Tuberculosis in Portugal: Intertwining History and Public Health Development

Abstract

Tuberculosis (TB) remains a major cause of global mortality and is a significant public health challenge, including in specific Portuguese regions. Key aspects in understanding TB’s historical dynamics and impacts on past and present populations are to consider cultural changes and the implementation of public health policies through time. Therefore, this survey aims to provide a more accurate history of TB in Portugal, based on the analysis of sanitary measures through time, illustrating the role of TB in the evolution of public health in Portugal. For this, bibliographic research was conducted across various academic databases and major Portuguese libraries, statistical archives, and public health repositories. Therefore, a detailed chronology, along with some new statistical data, is presented and correlated with sanitary and public health measures, illustrating the role of TB in the evolution of the public health system in Portugal. This research enhances our understanding of the past and sheds light on ongoing TB challenges.

1. Introduction

Environmental factors and human behavior significantly shaped infectious diseases’ emergence, spread, and persistence. Throughout history, various pathogens have triggered epidemics, leaving a lasting impact on past populations. Some of these diseases persist today, posing ongoing global public health concerns. Tuberculosis (TB) has been a persistent global health concern [1]. In Portugal, the burden of TB remains a significant public health concern, as the Western European country with the highest TB mortality rate, 2.75 per 100,000 inhabitants, though stable since 2015, according to the World Health Organization (WHO) [1,2].

TB can be the consequence of infection with three species of mycobacteria: Mycobacterium africanum, Mycobacterium canettii, and Mycobacterium tuberculosis (Mtb), with the last one being responsible for most cases of the disease. These species, together with several phylogenetically closely related mycobacterial species, which are responsible for TB in animals (M. caprae, M. bovis, M. microti, M. pinnipedii, M. mungi), comprise what is denominated the M. tuberculosis complex [3,4].

Infection with Mtb is mostly transmitted through aerosols [5,6]. The droplets inhaled are deposited in the lung’s alveoli, and the initial stages of infection are characterized by innate immune responses with the involvement of inflammatory cells in the lungs, leading to the formation of granulomas [5]. When the immune system fails to provide an adequate immune response, the disease can spread to other organs through lymphatic channels or the bloodstream. The most common symptoms of pulmonary TB are cough, purulent sputum, hemoptysis, breathlessness, gradual weight loss, anorexia, fever and night sweats, distress, and terminal cachexia. Nevertheless, most people who are infected with Mtb are clinically asymptomatic, a state that is called latent TB. However, the bacteria can be reactivated [7]. The elderly, the malnourished, and those who have concomitant diseases have a higher risk of reactivating the disease [8].

Humans can also be a secondary host to M. bovis (cattle pathogen) and M. caprae (goat pathogen), and in the past, M. bovis was likely significantly responsible for TB infections in humans. Although the infection with M. bovis in cattle is primarily a lung disease, humans contract the infection, in most cases, by eating or drinking infected milk or milk products, or by direct contact resulting from the handling of infected animals. In this way, the route of infection with M. bovis differs substantially from the one described above. From the gut, the bacteria go to the lymphatic system, infecting the lymph nodes, bones and joints, abdomen, and skin [9], and the manifestation of the disease is commonly referred to as scrofula. Following pasteurization and meat-control practices, infection with these mycobacteria decreased [10], being nowadays mostly relevant in Africa [11,12]. The manifestation of this disease was commonly referred to as scrofula, alporca (in Portuguese), and King’s Evil.

Throughout history, many other names were given to TB: phthisis, lupus vulgaris, consumption, and the White Plague. Narratives that could be related to TB have been found in literary descriptions dated millennia ago, including early Chinese medical manuscripts, Indian Vedic writings, the Old Testament from the Bible, and the writings of Hippocrates. TB is often represented in literary and artistic works throughout history, including in medieval art, where individuals affected by scrofula are often represented [13,14]. Additionally, the oldest fossil evidence of human tuberculosis came from the remains of a 9000-year-old woman and infant, which were recovered from a submerged site in the Eastern Mediterranean, where high-performance liquid chromatography (HPLC) was used to detect mycolic acid lipid biomarkers, specific for the MTBC, in bones presenting paleopathological TB-compatible lesions [15].

