An Interdisciplinary Perspective:
Infectious Diseases and History*

Jenifer Turco** and Melanie Byrd***



*This article was originally published in The American Biology Teacher, 63 (5), 325-335; 2001.  It is being made available electronically with permission.
** Jenifer Turco, Ph.D., is an Associate Professsor in the Department of Biology, Valdosta State University, Valdosta, GA 31698-0015; email: jturco@valdosta.edu .
***Melanie Byrd, Ph.D., is an Associate Professor in the Department of History, Valdosta State University, Valdosta, GA 31698-0015; email: mbyrd@valdosta.edu . 


       Freshman and sophomore students at Valdosta State University are learning about life sciences, infectious diseases, and history in an interdisciplinary course entitled Infectious Diseases and History. We developed and began offering this course in 1998 as an elective to satisfy (in part) the requirement for two interdisciplinary courses (two semester hours per course) in the revised core curriculum. The purposes of this course are: (i) to help students appreciate the role of infectious diseases in shaping world and regional history, (ii) to encourage students to develop their skills in using library and computer resources to further their learning, and (iii) to provide opportunities for students to develop their skills in oral and written communication. The response of students has been enthusiastic-- all sections of the course have been full each semester. Students with a variety of majors and interests have completed the course, which has no prerequisites.

Organization and Presentation of the Course
        The first part of the course consists of instructors' presentations and class discussions. Initial classes provide background on the different types of infectious agents, the human immune system, and the history of microbiology. After this introduction, each subsequent class focuses on a particular disease or topic. The specific diseases and topics covered each semester vary (Table 1). For each disease covered, information about the signs and symptoms, causative agent, transmission, pathogenesis, treatment, and prevention is summarized. Consideration of one or more related topics of historical importance follows.
        During the latter part of the course the students present oral reports (approximately eight minutes per student) on topics assigned by lottery. Each student is required to submit to the instructor a summary of his/her oral presentation along with a list of references used. Table 2 lists several examples of topics researched by students in the course. Because the students have varied backgrounds and experience in using library and computer resources, we give them a list of suggestions for researching their topics. In addition, we have used Web CT to develop a collection of links to relevant World Wide Web sites (Table 3) to enhance their interest.

Textbooks and Other Resources
        Two textbooks (Biddle 1996 and Oldstone 1998) have been used for the course. The first (A Field Guide to Germs) is available in paperback, is very readable, has some interesting black-and-white historical illustrations, and includes a "selected bibliography". The second (Viruses, Plagues, and History), which is available in hardcover, also has a nice selection of black-and-white illustrations. It provides more detailed coverage of viral and prion diseases and their history, along with a more extensive list of references.
        In addition, we are using a variety of other resources. These include illustrations from a variety of sources, Web sites, books, articles from periodicals, documentaries, and movies. Visual resources and firsthand accounts of disease greatly enhance students' responses to the material.

How Diseases Are Approached in the Course
        To illustrate how the instructors approach a particular disease in the course, the remainder of this article focuses on tuberculosis and how attitudes toward the disease and treatment of the disease have changed over time.
 

Tuberculosis, the Disease

Description of and Cause of the Disease
        Tuberculosis is an infectious disease that has killed millions of people and that remains a serious problem today. A person who has pulmonary tuberculosis may exhibit fever, coughing (often with bloody sputum), weight loss, loss of energy, and progressive destruction of the lungs. In some individuals, the disease may involve organs other than the lungs. The causative agent of tuberculosis is generally a bacterium called Mycobacterium tuberculosis. However, another species (Mycobacterium bovis) may also cause disease in humans.

Transmission and Pathogenesis
        Only about 10% of persons who become infected exhibit the signs and symptoms of tuberculosis. The bacteria are usually acquired by being inhaled into the lungs. Thereafter they are taken up by phagocytic cells called macrophages. The bacteria multiply locally and may spread to other body sites. After a few weeks, the person's immune response may control (though not eliminate) the infection; in this case, the person does not manifest the signs and symptoms of clinical disease. Lesions called tubercles develop at the sites of infection; and these lesions regress but may still contain viable bacteria. Should the person's immune response fail to control the infection (either initially or at a later time), bacterial multiplication may continue and these lesions may enlarge and liquefy. The person then develops clinical signs and symptoms of disease and becomes capable of transmitting the bacteria to other individuals.

