The Great White Plague Tuberculosis in Key West, 1917-1945

Home , History of tuberculosis, Sanatorium

Maria Melssen

Key West has long been considered an isolated island community known for beautiful sunsets, tropical drinks, and a colorful nightlife. Due to its location, it has historically been a stopping point for many sea travelers and a refuge for a largely transient and tourist population. Though famed to be one of writer Ernest Hemmingway’s favorite fishing spots and home, the culture and environment that make Key West a favored travel destination has also played a role in the myriad of health problems that have plagued its residents. These conditions included: yellow fever, small pox; the influenza epidemic of 1918, HIV, and multiple sclerosis. Though much attention has been given to these medical conditions, lit tle has been written on the island’s troubles with tuberculosis.1

From 1917, when vital statistics for the state of Florida were first made available, to 1945, when drugs such as PAS, streptomycin, and iso- niazed were available, tuberculosis was a prevalent health concern for the residents of Key West.2 This article will examine the sociocultural, sani tation, economic, and medical factors that prevented Key West from achieving the tuberculosis treatment and cure successes seen throughout the rest of the state of Florida as well as the United States. The major con tributing factors that not only led to the control of tuberculosis but had a long-standing impact on the improved general health conditions of Key West will also be addressed.

Understanding Tuberculosis

Tuberculosis, also known as consumption or the Great White Plague, is an infectious disease that targets the lungs. This medical scourge has been a global problem since the late 1800s and to this day 60 TEQUESTA

“remains the world’s leading infectious cause ot death." In 1993, tuber culosis was declared a global emergency by the World Health Organization. Today, tuberculosis strikes 20-40 percent ot the world's population annually and contributes to three million deaths worldwide each year. In 2005, the World Health Organization estimated that 8.8 million new cases of tuberculosis arose. In the United States, tuberculo sis is most prevalent among “HIV-infected, immigrant, and disadvan- taged/marginalized populations." Though the incidence of tuberculosis was controlled for many years, a number of factors led to its resurgence: the HIV epidemic, immigrants with undiagnosed tuberculosis from high-risk countries (i.e., those with multidrug-resistant tuberculosis), previously established suboptimal antimicrobial regimens, and patient noncompliance.”3

From the late 1920s to the early 1940s, tuberculosis was believed to be a hereditary disease caused by “overwork ... dissipation, excessive use of alcohol, lack of sleep, bad ventilation, neglect of personal hygiene, unhappy environment; excessive smoking.” Symptoms of note included weight and appetite loss, cough with sputum, fever, night sweats, and a general “loss of pep.” During the first half of the nineteenth century, tuberculosis was diagnosed using 14x17 x-ray films, 35mm films, chest examinations, the Volmer Patch Test, and the Mantoux Intra-Dermal Test. Treatment options of choice included “fresh air, cleanliness, scrupu lous care in destroying the germ laden sputum, absolute rest and whole some foods." The state of Florida was thought to be an ideal location for the treatment of tuberculosis due to its abundance of sunshine and fresh, sea air. Though hospitalization was desirable to treat and control the spread of tuberculosis, the lack of adequate facilities to do so was a major issue. With an ever increasing number of individuals diagnosed with tuberculosis, hospitals were unable to meet the growing demand.4 Sixty years later, it is now widely understood that tuberculosis is transmitted from person to person while coughing, sneezing, or speak ing. The most significant risk factor in contracting tuberculosis is being infected with HIV. Those afflicted with tuberculosis “appear chronically ill." The most common symptoms include cough and blood-streaked sputum, malaise, anorexia, weight loss, fever, and night sweats. Tuberculosis is typically diagnosed with various laboratory tests (tuber culin skin test; sputum smear samples), chest x-rays, bronchoscopy, and Tuberculous in Key West 61

needle biopsy of the pleura. Various drugs are used to treat tuberculosis (Isoniazid; Rifampin; Pyrazinamide; Ethambutol; Streptomycin) and surgery may be an option as well. Many patients can recover at home; however, hospitalization is recommended for those who are unable to care for themselves, or are likely to spread the disease to others. Though tuberculosis is curable, less than five percent of those with tuberculosis relapse as a result of non-adherence, disease transmission, or the devel opment of drug resistance—the most common barriers to successful treatment.’

