Abstract
The scourge of tuberculosis has long loomed large in world history, and perhaps our ongoing grappling with COVID-19 turns our thoughts to the invisible, transmissible, deadly tubercle bacillus. I place Irish fiction between 1800 and 2023 against the historical record, of which I here provide an overview. There existed little hope of a cure for tuberculosis before the watershed late 1940s, when Dr Noel Browne successfully tamed the scourge. Attempts to do so remained elusive until the coming together of a variety of fortuitous factors: manpower, knowledge, techniques, money and motivation. Tuberculosis has not entirely disappeared, but the conversation about the disease in Ireland is now conducted out in the open. Recent isolated outbreaks have been described in the newspapers with no attempts to conceal the facts. Vigilance remains necessary, and a comparison with the COVID-19 pandemic is useful. The responses developed and pushed by Drs Browne and Fauci in the face of a terrifying public health threat are striking in their similarities, and we would do well to heed the warnings from the past concerning the dangers of interweaving public health management with political agendas.
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Notes
- 1.
Steven Johnson, “The Living Century,” The New York Times Magazine, The Health Issue, Sunday 2 May 2021, 15.
- 2.
Greta Jones writes that “An effective vaccine only began to be a realistic possibility with the development of BCG (Bacillus Calmette and Guerin), by two French medical researchers, Leon Calmette and Camille Guerin at the Pasteur Institute at Lille between 1906–1924. In 1924 they announced that they had developed and tested a successful vaccine but the subsequent spread of BCG vaccination was patchy.” See “Captain of all these men of death”: The History of Tuberculosis in Nineteenth and Early Twentieth Century Ireland (Amsterdam and New York: Popodi, 2001), hereafter abbreviated to “Captain,” 133–4. This groundbreaking study is an invaluable complex, multifactor, transnational analysis. Thomas Dormandy also examines the troubled history surrounding the adoption of the effective BCG vaccine, concluding with these comments: “Reviewing ‘Fifty Years of BCG’ in 1971 the editor of Tubercle concluded that ‘future historians will find the story a strange mixture of endeavor, inertia and ineptitude.’ This was, in the view of one future historian, a charitable understatement.” See The White Death: A History of Tuberculosis (New York: New York University Press, 1999), hereafter abbreviated to WD, 340–8.
- 3.
The Mantoux test is an “intracutaneous test used to diagnose TB based on hypersensitivity to tuberculin, a concentrate of TB antigen, the standard preparation of which is purified protein derivative,” Segen’s Medical Dictionary (Farlex, Inc., 2012). https://medical-dictionary.thefreedictionary.com/Mantoux+test.
- 4.
Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 1978), hereafter abbreviated to IM, 5.
- 5.
Unsurprisingly, doctors admire and appreciate Sontag’s thinking, as is made abundantly clear from her obituary in the medical journal The Lancet after her death from breast cancer. Rita Charon, director of the narrative medicine program at Columbia University, is noted as saying that her work “was a bell that you rang—in the same way that you ring Hippocrates and Osler, you now ring Sontag.” The obituary also cites Sontag’s response during a book tour to a question on metaphor: “Metaphor is a code word for representations, stupidities, false ideas. I’d say people would be better off without them.” See Ivan Oransky, Susan Sontag, Obituary, The Lancet 365, issue 9548 (Feb 5, 2005), 468.
- 6.
See Greta Perletti, “‘[T]o Feel Powers at Work in the Common Air Unfelt by Others’: Receptivity and the Vanishing Body in Nineteenth-Century Literature and Culture,” in L. Cogan and M. O’Connell, editors, Life, Death, and Consciousness in the Long Nineteenth Century. Palgrave Studies in Literature, Science and Medicine (London and New York: Palgrave Macmillan, 2022), 210. I am indebted to Matthew Reznicek for sharing this source with me.
- 7.
Quoted by Susan Kelly in ‘Stigma and silence: oral histories of tuberculosis,” Oral History 39, no. 1 (Spring 2011), 65 and n. 1.
