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From Chaos to Coercion: Detention and the Control of Tuberculosis

BMJ 2000; 321 doi: (Published 16 December 2000) Cite this as: BMJ 2000;321:1536
  1. David Wilkinson, professor of rural health
  1. Adelaide University and University of South Australia, Australia

    Richard J Coker

    St Martin's Press, £19, pp 304 ISBN: 0312222505

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    Our enduring inability to control tuberculosis shames us all. More people die from the disease now than ever before, despite the availability of effective treatment. Poverty, inequity, and ineffective control programmes are our collective fault. The story of tuberculosis control in New York City—abject failure rapidly followed by extraordinary success at a cost of $1bn—has, in the past 10-15 years, developed almost mythical status.

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    In 1994 I was privileged to be at Columbia School of Public Health in New York City, and it was an ideal time to be studying infectious disease epidemiology. I have vivid recollections of the freezing mid-winter ride downtown on the subway to classes in the New York City Department of Health. It was worth it to be taught about tuberculosis control by Tom Frieden and his team just as they were starting to control the epidemic. Richard Coker, who visited New York on a Harkness Fellowship, writes with feeling and insight about the programme, focusing on the detention of patients who repeatedly failed to adhere to treatment.

    In May this year the Institute of Medicine published a report that shows the way towards the elimination of tuberculosis in the United States. This was unthinkable in 1994.

    So, how relevant to control is the detention of a small number of patients? It is impossible to be absolutely sure, but recent molecular epidemiological studies from the United States do suggest that a small number of non-adherent patients, even those traditionally considered least infectious, may account for a substantial proportion of the case load. Perhaps the point is that for maximal effect, maximal adherence is essential.

    But what role do coercion and detention play in this? And if not detention itself, is the threat of detention important in encouraging adherence?

    Coker explores this issue thoroughly, and in a balanced and considered way. His conclusion seems to be that, while coercion will always have a role in public health control, its use must be considered very carefully. This is not a profound conclusion, but what makes Coker's work special is that it is an insightful social commentary on a contemporary public health issue that is not written from the narrow perspective of a civil rights activist. Instead, Coker's starting point is the epidemiology, transmission dynamics, and biology of tuberculosis, and he positions society's response to it in a rational and caring social construct. It is the reflection, critique, and consideration that make this analysis a fascinating read.

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