Tuberculosis Control and Institutional Change in Shanghai, 1911–2011 by Rachel S. Core (review)

Long before Covid-19 had become a global pandemic, tuberculosis was the infectious disease that posed the most immediate threat to industrialized nations worldwide.Before 1956, tuberculosis was the leading cause of death in Shanghai.Yet, a mere quarter century after the Chinese Communist Party (CCP) had risen to power, rates of infection had fallen so significantly that tuberculosis had dropped to the tenth most frequent cause of death in the city.In Tuberculosis Control and Institutional Change in Shanghai, 1911-2011, Rachel S. Core seeks to understand how this shift occurred in such a short period of time and why the incidence of tuberculosis once again increased only a few decades after the CCP appeared to have gotten the disease under control.To answer this question, Core highlights the importance of the work unit ( danwei), a CCP innovation that not only tied individuals to their place of work but also served as a delivery mechanism for crucial social services, such as health insurance, public health education, and antibiotic provision.The creation of the work unit in the 1950s and its subsequent dismantling in the 1990s, Core argues, coincided with the decline and later reemergence of tuberculosis.Tuberculosis Control therefore sets out to delineate "the critical role the work-unit system played in making medical advances available" to the people inhabiting one of China's largest and most industrialized cities (3).In laying out this argument, Core also contributes to a broader contention in the sociology of global public health: that structural and socioeconomic factors, including divisions between those with and without access to health care, are crucial to understanding the spread of infectious disease.Proceeding chronologically, Tuberculosis Control first examines how tuberculosis was managed in the first half of the twentieth century, prior to the CCP's implementation of the work-unit system.Focusing on the public health mandates of the Shanghai Municipal Council-the governing body of Shanghai's International Settlement-Core argues that the treaty-port government consistently prioritized economic development over tuberculosis control.Since tuberculosis tends to be most widespread in industrializing regions with unsanitary and poor working conditions, stopping the spread of the disease would have entailed curbing industrialization, a concession that the council was not willing to make.When the Guomindang rose to power in 1928, its efforts to control tuberculosis were more intensive than those of the council but not altogether successful.Although the Guomindang implemented a series of public health and vaccination campaigns, many of these were aimed at the middle classes rather than the workers who tended to experience the highest rates of infection.The heart of the book examines how the work unit shaped health outcomes in and around Shanghai.Characterizing the work unit as a "total institution" (81), a concept borrowed from the sociologist Erving Goffman to describe a place of work and residence in which individuals lead controlled and regimented lives, Core argues that these organizational structures not only increased access to health care but also socialized their members to adopt more sanitary practices.Part of this socialization process involved coercion and surveillance.Neighbors and coworkers were encouraged to monitor one another's behavior and report possible cases of infection to municipal health authorities.