Carrots, sticks and tuberculosis

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Abstract
Pulic health authorities have long had at their disposal the authority to impose coercive measures to protect the public from perceived threats. Tuberculosis is a global emergency and the spectre of widespread drug resistance resulting from inadequate treatment is perhaps the most feared vision by those involved in control programmes. To improve treatment completion rates and reduce the development of drug resistance, the World Health Organisation (WHO) and others are advocating the broad use of observed therapy as a central plank in their tuberculosis control programme. Directly observed therapy (DOT) has been shown to be effective in several settings, perhaps most dramatically in New York City.1 The success of this particular programme has received widespread recognition, but what has perhaps received less international attention is the use of some measures to support this approach. In addition to a broad array of incentives, including cash payments, food coupons, shelter, and assistance with travel, the city underpinned the expansion of its DOT programme by amending its health codes and authorising the Commissioner of Health to detain both infectious and non-infectious individuals “where there is a substantial likelihood, based on such person’s past or present behaviour, that he or she can not (sic) be relied upon to participate in and/or to complete an appropriate prescribed course of medication for tuberculosis and/or, if necessary, to follow required contagion precautions for tuberculosis.”2 This represented a fundamental shift in officials’ authority to include measures directed towards the non-infectious recalcitrant patient. At the time the amended regulations were adopted, concern both from civil libertarians and city officials was focused upon “due process” protections with an emphasis on the use of less restrictive alternatives to detention. Both sides accepted the constitutional and ethical principles underlying the justification for detention of “recalcitrant” individuals and little distinction was …