Tuberculosis in Florida As noted, in 1917, the first vital statistics records for the state of Florida were made available. That year tuberculosis was the first leading cause of death for Florida residents and was the second leading cause of death in 1923. Though tuberculosis dropped steadily from third leading cause of death in 1928 to fifth in 1930, coming out of the top five in 1940, it continued to be a major health concern in the state of Florida throughout the 1930s and 1940s.<’

The state with the most promising climate and environment for the successful treatment of tuberculosis was also the one with the most tuber culosis related deaths. In 1933, the United States as a whole saw a decrease in the mortality rates from tuberculosis, but tuberculosis deaths remained on the rise in the state of Florida. A report in 1935 showed that in the state of Florida, “tuberculosis caused more deaths by half than automobile accidents, twice as many as malaria, eleven times as many as diphtheria, twenty times as many as typhoid." In 1935, Key West's local paper, The Citizen, noted that “more than 1,000 persons die annually in Florida of tuberculosis even though during the past 25 years, deaths have been reduced by one-half.” The state, and the nation, was at a loss as to why this was happening. Various organizations in Florida and across the nation stepped in to help fight tuberculosis. In 1930, the State Board of Health began taking active measures for the clinical diagnosis and control of tuberculosis. Other organizations soon followed, including the Tuberculosis and Public Health Committee of the Florida Medical Association, the State Tubercu losis Sanatorium, and the Florida Tuberculosis and Health Association. Such educational measures as mobile x-ray units, as well as the produc 62 TEQUESTA

tion and distribution of books, posters, bulletins, and films were taken to educate the public about tuberculosis. In 1939, tuberculosis treatment and control efforts by the State Board of Health focused on indigent, transient, and African American populations, as well as individuals who were unemployed. More work was still needed.8

Continuing efforts by the State Board of Health’s Division of Tuberculosis led to the launch of an intensive educational program in 1945 that included radio station interviews conducted at the mobile x- rav unit sites. University Days were also designed; university presidents regularly leading their students in having x-rays taken at the mobile x-ray units. Also, 35mm movie trailers providing information on the benefits of x-rays, and the locations and times of the mobile x-ray units were shown at movie theaters across the state. The State Board of Health even generated and distributed lapel pins stating, “My chest’s been x-rayed, has yours?”^

Slowly, Florida was winning the battle against tuberculosis; however, despite the efforts of various health organizations tuberculosis continued to be a menace in Key West.

Tuberculosis in Key West To the astonishment of many, the morbidity rates of tuberculosis in the city of Key West continued to be a blemish on the state of Florida’s success in controlling and treating the disease. According to Dr. W. H. Cox in 1919, 15% of deaths here should be caused by a preventable and cur able disease. In a city that boasts of a climate unsurpassed, where sunshine is a daily visitor, where all can spend their hours of recreation and rest in the open, something should be done by the City and State to educate the people and prevent such an economic loss.10

Key West’s populace did not stand for being an embarrassment to the set: working together, the citizens took action. In the 1930s, tuberculosis clinics and testing sites were opened in Key West and services were freely available to all Key West citizens. In addition to the availability of testing sites. Key West and Monroe County Tuberculous in Key West 63

citizens also showed a strong interest in the building of a tuberculosis sanatorium, and advocated on behalf of the project. Sadly, no such facil ity was constructed. Not only were proactive medical measures, such as the creation of clinics, testing sites, and sanatoriums taken, but educa tional awareness campaigns were also run. The residents of Key West joined the rest of the state of Florida in raising awareness about tubercu losis by participating in the annual Christmas Seals programs sponsored by the Florida Tuberculosis and Health Association and its affiliated organizations." Despite these efforts, by the mid 1930s tuberculosis conditions in Key West had shown little improvement, a trend that continued into the 1940s. In 1938, 121of 296 persons tested for tuberculosis in Key West tested positive. In 1944, the morbidity rate in Monroe Count)' was 69 (69 deaths per 100,000), 2.5 times higher than the state of Florida’s aver age of 26. Upon examining these troubling statistics, noted physician Dr. F. F. Furstenberg stated: “20 years of indifference to the city’s tuberculo sis problem has given Key West the highest death rate in the state from this dreaded disease.” Many were baffled: why was this happening in Key West? A careful examination of the health, medical, and social culture of Key West was in order.12

Sanitation and Economic Factors Dr. Alvan G. Foraker, a physician arriving in Key West in 1940, remarked that Key West seemed tropical, somnolent, shabby and badly in need of several coats of paint.” From the arrival of Key West’s first set tlers, proper sanitation had been a problem for its inhabitants. The prop er disposal of trash was a major concern. After World War I, the area near the Marine Hospital became a dumping ground for the city’s garbage. The situation worsened at the start of World War II when Key West experienced a population boom with the influx of military families. More people produced more trash and in an area with little housing to start with, miniature slums arose. Many homes had only outdoor, unscreened privies for their toilets, and a majority of the restaurants in Key West had no toilet or facility to wash one’s hands. The city’s trash pickup was also inconsistent, further complicating the sanitation problems. The combi nation of many people living in close quarters and unsanitary conditions promoted the spread of infectious disease. A major contributing factor to 64 TEQUESTA

the sanitation and overcrowding crisis in Key West was the economic meltdown of the Great Depression. There is a strong, positive correlation between a community’s eco nomic standing and that community's health status. A study by Waters, Saadah, and Pradhan (2003) found that decreases in government spend ing and reductions in household spending in concert with increases in the cost of food and health services, will negatively impact the general health and wellbeing of a community. Much like the economic situation in recent times, financial hardships were rampant for those in Key West between 1917 and 1945. The stock market crash in 1929, combined with a decline in military operations, was a major blow to the city’s econ omy. In 1934. Key West had declared bankruptcy and its financial plight, according to one observer “was just about the most desperate in the country.” There-after, and for the years between 1934 and 1936, it came under the jurisdiction of the Federal Emergency Relief Administration, which provided relief and the wherewithal of placing the Island City back on its feet through the introduction of a new economic base.14

