In the 19th century, tuberculosis caused roughly one in four deaths in Europe.
Yet somehow it became romantic, with poets like John Keats cast as tragic heroes and pale skin treated as fashionable.
This is the story of how the world misunderstood a killer, finally tracked it down, and why it still kills more than a million people a year.
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and today we are going to talk about one of the most deadly diseases in human history: tuberculosis.
[00:00:31] It's a story of science, of social class, of romanticism, and of the extraordinary way a deadly disease came to be seen as something beautiful.
[00:00:42] OK then, let's not waste a minute and get right into it.
[00:00:48] It is the winter of 1820, and a young English poet is coughing into his handkerchief.
[00:00:57] He looks at what he has produced. He sees blood. Bright red blood.
[00:01:04] He recognises it immediately. He has seen it before, in his brother, who died of the same disease two years earlier.
[00:01:13] "I know the colour of that blood", he says to a friend.
[00:01:17] "It is arterial blood;—I cannot be deceived by that colour"
[00:01:21] "That drop of blood is my death-warrant; I must die."
[00:01:28] The man is the famous Romantic poet, John Keats. He is twenty-five years old.
[00:01:35] He is not wrong. He will be dead within the year.
[00:01:40] Keats was just one of the millions of people who would die that year from the disease, a disease that was at its peak responsible for one in four deaths in Europe, and still kills more than a million people per year today.
[00:01:58] And here is the strange thing about this story, and about the peculiar nature of tuberculosis.
[00:02:05] Across Europe at this time, people were reading the poetry of men like Keats and weeping. Not just at the beauty of his words, of his poetry, but at the supposed beauty of his suffering. At the romance of his decline.
[00:02:24] Unlike diseases that had come before it, things like the Black Death, there was something different, almost admirable, enviable, about tuberculosis.
[00:02:37] The pale skin, the thinness, the bright feverish eyes, the sense of a person burning intensely and briefly, like a candle: these were considered by some to be marks of a sensitive soul. Of an artistic nature. Of someone too refined and too alive for the dull material world.
[00:03:04] Today, we are going to explore how that happened.
[00:03:09] Now, although most people associate tuberculosis with the nineteenth century, tuberculosis has been around for centuries, millennia even.
[00:03:20] There's evidence of it in Egyptian mummies, in ancient Rome, ancient India and China.
[00:03:27] It has always been there, but it wasn't until the late 18th century that it really reached its peak.
[00:03:36] For this, we have the Industrial Revolution to thank.
[00:03:40] From the late eighteenth century, starting in northern England and later spreading through Europe, millions of people left the countryside and moved to cities.
[00:03:52] They moved because the cities were where the work was, in the factories and mills and foundries that were springing up everywhere. The promise of wages. The promise of something better than the subsistence living they were eking out in the fields.
[00:04:10] What they found, in many cases, was this: twelve, fourteen, sixteen-hour working days in rooms with no natural light and no ventilation. Housing that was not really housing, more like stacked wooden boxes, each containing a family, each sharing walls and ceilings and air with six other families. Streets so narrow that sunlight barely reached the ground.
[00:04:41] This was the perfect breeding ground for tuberculosis, TB, or the White Plague, as it would come to be called.
[00:04:51] Now, tuberculosis is a contagious disease caused by a particular type of bacterium, Mycobacterium tuberculosis, to give it its official name.
[00:05:04] It spreads through the air. When an infected person coughs, sneezes, or simply breathes, tiny droplets carrying the bacteria disperse into the surrounding air.
[00:05:19] In a well-ventilated space, or outside, the droplets disperse and become harmless. In a packed, airless factory or a crowded tenement room, they do not.
[00:05:33] The bacterium is passed from one person to another. Perhaps interestingly enough, 90-95% of people who are infected do not become sick, and instead, the bacteria remain inactive in the body. This is called latent tuberculosis, and it's estimated that even today, around a quarter of the world's population have it.
[00:06:01] But for 5-10% of those infected, it turns into active tuberculosis, and for much of human history, that was a death sentence.
[00:06:16] In most cases, it affects the lungs, but it can also spread to other organs.
[00:06:23] The infected person will typically cough up blood and feel short of breath, they'll have high fever, they will lose weight, and for most of human history, this 'wasting away' would typically last anywhere from two to five years before the body finally succumbed.
[00:06:45] And by the middle of the 19th century, it was responsible for one out of every four deaths.
[00:06:53] It did not discriminate. It killed factory workers and it killed kings. It killed the young and the old, the healthy and the weak, the rich and the poor. It was so widespread it became simply a fact of life, as ordinary and expected as poverty or cold winters.
[00:07:16] Doctors did not know what caused it, or how to cure it.
[00:07:21] Because the disease was so widespread and so apparently random, striking some people and sparing others who lived in identical conditions, doctors didn't initially believe it was contagious.
[00:07:37] Two alternative explanations rose to fill the gap.
[00:07:41] The first was predisposition. Some people, it was believed, simply came from families prone to consumption, likely to get it. If your mother or sister had died of it, you were likely to follow. Now, this was not entirely wrong, and there is some link between genetics and likelihood of developing the disease.
[00:08:08] But it also gave doctors a convenient excuse — "well, you were always bound to get it".
[00:08:16] The second explanation was what they called excitement. Not excitement in an emotional sense, but in a medical sense: the idea that certain activities or conditions could trigger or worsen the disease in those who were predisposed to it.
[00:08:36] And the list of possible excitants, or things that could cause TB, was extraordinary.
