Between Decay and Maintenance: Tuberculosis Sanatoriums,Care Infrastructures and U.S. Health Policy Debates,1945–1972

Introduction

The development of streptomycin in 1944 and isoniazid in 1952 transformed the landscape of tuberculosis treatment. As treatments became standardized and widely accessible, the changing nature of an enduring public health challenge gave rise to optimism about eventual eradication. In 1953, the first year for which the Center for Disease Control and Prevention reported nationwide data, 84,304 tuberculosis cases were reported in the United States, compared to 54,042 cases a decade later, with the incidence rate falling from 52.6 to 28.6 per 100,000. Mortality rates also declined significantly, from 40 per 100,000 persons in 1945 to 22.5 per 100,000 by 1950 (Snider 1997; U.S. Center for Disease Control and Prevention 1953), and would fall again to 6.1 per 100,000 by 1960 (U.S. Department of Health, Education and Welfare 1963). After decades in which sanatorium-based care had developed with the goal of enabling temporary recovery from an illness that remained incurable, successful antibiotic treatment led to observable declines in the number of patients seeking sanatorium care and in average length of inpatient treatment (Holand 1971, 53; Zwick and Pepperell 2020). Instead of facilitating prolonged care aimed at partial recuperation, sanatoriums increasingly functioned as sites where patients could receive standardized antibiotic treatment.

While sanatoriums continued to play a role in tuberculosis treatment in the first decades of the antibiotic era, changing perceptions of the disease as both curable and a waning public health crisis sparked medical and legislative debates about their continued relevance and cost-effectiveness. By the mid-1970s, 6 of Wisconsin's 17 sanatoriums open in 1950 had closed, and the number of patient beds allocated for inpatient care had drastically declined (Holand 1971). Yet, the sanatorium's legitimacy as an infrastructure supporting both individual patient recovery and wider community health was negotiated in complex ways in medical and public health literature throughout the 1950s and 1960s. Physicians recognized a declining but continued need for specialized sanatorium or hospital-based care due to biomedical and social factors, for patients diagnosed in an advanced stage of illness, for those deemed “uncooperative” with treatment (Blackburn 2017), and for those who lacked the social support and financial resources for a successful home-based recovery (Peck 1956).

To illuminate how public health workers and physicians involved in tuberculosis care perceived sanatoriums as an infrastructural technology, this article draws on the archives of The Crusader, a monthly publication of the Wisconsin Anti-Tuberculosis Association (WATA), along with other medical literature from the mid-twentieth century. Examining the changing role of sanatoriums in Wisconsin as a representative case study, this paper adapts a state-specific approach, situated amid nationwide trends in the development of U.S. healthcare infrastructures. This approach allows for a case study conducted at multiple scales, attuned to both local and national contexts. As one of the first three states to make tuberculosis care completely free to all residents in 1945, Wisconsin's public health policy came to reflect a commitment to removing financial and geographic barriers to tuberculosis treatment (Holand 1971, 50). Wisconsin's relatively robust sanatorium infrastructure in the early and mid-twentieth century makes it an ideal case study for understanding how multiple stakeholders conceptualized these facilities’ changing roles while navigating maintenance and decay.

This case study contributes to a growing literature in science and technology studies (STS) that highlights opportunities for repair in care infrastructures as enabling more adaptable, equity-focused responses to enduring public health challenges (Kameda et al. 2021; Street and Kelly 2024). As Venkat (2019) suggested, the challenge of antibiotic resistance complicates expectations that pharmaceutical advances would herald the elimination of tuberculosis, instead revealing a need for renewed attention to systems of care alongside technologies of cure. As health systems grapple with limitations in biomedicine, it is crucial to better understand the affordances of maintenance and repair work in sustaining care infrastructures as a resource for responding to public health challenges and the social inequities that shape their impact. As Alice Street and Ann Kelly (2024) write in their analysis of diagnostic innovation during the 2014–2016 Ebola epidemic, designing and distributing health technologies equitably require “managing uncertainty” in light of changing epidemiological contexts, along with strategies for fostering “a reflexive and inclusive discussion” about the needs of impacted communities and the distribution of resources. By tracing how approaches to tuberculosis care rooted in maintenance and repair enabled sanatoriums to meet evolving patient and community needs, this study illustrates the methodological affordances of thinking infrastructurally about health policy. An infrastructural approach attunes scholars to how political uncertainty and resource limitations, as well as epidemiological and technical factors, shape the ways in which healthcare systems can effectively respond to health crises.

Infrastructural Thinking and Contested Domains of Public Health: A Novel Intervention

As sanatoriums both declined and were repurposed in novel ways, debates over the future of these sites of care revealed deeper disagreements and contingencies that would shape the field of public health and the inequalities that remain entrenched within the U.S. health system. While previous literature investigates the sanatorium as a spatial technology and a form of medical infrastructure (Adams et al. 2008; Venkat 2019), STS scholarship has yet to place its changing function in the context of mid-century legislative and policy debates in the United States, in which sanatoriums figured as either an essential public service or an avoidable cost. The terms of the debate about universal healthcare in the United States were shaped by a conceptualization of healthcare infrastructure in which sanatoriums played a visible and significant role. Indeed, debates about sanatorium closures in the United States offer novel insights into how healthcare policy was contested in the mid-twentieth century. Examining the changing imaginaries around sanatoriums as their relevance declined and debates about closure proliferated enables a distinctly temporal analysis of how processes of maintenance and decay in infrastructure impact larger policy debates.

