Matthew Gandy and Alimuddin Zumla (eds), The return of the white plague: global poverty and the ‘new’ tuberculosis, London and New York, Verso, 2003, pp. vi, 330, £25.00 (hardback 1-85984-669-6).

Abstract

Tuberculosis is now acknowledged as a global health catastrophe. A third of the world's population are infected with the bacillus; eight million people develop active tuberculosis every year; and some two million die. With co-infection with HIV and the emergence of drug-resistant strains that have led in turn to the adoption of the WHO Directly Observed Therapy, Shortcourse (DOTS) strategy, tuberculosis has “apparently made a resurgence almost everywhere in the world” (p. 100). This new book, edited by Matthew Gandy and Alimuddin Zumla, aims to provide an international survey of the historical, social, political and medical aspects of the crisis. Gandy and Zumla argue that the idea that infectious disease had been defeated, prevalent in the 1950s, has been proved to be wrong. With hindsight, it is now clear that public health professionals had too short a time horizon; looked only at people; played little attention to evolution and ecology; and were over-optimistic about development. Gandy and Zumla's overall argument is that the resurgence of tuberculosis is a telling indictment of the failure of global political and economic institutions to improve the lives of ordinary people. The book is organized in three sections. The first deals with historical and conceptual dimensions to the impact of tuberculosis on human societies, tracing the social and political context for its control, and exploring the roles of race, gender, and class. This includes historical studies; the connections between immigration, race, and geographies of difference; the links between tuberculosis and gender; and its association with war. The second section focuses on the “new” tuberculosis pandemic, including the impact of HIV infection and the spread of drug-resistant strains, not only in London, New York, and the former Soviet Union, but in sub-Saharan Africa and other developing countries. The third section explores issues around advocacy and action, looking at current understanding of tuberculosis and the implications of interdisciplinary, scientific, and ethical approaches for health policy. Thought-provoking and wide-ranging, it is not possible to do justice to the contents in the space available here. Among the highlights are Nick King's forensic dissection of essentialist and anti-essentialist views of disease. King argues that attention was focused on “the bodies of people crossing international borders” (p. 46), and in contrast the causal roles of inadequate health care and social and economic injustice were underplayed. The studies of New York and London link the tuberculosis epidemic to wider factors of “de-development”, that included internal migration and emigration, changes in housing, and homelessness, and they emphasize the need to deal with the “full spectrum of determinants” (p. 149). The chapter on Haiti and Peru contains striking portraits of the impact of tuberculosis on two families, showing its effects on health and family life, and linking this with access to appropriate treatment. The tuberculosis epidemic in Russian prisons in the mid-1990s showed how systems for tuberculosis control in the former Soviet Union were based on models from an earlier age, and also highlighted conflicts between the imperatives of public health and criminal justice. And an important chapter on interdisciplinary approaches shows the potential value of integrating the social sciences into operational research on tuberculosis control. Readers of this journal will find the historical dimensions of this story rather limited, and some of the arguments familiar from earlier secondary work. Similarly there is some repetition between the different chapters, for example, on the costs of treating multi-drug resistant tuberculosis. But this is a remarkably consistent and strong collection, with a powerful political message, and illuminating cross-national perspectives. Gandy and Zumla argue that the history of tuberculosis is one of medical failure, with the key question being why available means of treatment and control have not been more widely applied. They suggest that, while vaccines may become a new “magic bullet”, reliance cannot be placed on biomedical innovations alone. Gandy and Zumla conclude that “the failure to control TB worldwide is a direct consequence both of poor political leadership and of the burden of poverty borne by the great majority of its sufferers” (p. 241). Overall this is an important book that will be essential reading for all those—academics, policy-makers, medical personnel, students—interested in tuberculosis and global poverty.