- Email: [email protected]
A literary approach to tuberculosis: lessons learned from Anton Chekhov, Franz Kafka, and Katherine Mansfield
Accepted Manuscript Title: A literary approach to Tuberculosis: Lessons learnt from Chekhov, Kafka and Katherine Mansfield. Author: Cristina Vilaplana PII: DOI: Reference:
S1201-9712(16)31655-1 http://dx.doi.org/doi:10.1016/j.ijid.2016.12.012 IJID 2809
To appear in:
International Journal of Infectious Diseases
Received date: Accepted date:
7-10-2016 7-12-2016
Please cite this article as: Vilaplana C, A literary approach to Tuberculosis: Lessons learnt from Chekhov, Kafka and Katherine Mansfield., International Journal of Infectious Diseases (2016), http://dx.doi.org/10.1016/j.ijid.2016.12.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A literary approach to Tuberculosis: Lessons learnt from Chekhov,
cr
ip t
Kafka and Katherine Mansfield.
an
1
us
Cristina Vilaplana1,2*.
Experimental Tuberculosis Unit (UTE). Fundació Institut Germans Trias i Pujol (IGTP).
M
Universitat Autònoma de Barcelona (UAB). Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona; Catalonia; Spain. CIBER Enfermedades Respiratorias. Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0.
Ac ce p
te
28029, Madrid; Spain.
d
2
*Corresponding author: Dr. Cristina Vilaplana. Experimental Tuberculosis Unit. Fundació Institut Germans Trias i Pujol. Universitat Autònoma de Barcelona. Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona; Catalonia; Spain. Telf. +34 93 497 86 77 Fax. +34 93 497 86 54 Email: [email protected]
2
Page 1 of 10
ABSTRACT Letters from notable writers from the past century can provide valuable information on the times they lived. In this article, we would like to drive the attention to the lessons learnt from
ip t
three famous writers which died of tuberculosis: Chekhov, Kafka and Katherine Mansfield; including characteristics of the course of disease in the pre-antibiotic era, and the importance
us
cr
of addressing mental health in tuberculosis management.
an
HIGHLIGHTS
Chekhov, Kafka and Katherine Mansfield died of tuberculosis, and valuable
M
information can be extracted from their personal writings and correspondence. Tuberculosis is a chronic illness: in the pre-antibiotic era, people could be ill during a
d
long time. From the onset of their TB until their death, Kafka lived 7 years; Katherine
te
Mansfield, 12; and Chekhov, 20.
Ac ce p
Half of Western Europe had faulty lungs, and people had frightening haemoptysis in all sort of public places.
Patients often do not trust in doctors and other Health personnel; and suffer spiritual crisis.
Tuberculosis has a terrible impact on mental Health of patients. Health Quality of Life evaluation and active psychological support should be provided to TB patients within the management of their disease.
KEYWORDS Tuberculosis, literature, Kafka, Mansfield, Chekhov, mental health.
3
Page 2 of 10
Everyone knows Chekhov died from Tuberculosis, as did Kafka and Katherine Mansfield; even if most people know nothing on the disease but some of the symptoms, notably hemoptysis. When anyone not working on medicine or TB science is asked about the disease,
ip t
often recall a languid pallid woman from the mid XX century, coughing blood in a handkerchief. But TB is not a disease from the past. Approximately 9 million people get ill
cr
every year, in spite of an effective treatment, and 1.5 million die because of it(1). The existence of comorbidities as HIV infection or diabetes, and the emerging threat of strains
us
multiresistant to drugs, complicates the fight against TB, which should be a public health
an
priority(1). In this context, the pre-antibiotic era can provide valuable information on the course of the disease; and letters from notable writers from the past century are a good
M
example. In this article, we would like to drive your attention to the lessons learnt from 3 of them: Chekhov, Kafka and Katherine Mansfield (KM).