The role of sanatoriums figured substantively in these debates because they were a multiscalar infrastructure that took shape through individual local sites as much as state-wide (and nationwide) networks. To illustrate how infrastructural thinking about sanatoriums shaped broader health policy, I place the changing role of sanatoriums in the antibiotic era in the context of debates about healthcare reform, in which two kairotic framings of tuberculosis—as a continuing public health crisis with unequal impacts, and as a triumph of medical progress—were both deployed, without success, to make the case for a national health system. Second, I show that as opportunities for healthcare reform were foreclosed, widespread delays in diagnosis persisted as a major challenge to the twin goals of “tuberculosis control” and “elimination.” This, in turn, led some physicians to articulate a new social function for sanatoriums in filling the gaps left by underfunded health and social welfare systems while reconfiguring older functions related to risk management and disease surveillance. This reframing of the sanatorium's role isolated tuberculosis care as a public health issue almost universally recognized as requiring government resources, coordination, and oversight, separating it from the larger policy question of primary healthcare access and health equity.

This article contributes to a growing STS literature (Abadía-Barrero and Ernesto 2016; Howe et al. 2016; Johnson et al. 2021; Smith and Bryant 1988) on infrastructure by elucidating how ethical and equity-focused approaches to maintenance and repair might deepen our understanding of healthcare systems whose infrastructural dimensions, particularly in periods of transition and uncertainty, connect to questions of equitable access and social and political priorities. By grounding my study of the evolving sites of tuberculosis care in an infrastructural approach, I offer a novel conceptualization of how responses to a particular disease illuminated the contested politics and futures of larger healthcare systems. Comprehensive histories of healthcare in the United States have examined policy debates, the sociological history of care work, and the funding and cost structures that shape the allocation of resources (Hoffman 2008; Winant 2021). However, in their dimensions and methods, these groundbreaking studies miss key elements of how public health, particularly efforts to treat and eradicate tuberculosis, figured in debates about healthcare reform. Through a textual analysis of medical and public health literature from the 1950s and 1960s, I illustrate how sanatoriums persisted as infrastructural technologies that both influenced and revealed the contours of policy debates. The infrastructure of sanatoriums, and the networks of care they facilitated through outpatient facilities, adapted to address needs left unmet by a fractured, unequal healthcare system. In articulating a continued role for these institutions, however, medical and public health experts focused on piecemeal solutions rather than broaching the topic of nationwide healthcare reform. Serving as a stopgap for the harmful impacts of an unequal healthcare system, sanatoriums enabled a conceptual separation between care for certain infectious diseases, codified as a right inextricably linked to community well-being, and other forms of healthcare, placed outside the parameter of state responsibility. With its focus on how maintenance and repair respond to—and can challenge—inequities in healthcare access, this article situates a case study of infrastructural change in broader STS discussions about the relations between technology, social imaginaries, and health equity.

Tuberculosis Care and National Healthcare Reform Debates, 1945–1949

To trace the ways infrastructural thinking enabled maintenance and repair in response to changing community needs amid a crucial transition in tuberculosis treatment, I begin by outlining the policy landscape in which antibiotics prompted a gradual reconsideration of the sanatorium's role. After a textual analysis of key arguments in legislative debates about universal health coverage in the late 1940s, I trace how the National Tuberculosis Association, and in particular its Wisconsin chapter, responded to contemporary uncertainties around healthcare funding and the trajectory of population-level and community-specific health needs. These historical materials, assembled through archival research spanning the late 1940s through the early 1960s, enable an in-depth rhetorical analysis of how public health workers conceptualized sanatoriums within state-wide and national infrastructural contexts, raising issues of equitable resource access while reconceptualizing sites of care to meet changing, but still significant, patient needs.

Streptomycin and isoniazid transformed the role of sanatoriums at a critical juncture in the history of U.S. health policy, amid debates over the proposed creation of a national health service (Chapin 2010). In the political landscape of the early Cold War, stakeholders such as the American Medical Association linked a universal insurance program to socialism, state control, and the erosion of doctor–patient relationships in which care and individual need were ostensibly centered (Brickman 1994). In narratives highlighting the virtue of “voluntary” health insurance, critics of an expanded healthcare system omitted key information about the drastic inequities and steep costs that limited Americans’ access to healthcare. Opponents of reform appealed to affective anxieties about the loss of personalized care and patient choice, departing from the techno-utopian celebration of “the ideals of laboratory science” and claiming that the status quo of private, fragmented healthcare access kept the profession rooted in “compassion” and “loyalty to the patient as a human being” (Warner 2013). In contrast, caricatures of a national healthcare system portrayed a dehumanizing, atomized landscape of care in which “the patient became a nameless unit on a factory assembly line—a machine, not a person” (Warner 2013). These healthcare debates unfolded in a broader context of changes to U.S. political economy, as labor unions’ leverage declined with the passage of the Taft-Hartley Act, leading labor activism to refocus on workplace-based collective bargaining rather than demands for universal social programs (Winant 2021). Throughout the late twentieth century, access to healthcare came to be determined through employment benefits and needs-based social assistance programs that were often subject to funding cuts. Tuberculosis treatment remained a notable exception, with many states guaranteeing free sanatorium care for all residents in need of treatment.

