Most ruinously, the Department of Health slashed budgets, shuttering district health centers,
chest clinics, and the city’s TB hospital. As a result, when the crisis reemerged, existing
hospitals were overwhelmed, had fewer staff, and fewer resources to track the treatment
of those who were sick. Here we see why a medical intervention - antibiotics - is not
sufficient in and of itself in stemming a disease - you also need proper public health
infrastructure to administer the treatment, track the patients’ recovery, and prevent
further spread.
On a more global scale, Snowden also credits the disease’s reemergence to the massive
displacement caused by refugees fleeing war, economic catastrophe, or environmental disasters
citing refugee camps as a perfect incubator for spreading the illness or just reactivating
dormant cases. In Sub-Saharan Africa, the devastating proliferation of HIV made a huge
population vulnerable, while in Eastern Europe, the fall of communism dismantled the medical
infrastructure, making it harder to seek treatment for TB. To this day, doctors and scientists
face an often drug-resistant disease that, in the absence of adequate public health infrastructure,
appears to show no intention of letting up. In 2017 the World Health Organization estimated
that there were over a half a million cases of multi drug resistant TB.
So, as you can see, the battle against tuberculosis has been neither simple, nor entirely successful.
In 2018, 10 million folks fell ill from TB and 1.5 million died.
And importantly, the history of tuberculosis shows to some extent why waiting for medical
treatments is a gamble. Don’t get me wrong - there’s plenty of examples where a baseline
public health measure, like mass vaccination, can make us all chill out and not worry about
getting polio. But the reason TB is so interesting to us is that 1. We see a disease being GREATLY
reduced, at first without any substantial medical intervention and 2. We see the disease
RESURGING long after we discovered an effective medical treatment. What this shows is how
critical public health efforts, absent of medical intervention, really are to stop the
spread of a disease. And as we face down Covid 19, collectively holding our breaths that
a vaccine will manifest before the next football season, we might get a little too used to
relying on medical advancement instead of good public health infrastructure. And I’m
not just talking about “stay the f**k home” or the importance of looking like a bank robber
- I mean disease trackers who can stop a pandemic before it starts, research into diseases emerging
in livestock and bats, affordable distribution of vaccines and treatment, and so on.. Because,
if experts are warning us of anything, it’s that we can expect more novel diseases infecting
humans from our animal friends. And these might be way different, or worse, than COVID-19.
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