[00:08:44] Working too hard. Not working hard enough. Sleeping too much. Sleeping too little. Eating too much. Not eating enough. Being too cold. Being too warm. Reading too much. Doing too little exercise, or too much of it.
[00:08:59] And wearing the wrong clothes.
[00:09:03] The concern, broadly, was about too much or too little clothing, and there has been much commentary on the link between ideas about tuberculosis and the fashion of the time.
[00:09:16] Too little clothing exposed the body to cold and damp, which was thought to disrupt the circulation of the blood and allow disease to settle in the lungs. Off-the-shoulder styles that became fashionable in the 1820s and 1830s were condemned for exposing the collarbone and neckline. Thin stockings could also be a problem. Even the dropping of high men's waistcoats was a cause for concern.
[00:09:46] Too much clothing was equally problematic, and for the opposite reason.
[00:09:51] Too many layers were thought to trap the body's impurities inside, preventing the skin from expelling what it should.
[00:10:00] Of course, all of this was rubbish, it was medically incorrect. But it's quite revealing about the way Victorians thought about the connection between disease, behaviour, and morality.
[00:10:16] And the other thing to mention is that there is one school of thought, and quite a prominent book, that suggests that tuberculosis, and the physical effects of it, actually shaped fashion in the 18th and 19th century, that people — especially women — would do their make up in a way that made them look like they had tuberculosis. Pale skin, red lips, and even using toxic cosmetics to make their pupils more dilated.
[00:10:49] However, there are other historians who say that this connection is exaggerated, and that tuberculosis simply coincided with pre-existing fashion trends; it didn't cause them.
[00:11:02] What is agreed upon, however, is that the disease did have a glamorous quality to it.
[00:11:09] It didn't cover you with warts or turn you mad. It made you thin and pale, your cheeks rosy, your lips red, and your eyes sparkly.
[00:11:21] Lord Byron once said he wished he could die of consumption, because the ladies would say how interesting he looked in dying. And he spent considerable effort cultivating the aesthetic: the pallor, the thinness, the air of tragic intensity.
[00:11:40] What's more, the disease often took on an even a semi-religious quality.
[00:11:46] Death came slowly, typically over the course of months and years, not days.
[00:11:54] There was time for farewells, for forgiveness, for the expressions of comfort that both the dying and the grieving desperately needed.
[00:12:04] Physically, it was almost as if you could see the life drifting away from the bed-ridden patient, the body wasting away. The eyes large and luminous. A fever giving a certain intensity and brightness to everything.
[00:12:21] And a calmness. Even a serenity, as if this caused the dying person to accept their fate in a way other diseases did not. In their final hours, the patient existed somewhere between the living and the dead. Closer to heaven than any healthy person could be, half human, half angel.
[00:12:47] Now, so far we have really been talking about the romanticism of tuberculosis by a certain class of people: the wealthy, the leisured, the people who had the time and means to write poetry and gad about from townhouse to townhouse.
[00:13:05] For the majority of people who died of tuberculosis, there was of course nothing romantic about it. Factory workers dying alone in a crowded apartment, children dying in a workhouse, buried in an unmarked grave.
[00:13:22] These were the majority, forgotten to history.
[00:13:26] By the middle of the 19th century, TB was killing 1% of London's population every single year, and was responsible for 40% of all deaths of working-class people.
[00:13:42] But by the 1870s, the science of disease was changing.
[00:13:48] The old explanations — predisposition, excitement, bad air, moral weakness — they were rightly beginning to be dismissed, to be replaced by germ theory.
[00:14:02] This was the idea that many diseases were caused by specific living organisms, invisible to the naked eye, that invaded the body and reproduced within it.
[00:14:15] Robert Koch, a German doctor, was one of the great figures of this new science. And on the 24th of March, 1882, he stood before the Berlin Physiological Society and delivered one of the most important scientific announcements in history.
[00:14:36] He had found the bacterium that caused tuberculosis.
[00:14:41] Mycobacterium tuberculosis, he called it.
[00:14:46] Over the preceding months, Koch had developed entirely new laboratory techniques to isolate it, he had grown it in culture outside the body, he had infected healthy animals with it, and he had watched them develop the disease.
[00:15:03] He had proved, conclusively, that tuberculosis was not hereditary. Not caused by cold air or moral weakness or wearing the wrong stockings. It was an infection. A bacterium. Something that could, in principle, be understood and beaten.
[00:15:24] Koch won the Nobel Prize for his efforts. He had discovered what caused tuberculosis, but, importantly, this did not equal discovering how to treat it.
[00:15:37] No drug capable of killing the tuberculosis bacterium could be found. The organism was unusual: slow-growing and protected by a waxy outer coat that most substances could not penetrate.
[00:15:54] What grew up instead was something called the sanitarium, a type of specialised hospital, typically far from a city, near the sea or up in the mountains.
[00:16:07] The logic was straightforward. It was the urban environment where tuberculosis flourished, with its crowding, its pollution, its lack of sunlight and fresh air. So removing the patient from that environment might allow the body's own defences to fight the disease.
[00:16:27] Sanitaria spread across Europe and North America. They were built high in the Alps and the Scottish Highlands, on the coasts of southern Europe, in the mountain ranges of the American west.
[00:16:41] Patients were given beds on open-air terraces, even in winter. They were encouraged to sleep outdoors, to breathe deeply, to eat large amounts of food. Some facilities recommended as many as six thousand calories a day, which is about three times the daily recommendation for an adult woman, or for the McDonald's fans, 11 Big Macs.
[00:17:08] For those who could afford the better establishments, a sanitarium could be almost pleasant: a long rest in beautiful surroundings with regular meals and medical supervision.