Congressional proceedings featured testimonies from physicians arguing both for and against a national health system, but accounts from ordinary patients about their experience accessing care, or delaying it due to financial cost, were conspicuously absent. The centering of expert knowledge is not surprising, but indelibly marginalized forms of knowledge rooted in patient experiences of navigating the healthcare system, as well as broader knowledge of how barriers to care intersected with other social determinants of health. While patient knowledge based on embodied experience has historically often been subjugated within medical systems and their epistemic cultures, Jeannette Pols (2014) demonstrated the need for biomedicine to acknowledge the “translation work” that patients perform in developing care practices and making them accessible and legible to others.

The link between unequal healthcare access, underfunding of public health, and tuberculosis infection and mortality rates featured prominently in arguments supporting the 1946 National Health Bill S1606. Because advanced cases of tuberculosis remained most difficult to treat, even with effective antibiotics, financial and geographic barriers to early treatment constituted both a major “unmet medical need” and a public health concern for the wider community. The 1945 and 1946 health bills included provisions not only for ensuring individual access to affordable healthcare but also for expanding public health capacity at the state and local level, with inadequate sanatorium facilities and beds cited as a pivotal example of unmet need: “The tuberculosis death rate is generally highest in the States where facilities are least adequate and programs for tuberculosis control least developed” (U.S. Congress 1946, 2412). Thus, alongside pharmaceutical interventions, sanatoriums remained a spatial and architectural technology for treating early infections, and funding for their construction was recognized as a preventative measure, as well as a curative one. Senator John Snyder, a legislator active in discussions of healthcare reform, identified widespread delays in tuberculosis diagnosis and treatment as evidence that a private healthcare system was inadequate to population-level needs:

The Committee on the Costs of Medical Care found that nearly 40 percent of all illnesses in families in the lowest-income bracket (below $1,200) were unattended, while this was true of only 12 percent of the illnesses in families receiving $10,000 per year. Equally convincing data could be presented to indicate that low-income families receive inadequate care and that the care which is received often comes too late—especially in the case of such diseases as tuberculosis and cancer, which must be caught early to be cured. (U.S. Congress 1946: see Appendix 1)

Writing in the Journal of the National Medical Association, physician William Cobb cited continuing racial inequities in tuberculosis mortality rates as a key argument for the necessity of a national health system. In explaining the National Association for the Advancement of Colored People's support for S.1606, Cobb emphasized the importance of ensuring that grants to states be equitably distributed and that discrimination against predominantly Black communities in either state or federal budget allocations be prevented. Responding to the American Medical Association's arguments against a national health service, he emphasized that patients would retain the freedom to choose their doctors, and that guaranteed access to medical care would represent an expansion of choice for the tens of millions of Americans who could not afford “voluntary prepayment plans” or were denied access “by reason of racial discrimination” (Cobb 1946, 136). The direct issue of unequal access to sanatorium care, and the persistence of segregated sanatoriums in the U.S. South, was not directly addressed (Roberts 2009). However, Cobb identifies tuberculosis along with maternal mortality as a key example of how inequities in healthcare access, and the underfunding of health systems in predominately Black communities, negatively impact health outcomes. In particular, he contrasts the considerable decline in tuberculosis mortality among white patients between 1935 and 1946 with the mortality rate among Black patients which had not decreased since 1938. For Cobb, a national health system was a necessary corrective to systematic racial and economic inequities in U.S. healthcare and the resulting disparities in health outcomes, including in the disproportionate risk burden of tuberculosis on Black Americans. Other proponents of a national health service acknowledged significant patient and community need but primarily framed a national health system as having the potential to extend existing progress, which had depended on a gradual expansion of public health capacity through “organized programs of mass prevention or treatment.” Addressing the U.S. Senate Committee Hearings, Dr. Joseph W. Mountin, Chief of the States Relations Division of the U.S. Public Health Service, invoked medical progress against tuberculosis and other infectious diseases as providing a template for combatting increasing mortality from cancer, heart disease, arthritis, and rheumatic fever:

Typhoid fever, diarrhea and enteritis, malaria, and yellow fever were conquered by environmental sanitation; diphtheria and smallpox by immunization; pellagra by nutrition; and tuberculosis is now being steadily overcome through programs for the early discovery, isolation, and treatment of the disease. It is largely through progress in control of such diseases that the life expectancy for people under 40 has been so strikingly improved. (Mountin 1946)

While advocates for a national health system cited tuberculosis as a challenge that could only be addressed through comprehensive changes in the healthcare system, the defeat of such proposals in 1945, 1946, and 1949 inaugurated an era of policy stasis in which public health challenges related to infectious disease were viewed in isolation from broader questions of healthcare access (Winant 2021). How did these national policy debates impact attitudes toward the changing role of sanatoriums, and the ensuing debates about funding?

