An analysis of an urban health report on tuberculosis among an Asian group of ages between 20 and 35 years in Newham

Introduction

The report focuses on an analysis of tuberculosis in the London Borough of Newham; it discusses the rationale and background, and the justification for choosing the area, and the epidemiology of tuberculosis is addressed. It also investigates social determinants of health in relation to tuberculosis with supporting literature reviews. Moreover, the report examines the impact of tuberculosis on individuals and on the NHS. It later critically analyses the effective policy of 2004, to stop tuberculosis in England. Finally, the report concludes with a recommendation.

Background and Rationale

Newham is a borough in London, situated in the East End. According to ONS (2012), Newham has a population of around 308,000 people, over 70% are Black and Asian minorities, and it is comprised of 20 wards. The ethnicity breakdown of Newham by the GLA (2010) was as follows: Caucasian 29.8%, Black Caribbean 6.6%, Black African 15.9%, Black Other 3.1%, Indian 11.6%, Pakistani 10.7%, Bangladeshi 10.6%, Chinese 1.5%, Other Asian 4.8% and Other 5.3%. According to the statistics released by JSNA (2012), Newham has a young population and the age breakdown data are as follows: 8.2% are aged between 0 and 4 years; 19.7% are aged 5–19 years; 65.3% are aged 20–64 years; and 6.7% are aged over 64.

Newham is the third most deprived area in London and the fourth worst borough with regard to low income, compared with Hammersmith and Fulham, which shows inequality in income (London Poverty Profile 2015, p.11). The London Poverty Profile reported that 35% of residents are low paid, which has an impact on the health of people living in the borough, leading to a high level of inequality in health, which reflects on their life expectancy. For example, there is a high rate of respiratory and cardiovascular diseases, as well as tuberculosis and other diseases related to the urban environment coupled with lifestyles. In addition, the life expectancy for men in Newham is 79.3 years, compared with Kensington and Chelsea at 86.7 and Westminster at 85.3 (men’s life expectancy). The women’s life expectancy in Newham is 84, compared with Camden at 90.6, and Kensington and Chelsea and Westminster at 88 years, respectively (London Poverty Profile 2016). All these gaps in life expectancy also indicated health inequality in London’s borough of Newham.

Therefore, the rationale for this report is that the concentration of disease in Newham is due to a high inequality in income coupled with other determinants of health such as poverty, unemployment, poor housing and education. Historically, tuberculosis tends to be concentrated in urban areas in the poor community. All these characteristics are inner cities issues that have an impact on the habitants and make them prone to communicable and non-communicable disease. Wasylenki et al. (2001) noted that the health of individuals is influenced by the cities because they concentrate poor people; this makes the inhabitants prone to a high rate of diseases such as HIV infection, substance abuse, mental illness, asthma and tuberculosis, coupled with other conditions. This concept is known as the urban penalty. Another piece of evidence to support that the disease is concentrated in the cities is the subsequent study carried out by Andrulis Dennis on inner city health. It found a greater prevalence of serious health issues in cities rather than suburban and rural areas, which is called the ‘urban health penalty’ (Rodwin 2000).

The residents in an urban city have a tendency to suffer from the same chronic health conditions, according to the sick city hypothesis, which includes population density, inadequate housing, unemployment, poverty and social economy, which makes the situation worse for them (Freudenberg, Galea, and Viahov 2005). However, the concept of urban penalty has failed to recognise the positive aspects of inner cities, which are the ‘urban advantages’. People tend to move from rural areas into the urban city because of the positive aspects of urbanisation, that is good jobs, improved income, electricity, improved life expectancy and access to health care.

Newham was chosen for this report because there is a high prevalence of tuberculosis among the Asian male group of ages between 20 and 39 years compared to other boroughs in London. Tuberculosis is an urban health issue in Newham because of high-risk group immigrants from Asia (Public Health 2013).

