Cities for Tuberculosis: Portugal’s Reminders of the White Plague

When you reach Serra do Caramulo, or the hills above Guarda, you will eventually come across an imposing building that seems misplaced. It is too large for the village around it, too symmetrical, too full of long glass-fronted terraces facing the sun at a deliberate angle. If you do find one, you are probably looking at a sanatório. What was a sanatorium doing here, and why are there so many of them scattered across a country this size? If you are ever in one of these regions, these are places genuinely worth the detour.

A Disease Written Into the Landscape

For most of the 19th and 20th centuries, tuberculosis was a real and constant threat in Portugal. It was called the peste branca, the white plague, for the pale, wasted look it left on its victims. By the time the state formally organised its response in 1899, annual deaths from the disease were estimated at somewhere between 15,000 and 20,000, a mortality rate close to 300 to 400 per 100,000 people. It moved fastest through the crowded, poorly ventilated housing of Lisbon and Porto, where Portuguese doctors at the time cited something they called Strauss’s Law, the observation that tuberculosis deaths rose in step with how densely a city was built and how many floors its buildings had. The disease spread well beyond the working class, though, affecting writers such as António Nobre, Cesário Verde and Florbela Espanca, and it worked its way so deeply into the culture that it became a stock feature of Portuguese literature.

Building a cure out of sunlight

Before antibiotics existed, there was no drug that could treat tuberculosis. What doctors had instead was environment, and they treated it as seriously as any prescription. Medical thinking of the period divided Portugal into therapeutic zones. Mountain regions such as the Serra da Estrela, the Serra do Caramulo and the high plateau around Guarda were chosen for their thin, clean, ultraviolet-rich air, following a scientific expedition sent to the Serra da Estrela in 1881 specifically to measure whether its atmosphere was suited to treating the sick. Coastal sites near Setúbal and Carcavelos were used for marine heliotherapy, prescribed mostly for bone and joint tuberculosis. And on the edges of Lisbon and Porto, more modest facilities offered the same principle, rest, food and fresh air, to a working population that could never afford to travel to a mountain retreat.

The daily routine inside these buildings was almost monastic. Twice a day, patients would lie in reclining iron chairs on open balconies for the hora de cura, the cure hour, in total silence, breathing as deeply as they could regardless of the weather. Windows stayed open through the winter. Meals were built around getting as many calories as possible into a wasting body. It sounds too simple now, and in a sense it was, but the architecture built around that routine was the treatment itself. South-facing facades, curved wall-to-floor joints that left nowhere for dust to gather, wide steel-framed windows, pine forests planted as windbreaks: every element was there to do something, and it is exactly this that makes the buildings so striking to walk through today.

A nationwide effort to end the plague

What is easy to miss, looking at these buildings now, is how much organisation it took to put them there. Queen Amélia founded the Assistência Nacional aos Tuberculosos in 1899, and from that single institution came a national infrastructure programme, financed through a patchwork: direct state funds, a mandatory tax stamp on postal mail and legal documents, dedicated welfare funds paid into by the state railway company for its own workers, and, in the case of Caramulo, private joint-stock capital raised specifically to build a town.

That last case is worth pausing on, because Caramulo is not really a sanatorium, it is a sanatorium village. Built from the 1920s on the slopes of the Serra do Caramulo, it became the only municipality in Portugal designed and constructed from scratch to function as a health resort. At its peak, it held 19 sanatoriums and 18 private curing houses, more than 1,100 beds, along with its own water supply, sewage system, power grid, bakeries, a cinema and hotels.

Four buildings, four fates, four reasons to go

Guarda’s Sanatório de Sousa Martins, inaugurated in 1907 by King Carlos and Queen Amélia in person, never really stopped working. It is now Hospital Sousa Martins, the main hospital of the region’s local health unit, still treating patients under the same roof, a rare case where the transition from one era of medicine to the next left nothing idle. You will not tour it as a visitor, but the building itself, sitting on the plateau above the city, is worth a look on any trip to Guarda.

Caramulo itself is split in two directions. Part of its former Sanatório Salazar became the Hotel do Caramulo in the 1990s, and it is still open, so you can actually book a night inside a former sanatorium and see how little the bones of the building have changed. The Sanatório da Bela Vista, in the same town, has had a harder path, bought by private investors with plans to demolish it and build an aparthotel in its place, which is worth seeing sooner rather than later if you want to catch it before it disappears.

Higher up, in the Serra da Estrela, the old Sanatório dos Ferroviários sat abandoned and vandalised for decades before Pritzker Prize-winning architect Eduardo Souto de Moura rebuilt it into the Pousada da Serra da Estrela, keeping the original solar orientation and the deep curing verandas, now used as guest lounges rather than treatment terraces. Of all four, it is the one place where you can actually sleep inside the story, and probably the single best argument that these buildings can have a dignified second life.

And then there is the Sanatório Presidente Carmona in Paredes de Coura, built in 1934 for railway workers, later converted into a psychiatric hospital, closed in 2002, and abandoned since. A €50 million golf resort proposal collapsed in 2008, and although it was folded into the state’s REVIVE programme to attract hotel developers, the auctions kept stalling anyway. More than two decades after it shut its doors, nobody has resolved what to do with it, which makes it the rawest of the four, a genuine ruin rather than a restoration, and exactly the kind of place worth seeking out before someone finally decides its fate.

Shouldn’t we learn from the past?

Put these four side by side and an awkward thought arises. A country that, in the early twentieth century, was poorer, less industrialised and administratively far less capable than it is now, still managed to fund and build an entire national network of large-scale medical infrastructure in a matter of decades, including, in Caramulo’s case, an entire functioning town. It did this by improvising financing out of stamp duties, railway welfare funds and royal fundraising, because there was a problem that had to be solved and solving it was treated as non-negotiable.

It is worth asking why a wealthier, more institutionally developed Portugal seems to struggle so often with exactly this kind of large, physical, generational project, whether that is a new hospital, a high-speed rail line, or simply deciding what to do with a building it already owns, like Paredes de Coura, which has now sat in bureaucratic limbo for longer than the sanatorium era itself lasted.

Maybe the honest answer is that urgency, not capacity, was always the missing ingredient. The white plague forced a response because the alternative was unthinkable. Whatever the next such problem turns out to be, these hillside buildings are worth a visit in their own right, and a reminder, in any case, of what the country was once capable of building.