Ali Arsalo in TB seminar 18-19.9.2017 St Petersburg - Nordic Russian Health Programme

1. Joint Seminar on Tuberculosis
Introduction – with a few personal
memories and glances from history
St. Petersburg 18-19.9.2017
Ali Arsalo, M.D., PhD, Kevi Consulting Pvt.Ltd

2. Studying the history of tuberculosis
is extremely interesting!
Why? – Combination of
general history
beliefs and demons
development of science
socio-economic development
medicine
politics
education
civil society

3. The Return of the White Plague
Global Poverty and the Era of “New” Tuberculosis
From victory to new epidemic
Very difficult situation during the 19th and beginning of the 20th
century
In 1950’s general view that infectious diseases had been defeated
However, 1960’s and onwards pandemics and epidemics of cholera,
malaria, hemorrhagic fevers, HIV – and tuberculosis
In fact, now tuberculosis has strongly “increased and become the
leading cause of death in many parts of the world”
 Return of the White Plague

4. From Black Death to White Plague
Confirmed eruptions of plague, “Black Death” from 6th century
onwards, 14th century, 17th century – links to growth of population,
poverty, famine, migration
Hippokrates (460-370 BCE): phthisis (=pulmonary TB): “the greatest
and most terrible disease”
Archaeology: TB has been widespread in early Hindu, Greek and
Roman societies
By the early 19th century “White Plague” had become (one of) the
principal cause(s) of death in much of Europe and North America

5. Personal (indirect) contacts with tuberculosis
Early 1950’s
Very early memory: “Dr. Mikkelä” and “nitrogenization” – wondering what
does this mean
Later, understanding the idea of artificial pneumothorax as a treatment for TB
Then, what would THAT mean – gradually came to know that it is a disease
which almost has killed my mom before I was born (through Cesarean
section because of the aftermath of that strange and frightening disease)
Kinkomaa Sanatorium was another word which was mentioned several times
– place with good air for recovery from active pulmonary TB

7. Personal (indirect) contacts with tuberculosis II
Late 1950’s – Health education and fund raising
In trains signs “Spotta ej på golfvet” – I don’t know why the Swedish version
has remained in my mind; again didn’t understand what this meant
At school tuberculin tests
Fund raising: philatelic idea; special stamps called TB-stamps, with the sign
of the third sector work against TB
 I didn’t understand so much about TB then, but what I understood was that these
stamps were philatelisticly much more valuable than any normal stamps, so they
were to be sought and watched

11. Findings from biographies
The biography of professor Ferdinand Sauerbruch revealed
that his pressure chamber in 1904 was a remarkable
innovation in the development of open thoracic surgery

13. TB took high price also from among artists
The great piano composer Frédéric Chopin, suffering of pulmonary
TB which lead to his premature death
 It is said that the extraordinary piece Raindrop Prélude was created
during a difficult moment of semi-consciousness due to tuberculotic
bleeding in Mallorca; may be a legend but anyway, we can enjoy this
master piece on which his disease has certainly influenced

14. Great Polish composer
Frédéric CHOPIN
Prélude no 15, Op. 28, Des
”Raindrop” 

15. In the past, difficulties in classification
Not only pulmonary but also glandular, spine, skin, brain…
 mysterious and mystified disease, caused by demons
Early 1800’s
 hereditary and constitutional causes
 improper diet, impure air, deficient exercise, excessive labour,
imperfect clothing, defects of cleanliness, abuse of liquors, mental
causes, contagion
It was also noted that the surrounding air had much influence:
warm climates preferred over cold and humid
Gradually increasing suspicion that deteriorating overcrowded
social conditions were one principal cause for the terrified
epidemic

16. Anti-urbanism and sanatoria movement
“Disease of humid and dank / cold cities”
 Search for climate cure lead to the development of
specialized TB institutions, devoted to treatment, and
widespread construction of sanatoria, located on good
air and sunny places, providing healthy conditions for
getting the disease under control