d
1. TB is a chronic illness.
te
Anton Chekhov was born on 1860, Kafka on 1883, KM on 1888. The first was a Russian physician, and wrote plays and stories. Franz Kafka was a Czech Jew who studied law, and
Ac ce p
worked in an insurance company, but also dedicated a lot of time to write stories. KM was a writer, which came from New Zealand and soon moved to and worked in Europe. Chekhov was bright, hard-worker and had a lot of sense of humour. Kafka suffered from anxiety, insomnia, and emotional breakdowns, which impaired a lot his life. KM had a tempestuous life –she was a female adventurer- before being so impeded by disease: first ghonorrea and then tuberculosis. Chekhov and Kafka’s illness debut was with an haemoptysis; while KM suffered from pleurisy(2–4). Since the onset of their disease until their death, many years passed: 7 for Kafka, 12 for KM, and up to 20 years for Chekhov. If we consider that no effective treatment but thoracic surgery was then available, and that antibiotics only appeared
4
Page 3 of 10
much later on, it’s easy to infere that TB is a chronic illness, which course must depend on host factors as genetic background, environmental conditions and immunological status. 2. Europe was sick, and people had frightening haemoptysis in all sort of public
ip t
places. At that time, and according to Kafkas words, half of Western Europe had more or less faulty
cr
lungs(2). KM used to live in Paris in 1922, and had a lot of meals in filthy restaurants, due to her lack of money. In a letter to his husband Murry, she explained she was sitting in front of a
us
French poet who was coughing and spitting all the time, and who finally, after a glance at his
an
handkierchief, commented: «Still blood. I need 24 handkerchiefs every day, my wife is desperated!»(5). But this poet was not the only one. Chekhov first serious haemoptysis,
M
which led to the TB diagnosis, happened also in a restaurant, the Hermitage in Moscow, where he went to have dinner with his friend Suvorin. In a letter to his friend Lidia Avilova,
d
dated on March 1897, he explains: «hardly we had sat down to the table when a vigorous
te
flow of blood started streaming from my throat. Suvorin took me to the Slavyansky Bazaar and summoned doctors»(3). For Kakfa, it was not a restaurant, but the apartment he had at
Ac ce p
the Shönborn-Palais, in Prague. Worried for his friend and lover Milena, who announced him she was coughing blood and had been recently diagnosed of TB, he describes her in a letter his first haemoptysis, which happened in the middle of the night. Kafka, who always thought the physical disease was a manifestation of his mental disease, spitted so much blood that the maid, when visited him the morning after, said to him: «Her Doktor, you won’t last much longer»(2).
3. If you have TB, do not go to Paris. In the mid XX century, with a Europe eager for cultural revolution, Paris was the place to go. But Paris is also known for their humid and cold weather, which didn’t help TB patients to recover. KM, in September 1922, wrote to her friend Sylvia Land, complaining: «the bad
5
Page 4 of 10
weather here these last few days has brought my cough back again»(5). But it was not only Paris. TB patients often moved to dryer and warmer places, following doctors’ orders. Still nowadays, when you speak to long-term TB patients, they always comment their cough is
ip t
back every winter season (and hospitalizations peak (6)); and TB is often diagnosed in spring or summer seasons. Seasonality of TB has been explored later on, suggesting a decrease of
cr
Th1 responses and of vitamin D, and seasonal variation on habits among other causes(7); and even if it is a controversial issue (should it be due to a seasonal host susceptibility or a
us
seasonality in pathogens survival)(8,9), the fact is that published literature suggest a
an
link(6,10).
4. Patients often do not trust in doctors and suffer spiritual crisis.
M
KM did not had any faith in doctors or treatment. In February, 1919, she wrote in her diaries: «Saw the doctor- a fool»; and the day after: «Saw two of the doctors –an ass and an ass»(4).
