Dr. Alan L. Hart: The forgotten hero in the history of Tuberculosis screening
Medical journals left in hordes, files of patients that would never be consulted again, furniture and paintings that had just been installed, and a barren little medical clinic in Gardinier, Oregon, left without a practitioner, who had only occupied it for a short six months, with no warning or planning. Who could have run from such a perfect, peaceful post?
It was 1918, and Dr. Alan L. Hart had been running from a past that no longer belonged to him – he would continue to run for years to come. Over the next five years, Hart and Inez moved frequently, across Oregon, Washington, and rural Montana, Hart leaving jobs out of fear that he would be outed, which happened at least once. That is, until he was to settle in Seattle during the Depression in the 1930s with his wife Edna Ruddick Hart.
Despite his accomplished background as a medical doctor with a masters in Radiology and in Public Health and most notably, his trailblazing work on early Tuberculosis detection using X-Ray, Dr. Hart’s notability dimmed and decayed until his name was like any other, a mark on a gravestone few will remember.
And yet, the millions of lives he had saved through his work continued to flourish and impact the world. And yet, his influence in Medicine and the nascent field of Radiology can never be undone, despite the unwillingness of the common people to try to understand someone like Dr. Alan Hart.
In our knowledge of history, there are individuals remembered for being trailblazers, innovators, saints who saved lives, geniuses who unlocked secrets of the universe yet unimagined by anyone before them. But for every prominent figure put forward in the history books, there are 10 that were not chosen, or purposefully omitted from our collective memory. Every act of remembrance is a choice we make, and every thread left in their stead a statement in of itself. This is not necessarily malice (although it sometimes definitely is), but we tend to leave behind people who do not fit the mold of what a person should be at the time. Dr. Hart was a confusing character to explain in the history books.
He was a transgender man married to a woman, the first man to undergo gender affirming care, an accomplished author, and an illustrated practicing doctor. People at the time had a limited view of what a queer person looked like. Stigma made it so that the only lens through which they could understand queerness was through mental illness. But Dr. Hart was ardent about maintaining the life he had found, and if he had to run and restart his life every time he was discovered, he would do just that. Beyond his queer identity, Dr. Hart is a person worth remembering. But it is also thanks to his queerness that he was able to understand and treat his patients properly. He knew how stigma changed a person’s views, and acted accordingly. These facts of his life cannot be separated from each other. Unfortunately, that meant that for most he would disappear into the obscurity of the past, one into which most humans fall, lost to time and memory.
Dr. Alan Hart was the first person to use X-ray imaging for early detection of Tuberculosis (TB).
In the tumultuous history between tuberculosis and humanity, it is only in the last hundred years that we have progressed in the treatment of this disease. Highly contagious, especially among close-quartered urban dwellers, with no available tests and no known treatment, Tuberculosis became one of the most virulent killers in US History.
Tuberculosis is an infectious disease caused by the bacterium Mycobacterium tuberculosis. When a person is infected with TB, the bacteria primarily target the lungs, but it can also affect other parts of the body, such as the kidneys, spine, and brain. Once the bacteria enter the body, they can be in an active or latent state. In the latent state, the bacteria are present in the body but are inactive, causing no symptoms and not being contagious. However, they can become active later if the immune system weakens, leading to the development of active TB.
In active TB, the bacteria multiply and spread throughout the body. This triggers an immune response, which results in inflammation. If left untreated, TB can be life-threatening. Prompt diagnosis, appropriate treatment, and adherence to the prescribed medication regimen are crucial in managing and curing tuberculosis. In 1943, Selman Waksman, Elizabeth Bugie, and Albert Schatz developed streptomycin. Before this time, not much could be done for the patient. This entails that early detection was vital. Before treatments were available, there was nothing doctors could do but sequester those who were infected, and prevent further spread. Still, no one knew how to identify the disease before the onset of symptoms. By then, the disease was already highly infectious, and it was too late for anyone surrounding the unfortunate patient. Even doctors stayed away from the sickly. By the twentieth century, the romantic view of the sickly lady had faded. What remained was a stigma surrounding those who caught it. With nothing being done, the disease spread like wildfire, and hundreds of millions of people died.