During the Depression, over 60 percent of citizens were supported by the federally-funded Works Progress Administration, and many were unable to afford medical treatment. Bv 1943, the city of Key West was still struggling financially: few businesses were interested in coming or staying in Key West. Consequently, work was scarce tor residents. As a result of its financial situation, the city’s government did not have ade quate funding to provide medical care for the indigent. Without fund ing, proper sanitation, or housing, medical care could not be provided to the citizens of Key West.1'’

Medical Factors

In a depressed economy with a growing population. Key West’s abil ity to provide access to quality medical facilities and hire competent med ical staff was handicapped. According to Dr. Foraker, "Key West was not self-sufficient medically, as tar as furnishing hospital care, especially to the poor.” Few formal hospitals were available to the populace of Key West. The most common type of medical facility available during the early 1900s were cottage hospitals. These small, rural facilities were not new constructions; rather, they were converted cottages that provided Tuberculous in Key West 65

medical care for all members of the community for a small fee. The num ber of cottage hospitals, however, dropped to one by the end of 1939. In addition to the vanishing number of cottage hospitals, the Marine Hospital was the most reliable and at times the only functioning hospi tal on the island. Though the Marine Hospital was originally built to serve sick and injured seamen, the hospital staff served all members of the Key West community for nearly 100 years. When the Marine Hospital was scheduled to close in 1942, the citizens of Key West lobbied that it remain open due to “the lack of physicians and hospital beds with oper ating facilities for civilians."16

The Marine Hospital’s closure on February 15, 1943, left the citizens of Key West with three available facilities, none of which were approved by the medical organization, the Fellow of the American College of Surgeons. The facilities available to civilians were nothing short of subpar. Upon his arrival in 1941, Dr. Richard L. Pearse noted that “normal ly deliveries [obstetric] were carried out in a perfectly filthy room in a civilian hospital. Facilities were meager, no anesthesia, no personnel except an elderly practical nurse, and no means of blood transfusion.” Due to the poor condition of the available medical facilities, those who could afford to do so went to Miami, Havana, or other large cities for care. With regard to obstetric care, Dr. Pearse tried to convince all preg nant women to leave Key West and have their babies delivered elsewhere. For those who could not leave the island, Dr. Pearse performed home deliveries.1

Poor health care did not stop at the facilities themselves: medical staffing in Key West was also a significant concern and a barrier to the health of citizens. Between 1940 and 1942 there were four active prac ticing physicians in Key West, two of whom were elderly and one who was in poor health. Dr. Pearse noted that Key West physicians during this time viewed patients, especially women and children, as an inconven ience. When referring to the medical officer in Key West, Dr. Pearse observed that “he [the medical officer] obviously regarded care of dependents an annoying development.”18

In 1942, six civilian doctors served the people of Key West. Of the six, four were in their 60s and one was not in good standing with the local medical society’. Only one performed office consultations and two rarely 66 TEQUESTA

took calls after 6 pm. None of these physicians were members of the Fellow of the American College of Surgeons, and they rarely held count)' meetings. They did not get along with one another. Former Key West physician Dr. Albert W. Diddle noted that “the medical society often did not function as a progressive unit ... disagreement had been reported within the medical profession as well as without in decades past.” The general consensus was that this group of physicians failed to provide any benefit to the citizens of Key West. Diddle noted several reasons for the physicians’ lack of patient care: many were semi-retired and preferred to practice in their offices rather than take house calls. Others did not feel that they would be adequately compensated for their work, while some did not want the responsibility' of caring for another human being.19 Recruiting and retaining physicians for Key West was a significant problem. Though the Key West physicians at the time were unwilling to perform quality medical care, they would not allow others to practice there. At one point their aggressive nature caused a young physician to leave town. Not only did resident physician discourage new physicians from practicing in Key West, the health conditions in the area were a deterrent as well. Between July 1942 and January 1943, five physicians came to Key West, two saw the “hopelessness of the facilities available and left within a month of arrival,” while a third left after a few weeks due to legal difficulties. Three new physicians arrived; however, all left in a matter of months, one citing the “the lack of hospital and office accom modations and ... local political hardships” as his reasons for leaving. Several Negro physicians came, but left after a short stay “because of lit tle remunerative work and poor clinical facilities.”^®