d
Three years later and many doctors after, she still had no hope nor believed in any kind of
te
medical treatment: «It’s all sham. It amounts to nothing»(5). Chekhov, who was a physician himself, wrote a letter to his friend Suvorin in 1891 confessing his decision of not undergoing
Ac ce p
any treatment: «The idea of having to undergo treatment and fuss over my physical condition produces in me something akin to revulsion. I’m not going to be treated»(3). It is true that the available therapeutical options at the moment and the poor outcomes obtained did not offer big hope. Moreover, some of the doctors even tried to convince patients to undergo new treatments that sometimes turned out very bad. A white émigré from Russia, Manoukhin, submitted the very ill KM to X-radiation of the spleen for 15 weeks of treatment in 1922, for which she paid 300GBP at time (approximately 13230GBP and 14900€ in 2016)(5). Without having improved her TB and very sick of the Adverse Effects caused by the radiation, KM turned to mystic, philosopher who directed the Institute Fort he Harmonious Development of Man, where she lived the last months of her life, before dramatically dying of a massive
6
Page 5 of 10
hemoptysis(4,5). This spiritual crisis of KM is not an isolated fact in tuberculosis patients, and even common in other severe chronic illness. Facing isolation, fear of death or lack of support, patients turn to gods or any other kind of spiritual forces they believe in(11). Distrust
ip t
is common in tuberculosis, especially in non-adherent groups(12). However, since the existence of chemotherapy, which is effective, patients are commonly grateful for the
cr
treatment they receive, as they can feel a positive progress(11,13,14). In the case of MDR/XDR-TB patients, attending physicians and other health personnel sometimes are
us
scared of being infected, and this might also contribute to a distrustful relantionship(15).
an
5. Mental Health is important, and we should be systematically evaluating it. Because of the stigma, both Chekhov and Kafka tried to hide TB from their families. Kafka
M
asked Oskar Baum in October 1917: «By the way, my parents know nothing about the TB, so you will be careful, won’t you, if you should by chance run into them»(16). Chekhov had the
d
same request for his brother in March 1897: «I was diagnosed with pulmonary apical TB and
te
accordingly awarded the right to describe myself as an invalid. Nobody knows anything about my illness at home, so rein in your customary malice and don’t blab about it in your
Ac ce p
letters»(3). In high-incidence countries, stigma and the shame associated to it are still important problems to TB patients(17,18). Facing a severe life-threatening illness dominated everything. As said by Chekhov to Lidia Avilova in 1901: «You ask if I am happy? The first thing I have to tell you is that I am ill. And I now know that I am very ill»(3). The invalid KM, often felt miserable and wrote about it in her diaries. In 1922 records, she annotated: «The world as I know it is no joy to me and I am useless in it», and «This isolation is death to me»(4). Patients get desperated. «I feel as though I’m in prison and full of rage, terrible rage»; says Chekhov to his wife in 1899(3)c. And Kafka to Max Brod: But «Above all the fatigue increased. I lie for hours in the reclining chair in a twilight state. I am not doing well, event though the doctor maintains that the trouble in the lung has remitted by half. But I
7
Page 6 of 10
would say that is far more than twice as bad. I never had such coughing, such shortness of breath, never such weakness»(16)ka. Mental Health has been described to be highly impacted by TB. Patients show a wide spectrum of feelings, from anxiety, shame, loneliness, worry,
ip t
dispair and anger(19). Depression is often mentioned as a consequence of TB, as a result from the isolation, the stigma or from being chronically ill; and it has been reported that
cr
support from family and friends might be essential for improving mental health, selfperception and good social role functioning (11,20)(18,21). In my opinion, these articles
us
show that systematic evaluation of Health Quality of Life including impact of the disease on
an
mental health should be performed in all clinical studies, and active psychological support
M
should be provided to TB patients within the management of their disease.
CONCLUSIONS
d
Pre-antibiotic era provided us a lot of information on TB disease nowadays available and
te
which could be useful for better understanding and management of TB. Patients need information on their disease to trust their doctors and other health personnel, and tools to face
Ac ce p
the feelings associated to it. Systematic evaluation of mental health associated to the disease and psychological support should be included per routine in management of TB patients.
CONFLICT OF INTEREST: None
FUNDING This work was supported by the Plan Nacional I+D+I co-financed by ISCIII-Subdirección General de Evaluación and Fondo-EU de Desarrollo Regional (FEDER) through CV contract CP13/00174.
8
Page 7 of 10
REFERENCES 1.
