ACKNOWLEDGMENTS

A couple of thank-you notes, which probably still won’t get me out of sending Christmas gifts, but it was a nice try, wasn’t it?

To Katherine Tegen, my amazing editor, for believing in this book even when I was convinced it was a pile of potato salad and not actually a book at all. To Merrilee Heifetz, my incredible agent, whose encouragement and guidance was overwhelmingly wonderful. To the University of Pennsylvania’s Department of Medical Ethics and Health Policy, with particular gratitude to Professor Lance Wahlert, for giving me poems about tuberculosis and letting me write my master’s thesis on young adult disease narratives. Emily Kern and Abbey Stockstill, for the hours spent researching together in the library, and the very sincere question of “This book looks perfect, how fluent is your German?” My parents, who were very lovely about the time I spent five days in their guest room frantically finishing this book while essentially holding their poodle hostage, and whom I should note are very lovely people in general. Bru Coffee House, you know what you did, and what you did was give me internet and coffee and a quiet place to write, so basically I’m in love with you. Nova Ren Suma, for a heroic rescue. To Corrie and Miguel, my coffee-shop companions. Development: Daniel Inkeles. No thank-you to Netflix; I am dis-acknowledging you, wrecker of productivity. And, on that note, Tumblr, too. Evidently I still can’t write an acknowledgments without Tumblr. So it goes.

AUTHOR’S NOTE

The story contained in these pages is a work of fiction. There’s no such thing as total-drug-resistant tuberculosis. No protocillin. No Latham House. I made it up, because I wanted to tell a story about what could happen, as opposed to what really is.

Tuberculosis is a disease that has affected mankind for most of human history. It’s characterized by cough, fatigue, weight loss, and fever; and for thousands of years, no one knew what caused it or how to treat it. As time went on, tuberculosis became known by a variety of names: phthisis, the white plague, the dread disease, consumption, and, finally, TB.

The threat of tuberculosis reached its peak during the nineteenth century. TB became so prevalent that in 1815 it caused one in every four deaths in England. Its victims included such a who’s who of philosophers, writers, and musicians that TB was believed to affect those with artistic temperaments, heightening their genius as they faced early death. The Brontë sisters, Jane Austen, Elizabeth Barrett Browning, Henry David Thoreau, Robert Louis Stevenson, Kafka, Chopin, Chekhov, Voltaire, Rousseau, and Rembrandt all died from tuberculosis.

At the height of the nineteenth century’s Romantic Movement, illness was seen as a mark of distinction, and the pallor and waiflike appearance that tuberculosis lent its victims became fashionable. Women of high society copied the aesthetic, powdering their faces and feigning a lack of appetite. The art and theater of the nineteenth century is filled with wan, ethereal heroines, many of whom fall into a consumption brought on by a broken heart or an unrequited love, then die an easeful death. The idea that TB caused a “good” death was one that the Romantics seized upon, lauding TB as a pleasant way to die, even though it was far from the truth.

This widespread romanticization of tuberculosis may seem absurd now, but at the time, little was known about the disease, and most of the treatments offered were guesswork. Tuberculosis was considered a death sentence, and the sick were kept at home with the windows tightly sealed, passing the germs to their family members, who frequently fell sick as well. A few doctors advised their patients to set off for better climates, believing that fresh air and pure food would benefit them more than city living.

In 1854, a German doctor named Hermann Brehmer, himself suffering from TB, founded an institute that treated tuberculosis in the Bavarian Alps. After he reported beneficial results, others followed suit, and the sanatorium movement was born. Dr. Edward Livingston Trudeau founded the first US sanatorium in the Adirondacks in 1882, and later that year, German physician Robert Koch discovered the bacillus that caused TB, proving that the disease was contagious. The sanatoriums, which removed patients from their crowded surroundings, had unknowingly prevented the disease from spreading. Soon after Koch’s discovery, the invention of the X-ray allowed doctors to track the progress and severity of a patient’s disease. Over the next few decades, nearly a thousand sanatoriums opened across Europe and the United States.

The sanatoriums provided a dual function, both isolating the sick from the general population and enforcing rest, gentle exercise, fresh air, and healthy eating. No other treatment had any impact on the disease, and so patients set off for distant sanatoriums to “take the rest cure,” as it was called, hoping their lungs would wall off the infection. But isolating children in sanatoriums made it difficult for them to continue their schoolwork. Open-air schools, which offered fresh air, rest, and nutritious food, sprung up across the United States and Europe, enrolling children with TB.

And still the cure for tuberculosis eluded doctors and scientists. Many patients spent years at sanatoriums, which ranged from crowded, state-run facilities with rows of cots, to private institutions that resembled fancy resorts. A stay at a sanatorium was a break from the stresses and concerns of everyday life, and some patients found it difficult to return home. The Magic Mountain, a German coming-of-age novel published in 1924, details a young man’s seven-year stay at a luxurious Alpine sanatorium. Its author, Thomas Mann, was later awarded the Nobel Prize in Literature.

For a hundred years, the sanatoriums filled to capacity, until isoniazid, the miracle drug that cured tuberculosis, was introduced in 1952. Tuberculosis began to fade from memory, replaced with the far more pressing threats of HIV and cancer, until the hectic fever of the tortured artist was nearly forgotten.

These days, when we come across stories in which characters cough blood into a handkerchief, then die of “consumption,” it seems like a made-up illness or a quaint melodrama. But TB is far from erased. In recent decades, a new form of tuberculosis has risen, evolving a resistance to the medications that treat it. This multi-drug-resistant TB, which is found primarily in the developing world, had more than four hundred and fifty thousand cases reported in 2012, with almost 10 percent of the victims suffering from the even more life-threatening form, extensively drug-resistant TB. While MDR- and XDR-TB are far from being a worldwide health crisis, the fact remains that tuberculosis has not yet been defeated.

So, what led me to this research, and to tell a story that reinvents the recent history of tuberculosis? I’m a bioethicist, and in graduate school for bioethics, I studied the history of medicine. It was 2009, the height of Twilight mania, and one late night in the library, I looked up the history of the vampire myth on a whim.

It turned out that the modern vampire legend was born in the nineteenth century from the symptoms of tuberculosis. Outbreaks of vampire hysteria frequently coincided with outbreaks of tuberculosis: as entire families died of TB, superstitions circulated that the first to die had returned from the grave to feed on surviving family members. I was fascinated. So I decided to write a novel about a sanatorium full of vampires.

But the more I researched tuberculosis, the more I began to imagine a less-fantastical story. While I was sitting in my Cinema of Contagion class, I realized TB had never been portrayed as part of the contagion genre. The disease was cured during the early days of germ theory and antibiotics, and had been so romanticized at its height that quarantine and fear of outbreak weren’t a central part of its narrative.