During the 19th century, the endemic nature of the TB disease attributed a romantic ideal to this condition, making TB a mysterious disease that could affect anyone regardless of their social class. TB became associated with a romanticized notion of increased creativity, associated with a refinement of the mind and the spirit. It was considered the disease of artists, poets, and lovers [16]. Portuguese literature is full of descriptions and testimonies of TB illness from patients and family members, and even physicians, as well as several notable Portuguese writers who suffered from TB.

In Portugal, several studies have been conducted regarding TB and its characterization across history [14,17,18,19,20,21,22,23,24,25,26,27,28,29], including in human remains from identified skeleton collections, in which several individuals had suffered from TB, and some had developed specific bone lesions [29,30]. Santos and Roberts (2006) [27] studied the periosteal reaction on the visceral surface of the ribs and concluded that it was present in 85.2% of individuals who died from pulmonary TB. Although other causes for the periosteal lesions found in the visceral part of the ribs should be considered, when tuberculosis is endemic, it is the most common cause of these types of rib lesions [31].

In the present work, a detailed account of key TB-related events in Portugal is presented, revealing the historical impact of TB and its influence on the development of public health initiatives in the country. Alongside the governmental role in maintaining basic hygiene in urban areas, individual behaviors are also critical to public health. Understanding the delicate balance between these factors is crucial for effective disease prevention. Factors such as the level of education, information dissemination, the population’s standard of living, and a government’s awareness of its responsibilities in public health help to fight infectious agents and diseases.

Understanding the historical and demographic context of tuberculosis is crucial to informing current strategies for its prevention, control, and management. By analyzing the historical trajectory of TB in Portugal, this study aims to offer insights into the factors that have contributed to its long-standing endemic presence. This perspective seeks to support a better understanding of the disease’s persistence and to encourage reflection on how past experiences can inform more effective public health responses today.

2. Materials and Methods

Bibliographic research was conducted across various academic databases (PubMed, Scopus, Web of Science, and Google Scholar), and in major Portuguese Libraries, statistical archives, and public health repositories for grey literature. Search keywords included combinations of “tuberculosis”, “tísica”, “mycobacteria”, “public health history”, “Portugal”, “sanitary reform”, “epidemiological trends”, “ANT”, and “IANT”. Studies were included based on their relevance to the historical insights into the prevalence, management, and control of TB in Portugal. Studies not directly related to the historical context of TB in Portugal, as well as those lacking empirical data or substantial historical context, were excluded from the review. The data extraction was performed using a standardized form, including study title, author(s), publication year, key findings, and relevance to Portugal’s TB history. The data on epidemic statistics were extracted from the Portuguese Institute of Statistics (INE; Table S1) and used to create a database. R version 4.4.1 and RStudio 2024.12.1+563 were used to generate graphical representations. A narrative synthesis approach was used to interpret the findings from selected studies, ensuring a coherent reconstruction of TB’s historical trajectory and its interplay with evolving public-health measures in Portugal.

3. From the First Epidemics to the Emergence of Public Health

With the increase in urbanization in the High and Late Medieval periods, cities were places with high human traffic, a lot of production and the circulation of goods, and cultural and recreational places, where people gathered for social events. However, cities were also highly populated, especially in the poorest neighborhoods, which most of the time had poor hygiene conditions [32]. All of these make late medieval cities places with a high risk of the disease spreading.