WHO. Global Tuberculosis Report 2015 [Internet]. World Health Organization publications. 2015. Kafka F. Letters to Milena. Haas W, editor. London: Vintage Books; 1999. 192 p.
3.
Chekhov A. A life in letters. 4th ed. Bartlett R, editor. London: Penguin Classics;
ip t
2.
4.
cr
2004. 224 p.
Mansfield K. The Katherine Mansfield Notebooks. Scott M, editor. Minneapolis:
Mansfield K. The letters of Katherine Mansfield Volume II. Murry JM, editor. New York: Alfred A. Knopf, Inc; 1929. 232 p.
Atun RA, Samyshkin YA, Drobniewski F, Kuznetsov SI, Fedorin IM, Coker RJ.
M
6.
an
5.
us
University of Minnesota Pr; 2002. 355 p.
Seasonal variation and hospital utilization for tuberculosis in Russia: Hospitals as
d
social care institutions. Eur J Public Health. 2005;15(4):350–4. Fares A. Seasonality of tuberculosis. J Glob Infect Dis [Internet]. 2011;3:46–55.
8.
Naumova EN. Mystery of seasonality: getting the rhythm of nature. J Public Health
te
7.
9. 10.
Ac ce p
Policy [Internet]. 2006;27(1):2–12. Available from: Boulay. Seasonal Variation in Cryptogenic Hemoptysis. 1997;6–10. Khaliq A, Batool SA, Chaudhry MN. Seasonality and trend analysis of tuberculosis in Lahore, Pakistan from 2006 to 2013. J Epidemiol Glob Health [Internet]. Ministry of Health, Saudi Arabia; 2015;5(4):397–403.
11.
Hansel NN, Wu AW, Chang B, Diette GB. Quality of life in tuberculosis: Patient and provider perspectives. Qual Life Res. 2004;13(3):639–52.
12.
Jakubowiak WM, Bogorodskaya EM, Borisov SE, Danilova ID, Lomakina OB, Kourbatova E V. Impact of socio-psychological factors on treatment adherence of TB patients in Russia. Tuberculosis. 2008;88(5):495–502.
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13.
Boudioni M, McLaren S, Belling R, Woods L. Listening to those on the frontline: Service users’ experiences of London tuberculosis services. Patient Prefer Adherence. 2011;5:267–77. Dhuria M, Sharma N, Narender Pal Singh, Ram Chander Jiloha, Saha R, Gopal
ip t
14.
Krishan Ingle. A study of the impact of tuberculosis on the quality of life and the effect
15.
cr
after treatment with DOTS. Asia-Pacific J public Heal. 2009;21(3):312–20.
Padayatchi N, Daftary A, Moodley T, Madansein R, Ramjee A. Case series of the
16.
an
doctors. Int J Tuberc Lung Dis. 2010;14(8):960–6.
Kafka F. Letters to friends, family and editors. Academic B, editor. Richmond: Alma
M
Classics LTD; 2014. 528 p. 17.
us
long-term psychosocial impact of drug-resistant tuberculosis in HIV-negative medical
Armijos RX, Weigel MM, Qincha M, Ulloa B. The meaning and consequences of
18.
te
2008;23(3):188–97.
d
tuberculosis for an at-risk urban group in Ecuador. Rev Panam Salud Publica.
Karim F, Johansson E, Diwan VK, Kulane A. Community perceptions of tuberculosis:
Ac ce p
A qualitative exploration from a gender perspective. Public Health [Internet]. Elsevier Ltd; 2011;125(2):84–9. Available from: http://dx.doi.org/10.1016/j.puhe.2010.10.005
19.
Zhang S-R, Yan H, Zhang J-J, Zhang T-H, Li X-H, Zhang Y-P. The experience of college students with pulmonary tuberculosis in Shaanxi, China: a qualitative study. BMC Infect Dis [Internet]. 2010;10:174.
20.
Sharma R, Sharma R, Yadav R, Sharma M, Saini V, Koushal V. Quality of Life of Multi Drug Resistant Tuberculosis Patients: a Study of North India. Acta Med Iran. 2014;52(6):448–53.