[00:17:21] For the poor in the public sanitaria, the experience was something closer to a prison. You were removed from your family, your work, your life. You might stay for months or years.
[00:17:36] And unfortunately, the sanitaria didn't work particularly well, whether private or public.
[00:17:44] Rest and good food could strengthen a patient. Clean air reduced the spread of infection to others.
[00:17:51] But for those already seriously ill, the "cure" was often temporary. Many would stay for years, seemingly improving, only to relapse and die the moment they returned to the smog and poverty of the city.
[00:18:10] There was a step forward with the BCG vaccine, which was first administered in 1921, but while it reduced the risk of severe disease; it did not eliminate tuberculosis.
[00:18:24] The real answer arrived in 1943, in a soil laboratory in New Jersey.
[00:18:32] A scientist named Selman Waksman had spent years studying the microorganisms that live in soil, reasoning that if bacteria can destroy each other in nature, some of them might produce substances that could be useful as medicines.
[00:18:51] He and his team tested thousands of soil samples. Most produced nothing.
[00:18:59] Then they found one that did.
[00:19:02] A common soil bacterium produced a substance that could kill Mycobacterium tuberculosis in the laboratory. They called it streptomycin.
[00:19:14] On the 20th of November, 1944, streptomycin was given for the first time to a human patient: a young woman who was critically ill with tuberculosis and had been expected to die within weeks.
[00:19:30] Miraculously, she recovered.
[00:19:33] The response in the medical world was something close to disbelief. Here was a drug that could actually cure a disease that had killed large parts of the population for two centuries. Waksman received the Nobel Prize in Medicine in 1952.
[00:19:53] Over the following decades, more antibiotics followed. TB wards began to empty. Sanitaria closed. In the wealthy countries of Europe and North America, tuberculosis became increasingly rare. And by the 1980s, some public health officials were quietly talking about eliminating it entirely.
[00:20:18] But, as you may know, tuberculosis has never gone away.
[00:20:23] While the developed world was congratulating itself on all but defeating it, the disease continued in the parts of the world that could not afford antibiotics, could not build hospitals, and could not fund public health campaigns.
[00:20:40] Today, tuberculosis still infects around ten million people every year. In 2024, it killed approximately 1.25 million people, making it one of the leading infectious disease killers on the planet.
[00:21:00] The vast majority of those deaths occur in South-East Asia, sub-Saharan Africa, and the Western Pacific, in conditions of poverty and overcrowding that would have been familiar to the factory workers of Manchester in 1840.
[00:21:15] And now there is an additional problem making the situation considerably worse: drug-resistant tuberculosis.
[00:21:24] This happens when antibiotics are used incorrectly — when courses of treatment are interrupted, people are given the wrong doses, or lower quality drugs are used.
[00:21:36] In these cases, the tuberculosis bacteria can evolve to resist the drugs, and in 2024, an estimated 390,000 people developed drug-resistant tuberculosis. Treating it requires different, more expensive regimens, with more severe side effects and much lower success rates.
[00:22:02] Of those 390,000 people, only around two in five were able to access any treatment at all.
[00:22:12] So the unfortunate point we need to end with is this: Tuberculosis has had a cure since 1944. The drugs exist. The vaccine exists. The knowledge of how it spreads, and how to prevent it, has been established for well over a century.
[00:22:31] It doesn't have to kill anyone, yet it still kills 1.25 million people a year.
[00:22:39] And I think we can all agree that there is nothing romantic about that.
[00:22:45] OK, then, that is it for today's episode on the deadly history of tuberculosis.
[00:22:50] I hope it's been an interesting one and that you've learnt something new.
[00:22:54] We've already made a few episodes on things related to this episode, which you might like to check out if you haven't done so already.
[00:23:01] There's an episode on Lord Byron, which is episode 244, on the Brontë sisters, several of whom died of tuberculosis, which is episode 271, and on the Industrial Revolution, which is episode 150.
[00:23:18] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:22] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and today we are going to talk about one of the most deadly diseases in human history: tuberculosis.
[00:00:31] It's a story of science, of social class, of romanticism, and of the extraordinary way a deadly disease came to be seen as something beautiful.
[00:00:42] OK then, let's not waste a minute and get right into it.
[00:00:48] It is the winter of 1820, and a young English poet is coughing into his handkerchief.
[00:00:57] He looks at what he has produced. He sees blood. Bright red blood.
[00:01:04] He recognises it immediately. He has seen it before, in his brother, who died of the same disease two years earlier.
[00:01:13] "I know the colour of that blood", he says to a friend.
[00:01:17] "It is arterial blood;—I cannot be deceived by that colour"
[00:01:21] "That drop of blood is my death-warrant; I must die."
[00:01:28] The man is the famous Romantic poet, John Keats. He is twenty-five years old.
[00:01:35] He is not wrong. He will be dead within the year.
[00:01:40] Keats was just one of the millions of people who would die that year from the disease, a disease that was at its peak responsible for one in four deaths in Europe, and still kills more than a million people per year today.
[00:01:58] And here is the strange thing about this story, and about the peculiar nature of tuberculosis.
[00:02:05] Across Europe at this time, people were reading the poetry of men like Keats and weeping. Not just at the beauty of his words, of his poetry, but at the supposed beauty of his suffering. At the romance of his decline.
[00:02:24] Unlike diseases that had come before it, things like the Black Death, there was something different, almost admirable, enviable, about tuberculosis.
[00:02:37] The pale skin, the thinness, the bright feverish eyes, the sense of a person burning intensely and briefly, like a candle: these were considered by some to be marks of a sensitive soul. Of an artistic nature. Of someone too refined and too alive for the dull material world.