Treatment and Prevention
        Treatment of tuberculosis generally consists of two or more antimycobacterial drugs given for a period of several months. In addition, persons who are infected (but have not developed clinical disease) can be given antimycobacterial drugs to keep them from developing tuberculosis. Directly observed therapy (DOT) is used to improve patient compliance with treatment. Problems currently exist with strains of M. tuberculosis that have developed resistance to multiple antimycobacterial drugs. Tuberculosis caused by multidrug-resistant mycobacteria can be very difficult and expensive to treat.
        Prevention of tuberculosis focuses on identifying and treating infected and diseased individuals. (A skin test called the tuberculin test may be used to identify individuals who have been exposed to M. tuberculosis.) In addition, efforts to develop a vaccine to prevent the disease are underway. The efficacy of the BCG (bacille Calmette-Guérin) strain of M. bovis, which is used as a vaccine in some countries, remains unclear.
 

Tuberculosis, History

        Tuberculosis is an old disease-- its presence has been documented in studies of Egyptian mummies. Names for various forms of tuberculosis have included "phthisis" (which means "wasting away") and "consumption" (both names refer to pulmonary tuberculosis), "scrofula" (tuberculosis involving the lymph glands of the neck), "lupus vulgaris" (tuberculosis of the skin), and "Pott's disease" (tuberculosis of the spine). Tuberculosis was called the "white plague" by Oliver Wendell Holmes (1809-1894) (Weisse 1995); and in John Bunyan's The Life and Death of Mr. Badman, it was called the "captain of all these men of death" (Bunyan 1628-1688, 1970).
        Historically, increases in tuberculosis were associated with increases in population density (such as those associated with urbanization and industrialization). Thus tuberculosis increased in the eighteenth and early nineteenth centuries; and the response to tuberculosis in human society reflects cultural values and attitudes associated with the development of industrial society. In the early nineteenth century, as rapid urban growth led to the rise of factories and slums, tuberculosis became especially widespread, flourishing in the overcrowded, poorly ventilated and filthy urban conditions. Death and disease were omnipresent aspects of life, and the reaction to consumption, the popular name for tuberculosis, varied according to social class. While disease and early death were commonly associated with the poorer classes, middle class and wealthy individuals romanticized consumption, just as they sentimentalized death. A lingering death provided the opportunity for moral reflection, and the patient, suffering nobly, was to inspire friends and family members, and serve as a reminder of human mortality.
        Moreover, because various famous, talented individuals of the era, such as the Brontës, Chopin, Paganini, and Kafka died of the disease, it assumed a cachet of glamour, linked to the concept of the "suffering genius". In addition, the physical manifestations of consumption, like pallor, the flush of fever and weight loss were compatible with contemporary standards of beauty, especially female beauty. While medical researchers investigated the cause and nature of the disease, and whether or not it was hereditary, social and moral critics saw consumption as indicative of the vices of hectic, fast paced urban life. Those who drank to excess, indulged in sexual license and otherwise violated early Victorian standards of conduct were deemed most at risk for contracting and spreading the disease. Thus, in the popular nineteenth century novel, The Lady of the Camellias, the heroine, a pleasure-loving courtesan, repents of her lifestyle for selfless true love and dies an edifying, redemptive death from consumption.
        Until the development of drugs to treat tuberculosis, the "rest cure" at a sanatorium, far from the unhealthy urban environment, was the most common treatment of the disease. For the wealthy, the sanatorium was a combination luxury hotel and hospital, as immortalized in Thomas Mann’s novel The Magic Mountain. As the germ theory of disease gained acceptance, and after Robert Koch identified the bacterium that caused the disease in 1882, tuberculosis lost its glamour, and became an enemy to vanquish. Robust good health was the new standard of beauty and gauge of social status. No longer romantically called consumption, the "white plague" was associated with the poor, and in America with immigrants and African-Americans.
        The public health crusade of the late nineteenth and early twentieth centuries had moralistic overtones; patients had a duty to work to recover from the disease. The sanitoria became spartan, impersonal and clinical, especially those for lower income patients. Treatment increasingly focused on surgery to force the collapse of the infected lung. Far from experiencing a luxurious rest cure, patients suffered from boredom, isolation and frightening medical procedures, such as the removal of ribs.
        Eventually tuberculosis began to decline in developed countries such as the United States. Drugs were developed for treatment of the disease in the mid-twentieth century, and by the 1970s most of the sanitoria for tuberculosis patients were closed. However, during the 1980s, tuberculosis began to increase in the United States. This resurgence of the disease was associated with AIDS, homeless and displaced people, illegal drug abusers, people who entered the United States from countries where tuberculosis was prevalent, and multi-drug resistant strains of M. tuberculosis. Although the number of cases of tuberculosis in the United States has decreased since 1993, the disease remains a serious threat in many parts of the world (for example, Asia). In addition, strains of multidrug-resistant M. tuberculosis currently pose treatment problems throughout the world. That anyone can get tuberculosis is exemplified by the case of Debi French, a high school student in California who developed the disease in 1993 and had to have surgery as a result (Hall 1996). At present, research on tuberculosis pathogenesis, treatment, and prevention continues.
 