For physicians and public health experts such as physician W.M. Peck (1956), the sanatorium was a socially situated technology that facilitated the effective distribution of resources essential for care amid funding constraints that reflected larger structural problems. The role of the sanatorium had to be understood in the context of socioeconomic barriers to accessing other forms of care. For Peck (1956), home care was a preferable alternative to lengthy sanatorium stays, but making it available to all eligible patients proved challenging because of limitations to health system capacity: “a considerable staff is required, including medical and nursing staff and social workers. Central clinic, roentgenographic, and laboratory facilities must be readily available.” Policy decisions and their impact on health system capacity, in other words, played a significant role in determining to what extent sanatorium-based care could be phased out in cases manageable through home-based care. Staffing, health system resources, and patients’ access to social support systems or government assistance determined whether a transition to home-based care could be implemented when medically appropriate:

The components of a treatment program-the sanatorium, the clinic, the home-may be used with varying emphasis, depending on community resources… Programs relying heavily on clinic and home treatment are indeed possible and even justified by circumstances, but they should be undertaken only after sober evaluation of resources and as a major interest. Even so, under carefully con- trolled conditions, there is justification for further cautious exploration in this direction. There is danger, however, that home care programs may be undertaken somewhat hastily be- cause of a mistaken assumption of great economy, because of popular clamor, or because of insouciance. And there is danger that home care and sanatorium care may be pitted against one another in wasteful competition. (Peck 1956)

To be sure, Peck does not directly raise the question of federal and state investment in public health nor does he devote extensive analysis to inequities in healthcare access. These policy variables provide the unspoken context to decisions about where sanatorium-based care is still most necessary, and where home care can be more liberally implemented. At the same time, Peck recognizes that resource constraints provide perverse incentives for relying on home care as a cost-cutting measure, even when local health systems lack the capacity to adequately monitor discharged patients during their recovery.

Writing in 1957, Donald Trauger, Director of the NTA's Division of Social Research, warned that predictions of the imminent eradication of tuberculosis were overly optimistic, observing that declines in the number of new cases had stalled “at the rate of three or four per cent a year” and that fatality rates, while falling, remained concerningly high—one in 20 for patients aged 15 to 24 and as high as one in three for patients aged 65 and over (Trauger 1957). Trauger's concern that the continued impacts of tuberculosis were being understated in the narrative of medical progress reflects recurring questions of temporality in twentieth century medical advances. As Winner (1993, 370–71) argued, social inequities shape the application of new technologies in ways that hold key implications for thinking about the temporality of public health crises and the infrastructures created or refined to respond to them. First, the development of vaccines, treatments, or other preventative tools is only a source of progress to the extent that it translates into broad and equitable access. For such public health gains to occur, innovation must be coupled with a host of sustained policy interventions to facilitate access to its benefits. Yet, wealthy societies, and more privileged groups within them, frequently cite pharmaceutical breakthroughs to prematurely declare the end of health crises that are far from resolved. As epidemiologist Gregg Gonsalves (2022) observed, the mid 1990s witnessed a rush to declare the HIV pandemic “over” at a time when access to antiretroviral and preexposure prophylaxis treatments remained profoundly unequal and limited both globally and within the United States. Similarly, medical anthropologist Paul Farmer critiqued the historical amnesia evident in news coverage of the “return” of tuberculosis in the mid-1980s, when the illness had never gone away but had remained a major cause of death globally (Farmer 2001). As we will see, a similar tension animated temporal perceptions of public health responses to tuberculosis in the United States. in the two decades after the emergence of streptomycin and isonaizid.

The trajectory of tuberculosis care in the twentieth century illuminates broader organizational and policy developments in U.S. healthcare over the course of the century. A patchwork of private and public care infrastructure; the contested temporalities of health crises and epidemics; and the distribution of resources at federal, state, and local levels all emerged as key points of contention in debates over tuberculosis care. As it existed in the mid-twentieth century, U.S. healthcare infrastructure came to encompass private insurance providers and clinics, hospitals funded through public-private partnerships, and federal and state public health authorities. Proponents of a national health service defined an imaginary with both material and ethical components, in which universal health coverage would simplify primary care with the goal of equitable, consistent access while dramatically expanding the capacity of public health infrastructure. These arguments define a social imaginary in which universal health coverage links medical progress in eliminating tuberculosis—widely accepted at the time as an attainable goal—with normative arguments for an expansion of political rights to include a right to healthcare. Thus, public health workers and physicians making arguments about the role of sanatoriums faced a choice about where to rhetorically situate their institutions: within the already-existing, complex, and unequal infrastructures of U.S. healthcare or within a social imaginary centered on the transformation of the healthcare and public health infrastructures through a national health system.