21.
Deribew A, Tesfaye M, Hailmichael Y, Negussu N, Daba S, Wogi A, et al. Tuberculosis and HIV co-infection: its impact on quality of life. Health Qual Life
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Ac ce p
te
d
M
an
us
cr
ip t
Outcomes [Internet]. 2009;7:105.
11
Page 10 of 10
S1201-9712(16)31655-1 http://dx.doi.org/doi:10.1016/j.ijid.2016.12.012 IJID 2809
To appear in:
International Journal of Infectious Diseases
Received date: Accepted date:
7-10-2016 7-12-2016
Please cite this article as: Vilaplana C, A literary approach to Tuberculosis: Lessons learnt from Chekhov, Kafka and Katherine Mansfield., International Journal of Infectious Diseases (2016), http://dx.doi.org/10.1016/j.ijid.2016.12.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A literary approach to Tuberculosis: Lessons learnt from Chekhov,
cr
ip t
Kafka and Katherine Mansfield.
an
1
us
Cristina Vilaplana1,2*.
Experimental Tuberculosis Unit (UTE). Fundació Institut Germans Trias i Pujol (IGTP).
M
Universitat Autònoma de Barcelona (UAB). Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona; Catalonia; Spain. CIBER Enfermedades Respiratorias. Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0.
Ac ce p
te
28029, Madrid; Spain.
d
2
*Corresponding author: Dr. Cristina Vilaplana. Experimental Tuberculosis Unit. Fundació Institut Germans Trias i Pujol. Universitat Autònoma de Barcelona. Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona; Catalonia; Spain. Telf. +34 93 497 86 77 Fax. +34 93 497 86 54 Email: [email protected]
2
Page 1 of 10
ABSTRACT Letters from notable writers from the past century can provide valuable information on the times they lived. In this article, we would like to drive the attention to the lessons learnt from
ip t
three famous writers which died of tuberculosis: Chekhov, Kafka and Katherine Mansfield; including characteristics of the course of disease in the pre-antibiotic era, and the importance
us
cr
of addressing mental health in tuberculosis management.
an
HIGHLIGHTS
Chekhov, Kafka and Katherine Mansfield died of tuberculosis, and valuable
M
information can be extracted from their personal writings and correspondence. Tuberculosis is a chronic illness: in the pre-antibiotic era, people could be ill during a
d
long time. From the onset of their TB until their death, Kafka lived 7 years; Katherine
te
Mansfield, 12; and Chekhov, 20.
Ac ce p
Half of Western Europe had faulty lungs, and people had frightening haemoptysis in all sort of public places.
Patients often do not trust in doctors and other Health personnel; and suffer spiritual crisis.
Tuberculosis has a terrible impact on mental Health of patients. Health Quality of Life evaluation and active psychological support should be provided to TB patients within the management of their disease.
KEYWORDS Tuberculosis, literature, Kafka, Mansfield, Chekhov, mental health.
3
Page 2 of 10
Everyone knows Chekhov died from Tuberculosis, as did Kafka and Katherine Mansfield; even if most people know nothing on the disease but some of the symptoms, notably hemoptysis. When anyone not working on medicine or TB science is asked about the disease,
ip t
often recall a languid pallid woman from the mid XX century, coughing blood in a handkerchief. But TB is not a disease from the past. Approximately 9 million people get ill
cr
every year, in spite of an effective treatment, and 1.5 million die because of it(1). The existence of comorbidities as HIV infection or diabetes, and the emerging threat of strains
us
multiresistant to drugs, complicates the fight against TB, which should be a public health
an
priority(1). In this context, the pre-antibiotic era can provide valuable information on the course of the disease; and letters from notable writers from the past century are a good
M
example. In this article, we would like to drive your attention to the lessons learnt from 3 of them: Chekhov, Kafka and Katherine Mansfield (KM).