During the Middle Ages, Portugal dealt with several illnesses, commonly named “plagues”, that included the bubonic plague, tuberculosis, epilepsy, mange, erysipelas, anthrax, trachoma, and leprosy, all considered contagious [33,34]. Scrofula was the most common manifestation of tuberculosis in Portugal, as in the rest of Europe [16]. In Portugal, as in the rest of Europe, in the Middle Ages, written records of tuberculosis became sparse. However, there is archaeological evidence of TB in several sites throughout Europe [35,36,37,38,39], including Portugal [40,41], during this time.

At the end of the 15th century, three epidemic-related mortality crises were registered in Lisbon, resulting in a decline in population numbers [42]. These epidemics were facilitated by intense demographic movements, poor sanitary conditions, and low immunity caused by nutritional deficiencies. Also, Portugal’s maritime trade with Africa and the East was identified as the primary cause of this epidemic crisis [33]. In 1484, the 1st Regiment of Health was established to prevent the spread of plagues, an initiative with a significant impact on controlling the ships entering the capital, appointing health officials, and creating hospices, hospitals, and cemeteries [43]. In those days, the primary form of protection in cities involved quarantines, leprosaria, and cordon sanitaire, which were enforced on both land and sea borders, and were applied to endemic and epidemic disease outbreaks [44]. The first recorded instance of controlling endemic diseases dates to the 15th century. It advises isolating the sick so that they could either recover or die outside the urban center, burying the deceased in walled cemeteries, and closing their homes for fifteen to twenty days [32].

In response to these crises, the first draft of a health administration emerged in 1526. A Health Officer was appointed, whose role was to supervise matters of public health and oversee seaports, particularly in Lisbon [44,45]. Over time, his responsibilities expanded to include land border control, inspection of food commerce, factories, fountains, and urban spaces in the city and surrounding areas [45,46]. The implementation of these first public health measures played a pivotal role in reducing the spread of disease, reflecting an early recognition of the importance of organized interventions to safeguard community health.

The contagious nature of TB was first described by Girolamo Fracastoro (1478–1553), an Italian physician, during the 16th century [47]. Phthisis was described as the result of contagion by materials emanating from the breath or secretions of phthisic patients. Saliva, the patient’s clothes, or human milk were identified as capable of infecting anyone who had contact with them [18]. This theory was accepted in some Mediterranean countries, such as Italy and Spain. In Portugal, Amato Lusitano (1511–1568) was an influential Renaissance physician who made important connections between phthisis and hectic fever. He also focused on the prevalence of tuberculous manifestations in the pleura and studied the implications of pleurisy [18]. In 1643, Zacuto Lusitano proposed the idea that TB could be hereditary, highly contagious, more prevalent in females, and more lethal in autumn. He also linked the disease to breathing and observed its endemic presence in Portuguese valleys due to poor air quality. Despite these observations, knowledge about TB in Portugal lagged behind that of Central Europe [21].

In 1695, Curvo Semedo made significant progress in understanding TB by attributing its symptoms to substances produced by pulmonary activity. He described the presence of granulomatous cavities in infected lungs and detailed various treatments in his work “Polianteia Medicinal”, including mercury, human and donkey milk, antimuonium powder, rest, fresh countryside air, cough balms, cinchona for fever, and a nutritious diet. Semedo also emphasized the contagious nature of TB, identified sputum as a transmission agent, and advocated for the burning of belongings of the deceased to prevent the spread of the disease. His insights into the importance of water, air, and environmental factors in the prevention and management of tuberculosis were remarkably advanced for his time. However, these concepts were not incorporated into public health measures during his era and were only rediscovered in the 19th century with the introduction of sanatorium treatment.

4. Industrialization and the Arrival of the White Plague

The 18th century marked the explosion of TB across Europe, with a mortality rate of approximately 900 deaths per 100,000 people in Western Europe. The disease became known as the White Plague due to the extreme anemic paleness of the affected people [48]. The exponential increase in the number of TB cases was partially caused by the Industrial Revolution and the associated poor working and housing conditions, poverty, poor nutrition, and large-scale migration to urban spaces [20,48]. Due to political instability, Portugal faced a slow industrialization process and remained a rural and poor country compared to other European countries [49,50].

