Epidemic and Social Isolation: Research on the Tuberculosis Epidemic until the Middle of the 20 th Century and Patients’ Social Problems, Treatment and Adaptation

Epidemic and Social Isolation: Research on the Tuberculosis Epidemic until the Middle of the 20th Century and Patients’ Social Problems, Treatment and AdaptationThis article is a review of a study entitled Социалната болест. Туберкулозата в България през първата половина на ХХ век [The Social Disease – Tuberculosis in Bulgaria in the First Half of the 20th Century], authored by Milena Angelova (Blagoevgrad, 2021, 346 pp.).Izolacja epidemiologiczna i społeczna. Badania nad epidemią gruźlicy do połowy XX wieku oraz problemami społecznymi pacjentów, ich leczeniem i adaptacją Artykuł jest recenzją książki zatytułowanej Социалната болест. Туберкулозата в България през първата половина на ХХ век [Choroba społeczna – gruźlica w Bułgarii w pierwszej połowie XX wieku] autorstwa Mileny Angelovej (Blagoevgrad 2021, 346 ss.).

his family, and about the medical institution which was the first in the Balkans to deal with tuberculosis patients. By connecting the activities of the sanatorium with events in Bulgaria, Dr. Mondeshki's book is a history of medicine and popularized the community, traditions, and history of this settlement. This intriguing topic finds its unfolding in numerous similar publications throughout the 20 th century.
Milena Angelova's monograph Социалната болест. Туберкулозата в България през първата половина на ХХ век [The Social Disease -Tuberculosis in Bulgaria in the First Half of the 20th Century] (Ангелова, 2021) goes far beyond these "life" stories and takes on the huge task of studying the socio-historical processes in the Bulgarian society of the first half of the 20 th century. The in-depth scientific research in this monograph is not alone in the field of Bulgarian history and culture, but it is based on a number of studies from the International Seminar for Balkan Studies and Specializations at SWU "Neofit Rilski", a member of which is M. Angelova. The earlier endeavors of the University team (especially those of P. Vodenicharov, K. Popova, N. Muratova, M. Angelova, E. Tacheva, I. Nedin, M. Mladenova et al.) in the field of social issues (ethnosociology, sociolinguistics, socioeconomics, sociology of literature) related to the mobility, adaptability and settlement of different groups within communities in Bulgaria and the Balkans have made an indisputable contribution to the evolution and the determining of this authentic research topic. Studies on Muslim Bulgarians (Воденичаров et. al., 1998; Попова, Муратова 2011), studies on gender issues (Воденичаров et. al., 2002), studies on Balkan communities (Воденичаров et. al., 2005), issues related to the social commitment of institutions in Bulgaria in the recent past (Попова, Ангелова 2005) and others have a direct relation to the research arsenal of the monograph and topic under consideration, thus determining the historical scope and the discussion perspectives. The results of these works suggest that a research school has formed in the scientific space of the Neofit Rilski State University, Blagoevgrad, to which the Balkan Studies Seminar has provided abundant content. The results of their elaborations fit into the idea of a research school formed in the scientific space of SWU "Neofit Rilski", Blagoevgrad, which is richly and carefully filled by The International University Seminar for Balkan Studies and Specialization.