Tuberculosis, Other Topics and Illustrations of Historical Interest

        The chronology that follows summarizes important and interesting events related to tuberculosis in history. As time permits, the instructors explore selected topics from the chronology. Illustrations related to tuberculosis in history are used to heighten student interest in the topic; these are listed in Table 4.

Tuberculosis Chronology

4500 BC—Neolithic skeletons from Germany showed evidence of tuberculosis DNA.
3400 BC—Egyptian skeletons with Pott’s Disease showed Mycobacterium DNA.
Classical Greece and Rome—Hippocrates and Galen described Phthisis (consumption) in their medical works.
Early Medieval Europe—European and English kings began the practice of ceremonial touching of victims to heal scrofula,  called the "King’s Evil."
1000 AD—A Peruvian Mummy that predated Columbus by 500 years was found to contain Mycobacterium tuberculosis  DNA.
1037—Ibn Sina (Avicenna) the Islamic physician asserted that consumption was contagious.
17th and 18th centuries—TB became a constant factor in urban life with industrialization and the growth of cities.
19th century—TB, commonly called consumption, became romanticized and sentimentalized because it caused a lingering death through a process of gradual wasting and decay, thought at the time to be beautiful, dramatic and inspirational, at least for the prosperous classes.
Famous victims of tuberculosis included the Brontës, Frédéric Chopin, René Laennec, John Keats, Anton Chekov, D. H. Lawrence (20th century) and Eugene O'Neill (20th century), creating a mystique of suffering and creative power associated with the disease.
1852—Alexandre Dumas fils’ novel and play, The Lady of the Camellias, loosely based on his mistress, reflected the romantic, and most persistently popular view of consumption. Stars such as Eleanora Duse and Sarah Bernhardt played the lead role.
1853—Giuseppe Verdi’s opera, La Traviata, based on The Lady of the Camellias premiered in Venice.
1865—French surgeon Jean-Antoine Villemin proved that consumption was contagious.
1866—Louis Pasteur published the first description of the pasteurization process as applied to wine.
1870s—"Doc" (John) Holliday, a dentist and onetime resident of Valdosta (GA) who became a legendary gunfighter, developed chronic pulmonary tuberculosis. Following medical advice, he went west hoping his condition would improve.
1882—Robert Koch identified M. tuberculosis, and consumption became known as tuberculosis.
1884—Edward Livingston Trudeau, who suffered from TB, established the sanitorium at Saranac Lake in New York.
Late 1800s and early 1900s—Acceptance of the germ theory and the growth of a militant public health crusade caused TB to lose its romantic mystique. The fight against the disease assumed a moralistic, martial aspect. Victims and survivors were depicted as heroes in a war.
TB, commonly called the "white plague" became a stigma attached to the poor, foreign born and non-white in the United States.
Sanitoria flourished, usually in mountains or desert areas, believed to have healing fresh air.
1901—The famous Davos clinic, which later inspired Thomas Mann’s The Magic Mountain, opened in Switzerland to treat TB patients. It treated TB until 1972.
1903—Einar Holboell, a Danish postmaster, developed the idea of selling Christmas stamps to raise money to support the care of children with TB. Holboell’s stamps were first sold in 1904.
1904—The National Association For the Study and Prevention of Tuberculosis (National Tuberculosis Association) became the first nationwide voluntary health organization in the U. S. In 1973 it became the American Lung Association.
1906—Milton J. Rosenau developed a method for pasteurization of milk that did not damage the taste of the milk.
1907—Emily Bissell established the Christmas Seals program with help of photographer and activist Jacob Riis, to raise money for the National Association For the Study and Prevention of  Tuberculosis.
1909—Philanthropist Nathan Straus opened a tuberculosis Preventorium for children in Lakewood New Jersey to stop the disease before it developed in youngsters. He also supported the development of sanitoria for TB patients and the pasteurization of milk to prevent diseases like TB.
