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Tuberculosis, non-compliance and detention for the public health
  1. Richard Coker
  1. Consultant Physician, St Mary's Hospital, London

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    Coercion, the act of compelling someone to do something by the use of power, intimidation, or threats, has been deemed a necessary weapon in the public health armamentarium since before public health fell under the remit of physicians and out of the grip of “sanitarians” and civil engineers. This article examines the ethics of detention in the pursuit of public health and uses a contemporary example, detention of poorly compliant individuals with tuberculosis, to highlight the moral dilemmas posed, and examine whether recently proposed approaches are just. In particular I focus upon the public health response to non-infectious individuals who fail to comply with treatment (and who, therefore, may be at risk of relapsing and becoming infectious). Our response to them helps clarify contemporary attitudes to recalcitrant, often marginalised, individuals who pose an uncertain threat.

    Globally tuberculosis control is failing. The World Health Organisation (WHO) recently called this public health threat a global emergency.1 Transmission occurs through often casual contact from individuals who have pulmonary disease. Although there is much that is uncertain regarding the infectiousness of this ancient disease, we do know that those who are smear-positive, that is who have organisms of Mycobacterium tuberculosis visible in stained respiratory secretions, are considerably more infectious than those who do not.2, 3 Compliance with effective treatment rapidly (within a couple of weeks) makes previously infectious patients non-infectious. Standard treatment for fully drug-sensitive tuberculosis usually lasts for six months. Erratic adherence to chemotherapy, however, may result in relapse and the development of drug-resistant disease which is considerably more difficult to treat.

    In the 1980s and early 1990s New York City witnessed an epidemic of tuberculosis and, of particular concern, a marked increase in drug-resistant and multidrug-resistant strains. In the early 1990s the threat of a virtually untreatable, casually communicable, …

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    • Richard Coker, MD, FRCP, is a Consultant Physician at St Mary's Hospital, London.

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