The exceptional role of the archive materials in Angelova's monograph molds the historical knowledge and weaves the scope of these sources as a prerequisite for a comprehensive description of the problem, but it also proves these archives' relevance today. Angelova manages to extract new meanings from archival information that sound up-to-date during the COVID-19 pandemic, when much of the discussion about mid-20 th -century tuberculosis coincides with concerns about coronavirus today, in the 2020s. Or, in the words of N. Muratova, The archive is not a static but a dynamic process, even when it is seemingly frozen. This means that what is "taken out" of the archive is of great importance: which social functions it recognizes, because with time contexts are built, accumulated and most of all changed. The power of a document can change radically over time and gain a new reading. That is why the archive is in fact an unknown that awaits interpretations. (Муратова, 2021, р. 29)1 The topic of tuberculosis and its treatment in Bulgarian culture is present in several studies that have become emblematic. These include research on the history of medicine, ethnosociology, socio-historical research, philosophical-psychological and philosophical-cultural aspects. The topic of tuberculosis and its treatment is even present in literary history. Researchers write many studies and stratify many accents and descriptions of the problem of disease. In the field of literary history and criticism, there is an innovative study by Tatiana Ichevska, Медицината в българската литература [Medicine in Bulgarian Literature] (Ичевска, 2019), in which the topic of tuberculosis is considered as a profound layer in the literary works of Bulgarian writers. Presenting various motives and images, Ichevska puts forward an issue to which a number of foreign studies are devoted but is poorly touched upon in Bulgarian literature. In a narrower aspect, but specifically corresponding to the researched topic, is the long-term research of J. Nazarska, which opens the door to an unexplored layer: medics in Bulgaria and their role both in intellectual circles and as specialist innovators. Undoubtedly authoritative is Ichevska's research on the genesis of Bulgarian medicine in the middle of the 19 th century (Назърска, 2015) and the highlighting of women's presence and achievements in Bulgarian medical circles from the end of the 19 th until the middle of the 20 th century (Назърска, 2016a, 2016b). The activities of K. Popova regarding the social roles of medical staff in the period 1924-1935 are also extremely beneficial (Попова, 2011).
Angelova's impressive work draws the reader into a plainly painful, complex and uncertain world -that of disease and deprivation. Bordering almost on the instruments and techniques of criminal literature and history, the introduction indicates both the motives for this commitment to this topic and the sequence of search and discovery. On the issue of disease and deprivation, which has been the subject of her research for more than ten years, Angelova has published a number of works. Her first article was "В 'Eдинен противотуберкулозен фронт'. Борбата против туберкулозата в социалната и здравна политика на българската държава -1944-1951г (Ангелова, 2005). Here Angelova introduces the social dimensions of this disease and describes the strong influence of socio-political life on it. The monograph Социалната болест includes materials presented at a number of important scientific forums. This is how the further aspects of Angelova's research are formed. Her article "Научно и социално конструиране на болестта: туберкулозата в края на XIX -първата половина на XX век" [Scientific and Social Construction of Disease: Tuberculosis at the End of the 20 th -First Half of the 20 th Century] (Ангелова, 2015) is very important as it contains rich source material and offers specific scientific observations on the intersection of different cultural points of view (traditional and modern), professional innovations (following examples from abroad) and institutional support (building societies and unions, state support, even non-governmental organizations, etc.).
The monograph Социалната болест has a clearly defined structure with an introduction, four chapters, a conclusion, an attached bibliography, and a summary in English. The boundaries, goals, topics and aspects of the problems are outlined in the introductory part, and the social dimension is sought not only and not so much in the genealogy of tuberculosis, but in the possibility to control it with the help of social policies. The analysis is precise and concrete.
In Chapter One, "Научно и социално конструиране на болестта" [Scientific and social construction of tuberculosis], the author narrates the history, etiology, and social structure of this epidemic , and modern concepts concerning disease, etc. Through the exemplifying review of the literature on the history of tuberculosis and its historiography in the field of the metaphorical, Angelova creates a culturological basis on which she builds the foundations of her further scientific observations. Outlining the gradual transition of the topic from medical to the culturological discourse, she gradually derives the nomination "social disease" from the scientific readings. Mapping out the separate stages of social awareness, the presented public health policies and practices are applied as part of the socializing apparatus. Political debate is also involved in the discourse (Ангелова, 2021, p. 19). Various literary, journalistic, and medical metaphors are considered, proceeding from the disease to its control, cure, and eradication (Ангелова, 2021, p. 21).
Other methodological concepts are gradually introduced and included in the course of the research, which give it an interdisciplinary character: "methods of social history, history of medicine, history of everyday life, historical anthropology, political history, history of law" (Ангелова, 2021, p. 22). The extremely rich source material and concepts form a solid foundation for the further development of this study.
Examining several important questions about the social aspects of disease (Ангелова, 2021, p. 24), this study observes their evolution in England, France, USA, and Germany (pp. 24-28). The cases described illustrate the impossibility of accepting tuberculosis in society and integrating patients into society. Starting with a study of rich archaeological, mythological, and other materials (Ангелова, 2021, pp. 28-39), and continuing these observations until the modern era, Angelova outlines the social perception of tuberculosis and even its systematization: romantic metaphors and symbolisms which appeared during the acute epidemiological phase became descriptive and characterological for many generations.