1911—The Lady of the Camellias was filmed (for the first time) with Sarah Bernhardt.
World War One and the post war-era—Surgery on the chest, such as removal of the ribs or forced collapse of the infected lung, became common in the treatment of tuberculosis.
1920—The double-barred cross, a modification of the Cross of Lorraine, first appeared on Christmas Seals. [The Cross of Lorraine was used by Crusaders in the Middle Ages and was adopted by the National Tuberculosis Association (American Lung Association) to symbolize the crusade against TB (American Lung Association, Personal communication to M. Byrd, March 21, 2000).]
1921—Albert Calmette and Camille Guérin developed an anti-TB vaccine.
1924—Thomas Mann’s novel, The Magic Mountain, about life and death in a pre-war European sanitorium was published.
The U.S. Public Health Service prepared the Proposed Standard Milk Ordinance.
1930s and 1940s—The chest x-ray and tuberculin skin test became the two main tools of TB diagnosis.
1937—The film Camille (based on The Lady of the Camellias) starring Greta Garbo and Robert Taylor continued to promote a romanticized image of tuberculosis, at least as it applied to romantic types in the 19th century, divorced from the grim reality of the 20th century.
1940s—Antibiotics like streptomycin were first used to treat tuberculosis.
1944—On VE Day, residents of Harlem in New York City received free chest x-rays.
1945 to the mid-1980s—TB began to decline in developed countries suth as the U.S.
1951—The U. S. census showed more than 119,000 cases annually—more than three times the infection rate of polio.
1960s—Studies were published detailing the use of supervised administration of medication for TB in ambulatory patients in Madras (India), Hong Kong, and London.
1970s—With hospitalization and drug treatment for tuberculosis, most sanitoria closed down.
1985-1992—TB cases increased 20% in the U.S. The increase was associated with AIDS, homeless and displaced people, people who abused illegal drugs, people who entered the U.S. from countries where TB was still prevalent, and multi-drug resistant strains of M. tuberculosis.
1990s—Multi-drug resistant strains of tuberculosis made the news as a threat to world health, especially in the non-industrialized world and the former Soviet Union.
1993—The World Health Organization (WHO) declared tuberculosis a global emergency.
1994—The U. S. passed new guidelines for hospitals, nursing homes, medical facilities and prisons to curb drug resistant strains of tuberculosis.
1995—For every person who died of Ebola, 12,000 died of tuberculosis.
1996—WHO reported that multi-drug resistant TB was increasing. It also reported that TB was the leading cause of death in women and HIV-positive individuals.
1997—A connection between inconsistent or partial treatment of TB and the spread of drug resistant TB was documented in a cooperative study, Anti-tuberculosis Drug Resistance in the World. The study recommended the DOTS (Directly Observed Therapy, Short-course) strategy for reducing TB. It identified problem areas for drug-resistant TB, including India, Russia, Latvia, Estonia, The Dominican Republic, Argentina and the Ivory Coast. The study was conducted by WHO, the Centers for Disease Control and Prevention (U.S.A.), and the International Union Against Tuberculosis and Lung Disease, with financial support from the U.S. Agency for International Development.
1998—WHO estimated that one new person was infected with TB each second, and that only about 21% of all TB patients were treated by its DOTS strategy. It also identified 16 countries, including Mexico and Brazil, as TB trouble spots. According to the WHO, more than half of the new cases of TB were in six countries in Asia: India, China, Bangladesh, Pakistan, Indonesia and the Philippines.
1998—The genome of Mycobacterium tuberculosis was sequenced.
1999—The WHO Global TB Report identified Asia as having the largest number of TB cases lacking access to good treatment.
PRESENT—TB infects 1/3 of the world’s population and kills approximately 3 million people per year. In the U.S., 10 to 15 million people have TB infection.
World TB Day is March 24th, commemorating the date on which Koch announced his discovery of the bacterium that caused TB. The theme for World TB Day 2001 was "DOTS: TB Cure for All".