In 1813, the Health Board was established, marking a pivotal moment as the first major Public Health Institution in Portugal [45]. It represents an early and innovative approach to public health, particularly in disease control. Focused on preventive measures, the institution enforced sanitary regulations and measures at seaports and land borders, aiming to prevent the spread of epidemics and to promote cleanliness. They sought to improve conditions in prisons and hospitals and to establish cemeteries located outside of churches [45]. These targeted actions were groundbreaking for the time, significantly reducing mortality, increasing life expectancy, and facilitating a 75% population growth during the 19th century [51].

Subsequent developments in public health included the expansion of oversight that allowed for broader inspections, including visits to public cemeteries, civil hospitals, shelters, leprosaria, poorhouses, charitable establishments, prisons, and factories, providing a comprehensive understanding of public health conditions across various sectors, with the creation of the Public Health Council in 1837 [45,52]. However, while Portugal excelled in controlling disease and addressing immediate public health threats, its efforts were constrained by limited investments in large-scale infrastructure like urban sanitation systems or clean water supply networks.

In contrast, England’s Public Health Act of 1848 responded to industrial-era urbanization by addressing the systemic deficiencies in sanitation and environmental health. Its focus on infrastructure was transformative, establishing local boards of health with authority over sewerage, waste removal, and water supplies, supported by central government loans and national oversight. While Portugal’s early initiatives were reactive and relied heavily on inspection and regulation to contain epidemics, England’s reforms, introduced 35 years later, embodied a proactive model designed to build a sustainable framework for public health [53]. Between 1848 and 1872, tuberculosis was the leading cause of death in Britain, accounting for 15% [54], and about 20% of deaths in the four major French cities during the 19th century [55]. In France, a massive urban renewal program aimed at improving housing started in the 1850s until the 1870s, first in Paris, followed by the other major French cities [55].

In Portugal, during the second half of the 19th century, the main cause of death was infectious diseases, especially TB (approximately 44.4%) [50]. Also, bovine tuberculosis was one of the most common epizootic diseases, affecting 33% of cattle in dairy farms in Porto and Lisbon [18]. The lack of thorough inspections of dairy farms led to the spread of the disease. In 1886, an ordinance was released to order the inspection of cowsheds’ state and health conditions [56].

In 1882, Robert Koch discovered the microorganism that causes TB and acknowledged that sputum is a major carrier of TB bacteria. Spitting was a cultural habit in Portugal, and the first regulations prohibiting the projection of sputum on the ground and requiring the use of spittoons date to 1897 [57]. However, only in the 1930s, the Portuguese League for Social Prophylaxis (LPPS) launched a campaign against spitting in public. Regulations prohibiting spitting in public places were first adopted in Aveiro, Arouca, Lisbon, and Porto only in 1937 [57].

In 1894, due to the high number of cases, it was mandatory to report the disease in Porto and Lisbon, with compulsory disinfection practices in both cities [45,58]. Families were obliged by law to declare their relatives infected with TB and to have all their belongings disinfected. This procedure occurred when an infected person died or moved to another residence [58]. Frequently, the number of deaths exceeded house disinfections, as can be seen in Figure 1 [59]. A similar measure was already adopted in New York City in 1889, where care providers began reporting TB cases [47], since the TB death rate in New York City in the 1860s was actually higher than it had been in the 1840s [60].

In the last decade of the 19th century, TB represented almost 20% of all causes of death, with pulmonary TB as the most prominent manifestation of the disease (Figure 2) [59,61]. The problems of salubrity persisted in centers of higher population density. Porto was referred to as a “cemetery city” due to the high prevalence of various infectious diseases, such as TB, cholera, tetanus, and typhus [21]. The precarious living conditions, the lack of hygiene, and the harsh working conditions made TB one of the main causes of death, especially among young adults [18,62]. Infirmaries were opened to treat the patients, but offered limited medical care, focusing primarily on basic necessities like hygiene and nutrition [62].

