The disease that divides, and unites

World Tuberculosis (TB) Day falls on Saturday (March 24), commemorating Dr Robert Koch’s announcement of his discovery of the TB bacillus in 1882, and raising public awareness about the disease that still kills more than a million people each year.

TB provokes polarising responses ranging from fear and revulsion to galvanised endeavour. Dealing with the issue requires multiple measures.

Singapore’s history in the post-war pre-independence period – where national TB rates first started declining precipitously – provides two lessons: it took a collective effort to reduce the incidence of disease, and that effort went beyond medical care and drugs. It required relief for low-income patients and their caregivers, care for children’s health, as well as improved living conditions.

TB had long been a leading killing disease in colonial Singapore, but the trigger for action was World War II and the Japanese Occupation. According to post-war British medical reports – which must be read with care – deaths from the disease rose from 1,791 in 1941 to peak at 3,324 in 1944.

Reflecting the multi-causal nature of TB, the increase was partly due to the shortage of medical staff and supplies. But it was also because of widespread malnutrition and deteriorating housing. The doctor Farleigh Arthur Charles Oehlers recalled seeing people walking around with huge ulcers because of malnutrition.

Soon after the British returned to Singapore, a comprehensive programme was launched to correct the public health ills of the war: the Medical Plan of 1948, an ambitious 10-year plan to overhaul the hospital system at a cost of 51 million Straits dollars.

But quite shockingly, although TB was the leading post-war killer with a death rate of 2.35 per thousand, it was originally left on the backburner. The focus of the Medical Plan was on acute diseases. To Dr W J Vickers, Director of the Singapore Medical Services and the architect of the Medical Plan, TB, being a chronic disease, was to “take its proper place in the medical scheme”.

Rehousing people from congested shophouses and kampongs, Dr Vickers explained, was expensive. The Medical Plan would also not provide for a specialised TB hospital – a sanatorium. The incidence of TB had returned to the pre-war level, and he thought it could wait.

The colonial logic caused a public uproar. The war had made people critical of British rule and awakened nationalist sentiments. Here was seeming proof of naked imperial self-interest: the British were neglecting the health of the local population, from which most TB sufferers were drawn.

The Alumni Association of the King Edward VII College of Medicine criticised the Medical Plan as being drafted by Europeans and favouring the well-to-do. Tan Chye Cheng, a local lawyer and politician, urged the government to build a sanatorium, and the Malaya Tribune, a locally owned newspaper, ran a story of 103 people cramped into a poorly-ventilated shophouse meant for 30, where “every one appeared pale and sickly”.

These criticisms moved Dr Vickers to table a memorandum titled ‘Tuberculosis Policy: Singapore’, in which the government finally accepted its responsibility to tackle the disease. The memorandum is significant in laying out both preventive and curative measures.

For the latter, the British agreed to convert Tan Tock Seng Hospital – the original ‘pauper hospital’ – into a sanatorium with 800 beds. The government also recognised TB as an “economic disaster” for low-income families. It would finance relief subsidies for patients unable to work during the long period of treatment and rest. This would encourage them to seek treatment rather than hide the disease.

The prevention of TB was just as vital. One of the leading official concerns after the war was the wellbeing of children. They were becoming infected with TB – something quite rare previously. To tackle malnutrition, Dr Vickers stressed that “more and more food and a rapidly developing child feeding department must be envisaged as one of the most important and outstanding factors in any present day anti-tuberculosis scheme in Singapore”.

In 1951, school pupils began receiving the Bacillus Calmette-Guérin vaccination. This became a rite of passage for many Singaporeans growing up in the years when TB was a threat, and continues to this present day.

Finally housing reform – a vast and protracted undertaking – started after the war. The Singapore Improvement Trust (SIT) built low-cost modern houses for the general population. As the 1947 Singapore Housing Committee pointed out, “it is of little use to cure a man and then send him back to live again in the circumstances and conditions under which he contracted the diseases”.

The number of houses built by the SIT was relatively small, but the Housing & Development Board, formed in 1960, greatly expanded the housing programme, bringing thousands of families out of shophouses and kampongs into sanitary housing.

Complementing the government’s efforts was the robust response of the community. In 1947, a group of businessmen and professionals came together to form the non-governmental Singapore Anti-Tuberculosis Association (now SATA CommHealth), which provided various services in the community such as X-ray screening and rehabilitation of cured patients.

Two years later, the Rotary Club set up an outpatient TB clinic, which the government hailed as ‘an up-to-date tuberculosis clinic [built] on the most modern lines’ and ‘the first “brick” in the new Medical Plan’.

The theme of this year’s World TB Day is “Wanted: Leaders for a TB-Free World. You can make history. End TB”.

TB leaders in this context refers not just to heads of state, parliamentarians and community leaders, but also to “every person affected by or active in TB and willing and daring to speak up and engage to end TB through their work and personal engagement”.

Although more aspirational than realistic in the short term, this year’s theme and our own history remind us that TB is not simply a medical disease, left solely to healthcare practitioners and public health officials.

To deal with TB today – and in particular multidrug-resistant TB (MDR-TB) – a range of measures similar to those that appeared in post-war Singapore is necessary: good preventive and curative efforts supported by the government, community and patients; research and interventions beyond the medical aspects of the disease, including in urban planning and reducing socioeconomic inequality.

ABOUT THE AUTHORS:

Loh Kah Seng is a historian and Honorary Research Fellow at the University of Western Australia. Associate Professor Hsu Li Yang is the Programme Leader of the Antimicrobial Resistance Programme at the National University of Singapore’s Saw Swee Hock School of Public Health. They are currently co-writing a book on the history of tuberculosis in Singapore.