Chapter Two "Туберкулозата, общественият дебат и държавните политики в България 1879-1951 г." [Tuberculosis, the public debate and government policies in Bulgaria 1879-1951] also contains several parts that reveal another aspect of the social impact of tuberculosis: its inclusion in the state healthcare apparatus. Chapter Two describes the first publications of Bulgarians on the subject as well as the development of medical periodicals. Even here can be seen the definition of this disease as a "common" disease (Ангелова, 2021, p. 57) and a "social evil" (p. 57) because, in terms of its prevalence and scope, it mainly affects the poor rural and working populations. Here it is important to note the growing secularization in Bulgarian society in the early twentieth century -a factor that marks "a change not only in religious sentiment, but also in the very concept of religion, its importance in society and nation" (Джевиецка, 2016, p. 35). An important role in popularizing this problem is played by the translated literature, which is a reason for state institutions to pay attention to it. The presented legislative acts and tasks of the government institutions for control of the epidemiological spread outline the role of health centers in the organization of healthcare. Thus, it turns out that more empha-sis is placed on treatment than on prevention (Ангелова, 2021, p. 66), which raises the question of the need for health facilities and experts.
Facts about Bulgarians who graduated in medicine abroad before the Liberation (Ангелова, 2021, p. 69) give the feeling that the construction of Bulgarian healthcare started from foreign universities as some of the graduates abroad became teachers in medical schools and worked in the Bulgarian government administration after the Liberation. They are also the basis for the establishment of health services: hospitals, clinics and places for recovery and recreation. It is interesting that some monasteries played such a role before the Liberation (Ангелова, 2021, p. 70).
The third part of this chapter describes the opportunity for local medicine to outgrow simple treatments and move to another phase: taking measures to prevent infection. The regulations on "sanitary control and anti-epidemic initiatives" play an important role (Ангелова, 2021, p. 95); however, all these activities are reflected in standard of living levels (Ангелова, 2021, p. 97). Thus, tuberculosis and its treatment become a problem of the value and quality of life of the Bulgarian population. In this primary process of clarifying and structuring the role and involvement of state institutions (Ministry, dispensaries, sanatoriums, health centers, etc.), the Health Organization of the League of Nations, the Rockefeller Foundation, the American Middle East Foundation, etc. are presented, including the scandalous Friedman Institute.2 Thus, another aspect is gradually added to the ordeals of poverty, working conditions and hygiene, namely children's health, which motivates the establishment of children's health centers, colonies and camps.
This relative orderliness changed with the government practices in the 1944-1951 period. The new situation of lustration (only members of the Bulgarian Communist Party could be elected to management positions) found the health system unprepared; its organization was carried out in stages, despite targeted measures to tackle tuberculosis quickly and expeditiously (Ангелова, 2021, p. 108). The dynamics in political life (the elections for the Supreme National Assembly, the subsequent carnage of the opposition, the new Constitution, etc.) slowed down the fight against tuberculosis. Thus, the year 1951 proves to be key for the socialist government's introduction of innovations, which were based on the model of Soviet healthcare; these are described in detail by Angelova and reveal the formality and injustice of these processes, which ended with the nationalization of healthcare (Ангелова, 2021, pp. 110-113). The medical infrastructure in the 1944-1951 period is examined in a particular part of the chapter. It starts with the year 1947, when the Clinic of Phthisiology was opened by Prof. M. Mondeshki (Ангелова, 2021, p. 113). Other reorganizations follow, with nationalization and the Law on Denominations closing all hospitals at religious centers (Ангелова, 2021, p. 114). Special attention is paid to the popularization and widespread introduction of the BCG vaccine (Ангелова, 2021, pp. 120-123) and the establishment of drug therapy.