Not only were the physicians subpar, the nursing and other medical staff was inadequate if not outright unethical. In 1942, trained nurses and attendants were not available. Dr. Pearse recalled a specific patient abandoned by a member of his nursing staff: “to my embarrassment and dismay, one mother precipitated her first baby as I walked in to make rounds. The nurse had put her in a bed and avoided her." The horrors experienced by the living also carried on to the deceased. In the early 1930s, Karl Tanzler Von Cosel, an eccentric x-ray technician in his late 60s, fell in love with a young Cuban girl, Elena Ffoyos Mesa, a tubercu losis patient at the hospital where he worked. There is no evidence that these passionate feelings were mutual. Elena succumbed to tuberculosis Tuberculous in Key West (T7

in 1931 but Von Cosel’s love for her continued after her death. Nearly ten years later, local authorities and local physician Dr. Alvan Foraker discovered that Von Cosel had taken Elenas body from her tomb and hidden her remains in an airplane that he had constructed. Dr. Foraker was present during the autopsy of the reclaimed remains, where the grue some truth of what Elena’s corpse had undergone for nearly a decade was uncovered: “I attended the autopsy on the desiccated corpse which had a reconstructed face, breasts, arms, legs, trunk, and a vaginal tube con structed so that intercourse could be simulated.” Shortly after this hor rific discovery, Von Cosel was jailed and never again worked in a med ical facility.21

From poorly run and maintained facilities to the lack of acceptable medical staff, one can see how an infectious disease such as tuberculosis would run rampant in a small, over-populated, and economically depressed island community. As Dr. Diddle remarked, “although the combination of the City Clinic, Hospital and Dispensaries should sup ply the citizens with adequate hospitalization, the success of the future will depend largely on the availability of operating capital and induce ment to well trained physicians to remain in the community to adminis ter up-to-date-medical care.”22 Though these factors played a major role in the island’s health problems, the citizens of Key West also contributed to their own health maladies.

Social Factors The demographic makeup of Key West during the early to mid 1900s put the entire population at greater risk for disease. Key West experienced a population boom between 1902 and 1922 due to a rise in the tobacco industry; however, this population rise was over by the late 1920s and dropped precipitously into the 1940s due to cutbacks in cigar manufacturing. The population rose again at the start of World War II, when an increase in military personnel and their families nearly tripled Key West’s population.2^

Key West has historically had a predominantly mobile “Bohemian type,” tourist, and, during times of war, military-based population. Communities with a fluctuating population are at greater risk for illness and such diverse, migratory populations have historically been perceived 68 TEQUESTA

as threats to public health. According to Gushulak and MacPherson, “if the health and disease parameters that influence the prevalence of infec tions at a migrants point of origin and transition periods are different from those at the destination, the process of migration and travel can bridge the difference in disease prevalence and function as a method of transfer between regions.” Tuberculosis is a condition that thrives among such populations.24

In 1930, the tuberculosis-infected pauper-patient was identified as the “greatest menace" to the spread of tuberculosis. Such patients do not have the financial means to complete treatments nor do they typically have access to medical care. Their presence in the general population will naturally contribute to the spread of the tuberculosis infection.2’

If the indigent patient population was hard to control, travelers to Key West also presented a major challenge. Dr. Diddle noted that the “ingress of travelers from other ports constantly maintained the danger of contagions.” It is impossible to find a location on the planet that is com pletely free of germs. As a result, the more individuals travel, the greater their likelihood of being exposed to and spreading disease. Tuberculosis is one of the various human pathogens spread by travelers. With so many persons going in and out of Key West, the occurrence of infections such as tuberculosis would not be uncommon.21’

Further complicating the health situation among the residents of Key West were their own social behaviors. Flow a given community functions and operates will have a major effect on its citizens’ exposure to infectious disease. Infection will be prevalent in any society that is consumed by poor social choices. Wilson found that “humans may carry a pathogen that can be transmitted only if conditions are permissive. This permis siveness can pertain to human behavior, then environment, or the pres ence of appropriate vectors or intermediate hosts.”27

Key West physician Dr. Pearse found that “the situation at Key West was always tense and troubled,” largely due to problems with drinking and volatile behavior. With prostitution representing a thriving trade, venereal disease was a constant concern in Key West. According to Dr. Foraker’s experiences in the early 1940s, those citizens served by the physicians of Key West, “swore, fought, drank, fornicated, jumped off piers, stabbed and shot each other and themselves.” Based on the experi Tuberculous in Key West 69 ences of the practicing physicians of the time, it is evident that the actions of Key West’s citizens ultimately put them in a state of medical jeopardy. As stated by Dr. Diddle: “the citizens occasionally voiced their dissatisfaction against some physicians and the lack of proper facilities for hospitalization. On the other hand they were generally not interested enough to offer and see through corrective measures needed to improve the situation.”28

As a result of these issues, Diddle observed that “the local population is both incapable and unwilling to arrange for their own medical care. Some agency is necessary ultimately to care for the seriously ill in Key West.”29

