The World Health Organization report on tuberculosis (TB) reveals that in 2023 TB became the world's leading cause of death by infectious disease. As with other infectious diseases, TB can only properly be understood, managed and eliminated with the tools of population-level public health interventions – individual treatments are insufficient. TB is primarily spread in the crowded conditions created by urbanized industrialization such as Shanghai in the 20th century. The tuberculosis bacillus was discovered by Robert Koch in 1882, and a vaccine to prevent TB was created in Paris in 1921, but effective treatments were elusive until antibiotics were deployed in the 1940s and 1950s. Preventative and curative treatments for TB were not effective until they were distributed widely and affordably, as Rachel Core ably demonstrates in her book on TB control in Shanghai.
Tuberculosis is the deadliest infectious disease in China both in 1911, when the book begins, and in the 21st century where it ends. Effective public health interventions require robust action to produce and distribute treatments and public mobilization to accept and seek preventative and curative treatments. This book tells the story of how the Maoist period in China (1949–1976) was effective in producing and distributing treatments and in mobilizing society to accept them under the work-unit (danwei) system. A key claim of the book is that “because the work-unit system was intrusive [and] premised on social control, it could effectively squelch infectious disease outbreaks” and that correspondingly the turn towards a market-based economy and society that dismantled workplace entitlements beginning the post-Mao era “led to a crisis of public health, health insurance, and provision of care” (pp. 6–7).
The book comprises three parts. Part one includes two chapters on largely ineffective efforts at TB control in Republican Shanghai (1912–1949); the three chapters of part two cover the effective mobilization of society in work units in the urban area and cooperative medical system in rural areas after 1949; and part three comprises a final substantive chapter on the dismantling of the work-unit system focused on the 1990s as China rejected social safety nets and tuberculosis roared back. Based on archival materials, published reports, and a rich set of interviews of TB patients and public health workers, Core's book is sometimes sceptical of the statistics reported in the Maoist period, but ultimately concludes that the disease largely came to be controlled during a period of high surveillance and social engagement.
TB treatments in early Republican Shanghai “[was] a disgrace to medical science… thirty years behind any other city of equivalent importance,” as one contemporary put it (p. 61). Core demonstrates that even when a potentially stronger central state came on the scene after the Nationalist Revolution in the late 1920s, it was private and nonprofit actors that intervened with minimal results in the 1930s and 1940s. Antibiotics arrived to save lives in the Second World War, but TB infection required months or even years of antibiotic treatments which were not possible at population scale before 1949.
After 1950 a series of TB campaigns began to make headway against the disease. Between 1956 and 1983, TB went from the leading cause of death in Shanghai to the tenth (p. 105). This was due to a variety of factors. Diagnosis in the form of chest X-rays increased five-fold from 1951 to 1955. For those diagnosed, the number of beds necessary to isolate them and treat them with antibiotics for a series of months increased by a factor of 2.5 between 1949 and 1953 (p. 99). Ultimately, it was the urban work-unit system that created the conditions of population-level surveillance and control that allowed for rapid diminishment of the severity of TB in Shanghai. By 1963, TB inoculation rates in urban areas around the country had reached 90 percent among infants, thus protecting a generation of urban-born Shanghainese (p. 116).
In her chapter on the rural districts of Shanghai, Core gives the reader a glimpse of TB control in the countryside. The Cooperative Medical System, established in 1960, was the first effort in Chinese history to bring any form of organized healthcare to the countryside staffed by local paramedical “barefoot” doctors. Rural healthcare was further boosted in 1965 by Mao Zedong's June 26 Statement urging “emphasis of health work on the countryside” (p. 137). The impact for TB control was significant. TB patients interacted at least every two weeks with barefoot doctors to ensure compliance with drug therapy, and as a result TB declined significantly (p. 139). Yet even adjacent to Shanghai, none of these efforts matched the urban work-unit TB control system.
The final chapter details the decline of all these successes with the dismantling of work units in the post-socialist era in the 1980s and 1990s. The chapter begins with the first-hand account of an affluent college student in Canada with TB who was able to access drugs, and compares it with that of a working-class woman from Anhui who went into significant debt and then developed a drug-resistant strain of TB with only ten percent of the costs reimbursed. Ultimately, Core demonstrates that the decline of TB control in China is in inverse relationship to the decline of the work-unit system and the return of gross inequality in a market economy and disinvestment in public health.
Tuberculosis Control reveals the ebb and flow of public health efforts in China for a deadly but slow-moving disease that in an era of neoliberal globalization does not get the attention it deserves since it primarily affects underprivileged people living in poor conditions. Core reflects on parallels with COVID-19 control: having loosened public health and social control for four decades, the brutal zero-Covid policy managed the spread of Covid. But perhaps the final manuscript was submitted before December 2022 when the policy was abruptly abandoned, apparently causing millions of excess deaths in two months after several years of lockdowns. China's TB and Covid experiments seem to provide examples as much of effectiveness as of the extreme limits to public health social controls.
