Conspicuous Consumption

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Review of 'The Return of the White Plague', Editors Matthew Gandy and
Alimuddin Zumla, Verso £25

When I was a medical student in the 1970s, we were taught that tuberculosis (TB) - called the White Plague or consumption, as its victims died thin and an ashen white colour - was on the way out. It would shortly be added to the list of diseases like smallpox that had been eradicated or at least marginalised by progress in medical science. The antibiotics were good, and there was even a vaccine.

But the optimism was misplaced. Currently a third of the world's population carry the bacillus, albeit in a dormant form. There are 8 million new cases of active infectious TB worldwide, and 2 million deaths per year. Increasing world poverty, structural adjustment programmes put in place by the World Bank that destroy countries' health services, the spread of HIV, and the growing resistance of the tuberculosis bacillus to antibiotics, all combine to create the return of the White Plague. This by itself would not worry our rulers so long as these deaths confined themselves to the poor parts of the world, to Africa, to south east Asia and the western Pacific rim.

But disease does not respect borders. TB is striking into the heart of the developed world with major epidemics in New York, London, and the former Eastern Bloc.

This book is an excellent collection of essays covering the global spread of TB. The chapter on New York describes how drug-resistant TB bulldozed its way from working class areas like Harlem into the middle class neighbourhoods of Queens. It describes how in the 1980s New York cut its fire brigade in poor areas and how fire then demolished the social structure of the city, allowing TB to spread in the devastation. The city recovered some control by finally pouring the dollars into TB programmes. These involve directly observed administration of TB drugs for the six months or more necessary to produce a cure, and by paying fortunes to treat drug-resistant TB.

Despite this wake-up call to the so called 'world community' of ruling classes, a window of opportunity is closing. Drug resistance is growing as the bacillus adapts itself to survive the antibiotics. This happens faster when people abandon treatment halfway because they cannot afford the drugs, and they feel a bit better. We see this in Britain, when asylum seekers are denied access to regular services. To defeat TB using the existing strategy of directly observed treatment programmes would cost the World Health Organisation $3 billion just for 2004. But the rich donor countries are not paying. The fund, instead of growing, is shrinking.

But, as this book points out, even a well funded drug treatment strategy would not work long term. With a third of the world carrying the TB germ in a dormant form, it is poverty and overcrowding that needs to be defeated to keep TB at bay. As long as world poverty is on the increase the disease will keep coming back each time in a more virulent, drug-resistant form. And with mainly poor people dying, the drug companies will not invest in new drugs and vaccines. There is little profit in poor people's illnesses. But as the Victorians learned with cholera, epidemics soon jump from the cottages to the palaces. This book is worth reading to remind us how our rulers in their powerful world political and economic institutions are incapable of seeing the crisis they are creating, or of finding the solution. Another class will need to take control to do the job.