The history of the introduction of the BCG vaccine in Bulgaria has many parallels with the current introduction of the COVID vaccine. The attitude to both was extremely similar at the beginning of their introduction: distrust, caution, avoidance, and the subsequent hesitant acceptance by society. The application of the BCG vaccine did not become widespread until it was declared to be highly recommended and became government policy. While the BCG vaccine was introduced as mandatory only during the socialist period and many decades after the tuberculosis outbreak, the COVID vaccine is being introduced at the time of the pandemic through social mechanisms, such as free access to public places, work, health facilities, administration etc. The BCG vaccine had been under development in Bulgaria since 1926, and its mandatory implementation began in the 1949-1953 period, after the approval of the Council of Ministers (Ангелова, 2021, p. 121) and the business trip of a team of specialists (Dr. M. Mondeshki, H. Boyadzhiev, Dr. M. Zaharieva, Dr. A. Tashkov and Dr. L. Nedev) to Copenhagen, Denmark, whose aim was to organize the production of a Bulgarian vaccine (Ангелова, 2021, p. 122). Thus, the BCG vaccine in Bulgaria moved from the social register of voluntary use to a state regulation by the new socialist government.
Chapter Three, "Дружеството за борба против туберкулозата в България  ], presents the origin, development and role of this society in the fight against this social disease. After a brief history of organizations in Europe and the United States and the resulting International Union against Tuberculosis, Angelova reveals the developments in Bulgaria, logically dividing them into two: from 1909 (the founding of the Society for the Fight against Tuberculosis in Bulgaria) until 1944, and the influence of the socialist government on the functioning of the already established structures in the period 1944-1951. An essential element of the activity of the anti-tuberculosis Society is that it was financed mainly from charity. It first received state support only in 1938, as a result of interaction with state institutions and the insistence of the Society for commitment at the highest government level. A number of initiatives are taken: amendment of legal acts, proposition to introduce compulsory insurance against tuberculosis, arrangement of dispensaries, sanatoriums, hospitals and resort treatment, etc. In 1931, a "Национален план за борба против туберкулозата" [National Plan to Fight Tuberculosis] was also developed. Presenting the Plan's points of reference, Angelova also reveals its concept: "the reasons for the spread of tuberculosis, with special emphasis on the rural population", providing staff for treatment and prevention, "primarily looking for preventive policies" (Ангелова, 2021, p. 171).

" [The Society for the Fight against Tuberculosis in Bulgaria
After 1944, the situation changed due to the nature of policies based on state planning, which completely replaced charity activities. The Society for the Fight against Tuberculosis was renamed as the People's Union, following the example of the omnipresent "people's" and "socialist" organizations, societies, associations and institutions. Moreover, if until 1944 the main mechanism of the organizations had been the popularization of the problem and educating the population, then the People's Union for Fighting Tuberculosis emphasized massification and agitprop (Ангелова, 2021, p. 178). A number of activities were introduced, such as Tuberculosis Awareness Month, while the cartoons in newspapers and magazines were replaced by biased political ones. These cartoons emphasized the public perception of the disease as an important problem and discussed graphically (figuratively) the increasingly serious and decisive measures applied.
Chapter Four, "Туберкулозата и лечебните места -организация и режим" [Tuberculosis and medical facilities -organization and management], examines "specific social technologies for the organization of medical measures against tuberculosis in Bulgaria" (Ангелова, 2021, p. 185), including sanatorium amenities (public and private), children's schools and colonies, sanitoriums in healthy climates, dispensaries, and hospitals. Building a streamlined system of functioning facilities is a slow and time-consuming process. In Angelova's book, the developments in Bulgaria are presented in detail as a direct consequence of the construction of sanatoriums, hospitals, etc. abroad. At the beginning of this process in Bulgaria, huge organizational activity was carried out, which produced results. By 1944, several sanatoriums had opened in Bulgaria: 7 state ones, in Troyan, Varna, Iskrets, Ladjene, Raduntsi, Peshtera, Surdulitsa; and 8 private ones, of which 6 were in Sofia, one in Svoge and one in Tarnovo. The private sanatoriums offered better conditions: they were in Knyazhevo and Vladaya (belonging to Dr. Hadjiivanov), and there was also the Student Sanatorium, the Kraiselska Sanatorium, the Russian Sanatorium and Vitosha Sanatorium on Gornobansko Shosse, Dr. Koev's private sanatorium near Svoge, and the "Holy Mountain" of Dr. Treiman in Tarnovo. The children's institutions for treatment and rehabilitation are presented too: prevention centers, open-air schools and children's summer colonies, sanitoriums in healthy climates, dispensaries for the sick (in Sofia, Plovdiv, and others).