In 1892, the Bacteriological Institute, later known as the Câmara Pestana Institute, was established in Portugal. It brought in new guidelines for public hygiene and health, as well as scientific innovation [63,64]. The Institute began analyzing sputum to detect Koch’s bacillus, which led to the creation of the tuberculosis service in 1899 [64].

5. Tuberculosis and Political Shifts in the Early 20th Century

At the beginning of the 20th century, several public health measures were established in Portugal to combat infectious diseases, including the General Regulation of Public Health in 1901. This regulation led to a comprehensive reform of sanitary management, reinforcing the need for compulsory disinfection in cases of notifiable infectious diseases, the development of demographic and sanitary statistics, and the implementation of infectious disease prophylaxis in each village [45,63].

Regarding TB, it was the major infectious disease in Portugal. From 1902 to 1933, previous studies suggested that deaths due to TB rose from 120 to 175 cases per 100,000 inhabitants [65]. However, based on the data collected for this study [66,67,68], the actual values appear to be higher (Figure 3). To support the efforts of the medical and social movement focused on the disease, in 1902, a new decree focused on fighting and preventing TB was released. Clinicians were obliged to report cases and deaths from tuberculosis to the relevant health authorities and to apply prophylactic measures to the patients and their families [57,58]. Nevertheless, mandatory reporting of TB was criticized by the medical community, as it was seen as socially dangerous and ineffective, leading to the stigmatization of patients and their families without adequate treatment. Also, a request to conduct a comprehensive census of tuberculosis patients to accurately determine the spread of the disease was made. Schools were required to conduct sanitary inspections to check for vaccinations and contagious diseases like TB. If a student was found to be affected, they were temporarily withdrawn from the school, and the schools were disinfected during the summer holidays [69].

The change from a Monarchy to a Republic in 1910 resulted in the dismantling of TB services, which neglected the assistance and education campaigns. Combined with social problems, this created a greater predisposition for contracting and spreading the disease, making tuberculosis a persistent problem [18]. TB incidences were decreasing rapidly in Europe during the first half of the 20th century. Nevertheless, TB cases increased dramatically during World War I, due to the permanence of the military in the narrow spaces of the trenches. More than 5000 infected soldiers returned to Portugal [20], and a similar situation was seen in France with 4000–5000 infected soldiers [47].

In 1925, the mortality rates of TB in the Lisbon and Porto districts were, respectively, 245 cases and 300 cases per 100,000 inhabitants [21]. At this point, Portugal was behind other European countries in the fight against infectious diseases, and several European countries and the United States started to show a progressive decline in TB [18,34,60,65].

International pressure to implement crucial hygiene measures led the Portuguese government to recognize the need for changes in public health, in particular after the end of World War I. Discussions on hygienic and prophylactic conditions, along with standards of social action, became prominent topics in international conferences and conventions [62]. In 1926, Portuguese public health services were reorganized to prevent infectious diseases by improving workplace and school hygiene and inspecting food [57,62]. Even so, in 1930, the highest number of TB deaths was recorded (Figure 3).

6. The Role of TB’s Private Initiative in Public Health Development

In the 19th century, TB became a prevalent disease in Portugal, and several institutions were established to spread information about disease prevention and to organize national prophylaxis campaigns, like the National League Against Tuberculosis (LNCT) and the National Assistance for Tuberculosis (ANT). Both organizations played a crucial role in the later success of vaccination efforts. TB was not only a health issue but also an educational one due to widespread illiteracy. This made it challenging to understand its contagiousness and prophylaxis, making campaigns essential to raising population awareness (Figure 4) [20,34,57,70].

