Book Review

Disease and Class: Tuberculosis and the shaping of modern North American society

N Engl J Med 1996; 334:739-740March 14, 1996

Article

Disease and Class: Tuberculosis and the shaping of modern North American society
(Health and Medicine in American Society.) By Georgina D. Feldberg. 274 pp. New Brunswick, N.J., Rutgers University Press, 1995. $18.95. ISBN: 0-8135-2218-8

When I first picked up Disease and Class: Tuberculosis and the Shaping of Modern North American Society, the title led me to expect a polemic on capitalistic exploitation and repression of the working classes and the resultant epidemic of urban tuberculosis. Instead, I found a meticulously researched treatise on attitudes toward tuberculosis, once called consumption, on the part of the public health community, medical researchers, clinicians, social scientists, and the general public over the course of 150 momentous years. Like Professor Feldberg, I became interested in tuberculosis when it was no longer believed to present a threat to public health. The protean manifestations of the disease, its role as the difficult-to-diagnose, hidden possibility in persons with obscure illness, and its lethality if missed, but almost certain curability if correctly diagnosed, were enduringly fascinating. For Professor Feldberg, the unique experience of tuberculosis as a sociological phenomenon with tremendous variability from country to country in public and professional response to increasing knowledge, as well as the special U.S. resistance to the bacille Calmette–Guérin (BCG) vaccine, provided the fascination.

Professor Feldberg's introduction makes the case for the uniqueness of tuberculosis and society's response to it. Unlike other infectious scourges of the 19th and early 20th centuries — cholera, plague, and smallpox — which came and went as epidemics, tuberculosis “existed in all places at all times.” Yet, unlike cancer and heart disease, tuberculosis was contagious and thus raised questions about public responsibility and voluntary or involuntary confinement. Tuberculosis also had a strong socioeconomic component, since the disease was associated with poverty, overwork, poor nutrition, and crowded, poorly ventilated living quarters.

The main body of this slim book (214 pages with an additional 51 pages of notes) consists of six chapters, each covering a period of about 20 to 30 years, beginning around 1850, that represented a distinct Zeitgeist in the American view of tuberculosis. The chapters explore the historical and sociological roots of popular and professional attitudes toward tuberculosis in each period.

As the author delves into the written accounts of the reactions to and expectations raised by Robert Koch's discovery of the tubercle bacillus and his initial report of his findings, one cannot help but be reminded of the early events involving the isolation and characterization of the human immunodeficiency virus (HIV). History does repeat itself. As was the case with the identification of HIV, when the infectious agent of tuberculosis was discovered, the expectation that a cure could not be far behind was widespread — and unfulfilled. It was argued that the bacillus was only a fellow traveler, not the cause.

Another parallel with HIV and the AIDS epidemic is the long-standing emphasis on education and behavioral change as the most important means of preventing infection. Early in the 20th century, public health campaigns attempted to educate women about the importance of nutrition, fresh air, and moderate exercise for themselves and their families. Dieting in an effort to stay or become slim was severely criticized by public health physicians. Cartoons meant to appeal to children, developed by the National Tuberculosis Association, used battle motifs to portray the “Lives and Loves of Huber the Tuber.” These cartoons reflected a middle-class emphasis on the importance of outdoor recreation, sobriety, nutrition, and avoidance of “dirty” habits such as spitting.

The author is particularly effective in documenting early American efforts to use the specter of tuberculosis to change or reform society, from improving housing to shortening the workweek for industrial laborers. It was considered a matter of soil versus seed. The microbe (the seed) did not cause disease in most people who were infected, and the emphasis was on making the person (the soil) resistant to the development of symptomatic tuberculosis. Preventing the acquisition of infection was not thought to be possible. Improving the body's resistance to disease was the preferred approach and fit well with the beliefs of American reformists.

The unique American resistance to the use of the BCG vaccine against tuberculosis has been the subject of much analysis and commentary. Professor Feldberg makes a good case for the importance of sociopolitical factors in shaping U.S. public policy, in addition to medical factors. Vaccination was viewed as only a partial solution, and it was feared that an emphasis on vaccination would direct efforts away from education as a means of changing behavior and society and increasing the individual's resistance to tuberculosis. The power of the marketplace is also noted, with major U.S. drug companies showing little interest in pursuing licensure of the vaccine. Other issues — that tuberculin skin-test screening is not useful after vaccination and, as a corollary, that vaccination complicates decisions about the use of isoniazid prophylaxis, an intervention that has been proved effective — are mentioned but are given little weight as underlying reasons for America's reluctance to embrace the BCG vaccine.

This book grew out of a graduate thesis and reflects its origins. On the plus side, the work is thoroughly documented with extensive quotes and references from original sources. On the minus side, this is not a book for an evening's light reading. The language can be dense and is sometimes difficult to follow. Although the book is intended to provide a balanced presentation of the American response to the control of tuberculosis in general and the use of the BCG vaccine in particular, the author makes it clear that in her view the American approach has not fulfilled its promise and the role of vaccination should be reassessed.

Gisela Schecter, M.D., M.P.H.
University of California, San Francisco, San Francisco, CA 94110