- 8.
Lorenzo Servitje, Medicine is War: The Martial Metaphor in Victorian Literature and Culture (Albany, New York: SUNY Press, 2021), hereafter abbreviated to MW, 2.
- 9.
Diarmaid Ferriter quotes from Greta Jones’ chapter “The campaign against TB in Ireland, 1899–1914,” in Jones and Malcom, editors, Medicine, Disease, and the State in Ireland, 1650–1940 (Cork: Cork University Press, 1999). Jones notes that even as services began to improve in the first decades of the twentieth century, and “the dispensary and the sanatorium became a routine part of the experience of the disease in inter-war Ireland,” sufferers often preferred to avoid identification: “There remained a large minority who either deliberately or inadvertently avoided all contact with the TB services and suffered—and often died—quietly and privately beyond the gaze of officialdom,” Jones, “The Campaign against TB,” 167, quoted by Diarmaid Ferriter, The Transformation of Ireland 1900–2000 (London: Profile, 2005), hereafter abbreviated to TI, 55. Jacinta Prunty records that in a successful coming together of the forces of philanthropy and officialdom, “The designation of tuberculosis of the lung as a compulsorily notifiable disease within the county borough of Dublin from 1 October 1909 was directly attributable to the lobbying of the Countess of Aberdeen’s organization, and intense international pressure. It put in place the foundation on which the structure of the TB crusade could be built,” Dublin Slums, 1800–1925 (Dublin: Irish Academic Press, 1998), hereafter abbreviated to DS, 166.
- 10.
Carthy, Alan Francis, The treatment of tuberculosis in Ireland from the 1890s to the 1970s: a case study of medical care in Leinster, Thesis for the degree of PhD, Department of History, National University of Ireland, Maynooth, 2015, hereafter abbreviated to TTI, 105. James Deeney and Jacinta Prunty also reference this valiant attempt at preventative medicine. Deeney recounts that “Lady Aberdeen, wife of the Viceroy, became interested in tuberculosis and helped to set up the Women’s National Health Association in 1907 and this body held a tuberculosis exhibition as part of the International Exhibition then being held in Dublin. This tuberculosis exhibition travelled to all the main towns in Ireland, and on the suggestion of the Gaelic League, Dr. O’Beirne of Leenane travelled all over the Gaeltacht area, lecturing in Irish on tuberculosis,” “The Development of the Irish Tuberculosis Service,” Irish Journal of Medical Science 154, no. 5, suppl. 1 (1985), hereafter abbreviated to “DITS,” 29. See also Prunty, DS, 166.
- 11.
See Carthy, TTI, 86: “In the late nineteenth and early twentieth centuries it was national voluntary organisations, which, through their organised campaigns, brought anti-tuberculosis measures into public focus thus placing them on political agendas. In Ireland the National Association for the Prevention of Tuberculosis and the Women’s National Health Association fulfilled this function. Both organisations were to play a lead role in heightening awareness of the disease and the measures necessary to resist it.” Prunty stresses, however, that if the War on Consumption is to be won, the philanthropists will need to combine forces with “the principal body … to deal with TB in Dublin … the Public Health Committee of the Corporation,” DS, 164.
- 12.
Elizabeth Grubgeld, Disability and Life Writing in Post-Independence Ireland (London and New York: Palgrave Macmillan, 2020), hereafter abbreviated to DILW, 126.
- 13.
Maura Laverty, Full and Plenty (Dublin: The Irish Flour Millers Association, 1960), 402–3.
- 14.
McCourt, Frank. Angela’s Ashes (New York: Scribner, 1996), 1. Cited also by Dormandy, WD, 241. Dormandy cites not just the rain but “poverty…alcohol, ignorance, [and] overcrowding” as causative factors.
- 15.
For more on the “difficult problem” of bovine tuberculosis in Ireland see Jones, “Captain,” 223–5.
- 16.