The large-scale construction of sanatoria and dispensaries began mainly in the 20th century, which was later than in other European countries. Additionally, the country’s poverty limited treatment access for most of the population. The number of dispensaries did not meet the needs, even though it was the least expensive and most effective means for reducing the number of patients [62]. Despite the high rates of tuberculosis in Porto, the construction of a sanatorium was repeatedly delayed. The break of World War II and the subsequent economic crisis made it difficult to obtain funds to proceed with the sanatorium construction. So, the opening of the sanatorium occurred only in 1947 [62].

The BCG vaccine was a significant breakthrough in the medical field. It was Élio de Vasconcelos Dias who took the initiative and directly requested a BCG vaccine sample from Spain to vaccinate the first child in Portugal in March 1928 [71]. In 1928, LPPS began tuberculosis vaccination, and in 1929, the Câmara Pestana Institute installed services to provide the BCG vaccine. Even though the slow adoption of vaccines by the Portuguese medical community during the 1930s and early 1940s, the number of BCG vaccinations increased drastically from 1945 onwards [67,68,71] (Figure 5).

Until then, the antituberculosis campaigns and infrastructures had been funded essentially by private initiatives. In 1945, the government introduced new legislation, which nationalized the ANT and replaced it with the National Institute for Assistance to Tuberculosis (IANT). It played a crucial role in promoting prevention by emphasizing the importance of vaccination and individual and collective hygiene [21]. In 1950, new legislation declared TB a social disease and established the government’s role in the prevention and control of TB. This led to the establishment of three prophylaxis and diagnostic centers, regulation of the duties of dispensaries, creation of a BCG vaccine production laboratory, and formation of mobile brigades for radiographic screening and vaccination nationwide (Figure 6) [62,70,71].

7. The TB Fight at the End of the 20th Century

The use of the BCG vaccine and a better healthcare assistance program have positively impacted the reduction in TB cases in Portugal [71]. Yet, it is important to highlight that the IANT vaccination campaign coincided with the introduction of antibiotic therapy for TB treatment. The analysis of sanatorium records revealed that before the use of antibiotics, pulmonary TB patients had very poor prognoses when hospitalized in sanatoria [25]. After 1950, antibiotic treatment, together with an increase in the quality of life in the population, led to a decrease in the mortality rate of around 50% [34] and a constant decrease in TB incidence [21].

Due to new treatments, the ambulatory system was implemented in 1969 in Porto, and in 1972, the sanatoria started to close [18,21]. Consequently, dispensaries emerged as pivotal structures in the fight against tuberculosis. They were responsible for supervising patients and conducting home visits, and some had a small number of beds [62]. They received patients, confirmed diagnoses, investigated close contacts, administered treatments, conducted vaccinations for newborns, screened, organized prophylaxis campaigns, and referred patients to specialized hospitals in cases of comorbidities, disease advancement, social factors, or non-compliance with treatment. However, not all patients were hospitalized as the number of beds was reduced [21].

From 1965 to 1974, there was a relatively constant decline in tuberculosis rates. Consequently, in 1975, the IANT was dismantled and became part of the existing health service network [21], and the management of sanatoria and dispensaries was split between different institutions. This led to a lack of cooperation between these two main organizations that worked to combat tuberculosis, resulting in a decrease in the number of hospitalizations. In the first half of the decade, TB-related hospitalizations accounted for 65% of beds in pneumonology services, dropping to 25% in the second half of the decade [21].

In 1976, there was a slight resurgence in TB cases. While the arrival of populations from former colonies was suggested as a possible cause [62], the early dismantling of the institutions that had previously been dedicated to combating the disease may also have played a significant role [21]. In 1980, deaths by TB represented approximately 5% of the total national deaths [72], and between 1985 and 2002, around 300 per year remained constant [68,73] (Figure 7). The coinfection of TB and HIV in the 1980s led to a net increase in mortality numbers for TB worldwide. As a consequence, the WHO declared TB a ‘global emergency’ in 1993 [74].