d
1. TB is a chronic illness.
te
Anton Chekhov was born on 1860, Kafka on 1883, KM on 1888. The first was a Russian physician, and wrote plays and stories. Franz Kafka was a Czech Jew who studied law, and
Ac ce p
worked in an insurance company, but also dedicated a lot of time to write stories. KM was a writer, which came from New Zealand and soon moved to and worked in Europe. Chekhov was bright, hard-worker and had a lot of sense of humour. Kafka suffered from anxiety, insomnia, and emotional breakdowns, which impaired a lot his life. KM had a tempestuous life –she was a female adventurer- before being so impeded by disease: first ghonorrea and then tuberculosis. Chekhov and Kafka’s illness debut was with an haemoptysis; while KM suffered from pleurisy(2–4). Since the onset of their disease until their death, many years passed: 7 for Kafka, 12 for KM, and up to 20 years for Chekhov. If we consider that no effective treatment but thoracic surgery was then available, and that antibiotics only appeared
4
Page 3 of 10
much later on, it’s easy to infere that TB is a chronic illness, which course must depend on host factors as genetic background, environmental conditions and immunological status. 2. Europe was sick, and people had frightening haemoptysis in all sort of public
ip t
places. At that time, and according to Kafkas words, half of Western Europe had more or less faulty
cr
lungs(2). KM used to live in Paris in 1922, and had a lot of meals in filthy restaurants, due to her lack of money. In a letter to his husband Murry, she explained she was sitting in front of a
us
French poet who was coughing and spitting all the time, and who finally, after a glance at his
an
handkierchief, commented: «Still blood. I need 24 handkerchiefs every day, my wife is desperated!»(5). But this poet was not the only one. Chekhov first serious haemoptysis,
M
which led to the TB diagnosis, happened also in a restaurant, the Hermitage in Moscow, where he went to have dinner with his friend Suvorin. In a letter to his friend Lidia Avilova,
d
dated on March 1897, he explains: «hardly we had sat down to the table when a vigorous
te
flow of blood started streaming from my throat. Suvorin took me to the Slavyansky Bazaar and summoned doctors»(3). For Kakfa, it was not a restaurant, but the apartment he had at
Ac ce p
the Shönborn-Palais, in Prague. Worried for his friend and lover Milena, who announced him she was coughing blood and had been recently diagnosed of TB, he describes her in a letter his first haemoptysis, which happened in the middle of the night. Kafka, who always thought the physical disease was a manifestation of his mental disease, spitted so much blood that the maid, when visited him the morning after, said to him: «Her Doktor, you won’t last much longer»(2).
3. If you have TB, do not go to Paris. In the mid XX century, with a Europe eager for cultural revolution, Paris was the place to go. But Paris is also known for their humid and cold weather, which didn’t help TB patients to recover. KM, in September 1922, wrote to her friend Sylvia Land, complaining: «the bad
5
Page 4 of 10
weather here these last few days has brought my cough back again»(5). But it was not only Paris. TB patients often moved to dryer and warmer places, following doctors’ orders. Still nowadays, when you speak to long-term TB patients, they always comment their cough is
ip t
back every winter season (and hospitalizations peak (6)); and TB is often diagnosed in spring or summer seasons. Seasonality of TB has been explored later on, suggesting a decrease of
cr
Th1 responses and of vitamin D, and seasonal variation on habits among other causes(7); and even if it is a controversial issue (should it be due to a seasonal host susceptibility or a
us
seasonality in pathogens survival)(8,9), the fact is that published literature suggest a
an
link(6,10).
4. Patients often do not trust in doctors and suffer spiritual crisis.
M
KM did not had any faith in doctors or treatment. In February, 1919, she wrote in her diaries: «Saw the doctor- a fool»; and the day after: «Saw two of the doctors –an ass and an ass»(4).