 
 

Table 1. Diseases and Topics Covered in the Course

Diseases
cholera, dysentery, typhoid fever, plague, typhus, malaria, tuberculosis, Hansen's disease (leprosy), syphilis, ergotism, smallpox, influenza, poliomyelitis, measles, yellow fever, Ebola and Marburg diseases, Lassa fever, hantavirus diseases, AIDS, spongiform encephalopathies (e.g., mad cow disease, kuru, and scrapie)

Other Topics
The Irish Potato Famine, biological weapons, bioterrorism, resistance of microbes to antimicrobial medicines




 
 

Table 2. Examples of Topics for Student Reports

Japanese Experiments with Biological Weapons during World War II
Outbreaks of Foodborne Illness Due to Intentional Contamination of Food with Bacteria
How Smallpox Was Eradicated
Smallpox, Measles, and the Aztecs
Yellow Fever and the Panama Canal
History of the "March of Dimes"
Yellow Fever Outbreaks in New Orleans
The Influenza Pandemic of 1918-1919
HIV/AIDS in Georgia and the United States
Kimberly Bergalis
Randy Shilts
HIV/AIDS in Africa
Bovine Spongiform Encephalopathy and Variant Creutzfeldt-Jakob Disease
D. Carlton Gajdusek and Kuru




 
 

Table 3. Web Sites with Information about Diseases and History

Centers for Disease Control and Prevention (CDC)  http://www.cdc.gov/
Food and Drug Administration  http://www.fda.gov/
Bad Bug Book (FDA)  http://vm.cfsan.fda.gov/~mow/intro.html
U.S. Dept. of Agriculture  http://www.usda.gov/
World Health Organization  http://www.who.int/
American Society for Microbiology  http://www.asmusa.org/
Georgia Division of Public Health  http://www.ph.dhr.state.ga.us/
Karolinska Institutet (Alphabetic list of diseases/disorders)
http://www.mic.ki.se/Diseases/alphalist.html
Karolinska Institutet (History of Diseases)  http://www.mic.ki.se/HistDis.html
Medical Microbiology (Neal Chamberlain's Look at the Microbial World)  http://www.geocities.com/CapeCanaveral/3504/
Epidemic! (The World of Infectious Disease) (American Museum of Natural History)  http://www.amnh.org/exhibitions/epidemic/
National Foundation for Infectious Disease (NFID Recommended Web Sites & Virtual Library of Diseases)  http://www.nfid.org/library/
Microbial Literacy Collaborative  http://www.microbeworld.org/mlc/
Stalking the Mysterious Microbe  http://www.microbe.org/
CELLS alive!  http://www.cellsalive.com/
All the Virology on the World Wide Web (David M. Sander) http://www.tulane.edu/~dmsander/garryfavweb.html
Plague War (Frontline)  http://www.pbs.org/wgbh/pages/frontline/shows/plague/
The Brain Eater (NOVA)  http://www.pbs.org/wgbh/nova/madcow/
Surviving AIDS (NOVA)  http://www.pbs.org/wgbh/nova/aids/
Epidemic!  http://www.discovery.com/exp/epidemic/epidemic.html
Views of the Famine (Irish Potato Famine) (compiled by Steve Taylor)  http://vassun.vassar.edu/~sttaylor/FAMINE/




