Return of the White Plague: Global Poverty and the "New" Tuberculosis (review)

Tuberculosis is responsible for one in four preventable deaths worldwide, and given the scale of that catastrophy, the present volume is a welcome and overdue compilation of recent social research on the resurgence of this ancient human scourge. In their introduction Matthew Gandy and Alimuddin Zumla frankly designate the story of tuberculosis a chronicle of public policy failure. This book features critical social analysis at the intersection of anthropology, medicine, and public policy. Part 1 features new work on social and historical aspects of the disease; part 2 looks at the resurgence of TB; and part 3 deals with advocacy for effective programs.

Among the main themes that emerge from these chapters are new understandings about the relationship of tuberculosis to housing, ethnicity, and poverty in the modern settings in which resurgent epidemics are found. Housing emerges as key in Gandy's critical review of Thomas McKeown's thesis on nonmedical explanations for the decline in epidemics of TB in nineteenth- and twentieth-century Europe and North America: McKeown favored improved nutrition as the primary explanation, but Gandy reviews evidence suggesting that improved housing for the poor was also a key contributor. In addition, while it is true that sanatoria could not cure TB, Gandy argues that they effectively removed sources of contagion from the general population, a function that is often overlooked in histories of the disease.

In a highly empirical (although poorly written) chapter, Deborah and Rodrick Wallace draw connections between housing and New York City's TB epidemic of the early 1990s. They use urban mapping to show the tight correlation between early tuberculosis spread in slums and increasingly overcrowded housing between 1978 and 1990. The Wallaces examine the political causes of this "chronic urban decay" with similar empirical detail, charting block-by-block cutbacks in fire services and forced internal migrations due to abandoned housing in the 1980s, processes tied to Reagan-era policies that gutted social spending. Other chapters by Alistair Story and Ken Citron on resurgent TB in London, and by Vivien Stern on drug-resistant TB in the crowded prisons of post-Soviet republics, reinforce this emphasis on housing.

Another theme is a more careful reading of the correlation often noted between resurgent TB and immigrant populations. In a chapter on race, Nicholas King warns of the danger in relying on "origin stories" to explain contagious disease, for this approach essentializes difference and justifies forms of social exclusion (e.g., controlling the borders) rather than addressing real risk factors. Studies of urban TB epidemics in the United States show that while immigrants were indeed more likely to carry latent infections, the stress of migration, poverty, and risks of exposure to individuals with active disease were more important than immigrant status per se in determining who became ill. Story and Citron report finding similar evidence in their chapter on resurgent TB in London. A chapter by Matthew Smallman-Raynor and Andrew Cliff uses historical analysis to illustrate a key cause of the link between immigration, stress, and disease: they trace dozens of urban TB outbreaks from the early nineteenth century to the present that began among refugees who were forced to flee wars and civil strife.

Perhaps the most compelling contributions to this book point up the urgency of the threat posed by drug-resistance, and the limited window of opportunity that international health authorities have in which to mount an effective response before "hot spots" of resistance spread. Leopold Blanc and Makund Uplekar emphasize that the disease, by killing productive adults, literally destroys families, thereby creating more poverty. They note, however, that despite the World Health Organization's push to expand Short Course-Directly Observed Therapy (DOTS), at the end of the millennium only a little more than one in five TB patients worldwide had access to an effective treatment program.

In a chapter on multiple drug...