d
Three years later and many doctors after, she still had no hope nor believed in any kind of
te
medical treatment: «It’s all sham. It amounts to nothing»(5). Chekhov, who was a physician himself, wrote a letter to his friend Suvorin in 1891 confessing his decision of not undergoing
Ac ce p
any treatment: «The idea of having to undergo treatment and fuss over my physical condition produces in me something akin to revulsion. I’m not going to be treated»(3). It is true that the available therapeutical options at the moment and the poor outcomes obtained did not offer big hope. Moreover, some of the doctors even tried to convince patients to undergo new treatments that sometimes turned out very bad. A white émigré from Russia, Manoukhin, submitted the very ill KM to X-radiation of the spleen for 15 weeks of treatment in 1922, for which she paid 300GBP at time (approximately 13230GBP and 14900€ in 2016)(5). Without having improved her TB and very sick of the Adverse Effects caused by the radiation, KM turned to mystic, philosopher who directed the Institute Fort he Harmonious Development of Man, where she lived the last months of her life, before dramatically dying of a massive
6
Page 5 of 10
hemoptysis(4,5). This spiritual crisis of KM is not an isolated fact in tuberculosis patients, and even common in other severe chronic illness. Facing isolation, fear of death or lack of support, patients turn to gods or any other kind of spiritual forces they believe in(11). Distrust
ip t
is common in tuberculosis, especially in non-adherent groups(12). However, since the existence of chemotherapy, which is effective, patients are commonly grateful for the
cr
treatment they receive, as they can feel a positive progress(11,13,14). In the case of MDR/XDR-TB patients, attending physicians and other health personnel sometimes are
us
scared of being infected, and this might also contribute to a distrustful relantionship(15).
an
5. Mental Health is important, and we should be systematically evaluating it. Because of the stigma, both Chekhov and Kafka tried to hide TB from their families. Kafka
M
asked Oskar Baum in October 1917: «By the way, my parents know nothing about the TB, so you will be careful, won’t you, if you should by chance run into them»(16). Chekhov had the
d
same request for his brother in March 1897: «I was diagnosed with pulmonary apical TB and
te
accordingly awarded the right to describe myself as an invalid. Nobody knows anything about my illness at home, so rein in your customary malice and don’t blab about it in your
Ac ce p
letters»(3). In high-incidence countries, stigma and the shame associated to it are still important problems to TB patients(17,18). Facing a severe life-threatening illness dominated everything. As said by Chekhov to Lidia Avilova in 1901: «You ask if I am happy? The first thing I have to tell you is that I am ill. And I now know that I am very ill»(3). The invalid KM, often felt miserable and wrote about it in her diaries. In 1922 records, she annotated: «The world as I know it is no joy to me and I am useless in it», and «This isolation is death to me»(4). Patients get desperated. «I feel as though I’m in prison and full of rage, terrible rage»; says Chekhov to his wife in 1899(3)c. And Kafka to Max Brod: But «Above all the fatigue increased. I lie for hours in the reclining chair in a twilight state. I am not doing well, event though the doctor maintains that the trouble in the lung has remitted by half. But I
7
Page 6 of 10
would say that is far more than twice as bad. I never had such coughing, such shortness of breath, never such weakness»(16)ka. Mental Health has been described to be highly impacted by TB. Patients show a wide spectrum of feelings, from anxiety, shame, loneliness, worry,
ip t
dispair and anger(19). Depression is often mentioned as a consequence of TB, as a result from the isolation, the stigma or from being chronically ill; and it has been reported that
cr
support from family and friends might be essential for improving mental health, selfperception and good social role functioning (11,20)(18,21). In my opinion, these articles
us
show that systematic evaluation of Health Quality of Life including impact of the disease on
an
mental health should be performed in all clinical studies, and active psychological support
M
should be provided to TB patients within the management of their disease.
CONCLUSIONS
d
Pre-antibiotic era provided us a lot of information on TB disease nowadays available and
te
which could be useful for better understanding and management of TB. Patients need information on their disease to trust their doctors and other health personnel, and tools to face
Ac ce p
the feelings associated to it. Systematic evaluation of mental health associated to the disease and psychological support should be included per routine in management of TB patients.
CONFLICT OF INTEREST: None
FUNDING This work was supported by the Plan Nacional I+D+I co-financed by ISCIII-Subdirección General de Evaluación and Fondo-EU de Desarrollo Regional (FEDER) through CV contract CP13/00174.
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