The Improbable Path to Curing Tuberculosis

Bacteria meets racism meets Staten Island, with Maria Smilios

With the CDC considering ending the five-day isolation period for Covid, as well as rates of disease transmission spiking in Ukraine and Gaza, I thought it a poignant time to explore the history of one of the world’s most infectious diseases: tuberculosis. 

In her book, The Black Angels: The Untold Story of the Nurses Who Helped Cure Tuberculosis, and in conversation, author Maria Smilios traces the twists and turns of the journey to curing TB, and why too many people still go without treatment today.

A condensed transcript edited for clarity is below. You can also listen to the audio of the conversation, which includes discussion of the love story behind the invention of rubber gloves, the delicious reason pharmaceutical companies originally couldn’t patent the cure for TB, and more:

And (new!) here’s a link to Skipped History on Apple Podcasts, where you can listen to past interviews:

Turns out Voldemort was suffering more than we knew

Ben: To begin, I wonder if you could talk about the history of Seaview, a hospital at the center of your book, and what led to its founding in 1913.

MS: Absolutely. At the turn of the 20th century, tuberculosis was killing one in three people. It was a disease that stirred people's most potent fears. There was no remedy for it, except for sunshine and fresh air. People who got sick were ostracized from their communities, considered walking contagion. 

As tens of thousands of immigrants went from Europe to Manhattan’s Lower East Side, TB proliferated. People lived in buildings that the famous journalist Jacob Riis called “fever breeding structures”: cramped, unventilated, with residents sharing few, shared toilets. 

The head of New York’s Department of Charities was a bacteriologist named Hermann Biggs. Biggs saw that the Lower East Side (and Harlem, too) were hotbeds for the disease, and he went to the mayor and the Department of Health, saying the only way they could mitigate this disease was by building a hospital outside of Manhattan. They turned their eyes to Seaview on Staten Island, the highest point between Maine and Virginia. It's 400 feet above sea level.

Ben: Not the most impressive figure—

MS: Ha, no, but they were trying to create a sanatorium that was close to the city where people didn't have to pay much to get to, and Seaview was the spot.

Ben: One thing I thought was really interesting is that TB microbes reproduce very slowly.

MS: Yes. TB reproduces once every 24 hours versus something like E. coli, which reproduces every 20 minutes.

Ben: The bonobo of the bacteria world.

MS: Exactly. TB on the other hand has evolved to kill slowly. Once it enters your body, you won’t get sick for weeks, sometimes months. 

Ben: Can you talk a bit more about what the treatments were for TB?

MS: Before going to the hospital, many people would be sent to TB tents up on roofs, where they could get fresh air. They also turned to quack healers and quack medicine, at least until surgery started to come around in the late 1920s. By 1930 it had become the gold standard. 

There were different types of surgeries. One was the artificial pneumothorax, which was the deliberate collapse of your lung to try and deprive TB of oxygen. Sometimes it worked, but mostly it didn’t, and it was very uncomfortable. There are stories of people walking around with hissing noises coming out of them after the procedure. 

Ben: Makes you feel for Harry Potter and Voldemort. People thought they were speaking Parseltongue, but it turns out they each had a collapsed lung the whole time.

MS: There were more egregious surgeries, too, including a procedure where patients had ribs removed. But none of them worked so well. Surgery was more of a wing and a prayer kind of thing.

Ben: Let’s shift to the nurses at Seaview. Why in 1929 did the hospital face a sudden staffing shortage? 

MS: At first, Seaview was predominantly staffed by white nurses. Only four of New York’s 29 municipal hospitals allowed Black nurses to work. But in 1929, the white nurses began leaving for a few reasons.

First and foremost, their job was extremely dangerous. There was no PPE. There wasn’t even masking at the time. So nurses watched their colleagues get sick and die. White nurses had lots of options for jobs that wouldn’t kill them. Black nurses didn’t, and they began overseeing Seaview’s TB patients.

Ben: I noted that administrators at the hospital and citywide said handwashing was enough to fend off TB. They sound alarmingly like the CDC in 2020.

On the opposite side of the spectrum, you chronicle breakthroughs in treating tuberculosis. Maybe let’s begin with one that didn’t work out so well. Can you talk about Selman Waksman, please?

MS: Waksman was a soil microbiologist and professor at Rutgers University for many decades, during which he discovered several antibiotics and even coined the term, “antibiotics.” 

In the 1940s, most people searching for a cure for TB were looking for a synthetic antibiotic made in a lab, but Waksman thought it would come from the earth. He had a graduate student named Albert Schatz, hired at 23 years old to work in Waksman's lab — specifically, to work with actinomycetes, a type of bacteria found in soil. 

Waksman, who was deathly afraid of TB, tasked Schatz with sorting through the various types of actinomycetes to find one that worked against TB. Fast forward, they ended up finding two, one of which formed the basis of an antibiotic called streptomycin. People got so excited about the new treatment, and Waksman loved the spotlight, so he went along with it when the press said he’d found a cure.

But soon the British conducted the first long-term clinical trial of the drug. It worked for people who weren’t far along with TB, but for other patients, it sped up the disease. So the British were like, we're sorry to tell you that this is not the cure. 

Ben: There was a second treatment that did end up working. I wonder if you can talk about why it came to be tested at Seaview, in large part at the hands of the hospital’s Black nurses.

MS: Right. After people found out that streptomycin failed, there was a rush to find a new cure. 

Hoffman-La Roche, a drug company about 20 miles from Seaview, began working on a drug, something that was later called Isoniazid. The lab tested it against mice, and it worked. Then they did a test with Guinea pigs and it worked. So then they needed to test it on humans. 

In May 1951, Dr. Edward R. Robitzek, who was the acting medical director of Seaview Hospital, and his partner, Irving Sellikoff, agreed to test the drug on patients at Seaview. It was the perfect place for it, because of the wide diversity of people suffering from TB, and also because of the nurses.

They’d been working there for decades. They knew how tuberculosis ebbs and flows. They knew how wily the microbe is, how somebody could wake up one morning and seem fine, and then by afternoon something is off about them, and then by evening they hemorrhage.

The doctors administered the drug on an initial trial of five people, and then with the nurses' help, added 87 more. And, long story short, it worked. This combination of doctors, scientists, and nurses who were barred from working just about everywhere else pioneered a cure. Isoniazid allowed Seaview to close down in just ten years and has saved tens of millions of lives since.

Ben: I kind of took it for granted before reading your book, but the results are still unfolding. You note that just since 2000, Isoniazid has saved 66 million lives. 

MS: Yes. Globally, 10.6 million people still get sick every year from tuberculosis, mostly in TB-heavy countries like India and Sierra Leone, and in war zones. There are still over 1.5 million deaths annually.

Ben: Another astounding figure.

MS: Covid and TB are the leading infectious killers in the world. Fewer people would die from TB if drug companies lowered their prices — they’re completely preventable deaths.

It’s another reminder of how there are two healthcare systems in the world: one for the rich, and one for the poor. I lived in Astoria, New York when the city shut down in March 2020. I saw immigrant communities suffering disproportionately from a virus, just like a hundred years earlier. It rattled me. 

I think the history of Seaview and tuberculosis shows that we can’t go on existing with two healthcare systems: both for the sake of the people who are sick and also for the healthcare workers who do such important work yet often suffer needlessly themselves.

Ben: Clearly a lot has changed, but there's a lot more work to go and your book is certainly part of the effort pushing us in that direction. Thank you so much for being here to talk about it.

MS: Thank you for having me! It was fun.