Outbreak! Plagues That Changed History

by Bryn Barnard

  The bacterium Vibrio cholerae

  In Koch’s day, cholera’s life cycle was a mystery. Today we know that vibrios adhere to the lining of the small intestine, where they multiply and excrete a toxin that prevents intestinal cells from efficiently absorbing water and causes the body to lose water and salt into the intestines. Cholera diarrhea can range from mild to deadly. In extreme cases the host is so dehydrated that blood thickens to a tarlike consistency and the skin is tinted the telltale blue. Blood pressure plummets, and the host dies.

  We now understand that cholera vibrios can survive for years in a sporelike state on the bodies of copepods, millimeter-sized crustaceans that feed on algae. At one time this trio of organisms—vibrios, copepods, and algae—coexisted mostly in the Bay of Bengal. When water temperatures rose and enough nutrients were available, algae would bloom, and copepod and vibrio populations grew. If a tropical cyclone, tsunami, or other event caused this cholera-rich seawater to contaminate inland drinking-water supplies, cholera could reenter the human infection chain. But today ships have sucked up Bay of Bengal ballast water and spewed it out around the world, introducing the bacteria to other areas. Three different strains of the cholera vibrio now compete for dominance. The Classic strain is deadly but susceptible to disinfectants such as chlorine. It is now rarely encountered. The newer El Tor strain causes a milder illness but is more resistant to chlorine. It is now the most common strain by far. The hybrid Bengal strain is both deadly and resistant.

  So cheap yet so far

  Cholera remains a formidable illness. It would girdle the earth in a sixth pandemic that lasted from 1899 to 1909. A seventh—not yet over—began in 1961 in Indonesia. Unlike the cholera of Chadwick’s day, however, the disease is now a preventable, curable illness. We can treat and filter water to make it safe to drink. We can rehydrate cholera victims with water mixed with special salts and sugars. Nearly everyone so treated survives. Cholera should be history. Indeed, if all governments applied Chadwick’s recommendation of universal sanitation, cholera would be history. That cholera remains a health problem at all is testament to our continuing unwillingness to seriously grapple with its root cause: global poverty.

  Today a billion people around the world still lack access to improved water supplies such as piped systems, capped wells, and springs. Hundreds of millions more rely on water sources that, though improved, are still contaminated and unsafe. Two billion have no way of properly disposing of human waste. Two million to three million children die annually of waterborne diseases, including cholera. This problem could be fixed for $10 billion to $20 billion a year for fifteen years. That’s less than a third of the $61 billion Americans spend annually on soft drinks. We’re not talking fancy indoor plumbing, just basic water treatment and latrines for everyone on earth.

  One temporary solution to this hygiene nightmare is the U.S. Centers for Disease Control’s Safe Water System (SWS). This cheap, hardy, easy-to-use water-purification system has been deployed in twenty-two countries on three continents. It has been used in refugee camps, disaster areas, war zones, rural villages, and urban slums. It relies on a simple idea: bottle in-expensive chlorine for people to use to treat water stored in the home and keep the water in a closed, narrow-neck plastic bottle that, unlike traditional wide-mouthed containers, cannot easily be recontaminated by unclean hands. This is no permanent cure for contaminated water. It’s a stopgap. Until the next Edwin Chadwick comes along, however, a stopgap will have to do.

  Prove it

  As we have seen in previous chapters, disease is a screen on which we project our deepest fears, hopes, and prejudices. So it was with tuberculosis, an ancient illness that became epidemic during the nineteenth century at the same time a new cultural movement—Romanticism—was catching fire. In the growing cities of the industrial world, Romantic beliefs and tubercular symptoms intersected and reinforced one another. For a time, tuberculosis was welcomed in some households, envied in others, as a sure sign of creative genius. Eventually Romantic tuberculosis would completely upend ruling-class beliefs about beauty and status. But once TB’s real cause was understood, the disease’s reputation soured. TB became associated with poverty, overcrowding, and bad hygiene. Thus stigmatized, it became a powerful catalyst for the creation of modern public health systems, a control on both the disease and the poor people seen to be its carriers.