Making a Turnaround Despite the many medical, economic, and social troubles that plagued the citizens of Key West, a steady decline in death rates resulting from tuberculosis began in the mid to late 1940s. Florida saw the lowest recorded tuberculosis death rate in 1946, and in 1953 tuberculosis was no longer listed as one of the ten leading causes of death in the state. This marked decline in mortality and morbidity rates associated with tuber culosis began in 1945 with the birth of the drugs PAS, streptomycin and isoniazid.3°

In addition to these new wonder drugs, the mid and late 1940s brought many positive changes in Key West. During this time, Key West’s economy improved significantly as a result of various construction projects initiated by the US Navy. These projects helped to create jobs on the island, bringing economic stability. The continued and active pres ence of the US Navy and Coast Guard, in conjunction with a rise in the tourism and shrimping industries, brought more people to Key West and resulted in a major real estate boom.31 Such a dramatic economic turn around gave Key West the financial push it needed to improve its floun dering health care climate. Though the 1940s economic boom helped to elevate the health of Key Westers, 1942 brought a major change that would forever impact the health of Key West citizens: freshwater was now piped in from the main land. Unsanitary cisterns and excessive spending on the importation of water from mainland Florida now became a thing of the past. Key West residents now had immediate access to clean, fresh water. Such drastic 70 TEQUESTA

improvement in sanitation, combined with a renewed economy, brought vast improvements to the general health of the island's residents, and the ammunition the residents needed to successfully fight tuberculosis.

Conclusion While cases of tuberculosis can still be found in Key West, the num bers are a fraction of the figures for the early and mid-1940s. In 2009, a total of 821 cases of tuberculosis case were reported in Florida. Of those 821 cases, seven were found in Monroe County, where Key West is locat ed. Across the state, Monroe county ranks twentieth in the number of tuberculosis cases.Only time will tell if tuberculosis will be complete ly eradicated. Key West remains a heterogenous community with a culturally and ethnically diverse population whose “live and let live attitude” co-exists alongside a military presence and a thriving tourism industry. Key West plays host to over two million visitors annually. In 2008, Key West’s pop ulation was 22,364. In that same year, approximately 2,058,097 visitors came to the Island City, outnumbering residents 92 to 1. Though het erogenous, tourism-based communities such as Key West are at greater risk for the transmission of infectious diseases like tuberculosis, many from around the world will continue to be drawn to this island that is “like no other place in Florida.”^

Endnotes

1 Albert W. Diddle, “Medical Events in the History of Key West,” Tequesta 6 (1946): 19; E. Ashby Hammond, “Health and Medicine in Key West: 1832-1845, Journal of the Florida Medical Association, 56 (1969): 640; Maureen Ogle, “The Stuff of Which Legends are Made of,” in Key West : History of an Island of Dreams (Gainesville: University Press of Florida, 2003), 25. “To ‘Love at First Sight’ for Key West, Ernest Hemingway Attributes His Corning Here,” Key IFfcf Citizen, December 23, 1931. Diddle, Tequesta 6 (1946): 14-37; Albert W. Diddle, “The History of Civilian Medical Care in Key West up to 1945,” Journal of the Florida Medical Association, 34 (1947): 383-389: Herbert L. Tindall, “Yellowjack and the Conchs: The Impact of Yellow Fever on Key West,” Florida Keys Tuberculous in Key West 71

Sea Heritage Journal 2 (1992): 1-11; Hammond, Journal of the Florida Medical Association, 56 (1969): 637-643; William M. Straight, “Yellow Fever at Miami: The Epidemic of 1899,” Tequesta 55 (1995): 39-60; Frederick Eberson, “Yellow Fever Fighters—Dr. Joseph Y. Porter, Dr. Isaac Hulse,” Journal of the Florida Medical Association 59 (1972): 22-36; Diddle, Tequesta 6 (1946): 14-37; Diddle,/onrna/ of the Florida Medical Association 34 (1947): 383-389; Eric G. Benotsch, John J. Mikytuck, Kathleen Ragsdale and Steven D. Pinkerton, “Sexual Risk and HIV Acquisition Among Men who Have Sex with Men Travelers to Key West, Florida: a Mathematical Modeling Analysis,” AIDS Patient Care STDS 20 (2006): 549-556; Steven D. Pinkerton, Eric G. Benotsch and John Mikytuck, “When Do Simpler Sexual Behavior Data Collection Techniques Suffice? An Analysis of Consequent Uncertainly in HIV Acquisition Risk Estimates,” Evaluation Review 31 (2007): 401-412; Howard S. MacGregor and Quinton I. Latiwonk, “Complex Role of Gamma-herpesviruses in Multiple Sclerosis and Infectious Mononucleosis,” Neurological Research 15 (1993): 391-394; Geoffrey Dean and Richard Gray, “Do Nurses or Doctors have an Increased Risk of Developing Multiple Sclerosis?” Journal of Neurology Neurosurgurgery and Psychiatry 53 (1990): 899-902; Theodore H. Ingalls, “Endemic Clustering of Multiple Sclerosis in Time and Place, 1934-1984, Confirmation of a Hypothesis,” American Journal of Forensic Medicine and Pathology 7 (1986): 3-8; Howard S. MacGregor and Quinton I. Latiwonk, “Is MS an Auto-immune Disease or a Chronic Gammaherpesvirus Infection?” Journal of Clinical and Laboratory Immunology 48 (1996): 45-74; Holger Hennig, Karl Wessel. Paul Sondermeijer, Holger Kirchner and Klaus P. Wandinger, “Lack of Evidence for Marek’s Disease Virus Genomic Sequences in Leukocyte DNA from Multiple Sclerosis Patients in Germany,” Neurosci Lett 250, no. 2 (1998): 138-140; Gustavo C. Roman and William A. Sheremata, “Multiple Sclerosis (not Tropical Spastic Paraparesis) on Key West, Florida," Lancet 1, no. 8543 (1987): 1199; Charles G. Helmick, J. Michael. Wrigley, Matthew M. Zack, William J. Bigler, Janet L. Lehman, Robert S. Janssen, E. Charles Hartwig, and John J. Witte, “Multiple Sclerosis in Key West, Florida,” American Journal of Epidemiology 130, no. 5 (1989): 935-949.