[00:03:04] Today, we are going to explore how that happened.
[00:03:09] Now, although most people associate tuberculosis with the nineteenth century, tuberculosis has been around for centuries, millennia even.
[00:03:20] There's evidence of it in Egyptian mummies, in ancient Rome, ancient India and China.
[00:03:27] It has always been there, but it wasn't until the late 18th century that it really reached its peak.
[00:03:36] For this, we have the Industrial Revolution to thank.
[00:03:40] From the late eighteenth century, starting in northern England and later spreading through Europe, millions of people left the countryside and moved to cities.
[00:03:52] They moved because the cities were where the work was, in the factories and mills and foundries that were springing up everywhere. The promise of wages. The promise of something better than the subsistence living they were eking out in the fields.
[00:04:10] What they found, in many cases, was this: twelve, fourteen, sixteen-hour working days in rooms with no natural light and no ventilation. Housing that was not really housing, more like stacked wooden boxes, each containing a family, each sharing walls and ceilings and air with six other families. Streets so narrow that sunlight barely reached the ground.
[00:04:41] This was the perfect breeding ground for tuberculosis, TB, or the White Plague, as it would come to be called.
[00:04:51] Now, tuberculosis is a contagious disease caused by a particular type of bacterium, Mycobacterium tuberculosis, to give it its official name.
[00:05:04] It spreads through the air. When an infected person coughs, sneezes, or simply breathes, tiny droplets carrying the bacteria disperse into the surrounding air.
[00:05:19] In a well-ventilated space, or outside, the droplets disperse and become harmless. In a packed, airless factory or a crowded tenement room, they do not.
[00:05:33] The bacterium is passed from one person to another. Perhaps interestingly enough, 90-95% of people who are infected do not become sick, and instead, the bacteria remain inactive in the body. This is called latent tuberculosis, and it's estimated that even today, around a quarter of the world's population have it.
[00:06:01] But for 5-10% of those infected, it turns into active tuberculosis, and for much of human history, that was a death sentence.
[00:06:16] In most cases, it affects the lungs, but it can also spread to other organs.
[00:06:23] The infected person will typically cough up blood and feel short of breath, they'll have high fever, they will lose weight, and for most of human history, this 'wasting away' would typically last anywhere from two to five years before the body finally succumbed.
[00:06:45] And by the middle of the 19th century, it was responsible for one out of every four deaths.
[00:06:53] It did not discriminate. It killed factory workers and it killed kings. It killed the young and the old, the healthy and the weak, the rich and the poor. It was so widespread it became simply a fact of life, as ordinary and expected as poverty or cold winters.
[00:07:16] Doctors did not know what caused it, or how to cure it.
[00:07:21] Because the disease was so widespread and so apparently random, striking some people and sparing others who lived in identical conditions, doctors didn't initially believe it was contagious.
[00:07:37] Two alternative explanations rose to fill the gap.
[00:07:41] The first was predisposition. Some people, it was believed, simply came from families prone to consumption, likely to get it. If your mother or sister had died of it, you were likely to follow. Now, this was not entirely wrong, and there is some link between genetics and likelihood of developing the disease.
[00:08:08] But it also gave doctors a convenient excuse — "well, you were always bound to get it".
[00:08:16] The second explanation was what they called excitement. Not excitement in an emotional sense, but in a medical sense: the idea that certain activities or conditions could trigger or worsen the disease in those who were predisposed to it.
[00:08:36] And the list of possible excitants, or things that could cause TB, was extraordinary.
[00:08:44] Working too hard. Not working hard enough. Sleeping too much. Sleeping too little. Eating too much. Not eating enough. Being too cold. Being too warm. Reading too much. Doing too little exercise, or too much of it.
[00:08:59] And wearing the wrong clothes.
[00:09:03] The concern, broadly, was about too much or too little clothing, and there has been much commentary on the link between ideas about tuberculosis and the fashion of the time.
[00:09:16] Too little clothing exposed the body to cold and damp, which was thought to disrupt the circulation of the blood and allow disease to settle in the lungs. Off-the-shoulder styles that became fashionable in the 1820s and 1830s were condemned for exposing the collarbone and neckline. Thin stockings could also be a problem. Even the dropping of high men's waistcoats was a cause for concern.
[00:09:46] Too much clothing was equally problematic, and for the opposite reason.
[00:09:51] Too many layers were thought to trap the body's impurities inside, preventing the skin from expelling what it should.
[00:10:00] Of course, all of this was rubbish, it was medically incorrect. But it's quite revealing about the way Victorians thought about the connection between disease, behaviour, and morality.
[00:10:16] And the other thing to mention is that there is one school of thought, and quite a prominent book, that suggests that tuberculosis, and the physical effects of it, actually shaped fashion in the 18th and 19th century, that people — especially women — would do their make up in a way that made them look like they had tuberculosis. Pale skin, red lips, and even using toxic cosmetics to make their pupils more dilated.
[00:10:49] However, there are other historians who say that this connection is exaggerated, and that tuberculosis simply coincided with pre-existing fashion trends; it didn't cause them.
[00:11:02] What is agreed upon, however, is that the disease did have a glamorous quality to it.
[00:11:09] It didn't cover you with warts or turn you mad. It made you thin and pale, your cheeks rosy, your lips red, and your eyes sparkly.
[00:11:21] Lord Byron once said he wished he could die of consumption, because the ladies would say how interesting he looked in dying. And he spent considerable effort cultivating the aesthetic: the pallor, the thinness, the air of tragic intensity.
