Sir

Thomas Dormandy's review and Richard Coker's book From Chaos to Coercion: Detention and the Control of Tuberculosis (Nature 405, 995–996; 2000), about the late 1980s epidemic in New York City, both mention the socioeconomic context of tuberculosis (TB): “poverty, overcrowding, ignorance, homelessness, drug abuse and social alienation”. But neither discusses the history of this particular epidemic.

The federal and local government response to inner-city problems in the 1970s was to try to clear out these communities with policies of 'benign neglect' and 'planned shrinkage'. This meant reducing essential services in areas of need. More than 10% of the fire-fighting units in poor minority areas of New York City were cut. This led to an epidemic of fires, destroying between 200,000 and 300,000 poor and working-class homes.

An estimated 600,000 poor people were displaced by the housing loss: the 1980 census showed that 1.3 million white people left New York between 1970 and 1980. This flight was their response to the deteriorating physical and social conditions caused by the burn-out. Among those who remained, the incidence of TB increased dramatically. TB is linked with overcrowded conditions, social marginalization, substance abuse and poor nutrition — all factors influenced by this forced migration. The increase was sharpest in communities with large populations of the precariously housed (people moving in to share rented accommodation with the existing tenants).

Inner-city neglect and loss of fire-fighting units did not happen by chance. If they had not been carried out as public policy, there would have been no New York TB epidemic and no need for coercion and detention of patients. The lack of regard for the populations targeted by 'benign neglect' and 'planned shrinkage' is clear from the length of time the epidemic was allowed to rage through these communities. Only when it spilt over into middle-class neighbourhoods and into the suburbs did a serious control effort begin.