2 Florida State Board of Health and Stewart G. Thompson, in “Bureau of Vital Statistics: Tuberculosis Mortality,” in Florida Health Notes (Jacksonville, 1931): 188; Frank Ryan, “Premature Celebrations,” in The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost 72 TEQUESTA

(Boston: Little, Brown and Company, 1993), 323-341; Thomas Dormandy, “Dawn” in The White Death: a History of Tuberculosis (New York: New York University Press, 1999), 361-375.

3 State Board of Health and Stewart G. Thompson. 1931. Florida Health Notes. In Bureau of Vital Statistics: Tuberculosis Mortality. Jacksonville, Fla, 188; “Buy Christmas Seals,” Key West Citizen, December 18, 1935. “Tuberculosis, Pulmonary,” AccessMedicine from McGraw-Hill, Quick Answers to Medical Diagnosis and Therapy, accessed November 6, 2009, http://accessmedicine.com/content.aspx?aID=3273394&searchStr=pulmonary+tuberculosis. For background information about tuberculosis. Brian D. Gushulak and Douglas W. MacPherson, “Globalization ot Infectious Diseases: the Impact of Migration,” Clinical Infections Diseases 38, no. 12 (2004): 1745. “Tuberculosis, Pulmonary,” AccessMedicine from McGraw-Hill, Quick Answers to Medical Diagnosis and Therapy, accessed November 6, 2009, http://accessmedicine.com/content.aspx?a lD=3273394&searchStr=pulmonary+tuberculosis. A. Fauci, E. Braun- wald, D. Kasper, S. Hauser, D. Longo, J. Jameson and J. Loscalzo, “Chapter 158. Tuberculosis,” in Mario C. Raviglione and Richard J O’Brien, Harrison's Principles of Internal Medicine, (McGraw-Hill, 2008), accessed November 6, 2009, http://www.accessmedicine.com/content. aspx?aID=2895012. C. Stone and R. Humphries, “Current Diagnosis & Treatment: Emergency Medicine," in “Chapter 31. Pulmonary Emer gencies,” David A.Smith, AccessMedicine (McGraw-Hill, 2008), accessed November 6, 2009, http://www.accessmedicine.com/content. aspx?aID=3106264.

4 Florida State Board of Health and Fritz A. Brink, “Bureau ol Communicable Diseases: Tuberculosis Accessory Causes,” in Florida Health Notes (Jacksonville, 1929), 160; Florida State Board of Health and Fritz A. Brink, “Bureau of Communicable Diseases: What are the Determining Factors?" in Florida Health Notes (Jacksonville, 1929),161. Florida State Board of Health and Fritz A. Brink, “Bureau of Communicable Diseases: Tuberculosis,” in Florida Health Notes (Jacksonville, 1935): 189. Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1923-1932): 40; Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1941): 5; Florida State Board of Health and Fritz A. Brink, "Bureau of Communicable Diseases: Tuberculosis,” in Florida Health Notes (Jacksonville, 1935): 189; Florida State Board ol Health. Annual Report - State Board of Health, State of Florida, (Jacksonville, Tuberculous in Key West T^>

