A Historical Lesson in Disease Containment
Tuberculosis sanatoriums offered patients fresh air, entertainment, and socialization—for those who could afford them.
When Ruth Reed fell ill, she left behind her home, her job as a teacher, and her husband and young son to enter a contained medical facility. She had a highly contagious disease without a known cure, and isolated from the rest of the world, she wrote, she lived a “singularly serene … half-life.” Her days of “pajama-clad indifference” were a highly regimented cycle of rest and nourishing meals, overseen by trained caretakers operating with “white-coated efficiency.” She learned to find solace in the rotating cast of sick women who became her friends, in her locker “full of good books,” and in “the hills and trees beyond her window.”
“Within these walls I am secure from joy,—yes,” she reflected. “But from pain also.” The tuberculosis sanatoriums, as she described them, allowed her to shield the people she loved from her disease, and to manage her symptoms when they became most severe.
Infrastructure for containing infectious disease did once exist in the United States, in an era before the advent of antibiotics. Isolation hospitals and sanatoriums were part of a decades-long experiment in quarantine construction, which could be repeated, in some form, in the coming weeks and months.
As the novel coronavirus spread through Wuhan, China, earlier this year, Chinese authorities worked to construct emergency facilities where patients could live, receive care, and socialize with one another without the risk of infecting more people. The American medical system no longer includes spaces of that kind. Some preparations are being made to house patients in facilities beyond the hospital or the home; in California, for instance, Governor Gavin Newsom released an executive order allowing the state to take over hotels and medical facilities to house coronavirus patients. But most of those spaces, as my colleague James Hamblin notes, have been “hastily adapted” and have very limited capacities.
Beyond the practical advantage of providing contained spaces for contagious people, quarantine infrastructure changed “hygienic norms,” Graham Mooney, a professor of the history of public health at Johns Hopkins University, told me. The existence of isolation hospitals and sanatoriums, he observes, created a new expectation of civic duty for people with infectious diseases. “These aren’t just questions about disease, they’re also questions about social responsibility and citizenship and protecting your local community,” Mooney said. “The notion that [going into isolation] is something you should do, and the facilities were available to do it, meant that how people viewed disease and illness and what they should do under epidemic conditions was altered.”
This social pressure only worked, though, to the extent that patients could afford to leave normal life behind, and ail in isolation from their communities.
Overcome by waves of typhoid, scarlet fever, and influenza in the 18th and 19th centuries, cities established isolation wards within general hospitals and, later, entire isolation hospitals for contagious patients. A separate movement for the construction of dedicated care facilities targeted tuberculosis, by far the leading cause of death in the United States and Europe in the 1800s.
These sanatoriums were built not just to isolate patients from the community or to cure the disease—the medical community did not yet know how to do that. They were also meant “to create a more favorable treatment milieu,” said Philip Hopewell, a professor at the University of California at San Francisco School of Medicine and former president of the American Thoracic Society. In articles for The Atlantic in the 1860s, American doctors explained their thinking about lifestyle adjustments that would allow tuberculosis patients to manage their disease and improve their conditions enough to function in society.
H. I. Bowditch argued for the curative powers of “pure air and sunlight,” recounting the story of a 30-year-old woman whom he had treated for tuberculosis. “We directed that she should sit out on this piazza every day during the winter, unless it were too stormy,” he wrote. “The balmy influences exerted on her by daily sun and air bath were so grateful her breathing became so much easier after each of them, that, whenever a storm came, and prevented the resort to the piazza, the invalid suffered.” Bowditch also recommended “good food and proper digestion” and warned against sharing beds, or even bedrooms, with other people—though he did, in the case of at least one patient, justify “allowing [his] marriage to be consummated” despite his tuberculosis.
Another physician, this one unnamed, noted that regular motion appeared to help. “Dr. Rush,” he wrote, “informs us that he saw three persons who had been cured of consumption by the hardships of military life in the Revolutionary War.” The writer himself advised slightly less strenuous activities: horseback riding, hunting, and “muscular training” that could be done indoors. Sanatoriums were designed to allow patients to go out into the open air, with the aim of strengthening their bodies enough to withstand the disease’s assault. In a 1966 poem, David Cheshire described “white beds placed out, neatly in the sun” and “the delicate, antiseptic scrape of the surf / over the beach” at a French sanatorium—an idyllic scene for a medical facility.
When they weren’t outdoors, patients at some facilities were able to listen to the radio, watch movies, or even attend live talks from visiting lecturers. Contained within a community of fellow tuberculosis sufferers, they could also socialize inside the facilities—a feature shared now by the emergency hospitals in Wuhan. “My friends,” Ruth Reed wrote of her fellow patients, “know how to make the days easier.”
But the facilities were not resorts. The sanatorium, Cheshire wrote, was “a place / unplagued by uncertainties.” Patients lived by strict routines intended to help manage their disease, until they grew well enough to return to the wider world. Despite that “red tape and reliance on rules,” William Garrott Brown, another tuberculosis patient, wrote in 1914, “for the mass of us, a sanitarium is best.” But, he asserted, “the real sanitariums are far too few.”
Once begun, the movement developed quickly; between 1900 and 1925, the number of beds in sanatoriums across the United States increased from roughly 4,500 to almost 675,0000. But, Mooney, the Johns Hopkins professor, said, “these places never catered toward the vast majority of cases … although provision increased a lot in the early 20th century, it was never really enough to cope with the demand.”
And, he notes, many ailing people lacked the money they needed to buy themselves entry into facilities, or support them and their families while they were there.
“It was more imaginable for a person of resources and wealth to contemplate [going into a sanatorium] than it would be for somebody who was a working-class poor breadwinner,” Mooney said. “Just taking months off work wasn’t a possibility for everyone.”
Questions of disease and civic duty, he said, were complicated by the weight of patients’ other responsibilities: jobs, families, homes that could not easily be left behind.
Even after scientists realized the importance of containment, Western nations failed to build a health infrastructure that could effectively combat the infectious diseases of the 19th and 20th centuries. Tuberculosis killed hundreds of thousands of people living in Europe and the United States in the 1800s, but as the century turned and a new one began, most people who contracted the disease continued to live at home and go to work.
“I think if you’re going to ask people to do these things”—to enter sanatoriums and isolation hospitals, or even to self-quarantine in their homes for extended periods of time—“you’re going to have to have social-support networks in place,” Mooney said. Spaces can only contain a disease, after all, if the people carrying it have the motivation, and the means, to use them.