Anne Mac Lellan also productively interrogates the notion of Celtic susceptibility in “Victim or Vector?: Tubercular Irish Nurses in England 1930–1960,” in C. Cox and H. Marland, editors, Migration, Health and Ethnicity in the Modern World (Houndmills: Palgrave Macmillan, 2013), hereafter abbreviated to “Victim or Vector?’, 104–25. Irish and Welsh nurses suffered from tuberculosis with greater frequency than did their English counterparts. However, Mac Lellan argues that “the construction of Irish nurses as carriers of TB into England was based on a misconception. It gradually became evident to the medical profession and policy makers that the converse was true, and that young nurses’ lack of exposure to TB in Ireland rendered them more vulnerable to infection soon after their arrival in England,” 104–5.
- 17.
C. S. Breathnach and J. B. Moynihan, “William Wilde and the Early Records of Consumption in Ireland,” Ulster Medical Journal 80, no. 1 (2011), hereafter abbreviated to “Early Records,” 42–8.
- 18.
Breathnach and Moynihan point out that “The census schedules distributed throughout the country were filled in by the head of the household, so Wilde was at the mercy and veracity of each householder for the medical and mortality information in the returns, not to mention that a professional diagnosis had never been made in many instances,” “Early Records,” 47.
- 19.
Breathnach and Moynihan reference the later statistical work of Thomas Wrigley Grimshaw, who became Registrar General in 1879, noting that his mapping of cases of tuberculosis in Ireland “refuted Wilde’s notion of seaboard salubrity,” “Early Records,” 47. Wilde himself did not use a map “to display the geographical distribution of annual deaths from consumption,” a fact that Breathnach and Moynihan find “all the more remarkable” since precedent for such use existed to map other contagious illnesses as early as 1820, “Early Records,” 45.
- 20.
Timothy P. O’Neill, “The Catholic Church and Relief of the Poor 1815–45,” Archivum Hibernicum 31 (1973), 133–34. See also O’Neill, “Fever and Public Health in Pre-Famine Ireland,” hereafter abbreviated to “Fever and Public Health,” The Journal of the Royal Society of Antiquaries of Ireland 103 (1973), 3: “In June 1822… great numbers of medicants from Clare, Mayo and Galway caused the spread of disease.”
- 21.
See Jones,“Captain,” Chapter 2, “The Tuberculosis Epidemic in Ireland: 1.”
- 22.
Laurence M. Geary, “Famine, Fever, and the Bloody Flux,” in The Great Irish Famine, edited by Cathal Póirtéir (Cork: Mercier Press, 1995), 81.
- 23.
Ferriter, TI, 55.
- 24.
For example, as already mentioned, Irish dairy farmers resisted the pasteurization of milk. See also Jones,“Captain,” 140–1.
- 25.
See Table 3.2, Deaths from TB and other “general” diseases, Dublin 1896–1911, DS, 160.
- 26.
Dr Elizabeth Strangman undertook similar heroic sanitary reforms in her home city of Waterford. Waterford’s “first lady doctor,” she served as a City Councillor between 1912 and 1920. She acquired the needed expertise and practical experience during her years training at the Royal College of Surgeons in Dublin, and put it to excellent use back in Waterford. Irene Finn describes “a network of narrow lanes and ‘courts’, or cul-de-sacs” lurking behind the main streets of the city. They “contained numerous small, damp, poorly ventilated dwellings, some without any sanitary provision whatever. Many were described as ‘not fit for human habitation’. Tenement houses, 87 in all, housed 1450 individuals.” Tuberculosis caused one in five deaths between 1906 and 1910. Dr Strangman “was a founding member and honorary treasurer of the Waterford city Branch of the Women’s National Health Association, which was inaugurated on 18 March 1908,” devoting herself to educating the people of Waterford about tuberculosis and improving the conditions of the poor. She met considerable opposition to her reforming agenda after she became a Councillor, but she remaining unrelentingly “single-minded in her commitment to the health of the city.” See Irene Finn, “Councillor Mary Strangman and ‘the health of the city, 1912–1920,’” Decies, Journal of the Waterford Archaeological and Historical Society, no. 52 (2000), 188–203. My sincere thanks to Joseph Falvey for sharing this source.