Epidemiology of Tuberculosis

Public Health England (2014) defines tuberculosis as a bacterial infection caused by Mycobacterium complex, which includes M. tuberculosis, M. africanum, M. bovis, and some rare bacteria such as M. microti and M. pinnipeddii. London Health Programmes (2011) reported that over two million people globally have been estimated to be infected by TB; nine million people were reported to have developed symptomatic disease every year and 1.5 million die yearly. Tuberculosis is an infectious airborne disease that can pass from person to person through coughing and sneezing, from individuals with active tuberculosis.

In western Europe, the UK has one of the highest incidences of tuberculosis (TB) with historical of rates of death fluctuating from a high rate of 394 in 2003 to 300 deaths in 2007. The data from 2008 showed that the rate of death climbed to 334 premature deaths from TB. The reductions in the number of these deaths are the result of improved early diagnosis and adequate support for completing treatment (London Health Programmes 2011). In 2013, the incidence of TB in the UK was 12.3 per 100,000, making it 7,892 cases. These statistics demonstrated a decline of tuberculosis, but about 40% of these notifications were concentrated in the major boroughs in London (Public Health 2014).

According to Public Health (2015), in 2014 tuberculosis in London accounted for 2,572 new cases with an incidence of 30 per 100,000 per population, resulting in a 15% reduction on the 2012 rate and a 25% reduction from 2012. These reductions reflect national trends of TB incidence, with an overall decrease of 11% in England since 2013 and 21% since 2012. However, London has 39% of 6,520 TB cases in England. This means London still has the highest notification rate, as some of the London boroughs have the highest rate of TB, with more than 40 per 100,000 population, which the WHO considers to be a high rate (London Health Programmes 2011, p.10). Notifications of TB in London are higher among adults aged from 20 to 39 years, among which men have the highest rate at 61% (Public Health 2015, p.12). Ninety-one per cent of TB notifications were in those born outside the UK.

Newham is the one of the London boroughs with the highest rate of tuberculosis cases at the rate of 107 per 100,000 population (Public Health 2013). According to Public Health (2015), in 2014 the statistics of TB notifications fall with little changes among the local authority with high rates of TB. The rate in Newham has decreased from 305 cases, 107 per 100,000, to 255 cases, 79 per 100,000. However, Newham still has the highest rate, compared to Brent with 204 cases, 64 per 100,000, followed by Ealing at 211 cases, 62 per 100,000, Hounslow at 152 cases and Redbridge with 133 cases, per 100,000. It is clear from these statistics that Newham has a high level of TB and the trends are found among Asian males and the age group 20 to 39 years (Public Health 2015, p. 12). In addition, 87% of individuals with TB in Newham were born abroad, of which 60% were Asian (Newham TB profile 2013). Buckhurst et al. (2000), Local Authority Profiles (2012) and London Health Programmes (2011) studied factors that influence tuberculosis in Newham. The analysis showed a high correlation among Asian groups and those born outside the UK, which accounted for 84% of Asian and African males aged 20–39 years. However apart from the high-risk group migrants, there are lots social determinants of health that contributed to the high rate of tuberculosis in Newham. 

Social Determinants of Tuberculosis

Social determinants of health can be defined as follows: ‘The social conditions in which people live powerfully influence their chances to be healthy. Indeed factors such as poverty, food insecurity, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries’ (WHO 2004 cited in Farrell et al.2008, p.13).

Dahlgren and Whitehead (1991) used the policy rainbow model to demonstrate the layers of determinants that influence the health of individuals. The health of individuals is influenced negatively or positively by different factors, and it is grouped in layers with their interpretation. The major structural determinants of TB are global socio-economic inequalities, rapid urbanisation and increases in population growth. All these conditions resulted in a high rise in the imbalances of the key determinants of health, such as food insecurity and malnutrition, poor housing and environmental conditions, cultural barriers to health-care access (Przybylski et al. 2014). Cattani (2007) defines socio-economic inequalities as ‘extreme poverty’.

London Poverty Profile (2015) sees Newham as one of the four worst boroughs in terms of low income, and rate of unemployment at 8.6%, compared to London at the rate of 6.4%. Low income and unemployment lead to poverty, and, because of these factors, the residents cannot afford decent housing, causing overcrowding in the borough. The WHO (2010) notes that a powerful determinant of TB is poverty; this includes crowded houses and poorly ventilated living and working environments, which are associated with the transmission of tuberculosis. All these factors are incorporated in the last layer of the determinants of health.