1939): 20; A. J. Logie to M. J. Myres. Letter regarding tuberculosis test ing, August 22, 1939. Florida State Board of Health and Fritz A. Brink. “Bureau of Communicable Diseases: Tuberculosis Accessory Causes,” in Florida Health Notes (Jacksonville, 1929): 160; Florida State Board of Health and Ruth E. Mettinger, “Bureau of Public Health Nursing: Tuberculosis in Generalized Public Health Nursing Program,” in Florida Health Notes (Jacksonville, 1935): 185; Florida State Board of Health and Fritz A. Brink, “Bureau of Communicable Diseases: What are the Determining Factors?” in Florida Health Notes (Jacksonville, 1929): 161. Florida State Board of Health and Fritz A. Brink, “Bureau of Communicable Diseases: Florida and Tuberculosis” in Florida Health Notes, (Jacksonville, 1930): 144. Florida State Board of Health and Henry Hanson, “Administration: Tuberculosis” in Florida Health Notes, (Jacksonville, 1935): 183; Florida State Board of Health, Annual Report - State Board of Health, State of Florida (Jacksonville, 1943): 96; Florida State Board of Health, Annual Report - State Board of Health, State of Florida (Jacksonville, 1945): 36.

5 A. Fauci, E. Braunwald, D. Kasper, S. Hauser, D. Longo, J. Jameson and J. Loscalzo, “Chapter 158. Tuberculosis,” in Harrisons Principles of Inter nal Medicine, (McGraw-Hill, 2008), accessed November 6, 2009, http://www.accessmedicine.com/con tent.aspx?al D = 289501 2; “Tuberculosis, Pulmonary,” in Quick Answers to Medical Diagnosis and Therapy (McGraw-Hill), accessed November 6, 2009, http://www. accessmedicine.com/con tent.aspx?aID = 3273394&searchStr=pulmonary+tuberculosis. David A. Smith, “Current Diagnosis & Treatment: Emergency Medicine,” in “Chapter 31. Pulmonary Emergencies,” (McGraw-Hill, 2008), accessed November 6, 2009, http://www. accessmedicine.com/content.aspx?aID=3106264. “Tuberculosis, Pulmo nary,” in Quick Answers to Medical Diagnosis and Therapy (McGraw-Hill), accessed November 6, 2009), http://accessmedicine.com/content.aspx? aID=3273394&searchStr=pulmonary+tuberculosis.

6 Florida State Board of Health and Stewart G. Thompson, “Bureau of Vital Statistics: Tuberculosis Mortality” in Florida Health Notes, (Jacksonville, 1931): 188. Florida State Board of Health and Stewart Thompson, “Bureau of Vital Statistics,” in Florida Health Notes, 188; Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1923-1932): 9. Florida State Board ot Health. “Bureau of Vital Statistics” in Florida Health Notes, (Jacksonville, 1929): 53; Florida State Board of Health and Stewart G. Thompson, “Bureau of 74 TEQUESTA

Vital Statistics: Tuberculosis Mortality,” in Florida Health Notes, 188; Florida State Board ot Health, Life and Death in Florida: 1940-1949, (Jacksonville, 1950): 13.

Florida State Board of Health and Stewart G. Thompson, "Bureau of Vital Statistics Florida Health Notes, 188. Florida State Board of Health and Fritz A. Brink. “Bureau of Communicable Diseases: Tuberculosis,” in Florida Health Notes (Jacksonville, 1935): 190. “Christmas Seals Being Sent Out,” Key West Citizen, December 4, 1935.

8 Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1923-1932): 40. Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1942): 40. Florida State Board of Health and Fritz A. Brink, “Bureau of Communicable Diseases: Tuberculosis,” in Florida Health Notes (Jacksonville, 1935): 190; Florida State Board of Health, Annual Report - State Board of Health, State of Florida. (Jacksonville, 1941): .5; Lynne Baker and Florida State Board of Health, Facts about Tuberculosis (Jacksonville, 1943). Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1939): 20.

9 Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1945): 91.

10 Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jacksonville, 1919): 68.

11 “Tubercular Free Clinic Opens Here,” Key West Citizen, March 30, 1931; “Tests to be Made Here ofTuberculosis,” Key West Citizen, December 9, 1938. “Adjustment of Taxes Asked by Agent of Land,” Key West Citizen, August 8, 1935. "Christmas Seals Being Sent Out,” Key West Citizen, December 4, 1935; "Council Orders New Ordinance Drawn in Fixing of Salaries," Key West Citizen, December 5, 1935.

12 "Tuberculosis Examinations Held Monday,” Key West Citizen, December 14, 1938. “Dr. F.F. Furstenberg Give Address on Death Rate from Tuber culosis,” Key West Citizen, March 3, 1944.

13 Alvan G. Foraker, “The United States Marine Hospital, Key West, 1845- 1943,” Journal of the Florida Medical Association 59(1972): 39; Hammond, Journal of the Florida Medical Association 56: 638; Diddle, Journal of the Florida Medical Association, 34: 385; Mary E. Wilson, "Travel and the Emergence of Infectious Diseases,” Emerging Infectious Diseases 1 (1995): 41. Tuberculous in Key West 7 5

14 Hugh Waters, Fadia Saadah, and Menno Pradhan, “The Impact of the 1997-1998 East Asia Economic Crisis on Health and Health Care in Indonesia,” Health Policy and Planning 18 (2003): 172-181; Diddle, Tequesta, 6: 33. 15 Diddle, Journal of the Florida Medical Association, 34: 383, 387; Foraker, Journal of the Florida Medical Association, 59: 39.

