The pale avenger

The White Death: A History of Tuberculosis

Thomas Dormandy <em>The Hambledon Press, 433pp, £25</em

Medical students today still learn about diseased tissue by observing pickled specimens preserved in glass "pots". In the pathology museum at Cambridge University most of the pots were produced early this century. Charles Saatchi would probably pay millions to grab hold of such an extensive collection of Hirstian "old masters". A bright student I know, back in 1990, sneered at these fine antiques, containing abundant tuberculous tissue, as being about as useful to him as the finer points of dodo identification are to an ornithologist. Two years after his qualification a remarkable thing happened. Having hacked through the chest of the cadaver of a middle-aged, homeless male he was confronted with an unmistakable sight. A series of grain-like cavities perforated the lungs, just like something from the maligned old TB pots. A real case of tuberculosis. Since then he has been carving up half a dozen or so such cases each year. Tuberculosis is no longer a disease of the past.

The classic study of TB, The White Plague, was published by Rene and Jean Dubos in 1952, but never made it to a second edition. Thomas Dormandy's The White Death is a timely successor. So what is so white about this disease? Its victims assume an ashen, anaemic countenance (look at portraits of Robert Louis Stevenson). In the 19th century, TB was bizarrely associated with purity and innocence, killing as it did so many children and poets. The fashionability of pallid pre-Raphaelite models led many otherwise healthy young women to adopt starvation diets and chemically whiten their skin to mimic the sickly hue of consumption.

Most literary biographers would relish the opportunity of drawing links between Keats and Kafka, Beardsley and the Brontes, Chekhov, Lawrence, Orwell and Thomas Mann. Dormandy does so with impressive ease. Sometimes you feel it is hard to find a great writer who avoided consumption. Keats and Chekhov were both medically trained and poignantly understood the horrors associated with their condition. Chekhov's final four plays cryptically portray the insidious personal and social effects of TB. Keats's "Ode to a Nightingale" - "where youth grows pale, and spectre thin, and dies" - describes the disease in typically florid terms. And "La Belle Dame Sans Merci" could herself have been the disease, carrying off pale, fast-withering knights.

Before the discovery by Robert Koch in 1882 that a bacterium was responsible for TB, superstition abounded. Florence Nightingale attributed symptoms to the overuse of re-breathed air in confined spaces. Poor old Keats even wondered if it was linked to excessive masturbation.

Tuberculosis arrived in earnest with the industrial revolution. The emergence of cities, filth and persistent human contact fuelled the disease, which had been bubbling away in man since ancient times. Necessity is the mother of invention, so scientific advances against tuberculosis were inevitable. The stethoscope allowed physicians to hear the perilous state of consumptive lungs, and X-rays allowed visualisation. Diagnosis was all well and good but without cures, for much of the 19th and early 20th centuries, rest and fresh air were the only prescription. Hence the sanatorium movement was born to fleece wealthy consumptives.

Many of us will remember queuing at school for our TB jab. The resulting bump and scar on the shoulder became a source of playground misery once the bullies realised how painful the flimsiest of punches could be. But the vaccine was of vanishingly small use. It was pushed forward by its vociferous French inventor between the wars, in spite of protestations from les anglosaxons, who always disputed the validity of its early trials.

Dormandy smartly reminds us that TB was (and is) predominantly a disease of destitution, claiming the lives of one in 14 humans. Sub-Saharan Africa boasts a large proportion of today's cases, although in the mid-19th century David Livingstone was struck by its absence. Cecil Rhodes was diagnosed with consumption in 1870, and left Oxford for warmer climes, joining his brother in South Africa. He found diamonds, annexed a country and introduced the disease from which he eventually died. In 1988, during his incarceration, Nelson Mandela came close to dying from tuberculosis.

Effective treatment for TB finally arrived in the 1940s with the discovery of streptomycin in America. Nye Bevan, as health minister in 1947, at the request of David Astor, opened the way to bring one of the first samples of the antibiotic to Europe to treat George Orwell, who proved allergic to the drug. He died three years later. Other drugs emerged, and from the 1950s to the 1980s most people in the west genuinely believed we were living in a post-infectious society.

Two things have happened over the past 20 years to smash our complacency. Bacteria have evolved resistance to antibiotics and many immune systems have been weakened with the appearance of the HIV virus. The "fourth world", comprising a displaced underclass, has emerged in the west. Five per cent of London's homeless carry tuberculosis, and many carry the Aids virus, too. Occasionally they receive treatment but seldom enough to kill the bacteria. In these conditions drug-resistance grows. It is a fertile environment for the development of new strains of uncertain infectivity. The future may be bleak, but it need not be. The entire genome of the tuberculosis bacterium has been sequenced and a series of new drug targets and vaccine candidates have emerged. The pharmaceutical industry, however, remains obsessed with a Prozac-happy, Viagra-priapic, Zantac-desatiated world. New reagents in the fight against infection are appearing more slowly than are bacterial strains resistant to current drugs. Dormandy's message is clear: we ignore contagion at our peril.

