by Emeritus Professor Greta Jones, Ulster University
At the time of writing, we are now in the middle of a COVID epidemic. A hundred years ago, another epidemic affected the lives (and deaths) of millions of people in the world. This was tuberculosis, a disease caused by a bacteria which, like COVID, spread from person to person by inhalation of air breathed out by the infected. The bacteria invaded the lungs and this caused the most common form of the disease (pulmonary tuberculosis). Animals also suffered from TB and a smaller number of humans acquired it by eating meat or milk from infected animals often leading to the disease lodging in bones or organs of the body causing disability.
An Incurable Disease
TB has been with us a very long time. Before anti tuberculosis drugs were developed in the 1940s there was no certain cure and TB was endemic in most communities. What some now call herd immunity meant that not all who had the initial infection went on to develop tuberculosis but, each year, a certain number of mostly young people would die from this disease. This initial infection was experienced as cold-like symptoms, a fever and a cough, which cleared up after a week or so. But for the unlucky few, the fever would return, the cough get worse and eventually blood would appear signalling the beginning of the gradual destruction of the lungs.
The progress of the disease might be quite quick but often it would take a few years to run its course, giving rise to hope and despair along the way. The cruelty of the disease was the waiting and uncertainty, the optimism when, from time to time, the symptoms abated and despair when they returned.
Image: Dissections of diseased lungs affected by pneumonia and tuberculosis: two figures. Chromolithograph by W. Gummelt, c. 1897. Wellcome Collection.
It was a disease of young people. Adolescence was the most common age at which it appeared. But children were particularly vulnerable to TB of the bones and organs through the ingestion of infected milk from tubercular cows. Even those individuals who did not develop the full disease in their youth or seemed to recover might see its return in later life often due to failing health.
TB was endemic in most societies but at certain periods it became epidemic which meant that death rates began to rise. In most of Europe and America death from TB was falling in the late nineteenth century. The reasons for this have been widely debated among medical historians. In contrast, in Ireland it started to rise in the late nineteenth century. Although other nations of the British Isles saw mortality from TB fall, it peaked in Ireland around 1904. In 1901, 216 persons for every 100,000 of the population died from pulmonary TB in Ireland compared with 155 in Scotland and 128 in England and Wales. In 1939-41, Ireland still had a higher incidence of death from TB than England, Scotland and Wales. Death rates from all forms of TB were 104 in Northern Ireland and 138 in Eire compared with 85 in Scotland and 73 in England and Wales. Only in the 1950s did the rate of death from TB in Ireland began to converge with other parts of the British Isles.
Industrialisation and Infection
Most studies suggest that increased urbanisation and migration lead to a rise in the tuberculosis. Though the population of Ireland fell after the Famine, the proportion of the Irish people living in towns and cities increased. In 1851, 17 per cent of the Irish population lived in towns of 2,000 and over,but by 1901 this had risen to 33.5 per cent. The growth of urbanisation most marked in the industrialising north-east and this is where the rise in TB first took place. Rates of death from the disease were higher in Belfast and the north-east than elsewhere in Ireland in the last part of the nineteenth century. But by the first decade of the twentieth, it had begun to fall in Belfast and its surrounding areas. However, TB had now spread throughout Ireland so the peak of the epidemic in Ireland as a whole was around 1904.
The history of TB in Ireland was shaped by Ireland’s industrial revolution. For example, whilst seen by many historians as an urban disease (though not containable within cities). it was also seen as one which primarily affected the young urban male. But the linen industry in Belfast and its surrounding areas employed young females. In 1910, out of the seventy-five thousand linen textile workers in the linen industry five sixths were women. The female death rate from TB in Ireland remained higher overall than males for much of the period. In 1861-70 for every 100,000 living persons 220 females and 217 males died from pulmonary TB respectively. In 1901-10, the rate was 204 to 200. Linen mills were good vectors of the disease. They were crowded and hot and humid; hours were long and quite often ‘mill fever’ – fainting and nausea – occurred among new entrants to the mill, mostly young girls who entered the mill at the age most susceptible to infection. The higher overall death rate from TB for women lasted until the third decade of the twentieth century.
Germs and Public Health
In 1883, the German biochemist Robert Koch discovered the bacillus that caused TB and identified TB conclusively as an infectious disease passed on by human contact. There was no cure but a number of treatments were popular. One was the sanatorium. They already existed in Ireland offering cures for bad health in general through rest under medical supervision in healthy locations. They quickly became part of the cure offered for TB. A sanatorium offered a partial solution to the problem of TB, the isolation of the infected from the healthy and they practised a regime of rest, good feeding and above all fresh air (the breezes were meant to clear the air of the deadly bacillus). To achieve this, sanatoria were built on the principle of open verandahs and outside spaces onto which the beds of the patient could be wheeled in good and often bad weather.
