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From Chaos to Coercion: Detention and the Control of Tuberculosis
  1. J D H Porter

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    R Coker. St Martins Press, 2000, US$27.95, pp 261. ISBN 0-312-22250-5

    This is a fascinating book. It uses tuberculosis to look at the balance between individual liberty and the public good: the tensions created between personal liberty and social responsibility, a strong theme in all work in public health. The context is New York in the 1990s, but as Coker states, “This book uses the lens of tuberculosis control, and in particular the detention of non-infectious individuals, to examine America's response to its most vulnerable and marginalised citizens, and asks the question: `is detention of non-infectious, non-compliant individuals right from ethical, legal, and public health perspectives'”.

    The book is divided into nine chapters. It takes the reader through TB in New York City in the early 1990s through an exploration of the history of the disease, the legal ramifications, the media, the actors, and the process of how the disease was investigated and controlled. It also describes the “seeds of the epidemic” that were present before 1990. The analysis describes the interaction between the legal system and the health system and its relation to international, national and local policies, and people. Permeating all of these are the broad human themes that Coker brings to the work; issues of how we organise ourselves in society and the ethical themes that underpin what we do and how we do it (chapter 7: Culture, morality and tuberculosis). Contained within the treatise too are many questions about the broader society in which TB is allowed to flourish, for instance how society mirrors the disease ( . . . the disease modifies in a peculiar manner the emotional and intellectual climates of the societies that it attacks—Rene and Jean Dubos, 1952) and how, by looking at the disease from a perspective that is broader than biomedicine, many issues are highlighted. Examples are: the coercion of patients; legal themes; issues of health care, and finally an account of the perspectives of individuals (“actors”) and how they create health policy. Although the context for the story is New York, the messages it contains have a much wider relevance. This is because the broad themes addressed are issues about human beings, how they interrelate and what sort of society they create. The book highlights the potentially narrow perspectives that inform disease control strategies, and indicates the importance of other approaches. “A biomedical individualised approach that pays scant attention to the social causes of TB is often more acceptable to policy makers. It appears `tight' and there are no `loose ends'”(page 210). But as Coker argues, there are so many other ways to approach tuberculosis control, and history, in all its guises, has many lessons for us. The book is about a complex variety of subjects, but Coker makes it very readable and understandable. He uses strong research skills as well as bibliographic information to support his ideas and concepts. If you are a person who is interested in the broad issues of health and society and how health policy is created, and certainly if you are someone who works in the control of infectious diseases, I highly recommend this book to you.

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