  That graveyard cough

  Tuberculosis is caused by a bacterium. It appeared in human populations about fifteen thousand years ago, probably jumping to us from cattle when people began to domesticate livestock. TB did its work not in days or weeks but over years, striking when age, poor nutrition, overwork, or illness compromised a person’s immune system. TB robbed the body of energy, progressed to spasmodic coughing, advanced to hacking up blood and bits of lung, and ended in a gasping, lingering death. There was no cure. One could survive to old age, but most TB victims died young. TB thrived in crowded conditions, where the microbe could easily pass from person to person. It flourished in slums and sweatshops where people were ill fed and overworked and ventilation was poor. By the early 1800s, TB was killing about a quarter of all Europeans. Later, when Asia industrialized, TB death rates there were just as bad.

  The ancient Greeks called TB phthisis, a term that compares the inexorable destruction of the body’s vitality to the waning of the moon. The seventeenth-century English religious writer John Bunyan called tuberculosis “the Captain of all these Men of Death.” In the nineteenth century, the most common term for TB was consumption. It was also called pleural abscess, hectic fever, the white plague, the graveyard cough, inflammation of the lung, delicacy of the lungs, lung weakness, and complaint of the chest. Crucially, in much of the industrial West, consumption was thought to be hereditary, not contagious. Thus, most TB sufferers were not quarantined. They mixed freely with the uninfected, ensuring the spread of the disease.

  The Romantics believed tuberculosis signified artistic fire. Pale skin, flushed cheeks, and the bloody handkerchief were envied marks of passion and genius.

  Although tuberculosis of the lungs was the most common form of the illness, the bacterium could also manifest itself in other parts of the body with different symptoms and different names. Tuberculosis of the neck was called the king’s evil and scrofula. Tuberculosis of the bones was called the white swelling. Tuberculosis of the stomach was called mesenteric disease. Tuberculosis of the spine was called Pott’s disease. Tuberculosis of the skin was called lupus vulgaris. The term “tuberculosis” itself was coined in the early nineteenth century. It refers to the tiny inflamed scars on the lungs, called tubercles, that are a sure sign of the disease.

  The Age of Reason

  To understand how nineteenth-century tuberculosis became a popular disease, the beliefs of the day need to be understood. At the beginning of the nineteenth cen-tury, Enlightenment values exerted a profound effect on the intellectual life of Europe and America. The universe, formerly chaotic and terrible, was now seen as orderly, comprehensible, and measurable. Reason trumped religious faith. Atheism was trendy. Scientific progress ruled. In the arts, Classicism stressed order, calm, harmony, balance, and of course rationality.

  But this new thinking papered over ancient ideas about health and illness. The sick were still bled to rebalance bodily humors. Most people still thought appearance and disease were outward signs of inner character. A beautiful person was good. An ugly person was bad. A light-skinned person was superior to a dark one. One way new thinking and old mixed was a popular pseudoscience called phrenology. Practitioners claimed that personality, character, and intelligence could be determined by the systematic study of the shape and size of a person’s head. This was simply social prejudice and racism tricked out to look and sound like rational thought. In truth, it was nonsense.

  Appearance and disease were perceived not just as outer markers of inner truth but as signifiers of class. In an age when food was scarce and famine was always a possibility, body fat
was a good thing, a sign of wealth. One of the diseases brought on by the beef-and-burgundy diet of the wealthy was gout, a painful inflammation of the joints. It was a mark of distinction, like a Lexus or a Rolex today. The writer Edward Gibbon, a poor man made fat and rich by his acclaimed six-volume History of the Decline and Fall of the Roman Empire, was proud of his gout. He bragged about it to his friends.

  Consuming passion

  Romantics rebelled against Enlightenment ideals. They worshiped self-expression and imagination. They loathed the ideals of Classicism. They sought freedom from social conventions. But Romantics were also people of their time, and they believed that illness and appearance revealed inner truth. They adored TB.