Contextualizing Change: Sanatoriums as Spatial Technology Before Antibiotics

At the height of their role in tuberculosis care, sanatoriums emerged as a medical infrastructure in which building design reflected prevailing understandings of both disease characteristics and the recovery process. As anthropologist and STS scholar Bharat Venkat shows, sanatorium designs reflected a “vitalist forms of reason” that saw patient recovery as a prolonged, contingent process dependent on environmental and temporal factors. Geographic and topographic location served to create a treatment environment removed from “devitalizing” exposure to pollution, ensuring that “the tuberculous body and spirit could be exposed to the therapeutic energies of the air” (Venkat 2019). Architects, planners, and physicians conceptualized sanatoriums as spaces to facilitate rest, nutrition, and a supervised, cautious return to physical activity as patients recovered, in strict compliance with recovery timelines tailored to each patient. In other words, sanatoriums functioned as a technology for “mediating” relations between individual patients and urban environments often unconducive to health in general, and recovery in particular; thus, sanatoriums were sites of reprieve from environments that exacerbated illness rather than facilities where disease could be cured through strictly pharmaceutical interventions. “Bacteriological thinking” predictably rose to prominence as more effective pharmaceutical treatments made it possible to treat patients within a shorter, often standardized timeline, and in a range of clinical contexts. Despite their gradual phasing-out, physicians and public health experts envisioned sanatoriums as a place-based technology that could be adapted to changing population-level needs and treatment protocols. Physicians highlighted the role of sanatoriums in ensuring consistent treatment regimens were followed. As Lerner (1998, 56) noted, sanatoriums were credited with “providing what physicians believed was the optimal setting for monitoring the initial progress of patients on drug therapy.”

Risk was always central to the role of sanatoriums, which were defined as sites for protecting healthy community members from infection as well as a curative infrastructure where rest, clean air and nutrition could facilitate patient recovery (Lerner 1997). The antibiotic era raised the specter of new risks deriving from the limitations of pharmaceutical tools—namely, the risk of drug-resistant tuberculosis—and the possibility of more effectively managing familiar risks—for instance by using X-rays and laboratory testing to surveil entire communities for tuberculosis. Biomedical risks like the development of drug-resistant strains in patients with advanced illness were linked to socially contingent risks—continued community transmission resulting from access barriers to healthcare, which led to delayed diagnoses (Scarborough 1954; Widelock, Peizer and Klein 1955). The Wisconsin branch of the NTA reported with concern in 1957 that based on the most recent data from 1955, while 1,765 of the state's tuberculosis patients were receiving sanatorium care, 562 had “known active cases of TB at home,” warning that “the un-hospitalized patient, generally speaking, is not only losing his own best chance to get well, but may be infecting his family and associates” (WATA 1957).

Infrastructural Improvements Without Broader Policy Reform: State-Level Policy, WATA Advocacy, and Health System Imaginaries

Like its national parent organization, WATA's advocacy and educational work occurred at the intersection of medical and public health expertise, patient-led advocacy, and community-wide efforts to improve public health and support community members impacted by tuberculosis and its economic impact. The Crusader published articles by physicians, public health workers, and community members involved in WATA's advocacy work, alongside testimonies from current or former patients about their experiences in Wisconsin sanatoriums. These archival texts reflect the overlapping social and professional contexts in which the infrastructures of tuberculosis care were embedded. Because WATA conducted bipartisan lobbying efforts, articles published by the nonprofit shed light on how notions of sanatoriums as infrastructure figured in public policy arguments about their changing role.

As one of the first three states to make tuberculosis care completely free to all residents in 1945, Wisconsin's public health policy came to reflect a commitment to removing financial and geographic barriers to tuberculosis treatment. The role of the WATA in building bipartisan support for sanatorium funding was recognized as a national model for other NTA branches. Yet, tuberculosis as an infectious disease remained conceptually isolated from larger questions of healthcare access. As a result, the state's legislative debates provide an illustrative case study of how physicians, public health workers and community members negotiated the sanatorium's role in a landscape where most healthcare access was privatized and unequal. In 1961, the WATA joined other nonprofits in campaigning for the Community Health Services and Facilities Act, which sought to address unmet public health needs of communities in rural areas by enabling a more efficient sharing of resources. Highlighting the need for “county or multi-county health departments” so that smaller communities could hire full-time public health personnel, the Wisconsin Academy of General Practice acknowledged community-level resource needs: “all communities are entitled to adequate health services…it is a state responsibility to foster effective communication to local health authorities, to motivate public health efforts, and to strengthen local health services and resources” (Wisconsin Academy of General Practice 1961, 14). Similarly, “the present inefficient system leads to fragmentation of many professional services available to small communities” (Wisconsin Academy of General Practice 1961, 13). For health services already recognized as prerogatives of state and local health departments, including X-ray screening and later tuberculin testing along with sanatorium and outpatient care, communities’ right to equal access needed to be fulfilled. This recognition of a community right to “adequate health services” was portrayed as an organizational and distributional challenge, however, and WATA focused on the inefficiencies of the current system rather than inadequate funding. While recognizing public health as a social good, WATA did not connect public health goals to an individual right to healthcare.

Indeed, WATA's advocacy is significant because the organization walked a tightrope between criticizing the underfunding of public health and avoiding broader critiques of U.S. health policy, even as an unequal health system hindered the group's efforts to eradicate tuberculosis. Such political quietism may have been essential to making the group's advocacy on narrowly focused aspects of tuberculosis care relatively effective; from partnerships with employers to facilitate tuberculin testing to bipartisan legislative support for sanatoriums, the group's public role depended on gaining support from a range of stakeholders. Physicians’ leading role in the national organization and in many state chapters likely provides a further explanation for the NTA's abstention from debates about universal health coverage. Taking a stance on broader health policy debates could have sparked divisions within the nonprofit, where maintaining a narrow focus on tuberculosis care allowed it to unite physicians, public health workers, and other community members whose broader political views differed and were shaped by competing interests and positionalities. Indeed, the NTA's emphasis on civic voluntarism—and its frequent role as an intermediary between public health agencies and patients seeking sanatorium care and social support for their families (Best 2019)—provides a classic example of what historian Brian Balogh terms the associational state, in which functions of government are fulfilled jointly by civil society and state institutions with the former often taking a leading role. As Harold Holand (1958) reflected in the opening pages of his memoir:

The anti-tuberculosis campaign in the United States has characteristically been a voluntary one, at least since its inception; in Europe it has largely been state-inspired. The American public, wisely or unwisely, has set up all sorts of voluntary services to assist its tuberculous members and to prevent their disease from being visited upon the yet well; out of this voluntary experimentation and demonstration, sound public procedures have gradually been evolved.

