A Strong Nation Is a Healthy Nation

Letter

By: N. H. Heiligman

Date: November 1940

Source: National Library of Medicine. "A Strong Nation Is a Healthy Nation: Letter from the Lehigh Country Tuberculosis Society." 〈http://www.nlm.nih.gov/exhibition/ephemera/images/tb21.gif〉 (accessed December 12, 2005).

About the Author: Tuberculosis societies were voluntary organizations in the United States and elsewhere in the world that were organized to educate the public about the threat of tuberculosis, prevent its spread, and treat the disease. These societies were active in the United States from the end of the nineteenth century into the first few decades of the twentieth century. The physician N. H. Heiligman volunteered for his local tuberculosis society in Pennsylvania when he wrote this letter in 1940. Tuberculosis societies were generally organized under the auspices of the American Lung Association (ALA), which was called the National Association for the Study and Prevention of Tuberculosis when it was founded in 1904. Although its original intent was to prevent the spread of, and facilitate treatment for, tuberculosis, the American Lung Association has greatly broadened its mission to encompass prevention, treatment, and cure of all lung diseases, as well as education about them, both for those who are afflicted with them as well as for the general public. The American Lung Association has also designed a series of educational programs dealing with such topics as smoking cessation, the dangers of secondhand smoke, and the potentially damaging effects of smoking during pregnancy.

INTRODUCTION

Tuberculosis (TB) is an infectious disease that has existed for virtually as long as humans have lived in groups. Indeed, evidence of tuberculosis infection has been documented in Egyptian mummies. Throughout history, there have been periods of time when tuberculosis affected the world's various populations in epidemic proportions, and times when it was less virulent.

Tuberculosis has been called by a variety of names, such as consumption, white plague, and the people's plague. There was a worldwide epidemic of the disease near the end of the nineteenth century, which killed millions and affected many more. Until 1882 when Robert Koch (1843–1910) announced his discovery of the bacterium responsible for tuberculosis, the cause of the disease was unknown and there was neither an effective treatment nor a cure for it. All that was clearly understood was that the disease was contagious. Following Koch's discovery of Mycobacteriumtuberculosis, scientific research indicated that the bacterium could live for quite a few hours outside the human body, that it was able to thrive and multiply in warm, moist, dark places, and that the bacterium was spread through the air in sputum or mucus expelled during sneezing or coughing.

In Europe, the disease was viewed as slightly romantic, an illness affecting primarily the rich or privileged classes. In America, it manifested largely in poor and densely populated areas, where the sanitation was likely to be poor, the water suspect or potentially polluted, and the living conditions over-crowded. The move from rural to urban areas following the industrial revolution, as well as the influx of large numbers of immigrants, intensified the severity of the problem. It was impossible to know how many immigrants came to America already exposed to the bacillus, whether actively ill or simply carrying the disease. Unhealthy living conditions fostered the rapid spread of tuberculosis from person to person, due to repeated exposure. By the end of the nineteenth century, tuberculosis was the leading cause of death in the United States. Because both medicine and scientific research in the United States lagged behind the rapid progress being made in Europe and elsewhere in the world at the time, many American physicians at the end of the nineteenth century lacked a clear understanding of the concept of contagion. As a result, they sometimes placed sick people in groups in dark, damp conditions, with little or no ventilation and no sanitary precautions being taken by caregivers. This served as a very effective breeding ground for the bacteria.

Many folk remedies were tried, as well as myriad common-sense approaches, before effective antibiotics were developed in the 1940s. People were prescribed bed rest, varying amounts of activity, confinement indoors, sent outdoors, sent to the seaside, to the mountains, to hot and dry climates, or to cold and snowy areas. Around the turn of the twentieth century, numerous sanatoriums were built across the country (and around the world), to which people with active TB would be sent for rest, relaxation, moderate exercise, and fresh, healthy food, in the hope that they would be cured over time. The sanatoriums were closed by the end of the 1970s, when they were no longer needed.