Dr Michael Barrett is a lecturer in the institute of biomedical and life sciences at Glasgow University

This article first appeared in the 19 February 1999 issue of the New Statesman, We are richer than you think

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Sunjeev Sahota’s The Year of the Runaways: a subtle study of “economic migration”

Sahota’s Man Booker-shortlisted novel goes to places we would all rather not think about.

This summer’s crisis has reinforced the ­distinction that is often made between refugees, who deserve sanctuary because they are fleeing from conflict, and “economic migrants”, those coming to Europe in pursuit of “the good life”, who must be repelled at any cost. The entire bureaucratic and punitive capacity of our immigration system is pitted against these ne’er-do-wells and their impudent aspirations.

Sunjeev Sahota’s fine second novel, The Year of the Runaways, now shortlisted for the Man Booker Prize, takes a closer look at “economic migration”. Why do people – many of them educated, from loving families in peaceful communities – leave their old lives behind and come to Britain? Are they fleeing desperate circumstances or are they on the make? When they arrive here, do they find what they were looking for? Should we welcome them, or try to persuade them to stay at home? The book illuminates all of these questions while, much to its credit, offering no simple answers.

Sahota interweaves the stories of three people whose reasons for emigrating are as individual as they are. Both Avtar and Randeep are from Indian Sikh families that might be characterised as lower-middle-class. Avtar’s father has his own small business – a shawl shop – and Randeep’s father works for the government. Both boys are educated and Avtar, in particular, is smart and motivated. But with employment hard to come by and no social security net to fall back on, it doesn’t take much to make leaving the country seem like the only option. Avtar loses his job, his father’s business is failing and he has high hopes of earning enough to marry Lakhpreet, his girlfriend-on-the-sly. Randeep’s family’s finances fall apart after his father has a psychological breakdown; their only hope of maintaining a respectable lifestyle is for their eldest son to take his chances abroad.

For Tochi, the situation is very different. He is what used to be called an “untouchable” and, although people now use euphemisms (“scheduled”, or chamaar), the taboo remains as strong as ever. He comes to Britain not so much for financial reasons – although he is the poorest of the lot – but to escape the prejudice that killed his father, mother and pregnant sister.

Tying these disparate stories together is the book’s most intriguing character, Narinder, a British Sikh woman who comes to believe that it is her spiritual calling to rescue a desperate Indian by “visa marriage”. Narinder’s progress, from the very limited horizons for an obedient young woman to a greater sense of herself as an active participant in her destiny, reminded me of Nazneen, the protagonist in Monica Ali’s Brick Lane. But Narinder is a more thoughtful character and here the Hollywood-style journey of personal liberation is tempered by a recognition of the powerful bonds of tradition and family.

Once in Britain, Avtar, Randeep and Tochi enter a world of gangmasters, slum accommodation and zero job security, with an ever-present fear of “raids” by immigration officers. They work in fried chicken shops, down sewers, on building sites and cleaning nightclubs. Health care is off-limits for fear of immigration checks. Food is basic and the only charity comes from the gurdwara, or Sikh temple, which provides help in emergencies.

Avtar and Randeep struggle to send money back home while living in poverty and squalor that their families could barely imagine (at one point, Randeep notes with understandable bitterness that his mother has used his hard-earned contributions to buy herself a string of pearls). In the meantime, their desperation leads them to increasingly morally repellent behaviour, from selfishness to stealing and worse. Even if they do eventually find a measure of economic stability in Britain, they have done so at the cost of their better selves.

It has been pointed out that the novels on the Man Booker shortlist this year are even more depressing than usual and The Year of the Runaways certainly won’t have raised the laugh count. At times I had to put it down for a while, overwhelmed by tragedy after tragedy. It was the quality of Sahota’s prose and perceptions that brought me back. He is a wonderfully subtle writer who makes what he leaves unsaid as important as the words on the page. A wise and compassionate observer of humanity, he has gone to some dark places – places we would all rather not think about – to bring us this book. Whether we are prepared to extend a measure of his wisdom and compassion to real immigrants, in the real world, is another question.

“The Year of the Runaways” by Sunjeev Sahota is published by Picador (480pp, £14.99)

Alice O'Keeffe is an award-winning journalist and former arts editor of the New Statesman. She now works as a freelance writer and looks after two young children. You can find her on Twitter as @AliceOKeeffe.

This article first appeared in the 08 October 2015 issue of the New Statesman, Putin vs Isis