Tuberculosis, Income Inequality And The Great Depression


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Great Depression Hooverville in lower Manhattan. 1932.

Photo by Everett Collection

We now know from significant statistical evidence that the recent coronavirus pandemic has had a disproportionately adverse impact on poor people and even more on communities of color. This is not surprising given the fact that throughout history plagues and pandemics have affected lower income people in relatively greater numbers than individuals and families with higher income. This was true about tuberculosis which, until the 19th century, had been the deadliest disease in human history, killing an estimated one in seven people who had ever lived. Although the rate of infection dropped during the 19th and early 20th century, the disease continually ravaged low income communities, especially poor laborers who had to work in oppressive conditions in order to support themselves and their families. When the Great Depression struck in the early 1930s conditions became even worse for families struggling to support themselves, and the spread of tuberculosis among the poorest people made the struggle to survive even more difficult.

The disparity in illness and fatalities from tuberculosis was not limited only to income . During the 19th century the death rate from TB per 1000 among black people varied between two and four times the rate of fatalities among whites. This disparity continued throughout the 19th century and persisted into the 20th century. The spread of infection and subsequent fatalities was disproportionately high especially among workers in factories and sweatshops like the garment industry. There were few if any regulations regarding proper sanitation and health protocols to protect workers from TB and other contagious diseases.

While tuberculosis rates had dropped to 71.1 per one hundred thousand by 1930 from two hundred per one hundred thousand in 1900, health departments still considered it to be the “Great White Plague” which was particularly devastating to the working poor and their families. While it is true that improvements in treating tuberculosis did have an impact on the overall decline in the mortality rate from the disease, these benefits were largely available to wealthy and upper-middle class people while the working poor, unemployed individuals and their families continued to suffer greatly. Sick people unable to afford adequate medical care or access to charity had to deal with the effects as best they could until they eventually succumbed to the disease.

When the Great Depression hit hardest from 1930 to 1933, the ability of poor people to manage the impact of tuberculosis became even more difficult than it was in the previous decade. With millions of people unemployed access to affordable health care was practically nonexistent. While family members were unemployed, many workers with symptoms of the disease had to keep working to support those who were unable to support themselves. There was no unemployment insurance and universal health care coverage to take care of those who were sick, out of work and could not take care of themselves much less their dependants.

With millions of workers unemployed and their families living in poverty with no access to health care it wouldn’t be surprising that many cases of TB went unreported  Forced out of their homes millions of people had to live in shantytowns or “Hoovervilles”, living and sleeping in cars, tents, or whatever they could find and no health care available. Lack of sanitation and adequate public facilities exacerbated the crisis, contributing to the spread of the disease. Victims of TB literally coughed themselves to death and their bodies dumped in a makeshift or pauper’s grave.

Despite improvements in treatment, these benefits failed to reach the poorest and most vulnerable individuals as the impact of unemployment and poverty worsened during the first few years of the Depression from 1930 to 1933. Prior to the Depression charitable institutions which had been treating indigent TB patients without charge suddenly found that their financial support from wealthy patrons was severely reduced at the same time as demand for treatment increased from the number of indigent and unemployed sick people who could no longer pay for access to health care. From lack of financial support and increasing demand for treatment hospitals could no longer provide the same level of care as they did before.

With the election of Franklin Roosevelt and the promise of his “New Deal” policies there was optimistic hope that government intervention and support would provide the means by which public health in general and TB mortality rates in particular might be improved. Charity would no longer be the only option available to poor people with no access to affordable health care and treatment for deadly diseases such as TB. The long road to economic recovery and health care aid for the poor began with the Federal Emergency Relief Act of 1933 which provided for the first significant federal role in assisting states and local governments with monetary grants specifically allocated for medical and public health services. The passage of the Social Security Act of 1935 not only provided direct relief to elderly persons unable to pay for health care but also provided increasing amounts of aid and support to private institutions and public agencies dealing with TB and other serious diseases. Federal aid also funded policies and programs that contributed significantly to improvements in public sanitation, health and education which further reduced the spread of infection from TB.