Of course, the absence of free health care meant sanatoria were the preserve of the well off. But in 1906 Belfast Corporation built the first sanatorium in Ireland for the poor. This was Whiteabbey Sanatoria situated on Belfast Loch where Ulster University now stands. Over the following years, local authorities also subsidised a number of beds in private sanatoria to which patients could be sent by the local authorities for free or partially free treatment.
The infectious nature of TB led to advice from medical practitioners about avoiding contact with the infected; no sharing of vessels, no spitting in the streets, isolation of the infected at home, even care taken in religious observances. Out of this arose a new set of sensitivities around TB which increased the stigma of the disease. As for the TB Dispensary, it performed a function in locating the infectious and arranging sanatorium places but offered no more in the way of cure than advice, vitamins and cough medicines.
Image: Science Museum, London. Attribution 4.0 International (CC BY 4.0).
Tuberculosis in Northern Ireland
There were other cures tried out in the interwar years all unsuccessful and sometimes surgery – the removal of an infected lung for example. But a diagnosis of TB remained a death sentence for many as mortality rates from patients discharged from sanatoria attest. Then came the miracle stimulated by Waksman’s discovery in soil of bacteria which, to put it crudely ate up the TB bacillus. By the later 1940s, drugs had been developed based on this and word was getting out to the general public about their miraculous effects. But the drugs did not become widely available until the 1950s.
Before that, however, public consciousness about the inadequacy of health care in Northern Ireland and Britain had been growing and because the war years led to a sudden rise in mortality in TB due to migration and the increase in factory work, TB was back at the front of the political agenda. In 1940, a scandal engulfed the Whiteabbey sanatorium, run by Belfast Corporation, due to quarrels among its staff and accusations of favouritism in the awarding of outside contracts. This led to the Government of Northern Ireland suspending the Whiteabbey TB Committee and centralising TB care, in its own hands.
It is reasonable to argue that the problem of TB in Northern Ireland was one of the driving factors in the eventual adoption of the NHS. It certainly led to centralisation and a more generous and proactive public health policy. A central Northern Ireland Tuberculosis Authority was set up in 1944 -1959 to manage the disease and abolished only when it appeared that mortality from TB in Northern Ireland (not at that stage morbidity) was by then comparable to that in England and Wales and even lower for a while in 1950s than in Scotland. The drugs were of course indispensible to this success but so also was what we now call ‘track and trace. Sanatoria helped in this because they isolated TB patients and they turned into institutions for the administration of drugs. TB dispensaries also had lists of sufferers. As the number of TB sufferers fell it became easier to reach both them and their contacts and in the early 1950s the numbers of the tuberculous reached by the public health authorities in Northern Ireland was impressive.
Image: British Red Cross Society Medal – ‘Proficiency in Red Cross Tuberculosis Course’. © National Museums NI.
There is a human dimension to all this. The sanatorium was not just a hospital. Its architecture and the scenery surrounding, sometimes in spectacular remote mountain villages, is worthy of study in its own right. The sanatoria in Davos, Switzerland where many Irish patients went, are now the grand hotels which host the annual Davos economic summit. Because, until its last stages, sufferers could function for a time, many of them produced art and writing often influenced by their experience of their illness and some, like Thomas Mann and Franz Kafka are world famous. Many TB sufferers in the 1940s became politicised and were among the first patient militants, in revolt against the failures of government and the disparities in health between rich and poor.
Finally, Belfast’s human experience is perhaps best encapsulated by Van Morrison’s blues song ‘TB sheets’. Written in 1967 as Belfast’s TB epidemic was coming to an end, it encapsulates the fear, misery and regret TB aroused in many young people right through to the sixties. The TB sheets referred to were delivered by local councils to working class homes to ease the constant washing necessitated by caring for those suffering from the disease at home.
© The Author(s) 2021. Published by the Epidemic Belfast team on behalf of Ulster University.
Any unauthorised broadcasting, public performance, copying or re-recording will
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 This is based upon Greta Jones ‘“Captain of all these men of death”. The History of Tuberculosis in Nineteenth and Twentieth Century Ireland.’ The Wellcome Series in the History of Medicine, Rodopi Amsterdam and New York 2001.