In the early stages of active illness, people with TB developed fevers and night sweats, decreased appetite and weight loss, and an intermittent cough. As the disease progressed, the cough worsened and increased in frequency. Over time, the individual began to cough up bloody sputum, until the disease progressed to the point where they coughed up fresh blood due to respiratory, esophageal, and tracheal hemorrhages. Although the lungs were the primary organ of involvement, TB could spread throughout the blood and lymphatic systems, and affect the bones and joints, as well as other systems and organs. TB was a deadly disease, but a very small percentage of people did recover from it.

Tuberculosis is now known to be caused by the bacterium called Mycobacterium tuberculosis. It is spread by repeated exposure to airborne secretions carried by sneezing, coughing, laughing, talking, spitting, or singing (any forceful expulsion of moist air). Although many people who are exposed to the disease will carry it in a latent form inside their bodies, only those who are actively sick with the disease can transmit it to others. Being exposed to the disease without immediately developing it is not an indication that it will never become active. Latent TB is treated prophylactically to prevent development of the actual illness.

With the development of effective treatments for active TB, prophylactic medications for latent infections, and accurate, effective diagnostic techniques, TB became relatively well-controlled by the middle of the twentieth century, and was nearly eradicated in the United States by the end of the 1970s. As a result, the expansive public health systems that had developed around TB treatment, along with most volunteer tuberculosis societies, were gradually disbanded.

PRIMARY SOURCE

                   LEHIGH COUNTY
               TUBERCULOSIS SOCIETY
 
        719 HAMILOTN STREET, ALLENTOWN, PENNA.  
                                      November, 1940

A STRONG NATION
IS A HEALTHY NATION …

In the days when America is strengthening its defenses against attack from any quarter, the general health of the Nation assumes tremendous importance.

It is not enough that we have a strong Army, Navy, and Air Force, if the Nation that backs up these forces is deficient on bodily vigor and energy. The vitality of a country is the vitality of all its peoples in all classes of society.

Poor health is one of the enemies that bore from within. And tuberculosis must be listed as one of the causes of physical deficiency. Tuberculosis respects no class. It recognizes no national emergencies. Ruthlessly and relentlessly it reaches into the lowliest home and the loftiest mansion and claims more lives between the ages of 15 and 45 than any other cause … twice as many as the automobile.

Just as Tuberculosis is one of the most vicious enemies of society, so eternal vigilance is the greatest enemy of Tuberculosis. Cure is practically certain if the case is discovered soon enough. Christmas Seals help to make early discovery possible. They provide tuberculin tests, X-rays, rehabilitation service, and assistance in securing employment for recovered patients, not to mention education in the care and prevention of the disease. All this is the program of the Lehigh County Tuberculosis Society, a program that is entirely dependent on the financial support of its contributing members.

Enclosed you will find a Christmas Seal Sale Bond.

Your help in the past has meant much to the success of our work, and we hope you will let us list you once more as one of our contributors.

                                             Gratefully Yours,
                                       N.H. HEILIGMAN, M.D.
                                                  President

SIGNIFICANCE

Several seemingly unrelated events occurred in the early 1980s that acted as catalysts for the resurgence of tuberculosis in America and around the world (although the disease had never been close to eradication in many impoverished or undeveloped parts of the globe). In the aftermath of the Vietnam War, large numbers of disenfranchised young adults returned to the United States from Southeast Asia. This occurrence, coupled with the increasing incidence of poverty and overcrowding in urban areas, contributed to an upsurge in poverty and homelessness. Poverty and homelessness tend to breed, among other things, an increase in alcohol and substance abuse in those affected. In the late 1970s and throughout the 1980s, there was a significant increase in the use of injectable drugs. As a result, groups of people with compromised immune systems either shared needles or spent time in close quarters at shelters, homeless centers, and in prisons or jails. It was not uncommon for those individuals to either develop new cases of TB or to have previously latent TB become active.