As the country recovered from the Great Depression with higher rates of employment and improved living standards, the rate of infection from TB as well as mortality declined significantly. The coming of the Second World War also contributed to lower unemployment and poverty, which in turn led to lower infection and better treatment of TB victims. However, poor people and other minority groups such as African-Americans and Latinos continued to lag well behind the recovery rate from TB as that of higher-income Americans from European descent. Even though TB was largely eradicated as a significant threat to public health by the 1960s there is still some residual rate of infection among the poor, homeless, and those affected by addiction to drugs.

The same discrepancy with infection rates and fatalities from TB that differentiated poor people and minorities from wealthy individuals and those with European ancestry during the first half of the twentieth century exists today with the impact of the coronavirus pandemic. Like most pandemics throughout history, poor people and minorities are most at risk. Although elderly people with underlying conditions are the most vulnerable, there is also a discrepancy between infection rates and fatalities among patients on medicare and medicaid, mostly poor and people of color in substandard hospitals and nursing homes, than there is among white, wealthier individuals in superior facilities. Just as “Hooverville” shantytowns in the 1930s contributed to the spread of TB, we see the same thing happening today in crowded, substandard living conditions that characterize poverty-stricken inner-city neighborhoods. The massive New Deal relief program, along with the coming of the Second World War, became necessary to improve living conditions and hence reduce the spread and impact of TB. A similar effort today is also required to alleviate the pain and suffering caused by the coronavirus which is experienced by the most disadvantaged persons in our society.

2 Comments

  1. Sean March 15, 2021 7:31 pm 

    I was excited to see an article on TB, a great interest of mine and a very neglected problem, on ZNet. This is quite an interesting article, and an important story, which I’m glad Ken Bank has told. But I am very disappointed in how US-centric it is.

    The article talks about TB as if it is no longer with us, but sadly this could not be further from the truth. In fact, until last year and the arrival of COVID-19, TB killed more people globally each year than any other infectious disease. In 2019, 1.4 million people died of TB (https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2020), which is comparable to the 1.8 million globally who died of COVID-19 in 2020 – except that TB kills this many people every single year, has done for decades, and with the current rate of decline being very slow, will go on doing so for decades to come.

    While we have an excellent vaccine for COVID-19 and will likely see the end of it as a major public health problem in the next two years or so (notwithstanding the gross injustices in how this vaccine is being rolled out), no such efficacious vaccine exists for TB. We do have one vaccine (the BCG vaccine), but this is barely effective except to prevent severe disease in young children. This vaccine was invented in 1921, and yet 100 years later we still don’t have a better option. Why the difference in progress on vaccines between these two diseases? It’s partly scientific (TB is for sure a harder nut to crack), but of course the main reason is that COVID-19 has been affecting rich countries while nowadays TB only really affects poor countries – of those 1.4 million deaths, only ~500 were in the US. And of course, those it does affect in rich countries are despised and forgotten groups like the homeless and immigrants, as Bank notes. So we don’t care about the 1.4million that die of TB, because they’re over there, out of sight.

    Worse still, we’ve known the real way to eradicate TB for even longer than 100 years – it is to eradicate poverty and inequality, as it is these societal pathologies in which TB thrives. As Bank notes, TB declined in rich countries long before the first effective treatment (Streptomycin) became available in 1949, and this decline was due to improvements in living conditions and reduced poverty and inequality. But of course western elites have even less interest in reduced global inequality than they do in funding a vaccine for a disease of poverty.

    • Sean March 21, 2021 5:40 pm 

      I just re-read my comment and think I may have been more aggressive than intended. So I just want to make clear that I really enjoyed Ken Bank’s piece. I just always think it’s worth reiterating how big of a global problem TB is, as surprisingly many people think it’s just a problem of the past. Thanks!

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