Dr. Hart had taken interest in the cases of tuberculosis after taking note that many diseases that were known at the time (consumption, phthisis, phthisis pulmonalis, Koch’s disease, scrofula, lupus vulgaris, white plague, King’s evil, Pott’s disease and Gibbus) were actually all cases of Tuberculosis in different stages. He documented how it spread via the circulatory system, attacking the lungs first by causing lesions, then the kidney, heart, and ultimately the brain, killing them promptly. Seeing how patients kept dying, how doctors claimed nothing could be done for them. The only hope was quarantine.
X-Rays, or as they were called then, Roentgen rays, were only discovered five years after Dr. Hart’s birth. Though they were used to identify bone fractures, Dr. Hart took note that soft tissue lesions could also be observed in the imaging.
Using rudimentary X-ray equipment, he captured images of the lungs of tuberculosis patients, carefully studying the characteristic abnormalities associated with the disease. Hart’s observations and analyses helped establish a correlation between X-ray findings and clinical symptoms, allowing for earlier and more accurate diagnoses. Vitally, Dr. Hart identified a reliable way of detecting TB before it was symptomatic, and therefore before it could spread to others.
Building on his initial success, Hart developed innovative techniques to enhance the visualization of tuberculosis lesions on X-ray images. He introduced the concept of serial X-rays, a method that involved taking regular X-ray images of patients’ lungs to monitor the progression of the disease over time. This technique proved instrumental in assessing the efficacy of various treatments and guiding therapeutic interventions. His techniques were published in the book “These Mysterious Rays, A Nontechnical discussion of the Uses of X-Rays and Radium, Chiefly in Medicine”.
Notably, all this work took place 20 years before the epidemiological test for TB was discovered. His research is still referenced in TB standards today, and his work helped reduce the mortality rate of TB by about 98% at the end of WWII. It is commonly considered that his efforts saved millions of lives. This was groundbreaking not only because no one had thought to use radiology for detection of illnesses and not just structural damage, but also because Dr. Hart recognized the social nature of disease prevention, far before any sociologist had come to that conclusion.
As a result of what he had observed, Hart was an ardent advocate for improved healthcare access and social justice. He emphasized the need to address the socioeconomic factors that contributed to the spread of tuberculosis, particularly among marginalized communities. Hart’s insights helped shape public health policies, leading to the establishment of programs aimed at preventing and treating tuberculosis on a broader scale, such as public campaigns aimed at screening as many people as possible to identify early cases of the disease before they spread.
“The ugly things that have grown up in medicine are the result of the ugliness and falsity of society as a whole,”
Dr. Hart wrote in 1935, “of our American preoccupation with success and making money, of our concentration of effort on the production of things rather than their use for a fuller human life. These things are not the fault of the individual physician; and neither can they be remedied by him. So long as the American people are permeated with the spirit of ‘I’m going to get mine, no matter how’, just so long will that attitude filter into all the professions; doctors are people first and are affected by the current ideals just as other people are.”
The care and compassion that Alan offered to his patients could only have come from his own background of living a stigmatized identity.
Alan dealt the utmost discretion in caring for his patients, such as opening “chest clinics” and billing treatment as “chest operations” rather than mark them as sufferers of tuberculosis, which at the time was taboo.
Indeed, sufferers are less likely to visit tuberculosis clinics if people around them see them visit, and judge them for getting tested. It can never be understated how much impact this had on public health. Patients were no longer ashamed of seeking diagnosis because it would not expose them, and they would be quarantined until they healed, or until they died, because antibiotics had not yet reached the everyday sufferer. This resulted in much less people contracting tuberculosis, and dramatically decreasing the death toll. On top of this, early diagnosis was vital for the survival rate of those who had already unfortunately already contracted the disease. Alan understood the perspective of the stigmatized patient, as his entire life he had to deal with a society that did not understand his identity. Secrecy was his only option.
Alan moved from state to state, escaping a past that would put his livelihood at risk. He lived his life in stealth, and applied that understanding to other marginalized communities, by understanding the need for secrecy. This also meant he dedicated his time fundraising for these chest clinics, and giving people the means and the funds to sequester themselves properly in publicly funded sanitariums, as well as funding attributed to further research the treatment and cure for Tuberculosis. By the time antibiotics were introduced in the 1940s, doctors using the techniques Hart developed had managed to cut the tuberculosis death toll down to one fiftieth.