8. TB in Current Portugal

By 2015, Portugal reached the limit of low incidence defined by the WHO (20 per 100,000 cases per inhabitant). In 2022, according to the WHO, the incidence rate was 16 per 100,000 cases per inhabitant. Although TB incidence has decreased by 32% since 2015, the mortality rate has remained constant [1]. Furthermore, public authorities need to start dealing with novel threats related to multi-drug-resistant TB cases [75].

Since 2016, the BCG vaccine has no longer been routinely given to children under 6 years of age in Portugal, being reserved for specific risk cases, such as those co-habiting with individuals with a history of active TB, who are HIV/AIDS positive, or travelling to high TB-risk countries [76]. In 2022, for the age group 0–5 years, the notification rate was 6.2 cases per 100,000, verifying an increase in the incidence rate compared to 2021 (6.1 cases per 10,000 children) and 2020 (4.8 cases per 100,000 children. Only eight of the children (25%) with tuberculosis, reported in this age group, were vaccinated with BCG [2].

Regarding the distribution of TB cases, the northern region (which includes Porto City) and the region of Lisbon maintained the highest incidence rates. Between 2021 and 2022, in the Lisbon region, there was an increase in the notification rate from 16.8 to 17.8 cases per 100 thousand inhabitants, while in the North region, a decrease was identified from 17.5 to 15.8 per 100 thousand inhabitants [2]. In Lisbon, the higher incidence could be associated, like other European urban areas, with certain subgroups, including immigrants from high-TB-incidence countries, HIV-infected individuals, drug users, high alcohol consumers, prisoners, and the homeless. In Porto, the situation is still endemic, with human reservoirs that continue to exist in the city [77].

Measures established to combat TB in the past have been adapted and applied to other epidemic and endemic diseases, including the recent COVID-19 pandemic. Its impact on TB numbers is not fully understood. Preliminary studies have pointed to an additional 1.4 million TB deaths between the years 2020 and 2025 worldwide, due to delayed diagnosis, interruption, or treatment [78,79]. In Portugal, a slight increase between the time of first contact and the beginning of the treatment was observed [80]. Additionally, due to the current socioeconomic context, difficulties are anticipated in the coming years in achieving the WHO goals regarding TB control.

9. Conclusions

Today, the state of tuberculosis in Portugal reflects the public health policies implemented over time to combat the disease. The roots of these policies can be traced to the early 19th century with the establishment of the Health Board in 1813. This innovative institution prioritized epidemic prevention and disease control, resulting in significant public health improvements, including increased life expectancy. However, despite these early efforts, the lack of large-scale investments in urban sanitation and infrastructure limited the long-term impact of these measures. Later advancements expanded oversight and regulation, but did not address systemic disparities in access to healthcare.

Europe’s industrialization and urbanization led to the rise of diseases like TB. During the first half of the 20th century, in countries like England and France, TB mortality began to decrease well before the introduction of antibiotics, primarily due to improved living standards, better nutrition, and reduced residential crowding. Public health interventions, alongside advancements in housing and working conditions, further accelerated these declines, emphasizing the critical role of timely investment in urban infrastructure.

In Portugal, however, the slower pace of industrialization and a later adoption of urban reforms created unique challenges. The delayed construction of sanatoria, the late implementation of vaccination campaigns, and limited infrastructure exacerbated healthcare inequalities, particularly among disadvantaged populations. Moreover, recurrent dismantling of antituberculosis infrastructure and fragmented legislative action hindered long-term progress. These delays and missed opportunities may explain the persistence of TB as an endemic challenge in Portugal.

The relationship between infectious diseases and public health policies is evident in Portugal’s response to tuberculosis. While specialized regulations, research institutes, and targeted services for TB prophylaxis led to improvements, delayed infrastructure investments and fragmented approaches hindered sustained progress. Portugal’s experience with TB control underscores the importance of addressing systemic challenges, improving living conditions, and adopting timely public health measures.