In little more than a decade, the AIDS epidemic has exerted a profound effect on morbidity and mortality among young adults and children in many parts of the world. One of the more dramatic aspects of AIDS is that it seems to have arisen almost spontaneously as a new epidemic, spreading rapidly within at-risk populations in a way that is unprecedented for the serious infectious diseases of recent memory. Tuberculosis, on the other hand, had only recently been considered a disease of historical importance but of diminishing relevance to current public health priorities, especially in industrialized countries. Over the past decade, however, and in parallel with the AIDS epidemic, there has been a resurgence of tuberculosis in many of the same populations most affected by HIV infection. This has had important implications for clinical practice, public health, and the development of appropriate health policy. A number of elements have converged to promote the development of HIV-related tuberculosis, including biologic, social, and environmental factors. These will be discussed both to provide a context for understanding the relationship between the two epidemics, and as a basis for suggesting strategies for tuberculosis control in the AIDS era.

In 1882 Koch discovered the tubercle bacillus and transformed both the medical and the social history of tuberculosis and the experiences of those who contracted it. For the first time, the absence or presence of the bacillus made it possible to define, in Koch’s terms, “the boundaries of the diseases to be understood as tuberculosis.” And for the first time the sick became subject to oversight and discrimination.

Prior to Koch’s discovery, tuberculosis, or as it was then called, consumption, was considered a hereditary and non-contagious disease, albeit a very deadly and persistent one. Over the first half of the nineteenth century, it was responsible for one out of every five deaths. It crossed all boundaries of geography, social class, age, and sex affecting residents in rural as well as urban areas, the prosperous as well as the poor, the young even more notably than the old, females more often than males. Physicians assumed a familial predisposition existed (as in the case of insanity); following the precepts of humoral medicine, they postulated that the disease originated in “irritations” whose sources were to be found in the interaction of an inherited constitution with a particular lifestyle and environment.

Although HIV disease has set a new model for resolving the tensions between civil liberties and public health interests, with an unprecedented commitment to individual privacy and autonomy, the resurgence of tuberculosis has sparked new and troublesome concerns. One particularly intense controversy has emerged around the value and appropriateness of single disease hospitals. In HIV disease, the single hospital turns out to be an altogether unsuitable and unnecessary innovation. In the instance of tuberculosis, however, it appears to have a critical and legitimate role, particularly for involuntary commitment of patients who have been non-compliant with treatment regimens. To be sure, that role must be carefully circumscribed and the facilities themselves closely monitored. But a hospital dedicated to tuberculosis now occupies a central place in public policy that is not to be found for HIV disease. What considerations promote this difference, and how a single disease hospital for tuberculosis may avoid the pitfalls that make it so inapposite for HIV, are the two questions this essay will be exploring.

Planning of effective responses to the recent resurgence of tuberculosis in the United States, and particularly in New York City, requires review of our knowledge of (1) the factors that led to the decline of tuberculosis in the U.S. and other countries during the nineteenth and the first three-quarters of the twentieth century, and (2) the recent changes in these same factors and the rise of new factors that have contributed to its resurgence. Because the analysis of the impact of all of these factors in both the remote and the recent past is controversial, it is important to use a well-defined framework to organize the analysis. The framework we will use is shown in Table 1. To the classic epidemiologic triad of Agent, Host and Environment it adds the category of Health Services. In this paper we redefine both the classic and new categories using current disciplines and concepts applicable to tuberculosis.

There is a nationwide resurgence of tuberculosis (TB) in the country’s urban centers; New York City stands at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness.

The resurgence of tuberculosis in the United States is due, in part, to the dismantling of large-scale treatment systems that were a critical part of the disease control effort for the better part of the twentieth century. As the number of cases grows, clinicians, politicians, public health officials and community advocates have grappled with the difficult problem of building systems to care for infected people that are consonant with current knowledge and beliefs about quality care. As an example, the United Hospital Fund’s 1992 report, The Tuberculosis Revival: Individual and Societal Obligations in a Time of AIDS, discussed policies to guarantee adequate treatment that protects patients’ civil rights, needs for special facilities for care of TB patients, and the special problems faced by infected prisoners. This thoughtful report highlighted many areas of social policy that require further examination.

During the mid-nineteenth century the annual tuberculosis (TB) mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.

In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus.

“Recognizing that prisons disproportionately confine sick people, with mental illness, substance abuse, HIV disease among other illnesses; and that prisoners are subject to further morbidity and mortality in these institutions, due to lack of access and/or resources for health care, overcrowding, violence, emotional deprivation, and suicide.…(APHA) condemns the social practice of mass imprisonment.”

After decades of steady decline, tuberculosis has emerged as a significant public health threat in the United States. The rising rates of tuberculosis cases, an increasing proportion of which are resistant to standard chemotherapies, are linked to the many scourges threatening our communities: the explosion of poverty, drug use, violence, the HIV epidemic, and the concomitant rise in congregate housing including homeless shelters, residential drug treatment programs and incarceration facilities. Jails and prisons have disproportionately high rates of tuberculosis infection and have been implicated as points of tuberculosis spread and, as such, are a critical point for tuberculosis control interventions.

Nowhere in this nation is the return of tuberculosis more visible or more pronounced than in New York City. Fueled by poverty, homelessness and AIDS, tuberculosis has again reached epidemic proportions. New York City is at the forefront of the battle against this advancing disease. For this reason, and because the dynamics at work in New York City are a microcosm of those same forces at work in the larger society, what transpires here often foreshadows the direction that other urban centers will take. It is in this context that our New York experience provides a valuable framework for learning and for action.

Homelessness has existed in America since colonial times, and the attitudes, analyses and solutions offered through the succeeding centuries have evolved far less radically than recent media attention might suggest. From the building of the first poorhouse in Boston in 1664, to the conversion of massive armories into latter day poorhouses in New York City in the 1980s, our society has had ambivalent feelings towards the poor and the homeless. The outbreak and progression of tuberculosis in such settings—a seeming mystery at best, a reality denied at worst—reflects both society’s ambivalence towards this population, as well as a misguided belief that modern medicine can be viewed in the abstract as curative and divorced from the social context to which all disease is inextricably bound. Unless and until these beliefs are addressed and altered, TB among the homeless will continue unabated.