The last layer is general socio-economic, cultural and environmental conditions. The determinants of tuberculosis in this layer include unemployment, housing, health services, work environment and education. Starting from education, an individual with a low level of education cannot have a well-paid job, which reflects on income, which in turn influences housing, transport and community participation, which triggers other determinants of health. Doing an unskilled job affects individuals physically and psychologically in many cases, which in turn leads to unemployment. For example, stressful workplaces increase the risk of disease, such as lower back pain, cardiovascular disease and mental illness, resulting in individuals remaining unemployed. Many studies have identified the psychosocial factors in the working environment which influence physical and mental health of employees and which have a significant impact on their health, making them remain unemployed (Bourbonnais 2007; Kivimaki et al. 2002; Peter et al. 2002). As a result, unemployment and low income lead to poverty. This leads people to live in unhealthy environments, such as overcrowding and homelessness. Marmot and Wilkinson (2003), notes that in some cases social determinant of health is referred to as ‘causes of all causes’ because it recognised that health is not simply about behaviour or exposure to risk, but how the social economics structures shape our health. Newham has high level of overcrowding and homeless in London (Appendix figure1).

According to Newham London Local Economic Assessment (2010–2027), Newham is ranked thirteenth on the basis of the density of its population in 2008 at the average rate of 67 residents per hectare compared with London at an average rate of 48, resulting 19 people more per hectare (Newham London Local Economic Assessment 2010‒2020). The physiological effect of high density is overcrowding. Overcrowding is one of the elements that contribute to transmission of TB and it is another determinant of TB. London Poverty Profile (2015) reported that Newham has the highest overcrowding rate at 25%, with four of its wards having the rate of 30%, compared with Brent at the rate of 18%. People living in poorly ventilated and overcrowded conditions are prone to the transmission of tuberculosis, as Schmidt (2008) noted that the risk of transmitting TB is connected to poverty and overcrowding. According to Elender et al. (1998) and Mangtani et al. (1995), the risk factors of tuberculosis in London, England and Wales are related to larger households with more than one person per room and also increase in condensed locations of the town where deprivation is high, such as Newham borough (Elender et al. 1998; Mangtani et al. 1995). Newham also has a high rate of homelessness and people in temporary accommodations. These factors are also the consequences of poverty and are also determinants of TB, according to the researchers (Appendix figure1and 2).

Public health profiles (2015) report that Newham has fourth highest level of statutory homelessness at the rate of 7.9% at the rate per 1,000 households. Newham does not have the highest rate, but it is still high compared to Camden at the rate of 0.6 and Islington at the rate of 3.8 per 1,000 households. Having a high rate of homelessness also reflects on the prevalence of opiate and crack use, which is common among the homeless and this may reflect on the high rate of TB in the borough. Newham has a 13.1% rate of opiate and use of crack, compared to England at the rate 8.4% (Public Health England 2015). Story et al. (2007) conducted research on tuberculosis in London; the result was that there was an extreme high prevalence of TB among the homeless, drug users and prisoners. One of the reasons for the high prevalence is the lack of follow up; another reason is having a weak immune system, which made them susceptible to TB, and lastly access to health care. Center Disease Control and Prevention (2013) reported that homeless people normally experience conditions that increase the risk of TB, such as substance abuse, HIV infection and crowded shelters. Moreover, early diagnosis can be missed because of lack of access to the medical care that is required. There are many studies which have explained the risk factors between homeless people and the transmission of tuberculosis to others. Because of the lack of early follow-up for new arrivals in shelters, many will be susceptible to disease. Story et al. (2007) undertook a cohort study with all patients diagnosed with TB in Greater London to determine the prevalence of TB in homeless individuals, as well as those with problems of drug use and those in prisons. The results showed a high level of infectious diseases among these groups. As mentioned earlier, TB is an infectious disease of the lung; its impact on the individual, the population and the NHS can be fatal.

