"Hardly a Family Is Free from the Disease": Tuberculosis, Health Care, and Assimilation Policy on the Nez Perce Reservation, 1908-1942
James, Elizabeth, Oregon Historical Quarterly
IN THE SHORT BOOK Madonna Swan: A Lakota Woman's Story, the narrator recalls her life afflicted by tuberculosis. Madonna Swan, who was from the Cheyenne River reservation, spent several years in sanitariums--first at an Indian sanitarium and later at a sanitarium usually reserved for white patients. The white sanitarium, she stated, was where people went to be cured of tuberculosis; the Indian sanitarium was where people went to die. (1) She survived into her sixties and her memoirs provide a compelling and inspirational account of her illness and survival. Her personal story, however, only hints at the broader devastation of the tuberculosis epidemic that plagued American Indian communities across the country during the early twentieth century. It ravaged nearly every reservation, leaving few families unscathed by its tragic course. Madonna Swan could just as well have hailed from the Nez Perce reservation in North Idaho, where tuberculosis was widespread.
The Native American population in the twentieth century suffered disproportionately high rates of tuberculosis, but the disease has been one of the most deadly throughout history and remains a serious problem today. The World Health Organization (WHO) reported an estimated 9.4 million new cases of tuberculosis globally in 2008, with a mortality of 1.3 million among HIV-negative patients. Developing regions such as Southeast Asia and Africa accounted for 85 percent of the new cases; India, China, South Africa, Nigeria, and Indonesia generated the highest numbers of cases. (2)
Tuberculosis is caused directly by a bacillus, but unlike many contagious diseases, it can lie latent in an infected person's system for months, years, or even decades. Even once released, usually in a pulmonary form, tuberculosis kills slowly, physically deteriorating the body. Although the bacillus is a necessary cause of tuberculosis, some health professionals disagree as to whether the bacillus is also a sufficient cause. Strong evidence indicates multiple factors, especially poverty and disfranchisement, are significant underlying causes of tuberculosis. (3) The WHO today recognizes that "TB thrives in conditions of poverty and can worsen poverty. There is a long history of documented linkages ... between TB and poverty at societal, community and patient levels." (4)
The incidence of tuberculosis in developing regions such as Asia and Africa reflects this link between socio-economic factors and tuberculosis. Political and social upheaval may also be proximate causes: the fall of the Soviet Union, for example, ushered in an increase of tuberculosis cases in its successor states. Despite effective drug treatments developed in mid century, tuberculosis continues to impact most severely not only developing countries but also American Indian and Alaska Native communities in the United States where the people are faced with significant economic and social challenges. In 1985, the tuberculosis rate was 4.4 times higher in Native populations than among whites in the United States. (5)
Wealth and class disparities have historically correlated with tuberculosis rates, even in developed countries. Tuberculosis was a leading cause of death in the United States in the nineteenth century, especially among the urban poor living in crowded and unsanitary tenements. Statistics from New York City effectively demonstrate the difference class divisions made: 776 out of every 100,000 residents in lower Manhattan tenements succumbed to tuberculosis while 49 of every 100,000 residents of the Upper West Side did. (6) Nowhere, however, did tuberculosis morbidity and mortality exceed the rates among American Indians. The estimated rate of tuberculosis in 1913, among whites, was 12.1 percent, while among American Indians it was 35.4 percent. (7) Much like developing nations of today, Indian reservations of the past (and indeed the present) bore high rates of poverty, discrimination, disfranchisement, and isolation. …