[00:11:40] What's more, the disease often took on an even a semi-religious quality.
[00:11:46] Death came slowly, typically over the course of months and years, not days.
[00:11:54] There was time for farewells, for forgiveness, for the expressions of comfort that both the dying and the grieving desperately needed.
[00:12:04] Physically, it was almost as if you could see the life drifting away from the bed-ridden patient, the body wasting away. The eyes large and luminous. A fever giving a certain intensity and brightness to everything.
[00:12:21] And a calmness. Even a serenity, as if this caused the dying person to accept their fate in a way other diseases did not. In their final hours, the patient existed somewhere between the living and the dead. Closer to heaven than any healthy person could be, half human, half angel.
[00:12:47] Now, so far we have really been talking about the romanticism of tuberculosis by a certain class of people: the wealthy, the leisured, the people who had the time and means to write poetry and gad about from townhouse to townhouse.
[00:13:05] For the majority of people who died of tuberculosis, there was of course nothing romantic about it. Factory workers dying alone in a crowded apartment, children dying in a workhouse, buried in an unmarked grave.
[00:13:22] These were the majority, forgotten to history.
[00:13:26] By the middle of the 19th century, TB was killing 1% of London's population every single year, and was responsible for 40% of all deaths of working-class people.
[00:13:42] But by the 1870s, the science of disease was changing.
[00:13:48] The old explanations — predisposition, excitement, bad air, moral weakness — they were rightly beginning to be dismissed, to be replaced by germ theory.
[00:14:02] This was the idea that many diseases were caused by specific living organisms, invisible to the naked eye, that invaded the body and reproduced within it.
[00:14:15] Robert Koch, a German doctor, was one of the great figures of this new science. And on the 24th of March, 1882, he stood before the Berlin Physiological Society and delivered one of the most important scientific announcements in history.
[00:14:36] He had found the bacterium that caused tuberculosis.
[00:14:41] Mycobacterium tuberculosis, he called it.
[00:14:46] Over the preceding months, Koch had developed entirely new laboratory techniques to isolate it, he had grown it in culture outside the body, he had infected healthy animals with it, and he had watched them develop the disease.
[00:15:03] He had proved, conclusively, that tuberculosis was not hereditary. Not caused by cold air or moral weakness or wearing the wrong stockings. It was an infection. A bacterium. Something that could, in principle, be understood and beaten.
[00:15:24] Koch won the Nobel Prize for his efforts. He had discovered what caused tuberculosis, but, importantly, this did not equal discovering how to treat it.
[00:15:37] No drug capable of killing the tuberculosis bacterium could be found. The organism was unusual: slow-growing and protected by a waxy outer coat that most substances could not penetrate.
[00:15:54] What grew up instead was something called the sanitarium, a type of specialised hospital, typically far from a city, near the sea or up in the mountains.
[00:16:07] The logic was straightforward. It was the urban environment where tuberculosis flourished, with its crowding, its pollution, its lack of sunlight and fresh air. So removing the patient from that environment might allow the body's own defences to fight the disease.
[00:16:27] Sanitaria spread across Europe and North America. They were built high in the Alps and the Scottish Highlands, on the coasts of southern Europe, in the mountain ranges of the American west.
[00:16:41] Patients were given beds on open-air terraces, even in winter. They were encouraged to sleep outdoors, to breathe deeply, to eat large amounts of food. Some facilities recommended as many as six thousand calories a day, which is about three times the daily recommendation for an adult woman, or for the McDonald's fans, 11 Big Macs.
[00:17:08] For those who could afford the better establishments, a sanitarium could be almost pleasant: a long rest in beautiful surroundings with regular meals and medical supervision.
[00:17:21] For the poor in the public sanitaria, the experience was something closer to a prison. You were removed from your family, your work, your life. You might stay for months or years.
[00:17:36] And unfortunately, the sanitaria didn't work particularly well, whether private or public.
[00:17:44] Rest and good food could strengthen a patient. Clean air reduced the spread of infection to others.
[00:17:51] But for those already seriously ill, the "cure" was often temporary. Many would stay for years, seemingly improving, only to relapse and die the moment they returned to the smog and poverty of the city.
[00:18:10] There was a step forward with the BCG vaccine, which was first administered in 1921, but while it reduced the risk of severe disease; it did not eliminate tuberculosis.
[00:18:24] The real answer arrived in 1943, in a soil laboratory in New Jersey.
[00:18:32] A scientist named Selman Waksman had spent years studying the microorganisms that live in soil, reasoning that if bacteria can destroy each other in nature, some of them might produce substances that could be useful as medicines.
[00:18:51] He and his team tested thousands of soil samples. Most produced nothing.
[00:18:59] Then they found one that did.
[00:19:02] A common soil bacterium produced a substance that could kill Mycobacterium tuberculosis in the laboratory. They called it streptomycin.
[00:19:14] On the 20th of November, 1944, streptomycin was given for the first time to a human patient: a young woman who was critically ill with tuberculosis and had been expected to die within weeks.
[00:19:30] Miraculously, she recovered.
[00:19:33] The response in the medical world was something close to disbelief. Here was a drug that could actually cure a disease that had killed large parts of the population for two centuries. Waksman received the Nobel Prize in Medicine in 1952.
[00:19:53] Over the following decades, more antibiotics followed. TB wards began to empty. Sanitaria closed. In the wealthy countries of Europe and North America, tuberculosis became increasingly rare. And by the 1980s, some public health officials were quietly talking about eliminating it entirely.
[00:20:18] But, as you may know, tuberculosis has never gone away.