  Romantics were intoxicated with sensation and thought the well-lived life was bright, intense, and snuffed out in the bloom of youth. For them, TB was a badge of passion and genius. In a tubercular family of artists or writers, consumption in the children might be taken as a sign that they had inherited their parents’ creative talents. The best-known symptoms of the disease were inflamed cheeks, pallid skin (popular since ancient Roman times as a sign of genius), the coughing up of blood, and a thin, “consumed” body. These signs were thought to be manifestations of an inner artistic fire. Some people believed TB ignited the flames. Even doctors were influenced by Romanticism. One of the terms they used for TB was spes moribunda, Latin for “dying hope.” This referred to the flushed cheeks of the terminal consumptive, giving the false impression of good health.

  Death was a prevalent theme in Romantic writing. The Graveyard School of poetry celebrated death, nights, ruins, churchyards, and ghosts. One of the most popular themes was a veiled widow in black mourning dress. The poet John Keats died at age twenty-five from TB. One of his most famous poems is “Ode to a Nightingale,” which describes the agony of a dying patient.

  In painting, the Pre-Raphaelite Brotherhood obsessed over morbidity, usually showing models who were wistful, lonely, dispirited, and tubercular. Flaming redheads were especially popular subjects. Indeed, Elizabeth Siddall and Jane Burden, two of the favorite pre-Raphaelite models, actually had TB.

  Other Romantic tuberculars include the writers Robert Louis Stevenson, Jane Austen, and the three Brontë sisters; the philosopher Henry David Thoreau; the artist Aubrey Beardsley; and the composer Frédéric Chopin. Some lived for a long time, but all did their work in the knowledge that their lives might be cut short by consumption. Not all artistic types got TB, of course, however much they might wish for the disease. The poet Lord Byron was a fanatical dieter whose obsession with extra flesh bordered on anorexia. He thought consumption would make him more attractive to women. “Look at that poor Byron,” he imagined them saying. “How interesting he looks in dying.”

  Eventually this cult of youth and consumptive thinness began to resonate beyond Romantic circles, even reshaping ideals of the pudgy upper class. By the twentieth century, food was becoming plentiful and cheap in the industrial world, so a big waistline no longer had snob appeal. Instead, the long necks, bright eyes, rosy cheeks, and emaciated bodies of tubercular Romanticism became the elite standard, especially among upper-class women like American socialite, Nazi sympathizer, and wannabe queen of England Wallis Simpson. She announced that “one can never be too rich or too thin.” Today the tubercular look remains popular in the fashion industry’s unflagging obsession with malnourished models. Even young girls feel the pressure to emulate consumptive scrawniness. Early on they learn the premium society places on appearance—and may feel that to be popular and considered pretty, they need to be skinny. Ironically, in the supersized industrial world, it is not the rich but the fast-food-fed poor who are the fattest class of all.

  Western ideas about Romantic tuberculosis have parallels in Asia. In the eighteenth-century Chinese novel The Dream of the Red Chamber, the heroine, Lin Tai-yu, dies of TB at the moment her sweetheart marries another woman. In Japan, writers and some doctors called TB “lovesickness.” It was thought to be an illness brought on by longing or frustration that made people more intelligent and passionate. Love-starved daughters and diligent boys studying the Chinese classics were considered most susceptible. Tokutomi Roka’s 1898 novel Hototogisu (“Nightingale”) is about a young wife miraculously cured of her terminal tuberculosis when her beloved husband returns from abroad. This hugely popular book has been the subject of several films, many dramas, and a hit song. It is but one example of a Japanese literary genre that revolves around tuberculosis.

  In Japan, tuberculosis was thought to be lovesickness.

  The romance is gone

  Tuberculosis lost its romantic status once the true cause of the disease was understood. After the publication of Pasteur’s Germ Theory of Disease in 1880, researchers raced to discover one infectious microbe after another. In March 1882, after eight months of effort, Robert Koch finally isolated the TB bacterium. Consumption, it turned out, wasn’t hereditary at all. The Koch bacillus was a rod-shaped microbe that passed from person to person suspended in microscopic droplets of saliva from a person’s sneeze or cough. It could be avoided but not cured.