Contesting Closure and Decline: Infrastructural Retrofit and Outpatient Care

Forest Lawn became the first publicly funded Wisconsin sanatorium to close in 1956. Harold Holand warned in an editorial that the falling number of occupied beds in sanatoriums across the state did not neatly correspond to a decline in new cases but rather reflected a decline in average inpatient treatment time as a result of antibiotics. This distinction, he argued, made it essential to include an assessment of disease surveillance, diagnostic care, and outpatient care needs in evaluating the impacts of the closure. Indeed, sanatoriums’ central role in outpatient care made further closures ill-advised:

First, the job of out-patient service heretofore carried on in Jefferson County by Forest Lawn must somehow be planned for and carried on under other auspices.

Weckmueller (1957) disagreed that the State Sanatorium represented an inordinate cost, arguing that the estimated USD800,000 in annual savings resulting from closing “State San” would impose new costs on local hospitals and county sanatoriums instead. Accompanied by photos of young people engaged in workshops at the Tomahawk State Camp rehabilitation facility adjacent to the State Sanatorium, Weckmueller's article opens by situating the sanatorium itself within a larger infrastructure of rehabilitation facilities and outpatient follow-up care, emphasizing the state facility's central role in meeting needs that 53 counties without sanatoriums lacked the resources or capacity to meet. The closure of the state-wide facility would be a “major blow to TB control in Wisconsin” because many of its patients came “from a Wisconsin county which has no sanatorium facility of its own” (Weckmueller 1957, 5). Indeed, the sanatorium's closure could result in substantial savings only if other facilities across the state denied inpatient care to those for whom it was deemed medically necessary—a cost-cutting measure, Weckmueller emphasized, that would have profoundly harmful consequences for both individual and community health, as well as wider social well-being through “the spread of infection from State Sanatorium patients sent back to their homes; lessened earning capacity and greater likelihood of breakdown for Lake Tomahawk trainees denied its rehabilitation facilities” (Weckmueller 1957, 3). The primary argument Weckmueller is concerned with refuting here, it can be emphasized, is financial rather than medical; it is the efficiency, rather than the medical and public health necessity, of sanatorium-based care that the WATA official found it necessary to defend. Weckmueller's focus then turns to the sanatorium closure's likely impact on patients and communities. Keeping the state-wide facility open had become more essential, he argued, as smaller county sanatoriums had begun to fully close or, in some cases, reserve some of their beds for other chronically ill patients to receive additional state funding:

But let's consider people as well as money. These four young people from Sauk, St. Croix, Taylor and Price counties illustrate the dilemma of TB patients and county officials in the 53 counties without sanatoriums if the State Sanatorium is closed.

The state sanatorium, in Weckmueller's argument, plays a role that can only be understood within the changing financial pressures that led to county-level variations in health infrastructure. While county sanatoriums had once been better equipped to assist patients from other counties with fewer resources, the decline in overall need for inpatient care had paradoxically decreased this capacity for intracounty cooperation. Because county governments were obliged only to consider local, rather than state-wide, needs in deciding how many beds to reserve for tuberculosis patients, they increasingly limited the remaining tuberculosis beds for use by county residents. Weckmueller clearly viewed the closure of the Wisconsin state sanatorium as detrimental to both the rights of individual patients, the public health needs of communities, and the national and global projects of tuberculosis elimination. Yet, his critique remains narrowly focused on preserving what he acknowledges is a flawed status quo, in which the tuberculosis care infrastructure centered around sanatoriums remained unevenly resourced in different counties and divorced from the primary healthcare system. The perceived urgency of cost-cutting for county sanatoriums, despite their still-essential place in a state-wide health infrastructure, reflected a nationwide trend that extended beyond tuberculosis care and impacted hospital systems, nursing homes, and private practice as limited federal funding, combined with rising costs of increasingly high-quality healthcare, created an atmosphere of scarcity. While hinting that some Wisconsin residents faced geographic barriers in accessing tuberculosis care, Weckmueller treats as uncontroversial the distinction between tuberculosis care (a recognized right) and primary healthcare. As a result, he treats the cost-cutting pressures felt by county sanatoriums as an inevitable result of declining need rather than a symptom of underfunded public health services that in turn lacked effective coordination with the infrastructures of primary care. Public health remained universally recognized as an essential function of government and therefore received taxpayer funding, while hospital systems—and nearly all primary healthcare clinics—remained dependent on public–private partnerships or the funding provided through insurance premiums that remained out of reach for many (Roemer 1985, 843). Costs associated with hospital care thus continued to rise for individual patients, including insured patients, as a result (Falk 1963, 28). The contrast between widely accessible, free tuberculosis care and increasingly costly primary care receives little attention in Weckmueller's critique even as he appeals to a right to a disease-specific form of healthcare as essential to both individual well-being and public health.