The Impact of Tuberculosis on the individual, the population and the NHS

Tuberculosis is a disease that usually affects the lung and some other part of the body. The health implication for individuals affected by TB if untreated can result in lung damage, and this can lead to breathlessness and death. Zaman (2010) asserted that TB affects the lung and other parts of the body, such as the brain, which can cause meningitis and intestine, kidneys and spine problems and possibly lead to death. Moreover, socially, individuals suffering from TB can be stigmatised to the extent of losing their job, and this can have health implications for mental health. To support this, Baral et al. (2007) carried out qualitative research to investigate the causes of stigma and discrimination associated with TB. The result was that people fear the transmission of disease.

In addition, the impact of TB in society is that TB is an airborne disease, the society is at risk of being infected and this can lead to a TB epidemic. For example, people living with HIV or other health conditions can be easily infected because of weak immune systems, in addition, induviduals working in healthcare setting or receiving care are at a higher risk of contracting TB. Also, TB economically affects individual societies because people who have TB are unable to work because of the course of the treatment and repeated visits to the hospital. These people cannot be productive for the state (tax) (Lienhardt et al. 2001; Long et al. 1999).

Lastly, TB has a huge cost for the NHS. According to London Health Programmes (2012), the treatment was categorised into three groups: the first was uncomplicated patients, meaning the identified patient presented at an early stage with a prompt diagnosis and a treatment course of six months at a cost of £1,000. The second category is complex patients; these are patients who did not complete the treatment and are at risk of becoming drug resistant and having a long stay in the hospital, costing £10,000 (usually exceeds this). The last group are patients with a high mortality risk and may require lifelong care and support. A handful of these cases present each year and the cost is £100,000 (in some cases it may exceed that) (London Health Programme 2012) (appendix figure 3). On the basis of these determinants of health, in Newham there is the increased risk of tuberculosis, and also in London as whole. There is need for intervention to reduce this infectious disease so as to protect the urban residents.

Policies for Tuberculosis

Given the worldwide re-emergence of tuberculosis as a disease of concern both in developed and developing countries (Hargreaves et al. 2011, pp.654‒62), it is not surprising that there have been numerous policy directives at all levels, including international, national and local governmental. The World Health Organisation (WHO) has supported attempts to highlight the issue of tuberculosis with their Directly Observed Treatment Strategy (DOTS; World Health Organisation 1995, n.p.) and the STOP TB programme (World Health Organisation, 2006, n.p.), which, amongst other targets, set a goal of halting the increasing incidence of tuberculosis by 2015 and eliminating tuberculosis as a health concern by 2050. 

In line with such international strategies, successive UK governments have aimed specific policies at curbing the rise in tuberculosis within the UK. The most recent strategy, The Collaborative Strategy for Tuberculosis in England and Wales 2015‒2020 (Public Health England 2015a, n.p.) was announced less than a year ago.  However, it is not yet possible to critically analyse its effectiveness, as the policy is less than six months into a five-year plan. Thus, in order to assess the efficacy of the UK governmental response to the increasing rate of tuberculosis infection, the preceding policy will be addressed.

The previous policy was the Stopping Tuberculosis Action Plan (Department of Health, 2004, n.p.). This plan included 10 recommendations covering increasing awareness, improving standards of clinical care, more integrated patient services, improving laboratory diagnostics, improving population-level disease control, educating the tuberculosis workforce, increased research, and international partnerships. Within each of these ten areas, additional aspects were the focus of The Action Plan (2005, n.p.). It is important to note that, when the policy was released, the rates of tuberculosis in Newham were at a high (at that time) of 80 cases per 100,000 of the population (Davies 2005, pp.247‒8). This was superseded in 2015, when the incidence was 113.7 cases per 100,00 of the population (Public Health England 2015b, n.p.); a 40% increase in the intervening decade. Despite this dramatic increase, it is still not possible to say with certainty that the policy failed Newham and its residents. This is because it is impossible to know how the incidence of tuberculosis may have changed had the policy not been introduced, i.e. it may be that the incidence would now be far higher if The Action Plan (2005, n.p.) policy had not been developed. 

