In the shadows of some of London’s tallest skyscrapers and richest banks lurks a disease borne of the poverty and squalor usually associated with the Victorian era rather than a 21st-century financial capital.
Tuberculosis is staging a comeback in London, where some neighborhoods suffer infection rates found in African countries in which the disease is endemic. The number of cases surged 50 percent in the 10 years to 2009, according to a National Health Service agency.
The airborne bacteria has taken root in a population of recent immigrants, addicts and homeless who live close to affluent business districts and may pose a risk for those they rub elbows with.
“You wouldn’t expect to see that,” says Brian McCloskey, the Health Protection Agency’s regional director for London. “TB is one of the biggest public health problems we have.”
One hotspot is Tower Hamlets, a borough that draws together Canary Wharf, the home of some of Europe’s largest banks, and pockets of poverty that stretch along the Thames’ old docks east of the Tower of London and north past Whitechapel, where Jack the Ripper preyed on prostitutes in 1888.
Tuberculosis, transmitted by coughs and sneezes, doesn’t just strike the needy.
After a worker at a Canary Wharf bank fell ill in 2010, Julian Surey, a nurse at Tower Hamlets Tuberculosis Service in East London, says he was sent with colleagues to her office to screen 14 of her co-workers, a challenge in an open-space environment where employees share keyboards and telephones.
“They were hot-desking and it was a nightmare,” Surey says. “People did get concerned.” Some workers demanded to see private doctors rather than be tested and treated by the state-run NHS, the 37-year-old nurse recalled. One person who sat next to the original patient contracted TB, according to Surey. He declined to identify the bank, as did other nurses.
One sneeze can release up to 40,000 droplets and each one can potentially cause infection. An untreated patient can infect up to 15 others a year, the World Health Organization estimates.
The condition, which can remain dormant in the body for decades but spread through the air and require extended courses of antibiotics once it has been roused, is difficult to diagnose, treat and contain.
“Can you get it on the Tube? In theory, yes,” Surey says. “It can go to everyone,” he says of the disease, which once active can kill half of those it infects if they aren’t treated.
Transmission is more common among members of the same household, according to McCloskey. Treatment usually requires taking one or two antibiotics for three to six months, costing about 2,000 pounds ($3,155) for an uncomplicated case.
‘Not Just Tablets’
Drugs are only part of the solution. Tuberculosis is a sensitive subject with social and political ramifications, says Graham Cooke, a senior lecturer in the department of medicine at the Faculty of Medicine at Imperial College London.
In the U.K. capital, 84 percent of the 3,302 people infected in 2010 were foreign-born, according to the HPA, which means they may be grappling with language barriers, fear of stigmatization or homelessness.
“You don’t just give them tablets,” says Surey, who has worked as a nurse in Calcutta, India and Lima, Peru. “You have to understand the community.”
That’s why one of his most trusted tools for dealing with patients is a bike.
Since people who stop treatment early can become contagious and develop a form of the disease resistant to almost all antibiotics, Surey cycles around delivering appointment reminders to homeless patients, ensuring others take their pills and tracking down those who skip appointments.
Leaning on a Lamppost
“If they don’t take their medicine, they could become infectious again,” says Surey, who recently chased down a young addict after she absconded from a Royal London Hospital ward during treatment. “I went out on my bike and found her, bloodied and drunk on Brick Lane, leaning against a lamppost.”
The disease was as prevalent in London as in some of the world’s poorer nations in 2010. The city had 43 cases per 100,000 overall and rates of 65 or more per 100,000 in hotbeds such as Tower Hamlets, some of them on par with Karonga district in Malawi, says Ali Zumla, a professor at University College London. By contrast, New York reports nine cases per 100,000 people and Berlin eight.
The U.K.’s colonial history, which ties it to countries like India, Pakistan, Nigeria and Bangladesh where tuberculosis is rife, plays a role. London’s growth as a financial capital, which acts as an immigration magnet, combined with the city’s residual pockets of poverty, is also a factor, according to the HPA’s McCloskey.
The European Union’s most populous city, London is home to 241 foreign banks and 65 Michelin-starred restaurants. The average annual pay for a City of London worker is 42,000 pounds, according to a 2010 PriceWaterhouseCoopers report.
Tower Hamlets shares some of that wealth as bankers and lawyers jostle out of the Underground and into the headquarters of banks like Barclays Plc and HSBC Holdings Plc. Two miles from the stadium where the Summer Olympics will be held later this year, it also ranks as one of the country’s most deprived boroughs, with the highest child poverty rate in England as well as the capital’s fifth-highest tuberculosis rate.
“One of the richest areas of London is also cheek by jowl with one of the poorest,” says Francis Drobniewski, director of the HPA’s National Mycobacterium Reference Laboratory, which analyses laboratory samples for the presence of TB germs.
For some, the epidemic may be the price to pay for success.
“You can’t separate it from the fact that London has positioned itself as a financial capital,” Imperial College London’s Cooke said. “People have a tendency to see it as a bad thing. If you see it as a marker for international economic activity, it’s not.”
London isn’t the only city battling a resurgence of TB. Cities from Melbourne to the metropolitan area around Phoenix, Arizona, have also seen increases fuelled by the global movement of people and bugs. As infected humans zip across oceans, the bacteria can develop genetic mutations that enable it to evade drugs or linger longer in the respiratory tract. The medical journal Clinical Infectious Diseases in December reported a new strain in four patients in India that appears to resist all known antibiotics.
“The global threat from multi-drug resistant TB is huge,” says Cooke. “We should expect to see more in this country. There is a risk of resistance rates increasing if therapy is inadequate.”
About 87 percent of TB patients in London completed treatment in 2010, according to the HPA, exceeding the WHO’s global goal of at least 85 percent. The rate in Tower Hamlets was 75 percent in 2009. Surey says he’s aware of several drug-resistant cases “just south of Canary Wharf.”
Some patients find it difficult to stick with the antibiotics because of side effects such as nausea, vomiting, fatigue and in some cases liver complications, says Veronica White, a respiratory physician and director of the Tower Hamlets Tuberculosis Service.
“You never know before you start treatment how a person is going to react,” White says, emphasizing the role of the doctor and nurses in adjusting the dosage or using other medicines to make side effects more bearable. “It’s important that the patient feel supported.”
About 2 billion of the world’s 7 billion people carry the bacteria in a dormant form, says Drobniewski of the HPA’s reference laboratory. Most don’t experience symptoms until a weakening of the immune system rouses the disease, causing fever, night sweats, weight loss, shortness of breath, chest pain and coughing.
Humans have lived for centuries with tuberculosis, which writers before the early 1900s nicknamed “consumption” because sufferers wasted away. Researchers have found the bacteria in the spine of Egyptian mummies.
London Health Programmes, an NHS agency, aims to halve the number of tuberculosis cases in London in the coming decade. A proposal to change how patients are cared for is scheduled to be reviewed by local health system leaders in March, according to Lorraine Hutchings, a spokeswoman.
The draft plan proposes reorganizing some aspects of TB services. Local health authorities would run campaigns to raise awareness and standardize procedures to screen new patients and those at risk. TB clinic hours would be extended to accommodate patients who work or have chaotic lives. The proposal would also provide housing funding for those whose homelessness may derail treatment.