Interesting and exciting are the stories of the writers Alexander Vutimski, Hristo Smirnenski, Georgi Markov, whose stays in sanatoriums are presented through their memoirs, letters and works of art. Admission to and residence in a sanatorium until 1944 was difficult and expensive. The miserable existence of the ordinary Bulgarian after the First World War led to many deprivations and obstacles, the biggest of which was access to health care. The picture was no better immediately after 1944, when, in order to enter a sanatorium, the privilege of "active fighter against fascism" was used. This status in the time of socialism became, according to Ewelina Drzewiecka's successful definition, "a kind of ceremonial communication" "because it offers a new cultural meaning as a mediator in the transmission of the political revision of the historical narrative" (Джевиецка, 2020, p. 37).
The advancement of tuberculosis and research into it affect childcare. Initially, it was believed that "childhood is not such a dangerous period for the development of tuberculosis" (Ангелова, 2021, p. 254), but later it was found that infection with tuberculosis bacilli in childhood can cause a number of problems in adulthood (Emil von Bering's discovery in 1903). This activated a number of institutions and medical communities to seek more committed treatment of children. As a result, a number of facilities for young patients emerged: prevention centers, outdoor schools, children's summer colonies.
The opening of such medical institutions in Bulgaria was extremely delayed and difficult. Attempts were made in Sofia to take care of children at existing sanatoriums and hospitals for adults, but the first such special place was the Preventorium in Tryavna, personally sponsored by Tsaritsa Giovanna, which opened in 1944 under the name "Tsar Boris III Royal Children's Sanatorium" (Ангелова, 2021, p. 258). Similar ones were set up in Lyulin, Lovech, Gorna Banya and others. Numerous sanitoriums in healthy climates were also opened, where slightly sick people were sent. Dispensaries were also not forgotten as a successful form of disease prevention as they provided monitoring, information and referral of patients for treatment (Ангелова, 2021, p. 276).
The conclusion is constructive and summarizes the research. The bibliography contains literature in Bulgarian and other foreign languages. The list of English, German and French materials of various genres is impressive.
Along with the statistical data (indispensable in a historical study), Angelova's monograph also contains facts, documents, events, memoirs, letters and other subjective literary and artistic sources. These shape the feeling not only of an organized social structure, but also of an engaged social stratum that functioned as a living organism that cared for the sick and strove to ensure a tolerable standard of living (Ангелова, 2021, p. 296). Thus, the treatment of tuberculosis became a socially engaging problem for both the state and the various communities (Jewish, "white immigrants", etc.). Therefore, the combination of two points of view is especially valuable in the monograph: that of the patients and the activities of the medics.
The social aspect of tuberculosis is not just a metaphor: it has a concrete manifestation in which Angelova reveals the active elements of society, regardless of the political system. These energy cores are illustrated by a rich visual representation that serves to convincingly reveal the image of the disease as evil: the photos, illustrations, covers, cartoons, brochures, posters, stamps, etc. form comprehensive collection of illustrative material, thus making the text extremely multi-layered. The exhaustive documentary materials (archives, periodicals, government documents, history of medicine in Bulgaria, memoirs of doctors and public figures, letters and more) impress with their precise selection and structural-analytical arrangement, which reveals the in-depth look and systematizing skills of the researcher.
Angelova's research is original and makes a significant contribution to the overall process of reviewing, evaluating, and especially raising a number of awkward issues concerning the recent past in aspects of disease treatment. Some of them are the issues of eugenics, social poverty, injustice and division, loneliness and isolation of both the ailing and their families. Thus, tuberculosis is permanently seen as a social disease that is "directly related to living and working conditions or is specific to specific social groups" (Ангелова, 2021, p. 320). Angelova's research describes the social mechanisms of coping, adapt-ing, institutionalization and transformation of a health problem into a social technique. This book is written with inspiration, but also with the efforts of a skilled researcher who processes a large amount of literature over time, testing models and constructing her own concepts.
Социалната болест. Туберкулозата в България през първата половина на ХХ век by Milena Angelova examines both public debates and government policies in order to understand tuberculosis and the constitution of forms and places for treatment. The richly intertwined true stories become a kind of topos of healthcare in Bulgaria of the first half of the 20th century. Thus, the book largely touches on culturological concepts of behaviour and the development of mechanisms to deal with the epidemic of the first half of the last century. Even without any present-day references, it sounds relevant to the debate on the current pandemic.