- 27.
See Prunty, DS, for a full account of Dr Cameron’s reforms.
- 28.
Ernie O’Malley, On Another Man’s Wound (London: Anvil, 1979), 91.
- 29.
Ida Milne, Stacking the Coffins: Influenza, war and revolution in Ireland, 1918–1919 (Manchester: Manchester University Press, 2018), hereafter abbreviated to Stacking, 87. I have replaced acronyms in the original with full titles.
- 30.
The ideal of which Jones speaks is that laid out by the Rockefeller Foundation, which held “somewhat dogmatic views on what constituted a good TB service. It believed the first line of defense was the TB dispensary as a means of identifying and then treating TB in its early stages. It was cheaper and potentially more comprehensive than sanatorium treatment. The treatment actually available in the typical Irish dispensary fell short of their ideal,” “Captain,” 138.
- 31.
I limit myself here to an overview of the multifaceted history of Irish sanatoria. For a more comprehensive examination, please refer to Carthy and Jones.
- 32.
See Carthy, TTI, 206–9. Hospices before the establishment of the Free State were run by religious charities, both Catholic and Church of Ireland.
- 33.
See Carthy, TTI, 173–8. He describes the establishment of the Sutton Holiday Home and Preventorium in August 1909.
- 34.
Prunty notes the isolation of the infected from the healthy was “now advocated as the only way forward for the control of TB,” so the establishment of sanatoria in Dublin became a priority. The 1908 Tuberculosis Prevention Act (Dublin) allowed, among other things, for the levying of “a rate of twopence in the pound, with the permission of the Local Government Board, to raise funds” for the creation of sanatoria. Suitable land was purchased, and a new sanatorium built. “By 1914 this Crooksling sanatorium catered for ‘early consumptives’ while advanced ones were consigned to the Pigeon House Road sanatorium,” DS, 166.
- 35.
See Carthy, TTI, 25–42.
- 36.
For example, Carthy notes that Enniscorthy sanatorium in the 1920s had an “isolation hut,” TTI, 238. See also 185, 232.
- 37.
For a detailed account see Carthy, TTI, Chapter 2, “The establishment and early years of the National Hospital for Consumption in Ireland 1891–1907,” 49–85. He also describes attempts to set up smaller, private sanatoria, but they “floundered on economic grounds,” 85. Jones also notes the occasion: “The first purpose built sanatorium in Ireland was the Royal National Hospital for Consumptives which opened in 1896 at Newcastle, Co. Wicklow,” “Captain,” 159.
- 38.
For a more detailed account, see TTI, 163–7.
- 39.
The year 1947 saw the first use, in St Ultan’s hospital, of streptomycin, successfully, as the hospital’s annual report documents. “In November 1947 the hospital used for the first time the new drug streptomycin, administering it to a four month old patient suffering from tuberculous meningitis secondary to miliary disease. ‘In pre-streptomycin days her chances of recovery were nil,’ yet four months after the treatment she appeared ‘to be doing well,’” Carthy, TTI, 302.
- 40.
Mary Morrissy, “TB in a sanatorium of the imagination.” The Irish Times, 2 January 1996. Online: https://www.irishtimes.com/culture/tb-in-a-sanatorium-of-the-imagination-1.18338.
- 41.
Anne Mac Lellan, “Dorothy Stopford Price and the Irish tuberculosis epidemic,” https://dh.tcd.ie/pricediary/about-dorothy-price-her-family/dorothy-stopford-price-and-the-irish-tuberculosis-epidemic/.
- 42.
Anne Mac Lellan, “Alone among neutrals: Ireland’s unique experience of tuberculosis during the Second World War,” in Medicine, health, and Irish experiences of conflict, 1914–45, edited by David Durnin and Ian Miller (Manchester: Manchester University Press, 2017), 73.
- 43.
