COMMENTARY | Despite more than a century of opportunities to change, Oregon’s response to COVID-19 is all too similar to that of the tuberculosis scourge
“And does Oregon take rank in this work? Is our state caring for the homeless, friendless and penniless consumptive within its borders?”
As we negotiate the current COVID-19 plague that has descended upon our state, it is a worthwhile exercise to consider the above 1908 quote, and the public health strategies we are today extending to our most vulnerable populations.
That quote referred to a previous public health scourge, one that struck humanity for over three millennia. And while “consumption,” or tuberculous, is not on the tip of everyone’s tongue at this historic moment, the disease is still a public health concern, especially in unsheltered communities.
Called consumption or “the wasting disease,” TB is caused by a bacterium. The afflicted became emaciated and continuously coughed. Painful, bloody coughing sessions would lead to fatigue.
Half of those inflicted with active TB could expect to die within five years. “Galloping consumption” would progress toward death rather quickly; once it was in the bloodstream, the sufferer’s demise would come in just some weeks or very few months. But other cases of the disease took years to finally finish the afflicted. Slow. Agonizing. Some suffered for decades. By the 1800s, one in seven people had died from the disease.
Treatment for tuberculosis evolved over the centuries. In the mid-1800s, open spaces with scenic views and fresh, outdoor air were viewed as positive placement for consumptives and a potential cure for their malady. Nourishing food was served on verandas and porches, with the tubercular patients wrapped up in warming wool blankets or long fur coats. Treatments like these continued for months or even years.
Obviously, this was a health care option afforded to those with means. Hundreds of thousands of Americans each year tried to obtain medical care for TB. Much like the COVID-19 pandemic today, hospitals were overwhelmed.
Poorer people had poorer options. Tent cities were put up on the outskirts of western towns, filled with consumptives. Those with coughs were sent there — isolated, and without almost any support, and obviously without the nourishing meals the privileged consumed.
The tuberculosis crisis became the thrust of the first mass public health campaign in the United States. Citizens were warned to be cautious about coughing, sneezing and spitting. Progressive urban planners began to accommodate initiatives to fight the virus. Parks and playgrounds were laid out “to provide urban dwellers with islands of fresh air.”
By the early 20th century, this public health campaign began to lower the number of cases, but impoverished, crowded communities still suffered staggering figures of the affliction. Immigrant and black communities saw death rates that were three to four times higher than that of affluent, white communities.
Public health officials began to look at conditions within these poor communities: Overcrowded and dirty housing, as well as cramped working conditions, were viewed as contributors to the condition. As a public health response, many of the poor, often against their will, were sent to ill-equipped public housing options. As historian Nancy Tomes said, “There was a sense that if you were wealthy, you’re going to be allowed to manage your illness however you wanted to. It was the poorer people who really felt the pressure from public health officials to make their sick relatives leave the home and go into one of these institutional facilities.”
As one public health official of the era stated, “public health measures are sometimes autocratic.” The rights of the patient were dismissed in the interest of the community.
By 1910, hundreds of private TB sanitoriums had spread across the country, and state governments opened facilities for those who were unable to afford the private institutions. From 1900 to 1920, one out of every 170 Americans lived in a sanitorium. But this option was not available to every consumptive.
In 1910, there was hardly a treatment option for Portland’s homeless population, as classism dictated who lived and who died. Many were forced to live in congregate housing, and boarding houses around Burnside could sleep up to 25 men in an overcrowded, dank room. These sheltering options were ideal for the spread of TB and other infectious diseases and must have seemed so far away from sanatoriums in idyllic, natural settings.
Oregon’s original tuberculosis sanitorium was the first state-owned and -operated one on the West Coast. It was in Salem, at the abandoned Deaf-Mute School. Some years later, the Eastern Oregon Tuberculosis Hospital was established in The Dalles, and patients could recuperate amid the “unexcelled panorama of the Columbia River crescent and the pleasant country to the north, east and west.” But spaces in these state institutions were limited to just a few hundred patients, and the needs of all of the poor were never met.
By 1926, there were an estimated 6,000 tubercular Oregonians —the total population was about 750,000 — with half of that number under “constant treatment for the disease.”
Publicly funded care for those with the illness was difficult to come by, and that dearth of care options affected the poor most of all. In 1929 and 1930, 156 Portlanders were denied treatment at the state hospitals. Some of them died from the disease during the delay. As Louis Clarke, president of the Oregon Tuberculosis Association, said, “Portland and Multnomah County are providing practically no hospital care for their tuberculosis patients; homeless men, active tuberculosis cases, are walking the streets.”
A cure for tuberculosis was late in coming. Streptomycin antibiotic tests began in November 1944. Relapse and drug resistance were high, but four years later, a more potent drug combination was issued. Three thousand years after introduction, there was finally a cure for TB, and infectious rates began plummeting, but they did not completely disappear. By 1970, Oregon had only 265 new cases of tuberculosis and 225 in 1971. The disease still tended to flock in poor urban centers, affecting communities of color and “particularly the homeless alcoholic male.”
The 1980s experienced a spike in TB in the United States, including drug-resistant various of the disease. This coincided with the AIDS epidemic, and some inflicted with the immune deficiency disease would also have tuberculosis. Again, this was much more common in at-risk populations, including those unsheltered.
In our current COVID-19 pandemic, we see some similarities with the two diseases, and the story is a divide between have and have-not Oregonians.
Many of us with means, “self-quarantined,” have the privilege of staying at home in our houses, remotely performing paid labor on laptops, and receiving nourishing foods delivered to these houses by Amazon and Instacart gig workers. But for our neighbors who are experiencing housing insecurity in this crisis, the options available sound much like the congregate settings of state tuberculosis hospitals (albeit without the sweeping views of the Gorge).
With over 100 years of opportunity for change, we still see many of the same responses extended to the community.
As COVID-19 spread across the state, Multnomah County Health officials quickly spread out bed spaces in existing homeless shelters in an attempt to increase social distancing. The county also created hundreds of new bed spaces in “spacious, airy rooms in public buildings,” most famously the Oregon Convention Center.
Social distancing is the key concept, but the spread of infectious disease seems concerning in these living conditions. County officials agree that “transmission is certainly more likely for people sleeping in a congregate setting and the best public health practice would be for everyone to have homes. … Multnomah County has identified the best public health practice available.” Practices that harken back over a century.
COVID-19: Why is Multnomah County sheltering houseless people en masse?
Daily screening (not testing) for COVID-19 takes place at these county facilities, but as other congregate settings seem to suggest (Boston’s Pine Street Inn homeless shelter, USS Roosevelt), a large percentage of the individuals staying at Multnomah County facilities could be asymptomatic and unknowingly spreading the disease. Like the rest of the state, testing capacity is still limited.
Tuberculosis is still in our midst, and still affecting the unsheltered in Oregon. The Centers for Disease Control Prevention states, “People experiencing homelessness have a high occurrence of conditions that increase the risk of TB, including substance abuse, HIV infection and congregation in crowded shelters.” The solution is not more temporary, congregate housing of the ill. County health officials agree that “secure housing is a critical piece in successful tuberculosis treatment.” Surely the same could be said for those (symptomatic or asymptomatic) with COVID-19.
According to the most recent data from the Oregon Health Authority, in 2018, 81 TB disease cases were reported statewide. Of that number, only three cases (4%) were homeless in the year prior to or at the time of diagnosis.
And while those local numbers may seem small, the disease remains deadly. World Health Organization notes that over 1.5 million people across the globe died of tuberculosis in 2018.
Learn more about tuberculosis
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