With the advent affordable air travel, more and more people were able to move around the world quickly and easily. As a result, individuals carrying an active infection could move from one place to another, inadvertently exposing many others in previously unaffected or TB-eradicated areas to the bacteria. In addition, during the early stages of the global HIV and AIDS pandemic in the 1980s, there was a sudden, sharp rise in the number of individuals with impaired immune systems, rendering them vulnerable to acquisition of the tuberculosis bacterium. Once exposed, people with compromised immune systems were far more likely to rapidly develop the illness.

In both of these situations, people with TB symptoms may not have immediately sought medical treatment, since the disease may have either initially appeared to be a cold or a comparatively benign respiratory infection. Because TB was no longer considered a threat in the United States, the general public and the medical profession took some time to recognize its resurgence—particularly in the face of the enormity, both in terms of affected populations and in the number of attendant symptoms and syndromes, of the HIV/AIDS epidemic.

Finally, although there were effective medications for the treatment and prevention of tuberculosis, they required long-term dosing and carried significant side effects. It was quite common for patients to fail to complete the prescribed medication regimen, potentially leading to exacerbation of the symptoms of active TB or to the development of active infection among those with previously latent exposures. This failure to complete prescribed courses of treatment also led to the development of multi-drug resistant tuberculosis, which does not respond to traditional treatment regimens.

According to statistics released by the National Institute of Allergy and Infectious Diseases (NIAID) in 2002, roughly two billion people, or 30 percent of the world's population, were at that time infected with the bacteria that causes tuberculosis. In their report, they stated that eight million people developed active infection, and three million people around the world died from tuberculosis each year. Many of those who die from TB have little or no access to modern medicine or effective infectious disease treatments. The NIAID also estimated that between ten and fifteen million people in the United States carry latent (dormant) TB, and that about 10 percent of them will develop active disease in the future. Since the end of the 1980s, the disease has been gradually declining in incidence in the United States.

The World Health Organization has created several initiatives aimed at the control and eventual eradication of tuberculosis in developing countries. As of 2005, tuberculosis had the highest incidence of occurrence in Southeast Asia, but was most prevalent (highest rate of occurrence for the size of the population) in sub-Saharan Africa. Areas with the highest AIDS-infected populations also had the highest death rates from tuberculosis.

Until the early years of the twenty-first century, one of the greatest difficulties in the effective treatment of active or latent tuberculosis infection was the length of time needed to complete the treatment protocol—up to two full years in some places. The length of treatment, coupled with the burden of the required patient oversight on often fragile health care systems, impeded successful protocol completion. In addition, the long treatment regimen required a greater quantity of expensive medication, placing an additional financial strain on the health systems of poor and economically challenged countries. At the end of 2005, the World Health Organization announced that it had completed the second phase of clinical trials in its Stop TB program with a new combination drug therapy that has the potential to significantly shorten tuberculosis treatment time, possibly by as much as 33 percent. If the next phase of the trials goes as well as the first two have, the new therapies could be available for worldwide distribution by late 2009.

FURTHER RESOURCES

Periodicals

Special topic issue: "Tuberculosis." JAMA: The Journal of the American Medical Association 293 (June 8, 2005): 2693-2820.

Web sites

American Lung Association. "HIV and Tuberculosis Fact Sheet." http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35433〉 (accessed December 12, 2005).

American Lung Association. "Multi-Drug Resistant Tuberculosis Fact Sheet." http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35815〉(accessed December 12, 2005).

American Lung Association. "Tuberculosis Fact Sheet." http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35804〉 (accessed December 12, 2005).

CDC National Center for HIV, STD, and TB Prevention. Division of Tuberculosis Elimination. "Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America." 〈http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm〉 (accessed December 12, 2005).

Global Health Reporting.org. "Tuberculosis: Overview." 〈http://www.globalhealthreporting.org/tb.asp〉 (accessed December 12, 2005).

The Lung Association/L'Association Pulmonaire. "The Story of the Christmas Seals." 〈http://www.lung.ca/seals/〉 (accessed December 12, 2005).