Deeney “became chief medical officer at the Department of Health in the Free State in 1944,” Jones,“Captain,” 145.
- 44.
The 1908 Act authorized “County Councils to provide sanatoria, hospitals and dispensaries and to employ staff; to provide bacteriology services, veterinary services to control meat and milk; to provide drugs and to conduct education in preventing tuberculosis,” Deeney, “Development,” 31.
- 45.
C.S. Breathnach and J.B. Moynihan, “The Academy’s foray into the politics of phthisis (tuberculosis) 1940–1946,” Irish Journal of Medical Science 173, no. 1 (2004), hereafter abbreviated to “Politics of Phthisis,” 48.
- 46.
Interestingly, Breathnach and Moynihan describe in some detail the phenomenon of the “patient-physician.” Many doctors working in the sanitoria had themselves fallen victim to the scourge, and in the absence of a permanent cure, never fully recovered. Drs John Duffy and Theobald Wolfe Tone Dillon both fell into this category. See “Politics of Phthisis,” 48–9. Jones also recounts that “Medical staff working in sanatoria had a high incidence of the disease, a fact which, together with the often depressing nature of the work, and the distance between sanatoria and main centres of population made sanatorium nursing one of the less popular vocations. Sanatorium nurses and doctors were often recruited from recovered TB patients,” Jones,“Captain,” 169. Noel Browne shoots, as usual, from the hip. He cites his colleague Dr Peter Edwards, “who ran a sanatorium staffed almost entirely with former consumptives,” as saying, “he had developed the principle of employing tuberculosis staff in his hospital on the general thesis that the healthy doctor who chooses to go to work at the rather somnolent pace of a TB sanatorium must be either ‘a drug addict, an alcoholic, or a lazy bastard,’” Noel Browne, Against the Tide (Dublin: Gill and Macmillan, 2007), hereafter abbreviated to AT, 79.
- 47.
Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A.M. Sheridan Smith (New York: Vintage, 1975), 196.
- 48.
See Seanad Eireann Debate, Wednesday 4 October 1998, vol. 156, no. 12. https://www.oireachtas.ie/en/debates/debate/seanad/1998-10-14/3/.
- 49.
Dan Buckley, “The silent terror that consumed so many,” Irish Examiner, 24 August, 2010. https://www.irishexaminer.com/news/arid-20128709.html.
- 50.
Carthy also details the introduction of the Mass X-ray vans: “The company ‘The National Mass Radiography Association Ltd’ was incorporated in May 1951 and commenced service using its three Swedish designed and manufactured units. A further two units were acquired by September and another unit by January 1953. The costs of the association were met by a sanatorium grant and by a substantial levy imposed on participating authorities, apportioned ‘on the basis of the rateable valuation of their functional areas. In its first eleven months of operation the’ association x-rayed 56,210 persons.” By 1960, “20% of the annual cases found to be suffering from tuberculosis were discovered through the mass x-ray service,” TTI, 326–7.
- 51.
The BCG vaccination remained in general use in Ireland until 2015, after a joint recommendation in 2013 “from the National Immunisation Advisory Committee (NIAC) and the National TB Advisory Committee proposed moving from a universal neonatal BCG vaccination programme to a selective BCG vaccination programme targeting high risk groups only.” Since then the National Immunisation Office reports that the “overall incidence of TB continues to decline. The number of cases of TB decreased from 358 in 2012 to 222 in 2022. Based on this data Ireland is classed as a low TB incidence country.” https://www.hse.ie/eng/health/immunisation/news/bcg.html.
- 52.
See Jones, “Captain,” 227.
- 53.