  The bacterium Mycobacterium tuberculosis

  Confronted with this new knowledge, the middle class became obsessed with cleanliness, sure that TB microbes were lurking everywhere. Bodily fluids became scary, human smells repulsive (the search for effective underarm deodorants and antiperspirants starts here). Spitting, kissing, and even talking were now seen as bacteriological menaces. One story told of the tubercular worker who licked his fingers while he turned the pages of documents, spreading consumption far and wide. One British sign from that era reads, “Don’t Spit! It’s Disgusting and It Spreads Germs!”

  In the United States, control of tuberculosis was first systematized in New York City. By 1900, Dr. Herman Biggs of the Metropolitan Board of Health had developed the basic procedures still used for the control of TB around the world. These included free sputum exams, mandatory reporting of cases, mandatory isolation and treatment of those infected, education of the public about the disease, and monitoring of living conditions. The methods were despotic by today’s standards, and the system concentrated on the poor, by now stigmatized and stereotyped as society’s primary TB carriers. Biggs proceeded from the notion that still animates all public health systems: the well-being of society is more important than private liberty. Since he was focusing on people with little political or economic clout, few objected. By contrast, the middle class and wealthy enjoyed private medicine, where the well-being of the individual comes first. The two systems, public and private, developed separately, in tandem.

  Restrictions on the individual reached their apex with the creation of the sanitarium, an institution that totally cut off consumptives from society, sometimes voluntarily, sometimes mandatorily, sometimes for years, sometimes for life. If one was rich, a sanitarium might be a fancy seaside spa or a mountain resort. If one was poor, a sanitarium was little better than a prison. By 1950, over a hundred thousand sanitarium beds existed in the United States alone. Sanitarium doctors experimented with an amazing variety of therapies to try to treat TB. These included bed rest, fresh air, lung collapse, rib removal, exposure to heat, exposure to cold, exposure to sun, gold therapy, calcium therapy, iodine therapy, horse riding, the milk cure, the grape cure, the wine cure, and cod-liver oil. Dietary therapies ranged from strict limits on what a patient could eat to stuffing them with nutritious food. For society, the main benefit was the removal of infectious individuals.

  Before an antibiotic cure for tuberculosis was discovered, daily doses of fresh air were considered vital to preventing and treating the disease, even in the coldest weather.

  Meanwhile, a new social reform movement, moral environmentalism, lobbied for better housing for the poor, public parks, public schools, hospitals, efficient waste disposal, sewers, water systems, street cleaning, and the regulation of markets, slaughterhouses, and restaurants. The idea was simple and owes much to Edwin Chadwick: improve t
he environment and you improve the person. The combination of control, isolation, diet, and improved living conditions worked. In 1828, TB deaths in England were about four thousand per million. By 1948, TB deaths in the United States had dropped to about four hundred per mil-lion. With the advent of antibiotics—drugs that could actually kill the tuberculosis bacterium—the American TB death rate dropped to its lowest ever: ninety per million. The tuberculosis decline among American minorities was not so steep. Indeed, in many developing nations, rates had not declined at all. Nevertheless, the mood was so optimistic that in 1980, a panel of experts convened by the U.S. Congress was called the Advisory Committee for the Elimination of Tuberculosis. In retrospect, this seems astoundingly naive.

  Back with a vengeance

  Once TB was no longer a terror, tuberculosis control systems deteriorated. In the United States during the 1980s, sanitariums were shut down or converted into hospitals. Public health programs were defunded. Salaries stagnated for personnel responsible for monitoring and treating TB. Funding for poverty programs was slashed. Mental hospitals were emptied, pushing people unable to care for themselves onto the street or into crowded homeless shelters. In 1992, the Soviet Union collapsed and with it the expensive TB control program of SanEp, the Russian empire’s unwieldy state health system. Revolution in Africa and Central America ensured that people there with tuberculosis got partial treatment or no treatment.