17. Finding bacteriological evidence
In 1868 Rudolf Virchov considered TB to a kind of tumour,
rejecting the contagious theory of Jean-Antoine Villemin, a French
surgeon, and even earlier Gerolamo Fracastro, a Veronese
physician (1483-1553) who already warned about keeping lingerie
of phithisis sufferers in the rooms
 In Northern Europe, however, hereditary and constitutional
explanations prevailed
Changes of attitudes started to gain through Robert Koch’s
discovery of TB bacterium, Mycobacterium tuberculosis, in 1882: no
longer an indefinable Something but a definite parasite
Still, however, hereditary or constitutional transmission theories
prevailed for years
 during 20th century eventual recognition that TB was a social disease,
with its roots in poverty and poor housing

18. Key steps
Identification of Mycobacterium tuberculosis 1882
From 19th century different focuses on constitutional aspects,
medical science and social reforms
Development of sanatories and health education programs early
20th century
Decline of the epidemic – however, with wide variations and
differences globally
 Improvements of social and work place conditions
 Development of thoracic surgery
 BCG Vaccination Bacille Calmette-Guérin 1922
 Effective health education programs
 Antibiotic treatments since 1944 (streptomycin) and 1951 (isoniazide)

19. Contradictory views
However, contradictory views and interpretations of the relationship
between epidemiology and aspects of social reforms
Role of workplace reforms vs. municipal public health measures?
Decline of TB before systematic attempts to prevent its spread
 McKeown theory: TB (and other) infectious diseases decline as a by-
product of wider social and economic advances rather than as a result of
any specific medical interventions (1976)
 On the other hand, in France, e.g. in Paris with higher prevalence than in
London, historian Allan Mitchell claimed that the question was not about
general welfare and nutrition but, instead, the failure of French authorities
to implement local sanitary measures and national health reforms

21. Tuberculosis in Finland
During earlier centuries, the
priests were responsible for
monitoring diseases and
keeping records

22. In the beginning of the 19th century VERY high mortality from TB
It was, in fact, known but not believed already from the 17th century
that the TB is a contagious disease
The spread the disease took place through
 defects in hygiene
 poor and crowded living conditions
 poor social conditions
 malnutrition
Tuberculosis in Finland II

23. In 1870’s TB was the most important cause of death
In early 20th century a frightening disease which tackled
all, rich and poor
 (In a Norwegian statistics before 1890, TB killed 14 % of physicians)
Tuberculosis in Finland III

25. Development in Finland
The first national program against the spread of TB by “Duodecim”
in 1893
 Control of work places
 Improvements of workers’ conditions and housing
 Improvement of ventilation of houses
 Efficient general health education for the whole population
Preventive work by the civil society, medical community and
National Society to support the poor
Nurses trained for health education

26. Development in Finland II
Construction of sanatories, the first in 1933 (about 200-250
new cases / 100 000), in Paimio, designed by famous architect
Alvar Aalto, with motto: “Light – air – sun”

27. Development in Finland III
Mass screenings by mini-thorax x-rays
Surgery had essential role especially in1940-1950’s and even
until 1970’s
In 1920’s 9000 deaths from TB (1/400 individuals) - today, less
than 3 new cases / 100 000 / year but still considered as
potential danger, deserving high alertness

29. Eventually, successful eradication
programs in 1950’s and 1960’s
 However, At least two competing
interpretations of McKeown’s thesis:
 1) emphasis on general social
and economic improvements
(dismissing the role of
medicine) and
 2) role of medicine, hospitals and
better housing etc. decreasing the
spread of bacteria

30. BUT THEN…
… return of the White Plague

31. Personal (indirect) contacts with tuberculosis III
True story from Namibia in 1999
Statistics – doctors’ hand writing – bronchitis
Info from the North
Real value of statistical figures?

32. The Return of the White Plague
Global Poverty and the “New” Tuberculosis
Return of the White Plague – since 1980’s
 Deteriorating social conditions, poverty, migration and inequalities globally
 Appearance and rapid spread of HIV with the development of HIV/TB double
infection
 Development of worsening antibiotic resistance

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Building Capacity for the Future
Dr. Ali Arsalo
+ 358 50 537 6265
ali.arsalo@kevicon.fi
Kevi Consulting Pvt. Ltd
www.kevicon.fi