For personal use. Only reproduce with permission from The Lancet Publishing Group. can favourably affect energy balance. It may well be that minor food components have synergistic and cumulative benefits in the maintenance of a healthy degree of body fatness. *Mark L Wahlqvist, Naiyana Wattanapenpaiboon *International Health & Development Unit, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, VIC 3800, Australia (e-mail: mark.wahlqvist@med.monash.edu.au) 1 World Health Organization. Obesity. Preventing and managing the global epidemic. Report of a WHO Consultation on obesity. WHO: Geneva, 1998. 2 McCrory MA, Fuss PJ, McCallum JE, et al. Dietary variety within food groups: association with energy intake and body fatness in men and women. Am J Clin Nutr 1999; 69: 440–47. 3 Wahlqvist ML. Functional foods in the control of obesity. In: Goldberg I, ed. Functional foods: designer foods, pharmafoods, nutraceuticals. New York: Chapman & Hall, 1994: 71–86. 4 Kannar D, Wattanapenpaiboon N, Savige GS, Wahlqvist ML. Hypocholesterolemic effect of an enteric-coated garlic supplement. J Am Coll Nutr 2001; 20: 225–31. 5 Henry CJ, Emery B. Effect of spiced food on metabolic rate. Hum Nutr Clin Nutr 1986; 40: 165–68. 6 Colquhoun EQ, Eldershaw TP, Bennett KL, Hall JL, Dora KA, Clark MG. Functional and metabolic evidence for two different vanilloid (VN1 and VN2) receptors in perfused rat hindlimb. Life Sci 1995; 57: 91–102. 7 Yoshioka M, Doucet E, Drapeau V, Dionne I, Tremblay A. Combined effects of red pepper and caffeine consumption on 24 h energy balance in subjects given free access to foods. Br J Nutr 2001; 85: 203–11. 8 Cannon ME, Cooke CT, McCarthy JS. Caffeine-induced cardiac arrhythmia: an unrecognised danger of healthfood products. Med J Aust 2001; 174: 520–21. Council of Europe, on preventing dissemination of tuberculosis. It provides a legal framework for public policy in the prevention, diagnosis, and treatment of the disease and the rehabilitation of patients who have or have had tuberculosis. It also provides a structure for statistical monitoring, financing services, and occupational and social support, as well as details of individual and state responsibilities. The law makes clear that care will be free, and it highlights the fact that tuberculosis control is a government priority. There is little in the law, however, to encourage a formal shift from inpatient sanatoria-based care to ambulatory care based on WHO’s DOTS strategy. Nor is there much to enhance the coordination of services for those moving between systems (eg, prison and civilian) or to promote the development of integrated health-care and social-support structures. In response to the potential public-health threat posed by those with tuberculosis, the law provides the state with the authority to detain for up to 6 months in sanatoria individuals who do not comply with screening, diagnostic, or therapeutic regimens. Whether such authority covers surgical treatment, which is quite widely practised, is unclear. The law also stipulates, in its article on tuberculosis patients’ rights, provision of legal advice. The article relating to detention and mandatory treatment raises several important issues. First, in view of the impact on the epidemiology of tuberculosis that high incarceration rates and conditions within prisons and lack of linkages between the vertical health care structures seem to have, the attention being placed on “downstream” remedies may be premature. There is a concern, therefore, that this article in the law may provide a smokescreen for poor coordination of services and deficiencies in the criminal justice system. 5 Second, in the years since WHO called tuberculosis a global epidemic, the use of coercive public-health practices to constrain those perceived to be posing a public-health threat may be increasing. The 1990s saw Norway adopt legislation similar to the new Russian one; 6 detention of individuals with tuberculosis in England rose during the past decade; 7 laws were adopted and applied across the USA to detain non-compliant, non-infectious individuals since the early 1990s; 8–11 and prisons rather than hospitals have been used as detention centres for individuals with tuberculosis in countries such as the USA 9 and Israel (unpublished) in recent years. Despite loud calls this decade for an evidence-based approach to health-care policy, the evidence to support sanctions such as detention and mandatory treatment is scant if not non-existent. The third issue is that, perhaps in their haste to support reforms to tuberculosis control in Russia, WHO and the Council of Europe, both of which advocate observance of human rights, did not consider the potential ramifications that support for such articles in a law conveys, enhancing as it does the power of the state and limiting the freedom of vulnerable individuals. WHO Director-General Gro Harlem Brundtland has argued that the key values enshrined in human-rights legislation should inform health reform. 12 According to the 1984 Siracusa Principles, a set of principles under which departure from the 1966 International Covenant on Civil and Political Rights is recognised internationally, any restriction must be in accordance with the law, legitimate, and necessary, and the action must be the least restrictive alternative that is reasonably available, and its application must not be discriminatory. In essence, the Siracusa Principles expand upon and define more clearly Mill’s “harm principle” that provides the ethical foundation for determining whether public-health programmes that involve coercive elements THE LANCET • Vol 358 • August 4, 2001 349 COMMENTARY Detention and mandatory treatment for tuberculosis patients in Russia “The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”—John Stuart Mill, On Liberty, 1859. Over the past decade rates of tuberculosis in Russia have more than doubled, 1 and although this country accounts for 17% of the population of WHO’s European region, it has a third of Europe’s cases of tuberculosis. Since some Russian oblasts have among the highest rates of multidrug- resistant tuberculosis in the world, in all likelihood Russia’s contribution to the prevalence of such types of tuberculosis is considerably more than a third. 2 Tuberculosis affects the most marginalised in society. Rates of tuberculosis in prisoners in Russia, for example, are approximately a hundred times those of the general population. 3 Indeed, prisons have been graphically termed the epidemiological pump 4 of the Russian tuberculosis epidemic. The three important factors contributing to this pump are the conditions under which prisoners (and those in pre-trial detention centres) are held, the lack of resources for effective therapy, and the poor coordination between the vertical prison and civilian and other (such as military) health-service systems. Amnesties, such as the release of nearly 350 000 prisoners in March, 2001, put stress on efforts to coordinate health services, and the convergence of the HIV epidemic on these marginalised populations threatens to further challenge efforts to control tuberculosis. Because of its historical, cultural, and geopolitical position, tuberculosis-control policies in Russia may influence strategic approaches to control of the disease elsewhere. On the June 6, 2001, the Russian Federal Council adopted a law, supported by WHO and the