[00:20:23] While the developed world was congratulating itself on all but defeating it, the disease continued in the parts of the world that could not afford antibiotics, could not build hospitals, and could not fund public health campaigns.
[00:20:40] Today, tuberculosis still infects around ten million people every year. In 2024, it killed approximately 1.25 million people, making it one of the leading infectious disease killers on the planet.
[00:21:00] The vast majority of those deaths occur in South-East Asia, sub-Saharan Africa, and the Western Pacific, in conditions of poverty and overcrowding that would have been familiar to the factory workers of Manchester in 1840.
[00:21:15] And now there is an additional problem making the situation considerably worse: drug-resistant tuberculosis.
[00:21:24] This happens when antibiotics are used incorrectly — when courses of treatment are interrupted, people are given the wrong doses, or lower quality drugs are used.
[00:21:36] In these cases, the tuberculosis bacteria can evolve to resist the drugs, and in 2024, an estimated 390,000 people developed drug-resistant tuberculosis. Treating it requires different, more expensive regimens, with more severe side effects and much lower success rates.
[00:22:02] Of those 390,000 people, only around two in five were able to access any treatment at all.
[00:22:12] So the unfortunate point we need to end with is this: Tuberculosis has had a cure since 1944. The drugs exist. The vaccine exists. The knowledge of how it spreads, and how to prevent it, has been established for well over a century.
[00:22:31] It doesn't have to kill anyone, yet it still kills 1.25 million people a year.
[00:22:39] And I think we can all agree that there is nothing romantic about that.
[00:22:45] OK, then, that is it for today's episode on the deadly history of tuberculosis.
[00:22:50] I hope it's been an interesting one and that you've learnt something new.
[00:22:54] We've already made a few episodes on things related to this episode, which you might like to check out if you haven't done so already.
[00:23:01] There's an episode on Lord Byron, which is episode 244, on the Brontë sisters, several of whom died of tuberculosis, which is episode 271, and on the Industrial Revolution, which is episode 150.
[00:23:18] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:22] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and today we are going to talk about one of the most deadly diseases in human history: tuberculosis.
[00:00:31] It's a story of science, of social class, of romanticism, and of the extraordinary way a deadly disease came to be seen as something beautiful.
[00:00:42] OK then, let's not waste a minute and get right into it.
[00:00:48] It is the winter of 1820, and a young English poet is coughing into his handkerchief.
[00:00:57] He looks at what he has produced. He sees blood. Bright red blood.
[00:01:04] He recognises it immediately. He has seen it before, in his brother, who died of the same disease two years earlier.
[00:01:13] "I know the colour of that blood", he says to a friend.
[00:01:17] "It is arterial blood;—I cannot be deceived by that colour"
[00:01:21] "That drop of blood is my death-warrant; I must die."
[00:01:28] The man is the famous Romantic poet, John Keats. He is twenty-five years old.
[00:01:35] He is not wrong. He will be dead within the year.
[00:01:40] Keats was just one of the millions of people who would die that year from the disease, a disease that was at its peak responsible for one in four deaths in Europe, and still kills more than a million people per year today.
[00:01:58] And here is the strange thing about this story, and about the peculiar nature of tuberculosis.
[00:02:05] Across Europe at this time, people were reading the poetry of men like Keats and weeping. Not just at the beauty of his words, of his poetry, but at the supposed beauty of his suffering. At the romance of his decline.
[00:02:24] Unlike diseases that had come before it, things like the Black Death, there was something different, almost admirable, enviable, about tuberculosis.
[00:02:37] The pale skin, the thinness, the bright feverish eyes, the sense of a person burning intensely and briefly, like a candle: these were considered by some to be marks of a sensitive soul. Of an artistic nature. Of someone too refined and too alive for the dull material world.
[00:03:04] Today, we are going to explore how that happened.
[00:03:09] Now, although most people associate tuberculosis with the nineteenth century, tuberculosis has been around for centuries, millennia even.
[00:03:20] There's evidence of it in Egyptian mummies, in ancient Rome, ancient India and China.
[00:03:27] It has always been there, but it wasn't until the late 18th century that it really reached its peak.
[00:03:36] For this, we have the Industrial Revolution to thank.
[00:03:40] From the late eighteenth century, starting in northern England and later spreading through Europe, millions of people left the countryside and moved to cities.
[00:03:52] They moved because the cities were where the work was, in the factories and mills and foundries that were springing up everywhere. The promise of wages. The promise of something better than the subsistence living they were eking out in the fields.
[00:04:10] What they found, in many cases, was this: twelve, fourteen, sixteen-hour working days in rooms with no natural light and no ventilation. Housing that was not really housing, more like stacked wooden boxes, each containing a family, each sharing walls and ceilings and air with six other families. Streets so narrow that sunlight barely reached the ground.
[00:04:41] This was the perfect breeding ground for tuberculosis, TB, or the White Plague, as it would come to be called.
[00:04:51] Now, tuberculosis is a contagious disease caused by a particular type of bacterium, Mycobacterium tuberculosis, to give it its official name.
[00:05:04] It spreads through the air. When an infected person coughs, sneezes, or simply breathes, tiny droplets carrying the bacteria disperse into the surrounding air.
[00:05:19] In a well-ventilated space, or outside, the droplets disperse and become harmless. In a packed, airless factory or a crowded tenement room, they do not.
[00:05:33] The bacterium is passed from one person to another. Perhaps interestingly enough, 90-95% of people who are infected do not become sick, and instead, the bacteria remain inactive in the body. This is called latent tuberculosis, and it's estimated that even today, around a quarter of the world's population have it.