For a full account of the uses and abuses of the Irish asylum system in the nineteenth century, see Alice Mauger, The Cost of Insanity in Nineteenth-Century Ireland: Public, Private, and Voluntary Asylum Care (Houndmills: Palgrave Macmillan, 2017). For broader studies of mental healthcare in Ireland over the last 250 years, see Walsh, D and Daly, A, Mental Illness in Ireland, 1750–2002: Reflections on the Rise and Fall of Institutional Care (Dublin: Health Research Board 2004), and Asylums, Mental Health Care and the Irish: Historical Studies, 1800–2010 edited by Pauline Prior (Dublin: Irish Academic Press, 2017). Brendan D. Kelly interrogates the changes brought about by the Mental Treatment Act 1945 in “The Mental Treatment Act in Ireland 1945: An Historical Inquiry,” in History of Psychiatry (Sage Publications, 2007), 47–67. The implicit parallels between tuberculosis and mental illness are clear in another recent study, Torrey, E. F. and Miller, J. The Invisible Plague: The Rise of Mental Illness from 1750 to the Present (New Brunswick, NJ: Rutgers University Press, 2001).
- 54.
For example, James Deeney, who served as Chief Medical Officer to the Department of Health established in 1947, rejoices that, when compared to far larger earlier figures from the 1950s, “By October 1961, tuberculosis patients occupied 1,818 beds and there was a negligible waiting list. The tuberculosis epidemic which had been the scourge of the country for so long was at last under control.” See “Development,” 31.
- 55.
The Economist, vol. 343, issue 8019 (31 May 1997), 82.
- 56.
The Times, 23 May 1997.
- 57.
See James M. Smith, Ireland’s Magdalen Laundries and the Architecture of Containment (South Bend: Notre Dame University Press, 2007).
- 58.
Jones also weighs in on Browne’s “social revolution in health,” noting that “In one of the most famous and excoriating battles between Church and State in recent Irish history, significant because this time it was fought out in public, Browne became increasingly isolated within the cabinet over the Mother and Child scheme and in 1951 he was forced to tender his resignation,” “Captain,” 226.
- 59.
The Irish Times, 16 February 2013. https://www.irishtimes.com/life-and-style/people/exacting-economist-who-built-up-the-esri-1.1252768.
- 60.
Correspondence with Kieran Kennedy, January 2021. I am most grateful to him for sharing this source.
- 61.
Dick Hogan, “Health Board inquiry into outbreak of tuberculosis,” in The Irish Times, 22 October 1999. https://www.irishtimes.com/news/health-board-inquiry-into-outbreak-of-tuberculosis-1.243398.
- 62.
HSE Health Protection Surveillance Centre. ANNUAL EPIDEMIOLOGICAL REPORT FOR TUBERCULOSIS, 2019. Dublin: HSE HPSC; 2020. © HSE Health Protection Surveillance Centre, 2020.
- 63.
Dr Charles Daly, “The TB curse lives on,” The Irish Times, 11 May 2004. https://www.irishtimes.com/news/health/the-tb-curse-lives-on-1.1140012.
- 64.
Anne Mac Lellan makes the same point that tuberculosis in Ireland today is a disease of immigrants, not emigrants: “More than half a century after Irish immigrants and TB were emotive topics in England, the White Plague is increasingly being perceived in Ireland as a disease of ‘aliens,’” “Victim or Vector?,”121.
- 65.
Anne Dempsey, “The Disease that time forgot, The Irish Times, 3 November 2003. https://www.irishtimes.com/news/health/the-disease-that-time-forgot-1.388952.
- 66.
Niamh Griffin, “Ireland needs a national tuberculosis controller, expert warns,” The Irish Examiner, 23 March 2022. https://www.irishexaminer.com/news/arid-40835081.html.
- 67.
Dr Peter Hotez, co-director of the Center for Vaccine Development at Texas Children’s Hospital, coined this term because the letters, like X and Q, used to identify these variants are very valuable in games of Scrabble.
- 68.
Dr Fauci, News Center 5 at 5.00, WCVB Channel 5 Boston, 20 July 2021.
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Sealy Lynch, R. (2024). The Nameless Scourge: Tuberculosis in Ireland, 1800–the Present. In: Tuberculosis and Irish Fiction, 1800–2022. New Directions in Irish and Irish American Literature. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-031-40345-3_2
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