Richard J. Evans admires exhaustive coverage of an ancient killer that threatens a major comeback
Tuberculosis has claimed many famous victims over the centuries, in fiction and in real life, from John Keats to George Orwell, from the Bronte sisters to Robert Louis Stevenson, from the heroines of Verdi's La Traviata and Puccini's La Bohème to the consumptives who whiled away the hours in conversation on Thomas Mann's magic mountain. It became quite fashionable in the 19th century, seeming to lend its victims an air of noble suffering and heightened sexual allure. "I look pale," Lord Byron is said to have remarked, gazing into the mirror during a visit by the diarist Tom Moore: "I should like to die of a consumption." "Why?" his guest asked. "Because the ladies would all say: 'Look at that poor Byron, how interesting he looks in dying!'"
In fact, tuberculosis was a disease of the poor, encouraged by inadequate nutrition and spread by cramped and overcrowded living conditions. As industrialisation spread across the world, packing the new working classes into damp mills, unhygienic factories and fetid slums, so TB casualties soared. In Hamburg between 1885 and 1894, death rates from the disease in the richest city precincts averaged 1.3 per 1,000 population, in the new working-class areas 2.6, in the waterfront tenements where the casual dock labourers lived, 3.4. The unlovely realities of the disease's incidence were conveyed in a terrifying scene in Dostoevsky's Crime and Punishment, when the consumptive, poverty-stricken widow Katerina Ivanova, thrown into destitution by the alcoholism of her irresponsible husband and even more so by his eventual death, becomes delirious and takes her small children out on to the streets to sing and dance for a few kopeks; arrested by a policeman, she runs breathlessly away, stumbles and falls dead in the street, blood gushing out of her throat. "I've seen it before," says the policeman. "That's consumption." Her death is undignified and grotesque, the product of extreme poverty that has driven her not into an exalted, otherworldly state of mind but into madness and degradation.
There have been many good studies of the history of this disease, not surprisingly given its near-universal incidence and the mass mortality to which it led. Nearly 4 million people are said to have died from it in England and Wales between 1851 and 1910, three-quarters of them from tuberculosis of the lungs. It was the greatest of the killer diseases because its presence was permanent, unlike that of the cholera and other epidemics that appeared only at sporadic intervals. Helen Bynum's new treatment of the topic, which appears in Oxford University Press' Biographies of Disease series, is outstanding above all because of its knowledgeable and precise coverage of the disease's medical history (other surveys, such as Thomas Dormandy's The White Death: A History of Tuberculosis and René and Jean Dubos' The White Plague: Tuberculosis, Man and Society, both excellent in their way, have focused more on the cultural processing of TB). Spitting Blood starts with TB's appearance as phthisis in the ancient world and takes the reader right up to the present.
Given industrialism's influence in spreading and deepening the impact of the disease, it is not surprising that the 19th century was the classic age of TB. Its decline in Britain and Europe in the second half of the century remains something of a mystery, to which Bynum might perhaps have devoted more detailed attention; clearly it had something to do with improved housing and better diet, along with the "sanitary revolution", the "great clean-up" of towns and cities, and the clearance of dismal industrial slums. When the cotton industry in Salford suffered a slump as a result of the American Civil War, the previous decline in deaths from consumption was reversed as working-class families saved on rent by moving into cheaper and thus smaller and more congested housing, and the women and children went without food to keep the male breadwinners' strength up. Yet precise correlations are difficult to establish. What was clear was that direct medical intervention had relatively little to do with it, even after the German medical scientist Robert Koch's much-vaunted discovery of the disease's causative bacillus in 1882.
It is sobering to remember how recently TB became effectively treatable through the use of antibiotics, notably streptomycin. I lost an uncle to the disease and still remember being mystified by the "No Spitting" signs on country buses in my childhood. It was phlegm that the countryfolk were wont to spit, not blood, but it still commonly carried the infection and was dangerous to everyone around. Now TB is back again. Part of the problem lies in the fact that after it was effectively overcome in the developed world, it began to slip from the consciousness of governments, medical professions and voluntary associations for the combating of consumption, many of which dropped the word "tuberculosis" from their title or expanded their remit in the 1960s to include other infections.
Yet like all diseases, TB is woven into the fabric of human society and especially human conflict. War, revolution, famine and migration spread it, especially where people already weakened by malnutrition are crowded into poorly managed and unhygienic refugee camps. Political crisis and the weakness of the state in war-torn countries such as Somalia meant that the majority of patients who began treatment abandoned the programme before completing it. In the developed world, hospitalisation became politically unfashionable. Harsh economic and social policies widely adopted after the oil crisis of the mid-1970s created an underclass of the homeless, the unemployed and the vagrant, among whom the incidence of the disease began to rise again. In 1979, TB cases in New York began to increase just as the city's Bureau of Tuberculosis Control was being wound down. When I lived in New York in the early 1980s there were vast areas of burnt-out slums, torched by landlords keen to reuse the land for development: 200,000 housing units were lost, and the blackened ruins became the haunt of drug users and homeless people, unable to receive adequate long-term medical treatment because they were not insured. Some 600,000 people were forced to leave the incinerated areas, increasing overcrowding in the other low-rent parts of the city. The new housing that went up as these areas were gentrified contained larger and fewer units than before.
And just as the city began to be cleaned up, HIV/Aids arrived, opening up a new series of possibilities for TB as an opportunistic infection. By 1990, half the TB patients in New York's hospitals were HIV-positive. On top of this, new drug-resistant strains of the disease began to make their appearance. The optimism of the 1960s and early 1970s, when some reports spoke of the "eradication of the disease", disappeared. By the end of the century, it had spread once more across the globe.
As Bynum says, the conquest of TB is only "a job half done". She makes a persuasive and academically cogent case for the world health community to take TB very seriously indeed. The "tuberculous pasts" she discusses in this very readable book remain, she says in a very downbeat conclusion, "our potential future". Her excellent survey deserves a wide readership, not only among historians but also in a medical profession struggling to come to terms with TB's reappearance.