16 Foraker, Journal the Florida Medical Association, 59: 39-40; Richard Maurice McConaghey, “The Evolution of the Cottage Hospital,” Medical History, 11(1967): 128-140; Diddle, Journal of the Florida Medical Association, 34: 387; Diddle, Tequesta 6 (1946): 15. 35.

17 Diddle, Tequesta 6 (1946): 33, 35-36; Richard L. Pearse, “Reminiscences of Navy Medicine, Key West, 1941-1943,” Journal of the Florida Medical Association, 59 (1972): 42-43.

18 Foraker, Journal of the Florida Medical Association, 59: 40; Pearse, Journal of the Florida Medical Association, 59: 42.

19 Diddle, Tequesta, 6 (1946): 35; Diddle, Journal of the Florida Medical Association, 34: 383-384.

20 Diddle, Tequesta, 6 (1946): 35; Diddle, Journal of the Florida Medical Association, 34: 388-389.

21 Diddle, Tequesta, 6 (1946): 35; Pearse, Journal of the Florida Medical Association, 59: 43; Foraker, Journal ofthe Florida Medical Association, 63: 642.

22 Diddle, Journal of the Florida Medical Association, 34: 388.

23 Diddle, Tequesta 6 (1946): 31. 33; Diddle, Journal of the Florida Medical Association, 34: 385.

24 Foraker, Journal of the Florida Medical Association, 59: 40; Gushulak and MacPherson, Clininical Infectious Diseases, 38: 1742-1743; Douglas W. Macpherson, Brian D. Gushulak and Liane MacDonald, “Health and Foreign Policy: Influences of Migration and Population Mobility, Bull World Health Organ 85 (2007): 201.

25 Florida State Board of Health and Henry Hanson, “Administration: Tuberculosis and Hope,” in Florida Health Notes (Jacksonville, 1930): 187; Wilson, Emerging Infectious Diseases, 1: 42.

26 Diddle, Journal of the Florida Medical Association, 34: 384; Wilson, Emerging Infectious Diseases, 1: 40, 45. 76 TEQUESTA

27 Rajeev Gupta and Praneet Kumar, “Social Evils, Poverty & Health," Indian Journal of Medical Research, 126 (2007): 279-288, 279; Wilson, Emerging Infectious Diseases, 1: 42.

28 Pearse, Journal of the Florida Medical Association, 59: 43; Foraker, Journal of the Florida Medical Association, 59: 40; Diddle, Journal of the Florida Medical Association, 34: 383, 385.

29 Diddle, Tequesta, 6 (1946): 36.

30 Florida State Board of Health, “Life and Death in Florida: 1940-1949,” (Jacksonville: Florida State Board of Health, 1950); Florida State Board of Health, Annual Report - State Board of Health, State of Florida, (Jack sonville, 1947): 29; Florida State Archives, Department of State, Tallahassee, Florida,“Tuberculosis Control,” series 751, carton 1, file folder 29; Frank Ryan, “Premature Celebrations,” in The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost (Boston: Little, Brown and Company, 1993): 323-341; Thomas Dormandy, “Dawn,” in The White Death: a History ofTuberculosis (New York: New York University Press, 1999): 361-375.

31 Key West Chamber of Commerce, “Key West and Monroe County Demographics,” accessed May 2, 2010, http://www.keywestchamber.org /PDF/demographics.pdf.

32 Maureen Ogle, “Boom Town," in Key West: History of an Island of Dreams (Gainesville: University Press of Florida, 2003): 198; Jerry Wilkinson, “History of the Florida Keys Aqueduct Authority,” accessed May 27, 2010, http://www.keyshistory.org/fkaa.html.

33 Bureau of TB and Refugee Health, “2009 Florida TB Incidence Rates.” accessed October 4, 2010, http://www.doh.state.fl.us/disease_ctrl/tb/ Trends-Stats/Fact-Sheets/ Florida/Co unty%201 ncidence/2009- TBCountyincidentrates.pdf.

34 Key West Chamber of Commerce, “Key West and Monroe Countv Demographics,” accessed May 2, 2010, http://www.keywestchamber .org/PDF/demographics.pdf; Key West Chamber of Commerce, Community Information, accessed May 2~, 2010, http://keywestchamber. org/community_info/; Key West Chamber of Commerce, “Key West and Monroe County Demographics," accessed May 2, 2010, http://keywestchamber.org/PDF/demographics.pdf; Wilson, Emerging Infectious Diseases, 1; John Dos Passos, “Old Hem Was A Sport,” Sports Illustrated, 29( June 29, 1964): 58-67.