A similarly limited critique of the logic of austerity emerges in a 1957 article by Wisconsin Rehabilitation Association Secretary Fred Broecker arguing against the imminent closure of Lake Tomahawk rehabilitation facility adjacent to the State Sanatorium, which served “a bridge between the isolation of the sanatorium and the full return of the convalescent to the community.” Broecker began by highlighting the adaptability of sanatorium-affiliated rehabilitation facilities as the emergence of antibiotics transformed the timeline of treatment and recovery:

The new drugs and surgical procedures burst upon the cure-taker's horizon around 1950. Up to then, the rehabilitation of the tuberculous was concerned with the gradual physical development of a safe working capacity and such training as was demanded by the patient's limitations.

For patients affected with other health conditions or disabilities in addition to tuberculosis, however, physical rehabilitation remained a crucial part of the inpatient process. Under the leadership of Leonard Heise, Broecker (1957) argued, Lake Tomahawk had expanded its vocational training programs and developed a more individualized approach to training. Because physical strain and economic and social precarity contributed to the risk of relapse, patients who completed job training programs as part of a physical rehabilitation process had better health outcomes than those “who have gone back to a job immediately after discharge from a sanatorium” (Broeker 1957, 11). Rather than becoming obsolete in an age of improving treatment option, rehabilitation facilities attached to sanatoriums remained essential for individuals’ physical well-being and their long-term financial stability. In directly responding to calls for Lake Tomahawk's closure, however, Broecker echoes Weckmueller in framing the right to rehabilitative care as a matter of importance for community-wide health and for enabling patients to become successful “taxpaying citizens” (1957, 11).

Sadly enough, the Lake Tomahawk State Camp now faces the serious threat of an ending to its service. Simply on the basis of dollars and cents, some legislators are proposing that it be closed.

While critiquing state legislators’ “financial unwillingness” to commit sustained resources to physical rehabilitation as part of the larger infrastructure of tuberculosis care, Broecker emphasizes “the definite financial gain” incurred by the state as a result of each patient's successful recovery and prevented relapse (Broeker 1957). In theory, sanatoriums had access to more stable sources of funding than other parts of the nation's patchwork health infrastructure, but as Senator John Snyder argued in a statement to congress in 1946 (U.S. Congress 1946), the very separation of public health from a national health system led to underinvestment and a lack of effective coordination. To be sure, federal investments in medical research increased substantially in the 1950s with bipartisan support (Douglas 1948), but federal appropriations for public health specifically remained limited, particularly as public health financing “became more regionally based,” at the discretion of state and local governments. State and local public health agencies, in turn, became dependent on block grants which were, and largely remain, “unstable and vulnerable to decreases in funding and to elimination as a result of fiscal changes or shifts in political will” (National Academies of Science, Engineering and Medicine Committee on Public Health Strategies to Improve Health 2012). While the rise of disease-focused funding focused on specific public health threats ensured that novel pathogens received proper attention, they also led to “duplicative and inefficient” funding mechanisms that limited cooperation and resource sharing (National Academies of Science, Engineering and Medicine Committee on Public Health Strategies to Improve Health 2012). Moreover, a model of disease-specific funding created harmfully narrow criteria for the use of funds, excluding “the broader determinants of health” from much federally funded research (National Academies of Science, Engineering and Medicine Committee on Public Health Strategies to Improve Health 2012).

Infrastructural Networks and Interdependent Sites of Care

If inpatient care and supervised rehabilitation were still central functions of sanatoriums in the 1950s, these functions gradually receded, without becoming fully obsolete. Writing in 1961, Harold Holand presents the declining reliance on sanatoriums as clear evidence of medical progress, noting the number of hospitalized patients in Wisconsin sanatoriums declined by 18 percent between 1955 and 1959, while the rise of outpatient services signaled a shift toward more flexible treatment methods and successful early detection (Holand 1961). Yet, the potential closure of such facilities in the absence of other investments in public health created a new set of challenges:

It is a happy development. But with it certain questions must be faced. If and when any of Wisconsin's sanatoriums are closed, will their outpatient facilities be lost (as happened at Forest Lawn in 1955)? or will adequate outpatient services be set up under other auspices? And meantime, as our sanatoriums continue to provide needed inpatient care, will their outpatient departments be maintained and strengthened to meet the increasing demands upon them? (Holand 1961, 13)