[00:06:01] But for 5-10% of those infected, it turns into active tuberculosis, and for much of human history, that was a death sentence.
[00:06:16] In most cases, it affects the lungs, but it can also spread to other organs.
[00:06:23] The infected person will typically cough up blood and feel short of breath, they'll have high fever, they will lose weight, and for most of human history, this 'wasting away' would typically last anywhere from two to five years before the body finally succumbed.
[00:06:45] And by the middle of the 19th century, it was responsible for one out of every four deaths.
[00:06:53] It did not discriminate. It killed factory workers and it killed kings. It killed the young and the old, the healthy and the weak, the rich and the poor. It was so widespread it became simply a fact of life, as ordinary and expected as poverty or cold winters.
[00:07:16] Doctors did not know what caused it, or how to cure it.
[00:07:21] Because the disease was so widespread and so apparently random, striking some people and sparing others who lived in identical conditions, doctors didn't initially believe it was contagious.
[00:07:37] Two alternative explanations rose to fill the gap.
[00:07:41] The first was predisposition. Some people, it was believed, simply came from families prone to consumption, likely to get it. If your mother or sister had died of it, you were likely to follow. Now, this was not entirely wrong, and there is some link between genetics and likelihood of developing the disease.
[00:08:08] But it also gave doctors a convenient excuse — "well, you were always bound to get it".
[00:08:16] The second explanation was what they called excitement. Not excitement in an emotional sense, but in a medical sense: the idea that certain activities or conditions could trigger or worsen the disease in those who were predisposed to it.
[00:08:36] And the list of possible excitants, or things that could cause TB, was extraordinary.
[00:08:44] Working too hard. Not working hard enough. Sleeping too much. Sleeping too little. Eating too much. Not eating enough. Being too cold. Being too warm. Reading too much. Doing too little exercise, or too much of it.
[00:08:59] And wearing the wrong clothes.
[00:09:03] The concern, broadly, was about too much or too little clothing, and there has been much commentary on the link between ideas about tuberculosis and the fashion of the time.
[00:09:16] Too little clothing exposed the body to cold and damp, which was thought to disrupt the circulation of the blood and allow disease to settle in the lungs. Off-the-shoulder styles that became fashionable in the 1820s and 1830s were condemned for exposing the collarbone and neckline. Thin stockings could also be a problem. Even the dropping of high men's waistcoats was a cause for concern.
[00:09:46] Too much clothing was equally problematic, and for the opposite reason.
[00:09:51] Too many layers were thought to trap the body's impurities inside, preventing the skin from expelling what it should.
[00:10:00] Of course, all of this was rubbish, it was medically incorrect. But it's quite revealing about the way Victorians thought about the connection between disease, behaviour, and morality.
[00:10:16] And the other thing to mention is that there is one school of thought, and quite a prominent book, that suggests that tuberculosis, and the physical effects of it, actually shaped fashion in the 18th and 19th century, that people — especially women — would do their make up in a way that made them look like they had tuberculosis. Pale skin, red lips, and even using toxic cosmetics to make their pupils more dilated.
[00:10:49] However, there are other historians who say that this connection is exaggerated, and that tuberculosis simply coincided with pre-existing fashion trends; it didn't cause them.
[00:11:02] What is agreed upon, however, is that the disease did have a glamorous quality to it.
[00:11:09] It didn't cover you with warts or turn you mad. It made you thin and pale, your cheeks rosy, your lips red, and your eyes sparkly.
[00:11:21] Lord Byron once said he wished he could die of consumption, because the ladies would say how interesting he looked in dying. And he spent considerable effort cultivating the aesthetic: the pallor, the thinness, the air of tragic intensity.
[00:11:40] What's more, the disease often took on an even a semi-religious quality.
[00:11:46] Death came slowly, typically over the course of months and years, not days.
[00:11:54] There was time for farewells, for forgiveness, for the expressions of comfort that both the dying and the grieving desperately needed.
[00:12:04] Physically, it was almost as if you could see the life drifting away from the bed-ridden patient, the body wasting away. The eyes large and luminous. A fever giving a certain intensity and brightness to everything.
[00:12:21] And a calmness. Even a serenity, as if this caused the dying person to accept their fate in a way other diseases did not. In their final hours, the patient existed somewhere between the living and the dead. Closer to heaven than any healthy person could be, half human, half angel.
[00:12:47] Now, so far we have really been talking about the romanticism of tuberculosis by a certain class of people: the wealthy, the leisured, the people who had the time and means to write poetry and gad about from townhouse to townhouse.
[00:13:05] For the majority of people who died of tuberculosis, there was of course nothing romantic about it. Factory workers dying alone in a crowded apartment, children dying in a workhouse, buried in an unmarked grave.
[00:13:22] These were the majority, forgotten to history.
[00:13:26] By the middle of the 19th century, TB was killing 1% of London's population every single year, and was responsible for 40% of all deaths of working-class people.
[00:13:42] But by the 1870s, the science of disease was changing.
[00:13:48] The old explanations — predisposition, excitement, bad air, moral weakness — they were rightly beginning to be dismissed, to be replaced by germ theory.
[00:14:02] This was the idea that many diseases were caused by specific living organisms, invisible to the naked eye, that invaded the body and reproduced within it.
[00:14:15] Robert Koch, a German doctor, was one of the great figures of this new science. And on the 24th of March, 1882, he stood before the Berlin Physiological Society and delivered one of the most important scientific announcements in history.
[00:14:36] He had found the bacterium that caused tuberculosis.
[00:14:41] Mycobacterium tuberculosis, he called it.
