Globally, tuberculosis remains among the 10 major causes of mortality and is a significant public health problem in Asia despite a worldwide alert for the disease over a decade and half ago.1 On the contrary, countries such as Australia have a relatively low incidence of the disease with new cases primarily being identified in migrant populations a decade after their settlement.2 In some European nations with substantial public health care facilities, tuberculosis continues to be a problem particularly within large thriving cities such as London.3,4 This disproportionate increase in disease incidence compared with other community groups and national rates can be found in those who are socially disadvantaged including the homeless, drug and alcohol addicted, people with HIV, prisoner populations as well as refugees and migrants from high-risk areas.5–7 For these socially disadvantaged communities and individuals access to mainstream healthcare may be limited due to a variety of reasons8 and hence we may have to look beyond traditional practice while reflecting on the social history and impact of tuberculosis to identify new ways to institute treatment and care for these individuals.
Mycobacterium tuberculosis was isolated by Koch in 18829 and recognition was given that the disease's transmission from person to person by droplet was facilitated by overcrowded living conditions, inadequate nutrition and an impoverished lifestyle. Historically tuberculosis has been evident for centuries as part of the recollection and expression of people's beliefs. Most obviously, tuberculosis has been constructed socially and biologically; biologically through science as an organism and socially by the community as a slow wasting death that was often associated with pale individuals being removed from the community.10 Also, many social constructions of the disease have been reported10–12 and at times tuberculosis was associated with divine powers13 as well as creative and artistic qualities.14 The reality was often very different as Aronson suggests that ‘large numbers of anonymous everyday folk who could not distinguish a sonnet from a sonata’ (p. 431) died of tuberculosis.14 In health care, these descriptions often emerge from the historical developments in medicine15,16 and provide a social commentary on everyday people and their activities at various time points.17
Much of the English and North American fictional literature of the nineteenth century romanticized the disease and reinforced the beliefs and practices prevalent at the time.14,18 People were described as being consumed and exhausted by the disease as individuals became more ‘delicate’, ‘pale’ and ‘drained’ of energy. Tuberculosis treatment in the period of history mirrored these thematic descriptions immortalized in novels. Medical care in sanatoriums was often described as a combination of companionship, fresh air and rest to enable the patient to return to good health.11,19 However in contrast, some non-European countries negatively popularized tuberculosis as part of vampire myths as people tried to make sense of the disease symptoms.10 As a result, diseased bodies were exhumed and ritually burnt to remove the vampire's existence.10
Tuberculosis was considered and accepted as part of community life prior to Koch's discovery and the link being established between poor social conditions and the spread of disease became known.18,20 In the early twentieth century, ‘contagion’ became a fearful term as medical knowledge and technology provided the tools to identify individuals with tuberculosis more accurately.21–24 During this period, ‘plagues’ had been regarded as negative judgements on society10,25 and tuberculosis had been reported as a form of societal assessment, infecting the ‘bad’ and the ‘good’ being disease free.12,26 A number of reports suggest a sense of apprehension became apparent as differing tuberculosis beliefs began to emerge.20,21
In response to this disease threat, public health measures were developed and most consisted of community surveys, using relatively new chest radiograph technology. The Australian tuberculosis campaign is an example of a population-based survey where all adults were screened using chest radiographs in caravans which travelled to cities, towns and remote communities. At the heart of this government initiative was the assessment of risk, risk of disease within the person and the population.27 Mass x-ray screening was also instituted in New York during a similar period for the purpose of identifying those who may have the disease without being aware of it.28,29 Along with the assessment of risk, disease-specific health service infrastructure were developed as part of these programmes which provided improved health care facilities to isolate and treat patients along with extensive unique outpatient services.30–32
Despite the positive nature in which the Australian campaign was launched, fears and concerns within the community were evident as the ‘jolly consumptive’ song of that era portrayed the disease in a negative light while attaching stigma and ridicule to those in all social classes who had been infected with the disease.33 In the course of this period of history, the need for education was identified as a strategy to reduce misinformation regarding tuberculosis, its spread and treatment hence patient education as an integral part of tuberculosis health care services was borne.
However, historical reports seem to suggest that not all medical practitioners agreed with this form of case finding and the institutionalization of the patients.34,35 More recently, disease screening as a public health activity has once again been at the centre of a number of ethical and clinical discussions.36 Reports of today's disease screening programmes suggest this perception of being at risk is common with a relative increase in anxiety according to the number of tests patients undergo.37
The current approaches to public health education, disease screening and treatment may differ from the past however; the stigma of TB and the concerns and fears of patients being screened or treated remain common worldwide. The recognition and acknowledgment of these very human responses resonate with health professionals and health educators as counselling and support continues to form a central part of tuberculosis services that deliver ‘best’ practice.
Tuberculosis remains both a biological and social disease and despite important advancements in case finding strategies, diagnostic techniques, pharmacological treatment and patient care during the twentieth century, tuberculosis remains a significant health problem for many countries, including most Asian nations, today.
Recent reviews on TB in Respirology have all generated great enthusiasm,38–40 and research articles on TB continue to account for a significant proportion of the original publications in the journal. Starting from this issue of the journal, Dr WW Yew has kindly organized a comprehensive, state-of-the-art review series on TB covering key issues on public health, clinical management and translational research, all pertinent to both the high and low incidence countries within the Asian Pacific region.