 
 

Table 4. Illustrations Related to Tuberculosis and History‡

Colonies of M. tuberculosis growing on artificial medium in the laboratory; microscopic image of stained M. tuberculosis bacteria; chest x-ray of a person with tuberculosis (CDC Web site, Self-Study Modules on Tuberculosis)
Dr. Edward Livingston Trudeau and the sanitorium at Saranac Lake (Trudeau Institute Web site; Tobey 1930)
National Tuberculosis Association, History (Shryock 1957)
Old Georgia newspaper advertisements for medicines to cure scrofula and Consumption (The Swift Specific Co. 1886 and J.W. Peacock Co. 1881)
Guenther's Lung Healer March, 19th century piano sheet music advertising a patent medicine to cure consumption (Guenther 1882)
European and English kings (17th -18th centuries) touching victims of scrofula in an effort to cure the disease (Bloch 1973; Jones 1994)
Doc Holliday (Marks 1989; Traywick 1996)
Louis Pasteur and pasteurization (Dubos 1988)
Robert Koch (Watts 1997; Hall 1996)
Robert Koch portrayed on an antique trading card from a box of French or Belgian chocolates (Champenois)
Paintings (portraying tuberculosis) by Norwegian Expressionist Edvard Munch [The Dead Mother (1900) and Death in the Sickroom (1893)]  (Pioch 1995)
Christmas Seals (American Lung Association 1999)
Historical posters advertising Christmas Seals (National Library of MedicineWeb site)
Monaco stamp of Calmette and Guérin (Wistreich 1999)
Posters and advertisements relating to tuberculosis and the public health crusade of the early 20th century (Tomes 1998)
Nathan Straus and his work related to tuberculosis and pasteurization of milk (Straus 1977)
Icelandic stamp from 1933 used to raise funds for treatment of children with scrofula (Magnusson 1933)
Stamps from the Bahamas (Wistreich 1999) and Croatia (Worldwide Stamps Web site) commemorating the fight against tuberculosis
The Paris grave of Alphonsine Plessis, mistress of Alexandre Dumas fils who inspired the consumptive heroine in The Lady of the Camellias (Mockus)
Madonna Swan, a Native American woman who suffered from tuberculosis and spent time in various sanitoria during the 20th century (St. Pierre 1991)
Twentieth century surgical treatments for tuberculosis (Ott 1996)
TB posters and historical photographs of the White Haven Sanitorium (Bates 1992)
T.B. Harlem (1940), painting by American expressionist Alice Neel, who lived in Spanish Harlem while she painted for The Works Progress Administration (Buschen 2000)
Contemporary maps and charts illustrating the prevalence of tuberculosis (Centers for Disease Control and Prevention Web site; World Health Organization Web site; LSUMC/Wetmore TB Foundation Web site)
Debi French - high school student in Calilfornia who developed tuberculosis in 1993 (Hall 1996)
Photographs of Russian convicts held in prisons where tuberculosis is a serious problem (Farmer 1999; Holden 1999)


‡Complete citations for these illustrations are marked with this symbol in the list of references.



 

References†‡

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†Anonymous. (1999). A new defense in the fight against tuberculosis. Awake (March 22), 21-24.
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†References with information about tuberculosis.
‡References with illustrations relating to tuberculosis in history. Some of these sources also contain information about tuberculosis.