[00:14:46] Over the preceding months, Koch had developed entirely new laboratory techniques to isolate it, he had grown it in culture outside the body, he had infected healthy animals with it, and he had watched them develop the disease.
[00:15:03] He had proved, conclusively, that tuberculosis was not hereditary. Not caused by cold air or moral weakness or wearing the wrong stockings. It was an infection. A bacterium. Something that could, in principle, be understood and beaten.
[00:15:24] Koch won the Nobel Prize for his efforts. He had discovered what caused tuberculosis, but, importantly, this did not equal discovering how to treat it.
[00:15:37] No drug capable of killing the tuberculosis bacterium could be found. The organism was unusual: slow-growing and protected by a waxy outer coat that most substances could not penetrate.
[00:15:54] What grew up instead was something called the sanitarium, a type of specialised hospital, typically far from a city, near the sea or up in the mountains.
[00:16:07] The logic was straightforward. It was the urban environment where tuberculosis flourished, with its crowding, its pollution, its lack of sunlight and fresh air. So removing the patient from that environment might allow the body's own defences to fight the disease.
[00:16:27] Sanitaria spread across Europe and North America. They were built high in the Alps and the Scottish Highlands, on the coasts of southern Europe, in the mountain ranges of the American west.
[00:16:41] Patients were given beds on open-air terraces, even in winter. They were encouraged to sleep outdoors, to breathe deeply, to eat large amounts of food. Some facilities recommended as many as six thousand calories a day, which is about three times the daily recommendation for an adult woman, or for the McDonald's fans, 11 Big Macs.
[00:17:08] For those who could afford the better establishments, a sanitarium could be almost pleasant: a long rest in beautiful surroundings with regular meals and medical supervision.
[00:17:21] For the poor in the public sanitaria, the experience was something closer to a prison. You were removed from your family, your work, your life. You might stay for months or years.
[00:17:36] And unfortunately, the sanitaria didn't work particularly well, whether private or public.
[00:17:44] Rest and good food could strengthen a patient. Clean air reduced the spread of infection to others.
[00:17:51] But for those already seriously ill, the "cure" was often temporary. Many would stay for years, seemingly improving, only to relapse and die the moment they returned to the smog and poverty of the city.
[00:18:10] There was a step forward with the BCG vaccine, which was first administered in 1921, but while it reduced the risk of severe disease; it did not eliminate tuberculosis.
[00:18:24] The real answer arrived in 1943, in a soil laboratory in New Jersey.
[00:18:32] A scientist named Selman Waksman had spent years studying the microorganisms that live in soil, reasoning that if bacteria can destroy each other in nature, some of them might produce substances that could be useful as medicines.
[00:18:51] He and his team tested thousands of soil samples. Most produced nothing.
[00:18:59] Then they found one that did.
[00:19:02] A common soil bacterium produced a substance that could kill Mycobacterium tuberculosis in the laboratory. They called it streptomycin.
[00:19:14] On the 20th of November, 1944, streptomycin was given for the first time to a human patient: a young woman who was critically ill with tuberculosis and had been expected to die within weeks.
[00:19:30] Miraculously, she recovered.
[00:19:33] The response in the medical world was something close to disbelief. Here was a drug that could actually cure a disease that had killed large parts of the population for two centuries. Waksman received the Nobel Prize in Medicine in 1952.
[00:19:53] Over the following decades, more antibiotics followed. TB wards began to empty. Sanitaria closed. In the wealthy countries of Europe and North America, tuberculosis became increasingly rare. And by the 1980s, some public health officials were quietly talking about eliminating it entirely.
[00:20:18] But, as you may know, tuberculosis has never gone away.
[00:20:23] While the developed world was congratulating itself on all but defeating it, the disease continued in the parts of the world that could not afford antibiotics, could not build hospitals, and could not fund public health campaigns.
[00:20:40] Today, tuberculosis still infects around ten million people every year. In 2024, it killed approximately 1.25 million people, making it one of the leading infectious disease killers on the planet.
[00:21:00] The vast majority of those deaths occur in South-East Asia, sub-Saharan Africa, and the Western Pacific, in conditions of poverty and overcrowding that would have been familiar to the factory workers of Manchester in 1840.
[00:21:15] And now there is an additional problem making the situation considerably worse: drug-resistant tuberculosis.
[00:21:24] This happens when antibiotics are used incorrectly — when courses of treatment are interrupted, people are given the wrong doses, or lower quality drugs are used.
[00:21:36] In these cases, the tuberculosis bacteria can evolve to resist the drugs, and in 2024, an estimated 390,000 people developed drug-resistant tuberculosis. Treating it requires different, more expensive regimens, with more severe side effects and much lower success rates.
[00:22:02] Of those 390,000 people, only around two in five were able to access any treatment at all.
[00:22:12] So the unfortunate point we need to end with is this: Tuberculosis has had a cure since 1944. The drugs exist. The vaccine exists. The knowledge of how it spreads, and how to prevent it, has been established for well over a century.
[00:22:31] It doesn't have to kill anyone, yet it still kills 1.25 million people a year.
[00:22:39] And I think we can all agree that there is nothing romantic about that.
[00:22:45] OK, then, that is it for today's episode on the deadly history of tuberculosis.
[00:22:50] I hope it's been an interesting one and that you've learnt something new.
[00:22:54] We've already made a few episodes on things related to this episode, which you might like to check out if you haven't done so already.
[00:23:01] There's an episode on Lord Byron, which is episode 244, on the Brontë sisters, several of whom died of tuberculosis, which is episode 271, and on the Industrial Revolution, which is episode 150.
[00:23:18] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:22] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
