THE BERT AND PEGGY DUPONT LECTURE: TUBERCULOSIS AND THE BUILDING OF THE AMERICAN WEST

More than any infectious disease in the past century, COVID-19 has had a profound impact on society. Even as life has returned largely to normal and the death rate has dropped, there have been persistent changes in many aspects of life. Remote work for many has become the norm rather than the exception. Masking is now accepted and even required in some communities. And people with immunocompromising conditions lead lives of constant consideration, weighing the risks and benefits of everyday activities.

Of course, this is not the first outbreak of an infection that has changed how people live. The original SARS epidemic produced lockdowns across much of Asia and restricted travel even from less affected areas such as North America (1). Ebola not only devastated a set of West African countries during the largest outbreak in 2014–2015, but also led to large-scale social measures to avoid infection (2). During a large Dengue outbreak in Cuba, neighborhoods were organized to search for mosquito breeding areas (3), while, when Zika spread widely through Latin America, many people, particularly pregnant women, took substantial measures to avoid insect bites (4).

However substantial were the changes brought about by these epidemics, from a historical perspective, all were relatively brief. We have recently seen more sustained epidemics, such as the continuing spread of HIV, which brought about enormous changes in medical practice and sexual behavior that have persisted, particularly among the most affected communities. But the few decades that HIV has circulated pale in comparison to tuberculosis, a disease that dominated societies for centuries.

Although there is pathologic evidence of tuberculosis in antiquity, the first recorded evidence of epidemic spread was in Europe in the late fifteenth and early sixteenth centuries. In fact, within the span of a decade, tuberculosis rose to be the leading cause of death on the continent. The bacterial cause of tuberculosis would not be recognized for almost three centuries; thus, disease susceptibility was ascribed to any number of causes. This led to an intertwining of disease with many social issues. Unlike many infections, tuberculosis affected all social classes and large numbers of prominent members of society. One unusual aspect of tuberculosis is its chronicity, with many suffering from illness for months or years before either recovering or succumbing. This meant that, at any given time, many people were suffering from the disease and its attendant pulmonary symptoms and wasting. In fact, the disease became associated with notions of beauty, romance, and creativity. Characters in many of the best-known operas and novels of the period were afflicted with tuberculosis as were the artists who wrote and performed them and the disease itself became integral to many plots.

The changes brought about in society were not limited to Europe. Tuberculosis remained a common illness throughout the 1800s in the United States. As the century went on, the idea that tuberculosis was associated with the atmosphere took hold. Since this was a disease that spread in cities, the fresh air of the countryside was thought to be both preventative and therapeutic for people with tuberculosis. Even before the sanitorium movement, which embraced this concept, people with real or suspected tuberculosis were moving west in droves. This, in turn, led to an enormous expansion of areas located in New Mexico, Arizona, Utah, and, particularly, Colorado.

The concept of an appropriate environment being conducive to good health played a dominant role in medical thinking during the latter half of the nineteenth century. In his Lumleian Lectures delivered to the Royal College of Physicians in 1893, Charles Theodore Williams discussed the importance of what he termed “aerobiology” in disease (5). He particularly called out tuberculosis and the favorable responses of patients to not only moving to but also staying in Colorado: “The opinion of most of the American doctors is that for most patients it is necessary to spend years before quitting the high altitudes, and that often permanent residence is the only safeguard against relapse.” Charles Fox Gardiner dedicated an entire chapter of The Care of the Consumptive to the health benefits of Colorado (6). While there were contrary opinions, The Colorado Souvenir Book for the International Congress on Tuberculosis published in 1908 touted the undoubted benefits of the climate, rejecting the argument of others by empirical evidence that represented “… a practical demonstration of the utter fallacy of the anticlimactic propaganda” (7). In fact, the link between the climate and tuberculosis was one of the major founding principles of the American Clinical and Climatological Association (8). Charles Denison, one of its prominent members who himself moved to Colorado to recover from tuberculosis, wrote the treatise which led many to follow in his footsteps (9). The idea of the importance of climate for tuberculosis treatment persisted long after the discovery of the causative organism by Koch in 1882, and sanitoria remained common through much of the first half of the twentieth century despite a relative dearth of data supporting their importance.

Colorado was a particular magnet for tuberculosis patients and their families. Books by medical “authorities” touted the ability of the Colorado air to improve symptoms and cure disease. The statistics and stories of individuals are described by Cynthia Kay Stout in her dissertation (10). In 1900, approximately one-third of the population of Colorado arrived because of tuberculosis. The town of Colorado Springs was built largely to cater to tuberculosis patients and their families. By 1911, there were 45 TB sanitoria in the state with almost half in Colorado Springs. Colorado had more sanitorium beds per capita than any state except New Mexico. The disease caught up vast swathes of society from saints (like Frances Wisebart Jacobs, the philanthropist who, among many activities, founded the tuberculosis hospital that was the predecessor of the National Jewish Hospital) to sinners (such as John “Doc” Holliday, the gunfighter best known for his role in the gunfight at the OK Corral). Many of the political leaders of the state, mayors, governors, and two U.S. senators had come to Colorado to recover from tuberculosis. And tuberculosis built the medical establishment of -Denver. In fact, in 1908, it is thought that approximately one-third of all physicians in the state arrived because a family member had tuberculosis (11).

The formative influence of tuberculosis in Colorado resulted from an unusual nexus of an enormous epidemic of a deadly but chronic disease, a largely fallacious medical hypothesis and the wide-open opportunities presented by a new area that only attained statehood in 1876. These are unlikely to be precisely replicated. But, as we have seen in recent pandemics, infectious disease will continue to shape history.