 | A girl's ward on the porch of Cleveland Cottage, a preventorium for children from New York City in Lakewood, New Jersey. Exposure to fresh air, nutritious food, and instruction in personal hygiene was intended to protect the children from developing TB. |
At the turn of the century, physicians, nurses and social workers, in the name of public health, took the unprecedented action of removing thousands of impoverished children they had labeled "pre-tubercular" from their homes and transporting them to institutions known as preventoriums.
The preventoriums, part hospital and part open-air school, were located in the countryside and were modeled after similar institutions in France and Germany. They were intended to prevent the children from developing tuberculosis (TB) by exposing them to fresh air and nutritious food. Children stayed there for months or years, with only limited visits from their parents.
At the peak of this public health campaign in the 1920s, there were about 100 preventoriums in the United States with a total of about 10,000 beds.
"All of these children were exposed to TB, but had not yet developed symptoms," says Cindy Connolly, an assistant professor at the School of Nursing and the School of Medicine. "Once it was known that TB in adults was a reactivation of an infection acquired during childhood, the goal became prevention in childhood."
Connolly is in the process of writing a book about this movement, titled "The History of the TB Preventorium 1900-1945." She is looking in particular at a preventorium established by a philanthropist in Lakewood, New Jersey, for immigrant children living in overcrowded tenements in New York City. In 1909, in the Lower East Side of Manhattan, an estimated 40,000 children lived with a parent who had TB.
Connolly says the era of the preventorium offers a compelling window into the development of pediatric health care and child protection policy. It also reveals good intentions sometimes muddied by bias against the immigrants arriving at Ellis Island, she notes.
"Rich children were never sent to these institutions," the Yale researcher says. "You had to react positively to the newly developed tuberculin test, have a parent who had TB, and you had to be poor. It was assumed that if you were a child in a wealthy home your parents knew enough not to cough on you, or, if you had been exposed to TB, your parents could afford to take you to the countryside."
"The question is always how much do you infringe on an individual's rights in order to protect the right of society," she says. "You're always having to balance that. It's also something that was just as relevant 100 years ago as it is today. The nurses and doctors and social workers were judgmental, but at least they were trying to do something about the problem. The vast majority of people did not get in the trenches and try to do something about the TB epidemic."
The preventorium arose from European initiatives. In France, children who were considered pre-tubercular were sent to live with peasant families in the countryside until they reached the age of 13. German children who had been exposed to TB were allowed to remain in their homes, but spent 11 hours a day at open-air schools, eating five meals daily and attending three hours of classes. Roughhousing or any vigorous activity was discouraged since it might dissipate the energy needed to turn pale cheeks pink and to bulk up thin bodies. Health care workers also taught the children personal hygiene, good nutrition and overall cleanliness -- practices it was believed indigent families were lacking.
The parents were given little choice in giving up their children temporarily, notes Connolly.
"Officially, the preventorium was voluntary on the part of the parents, but you had to agree to bring your kids to be checked if you wanted treatment for your own TB," she says. "A 'friendly visitor,' usually a nurse or a social worker, would come to your home to see how clean you kept your house and to pass some pretty hard judgments on you. Though some visitors understood it would be difficult not to have a dirty house if you had eight people living in one room, a bathroom down the street, and no place to put your garbage, others didn't understand.
"Again, officially, the preventorium was designed to get children healthy," notes Connolly. "But in many instances there was a subtext as well: The children would hopefully become more American, and they would be inculcated with middle-class values."
Despite the moral and social undercurrents surrounding the preventorium, the TB epidemic was all too real, explains Connolly. Throughout the 19th century, TB -- or consumption and the "White Plague," as it was called -- was the most common cause of death among Americans. Eleanor Roosevelt, for instance, had TB for years and eventually died from the disease. It was not clear TB was infectious until German scientist Robert Koch discovered in 1882 that the respiratory disease was caused by tubercle bacilli spread by airborne droplets. There was no cure until the 1950s.
In the early years when little was known about TB, treatment was primitive, explains Connolly. Remedies ranged from ingesting garlic mixed with dog fat to inhaling smoke from burning cow dung and exercising the chest with extended vomiting. King Clovis of 5th-century France believed his divine appointment gave him special powers, including the ability to cure TB with the "Royal Touch." Still others thought placing seaweed under the patient's bed would help since the sea air seemed restorative.
By 1908, physicians knew that many children who had no obvious signs of the disease were infected. Early 20th-century autopsy studies revealed that many children who had died from non-tuberculosis-related causes were, in fact, actually infected with the disease. But it was Clemens von Pirquet's 1908 realization that tuberculin, a byproduct of tubercule bacilli culture, could be used as a diagnostic agent for TB infection that gave scientists, nurses and physicians hope that children considered "at risk" for TB could be identified early. Pirquet's work helped forge the diagnosis of "pre-tuberculosis" upon which the preventorium was predicated, says Connolly.
The perceived value of the preventorium ended with the advent of antibiotics, which transformed TB from a chronic disease to one readily treatable as an outpatient. "By the 1940s, in addition to the declining incidence of TB and the availability of antibiotics to treat the disease, one of the reasons the preventorium seemed outmoded to many was because its supporters were not able to demonstrate its efficacy through research," the Yale scholar says.
A pediatric nurse practitioner, Connolly decided when she went back to school for her Ph.D. in nursing history at the University of Pennsylvania that she wanted to study a topic with contemporary relevance. The TB epidemic, she says, provided that connection since it has some similarities to the AIDS epidemic. Persons with AIDS, like those with TB, may be infected with the microorganism that causes the disease but not yet be ill. AIDS sufferers often are stigmatized, just as persons with TB were stigmatized, notes the professor, and persons with AIDS, like indigent TB patients, are often blamed for their own plight.
Connolly says there also are parallels between the TB epidemic and today's obesity epidemic, particularly among children.
"There are many instances today in which we 'blame the victim' for his or her condition," she says. "For example, obese children often live in places where fresh food is either inaccessible or too expensive for their parents to purchase. The fear of violence also makes it harder for parents to follow in the steps of earlier generations and let their children exercise and play outside unsupervised."
Connolly says there are three ways in which consideration of the preventorium movement can benefit contemporary health care providers.
Many families during the TB epidemic welcomed the fact that there was a child-saving venture such as a preventorium in their community, she says. "What I am suggesting is that we use all available resources, including history, to study child health and welfare issues critically and that we use this data to engage in an open, informed, rational debate," Connolly asserts.
Second, she says, a critical examination of the preventorium movement also forces contemporary health care providers to consider their own biases and the subtle impact of patients' social class, race or ethnicity on contemporary practice.
"Third, the preventorium movement case example can serve as a reminder to nurses and physicians that all clinical knowledge must be interpreted with the understanding of the dynamic nature of such information," Connolly says. "This is no less true today than it was at the beginning of the century. Only in hindsight can we know which of today's health care 'truths' stand the test of time and which are, like the early 20th-century preventorium movement, therapeutic artifacts."
-- By Jacqueline Weaver
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