Dr. Alan Hart was a skilled writer and communicator. Not only did he publish his findings in Tuberculosis detection, but he spent the latter part of his life writing novels loosely based on his own life experiences. Melding medicine, sociology, and psychology his memoir-based fiction novels are gripping stories. Hart’s experience in medicine is telling of how the field is entrenched in societal injustices. Over time, our perception of what consists of illness and what consists of simply difference morphs, attaches itself to the issues of the times, but it always leaves someone out. One of the few pre-WWII writers in the pacific northwest writing about social issues, he was overlooked in studies of the region’s literature.
In seven busy years, Dr. Hart published four novels: Doctor Mallory (1935), The Undaunted (1936), In The Lives of Men (1937), and Dr. Finlay Sees It Through (1942).
Hart’s first novel, Dr. Mallory is inspired by Hart’s own experience of being a small-town doctor in Gardinier, Oregon. All his literary works give his readers the unique perspective of a medical doctor of the time, the difficulties one encounters in the development of medical science, the perspective of the humanity of those who work in healthcare, from nurses to X-ray technologists. But his works are also deeply human, and ask questions that appeal to everyone living in society together.
As the New York Times put in 1936 in a review of his second novel, The Undaunted:
“For anyone interested in the development of medical science—and to which of us is that development not a matter of immense importance?—Alan Hart’s new novel will prove little less than fascinating. It takes us into the world of the research laboratory and the hospital and shows us the men and women who dwell therein—petty, some of them; magnificent, some of them; self-seeking, self-sacrificing, jealous, generous, and few truly heroic.” —Louise Maunsell Field, The New York Times, 1936.
The novel follows a doctor’s search for a cure for pernicious anemia, a life-threatening disease in the early 1920s. The Undaunted is ultimately a reflection of what masculinity represents to those who are embodying it, and those who fail to live up to it in the standards of the times. Through the perspective of a closeted gay man, Sandy Farquhar, it poses serious questions like how one exists authentically to oneself in a society that is hostile to one’s very existence, or what it looks like to be regarded as an outsider, no matter where one turns? What effect does secrecy and shame have on a person’s life?
He had been driven from place to place, from job to job, for fifteen years because of something he could not alter any more than he could change the color of his eyes”
His queer identity was something he ran from in his life, though once he had seen his true self peek through, he held onto it dearly, and never once let it go. Alan Hart transitioned at an early age, before male hormone therapy was even available. His transition was recorded and published by Portland Psychiatrist, Dr. Allen Gilbert, under the name H in the case study “Homosexuality and Its Treatment” in the Journal of Mental and Nervous Disease (1920).”
“Her hair was cut, a complete male outfit was secured and having previously identified herself with the Red Cross, she made her exit as a female and started as a male with a new hold on life and ambitions worthy of her high degree and intellectuality.” Dr. Gilbert
Hart was the first person to undergo female to male gender affirming surgery. In Dr. Hart’s only comment ever made public about his transition, he comments:”
“I had to do it… For years I had been unhappy. With all the inclinations and desires of the boy I had to restrain myself to the more conventional ways of the other sex. I have been happier since I made this change than I ever have in my life, and will continue this way as long as I live… I have long suspected my condition, and now I know” (from Boag, p. 481)
Alan Hart’s early life was spent running from an identity that was fundamental to himself and his happiness. When he was able to find that happiness, he did not let it go again. He died in 1962 from heart failure. Hart’s struggles as a transgender person led him to be a successful doctor, social critic, novelist, public health advocate,and husband, and he deserves to be remembered as such. Dr. Hart’s unique perspective allowed him to enact the change he wished to see in the world. He saw a way to live for himself in a way no one had done before him more than one hundred years ago, and never stopped being true to himself. He saw a world with more kindness, and never relented in his mission to make it as real as possible. It is impossible to know whether he could have accomplished what he did had he not been what he was, but we do know that it is thanks to his unique perspective on life at the time that he could help as many people as he did, and see other marginalized individuals with empathy and compassion. We can learn a lot from his unique perspective, and that is why we must put in the active effort to remember him, and the impact he had on the world around him.
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