Similarly, the Wisconsin Board of Health reported that “over half of Wisconsin's 1,597 new reported cases of TB were already in the moderately or far advanced stage,” meaning that “by the time arrangements have been made for sanatorium care and isolation, the proportion of advanced illness inevitably rises” (WATA 1957, 12). Superintendent of Hickory Grove Sanatorium Freda Breaker emphasized that greater funding for outpatient departments would “give sanatoriums opportunities to work with public health nurses, public health departments and private physicians” in building capacity for home-based treatment and outpatient care, and that better-resourced outpatient departments in the state's remaining sanatoriums would “give many more people the opportunity to go on treatment” (WATA 1963, 4). Thus, Breaker implicitly recognized that in the absence of robust public health funding or a national health system, sanatoriums—and the effective collaboration between them—constituted a vital infrastructure for facilitating access to outpatient care. In effect, sanatoriums played a logistical role in coordinating outpatient care, but had long lacked the resources to ensure every patient in need received such care, particularly in rural areas. Assistant U.S. Surgeon General James Goddard told WATA's 1965 conference that for “significant progress” to be made, an estimated 13 million people would need “some kind of public health service” in the form of care for hospitalized patients, follow-up care for discharged patients with inactive cases, and community-wide screening, and that nationwide annual spending on tuberculosis care and prevention would need an increase of some $20 million to meet these needs (Goddard 1965). Even without reviving calls for universal health coverage, public health authorities engaged with the challenges of tuberculosis treatment identified the inequities and inefficiencies of the U.S. health system as prolonging a public health crisis that could only be resolved through more robust investment in prevention, detection, and treatment.

Conclusion

This article makes several contributions to STS scholarship that can lend new insights to understandings of maintenance and repair in care infrastructures, which can play a crucial role in addressing enduring public health challenges shaped by health inequities and access barriers. First, my infrastructural approach demonstrates the methodological value of attending to changes over time, including periods of decay and retrofit, as health systems created for one context evolve to meet new exigencies. In conversation with STS scholars concerned with imaginaries of cure (Venkat 2021), disease elimination (Street and Kelly 2024), and the capacity of infrastructural repair to challenge social and political inequities (Anand 2012; Jackson 2014), this case study highlights the affordances of infrastructural repair—and its relevance in contexts of uncertainty and change—as healthcare systems, policymakers, and researchers respond to limitations in biomedicine, what Venkat terms the “limits of cure,” as illustrated by antibiotic resistance. Second, by examining the shifting imaginaries around sanatoriums that were subject to debates about closure, I propose a novel understanding of how multiscalar infrastructural thinking figured in debates about the wider healthcare system in which sanatoriums were enmeshed. In the years before the emergence of effective antibiotic treatments, proponents of a national health system cited tuberculosis as a public health crisis that only a robust, well-funded healthcare infrastructure committed to universal access could adequately meet. By codifying a right to healthcare, proponents of SB1060 argued, a national health system would create new infrastructural possibilities for coordination between public health agencies and healthcare providers. As possibilities for healthcare reform were foreclosed, however, public health workers in the United States increasingly conceptualized sanatoriums as a distributional and informational infrastructure uniquely suited to compensate for the shortcomings of a fractured, underfunded health system that led to delays in tuberculosis diagnosis and treatment. Building on previous scholarship that conceptualized sanatoriums as medical infrastructure (Adams et al. 2008; Campisi and Saeli 2013; Venkat 2019), I illustrate that debates about the future of specific curative sites revealed the contested nature of medical and public health systems at a larger scale. In their 1950s and early 1960s public advocacy work, public health workers in the WATA framed sanatoriums as a complex distributional medical infrastructure, tasked with meeting patient needs that could not be adequately met by other components of a privatized and unequal health system. In asserting the continued need for statewide and national networks of sanatoriums, medical and public health experts critiqued the logic of austerity that saw sanatorium closure as an opportunity for cost-cutting, arguing that the distributional infrastructure of sanatorium networks played an indispensable role in both individual well-being and community health. Yet, in positioning sanatoriums as an adaptable medical infrastructure given new utility by the shortcomings of the broader health system, these arguments stopped short of reviving early 1950s proposals for a national health system.

Although I examine these issues of maintenance and decay in medical infrastructure with respect to tuberculosis in the mid-twentieth century, the relation between specific infrastructural imaginaries and larger questions of health policy remains salient in a contemporary context. Hospital closures in rural and urban communities, often driven by concerns about unprofitability or underusage, have contributed to worsening health outcomes and exacerbated geographic barriers in accessing healthcare (Gujral and Basu 2019; Kaufman et al. 2016; Romero et al. 2012). The absence of universal health coverage in the United States continues to make health system capacity dependent on the vicissitudes of state-level decisions on Medicaid expansion, with the American Hospital Association (AHA 2022) reporting that 74 percent of rural hospital closures between 2010 and 2021 occurred in states where Medicaid expansion had not occurred. A 2022 study concluded that universal health coverage in the United States could have saved 212,000 lives in the first year of the ongoing pandemic, in part because a “fragmented and inefficient” private system creates preventable barriers to early diagnosis and continuous access to care (Galvani et al. 2022, 1).

As a result, thinking infrastructurally about specific sites of care illustrates the need for viewing discreet medical infrastructures as interconnected and shaped by the inequities within particular health systems and national contexts. As the history of tuberculosis treatment in the United States during the pivotal transition period between 1949 and 1972 illustrates, attempts to conceptualize the changing role of specific infrastructures shapes the parameters of debate about medical and public health systems writ large. The associational model that has shaped political development in the United States continues to hinder the feasibility of universal social programs, including universal health coverage. Yet, the very centrality of public health infrastructures in mid-1940s arguments in favor of a national health system illustrates that the conceptual separation between medicine and public health is not uncontested or inevitable. Infrastructural imaginaries grounded in the connectedness of complex systems—and their capacities for maintenance and repair in response to wider health inequities—can reorient discussions of health policy toward a recognition that community health and individual access to care are mutually constitutive.

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