Nevertheless, it is the case that the policy failed to halt the increasing incidence of tuberculosis either at a local level (e.g. Newham) or regionally (incidence in London as a region increased yearly between 2005 and 2011). Indeed, the policy had no discernible effect on the national picture either, with the incidence of tuberculosis in the UK varying negligibly between 2005 and 2012 (~13.5 cases per 100,000 individuals). There are numerous possible reasons that explain the poor performance of the 2005 strategy. One reason is that there was no additional funding made available to implement the policy (Davies 2005, pp.247‒8). The omission of additional funding (or indeed any discussion of funding) within the policy is a particular concern given that one of the guiding examples cited by the policy was that of the USA, where an increasing incidence of tuberculosis was reversed between 1992 and 2002 (Department of Health 2004, n.p.). However, the cost of this success is notably absent in the report, despite each individual case of prevented tuberculosis costing an estimated $10,000 (Frieden et al. 1995, pp.229‒33). Thus, it seems evident that the ambition of emulating the American experience was to be extremely limited without the additional funding which had underpinned that programme. 

In addition, there have been questions regarding where the plan urged health authorities to focus their attention. A key aspect of the plan was the screening of populations deemed at risk. However, subsequent analysis indicates that although such plans appear logical, they are not cost effective, with an estimate of one person with active tuberculosis identified for every one thousand immigrants screened (Davies 2005, pp.247‒8). Moreover, the majority of immigrants who develop the disease do so between one and five years after entering the UK and are therefore unlikely to be identified during any routine immigration screening (Davies 2005, pp.247‒8; Public Health England 2013, n.p.).

In addition, at the time of the policy, there was evidence that screening in primary care (i.e. when individuals visited their GP for some other reason) resulted in a more cost-effective identification of those infected (Moore-Gillon et al. 2010, pp.663‒5). The focus on immigrant screening was also exacerbated by the recommendations of the policy which arguably centre almost exclusively on screening, education and collecting data (recommendations 1‒8). Despite the wealth of available evidence, the policy fails to mention tackling any of the social determinants of health. There is no discussion of health inequalities in terms of access to health care, housing, overcrowding, lifestyle behaviours, poverty, deprivation, intravenous drug use, or comorbidities that reduce immune function, such as HIV and cancer (Carlisle 2005, pp.385‒6; Commission on Social Determinants of Health 2010, n.p.; Hargreaves et al. 2011, pp.654‒62). To this end, the policy was a response to the ‘symptom’ of high tuberculosis incidence but did little to address the underlying causes.

One problem of inadequate governmental policy is that it necessarily drives inadequate local initiatives. For example, Choudhury and Mayho (2003, n.p.) implemented a tuberculosis programme within Newham as part of a public service agreement with the borough council. Their intervention was entirely consistent with the rationale and aims of the The Action Plan (2005, n.p.). The programme included improved mapping of outbreaks within the authority and improved education, aimed at those at risk and available in a variety of languages, screening of immigrants at a drop in centre on a voluntary basis, and research into additional contributing factors such as vitamin D deficiency.  While, again, it is not possible to determine how the incidence of tuberculosis would have been affected if no such interventions had been undertaken, it is clear that the incidence in Newham has been rising steadily. Given the alignment of the local programme and the national policy, it is perhaps not surprising that there was limited effectiveness in combating tuberculosis rates in Newham.

Recommendation and Conclusion

The recommendation for this report is that the Government should focus more on underlying causes of TB in Newham, which are social determinants of health such as

• Health inequalities in terms of access to health care
• Income inequality and overcrowding in the borough.

In addition, the Government should

• Reduce the stigma associated with TB
• Offer financial support for vulnerable TB patients, for costs such as transport fares
• Tackle social determinants of health to eradicate poverty, which influences the health of urban residents, so that the city can become healthy.

This report has detailed the epidemiology of tuberculosis in Newham and how income inequality affects the health of the residents. It also discussed how the disease is concentrated in cities as a result of urbanisation, which in turn affects the residents’ health. It also explained that poverty remains the main social determinant of tuberculosis and finally criticised the policy and ended with a recommendation.

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