Case Study; Public Health Risk Posed By Tuberculosis In Newham, London
Introduction
Tuberculosis is a contagious airborne disease caused by mycobacterium tuberculosis (Harries & Dye 2006). Tuberculosis mainly affects the lungs but can also affect other parts of the body such as the brain and the bloodstream (Harries & Dye 2006). Despite the fact that tuberculosis is preventable, detectable, and curable, it is estimated that over 9.6 million people are infected by the disease annually. Of the 9.6 million people, 1.5 million of them die from TB-related complications annually. This makes tuberculosis to be a major public health problem. Over 95% of TB cases and deaths occur in developing countries (Goal-03 2016). However, tuberculosis is not limited to developing countries but is also a major public health issue in developed economies. Harries and Izumi (2006) are of the view that ‘TB is still a significant public health issue in low and middle incidence countries, especially among certain high-risk groups in urban areas (p. 2).
The UK is one of the European countries characterized by an increase in cases of Tuberculosis. A report by the EMAP Publishing Limited Company in 2010 identifies London as ‘the TB capital of Europe’ (Nursing Times 2011). Adams (2010) asserts that most boroughs in London still harbor a rate of tuberculosis that is double that defined as high risk by the World Health Organization (Patel & Sharma 2012). Adams (2010) affirms that over 9,000 new cases of tuberculosis are diagnosed annually in the UK. Four out of the 10 new TB cases are diagnosed within London. Between 1999 and 2010, the number of TB cases increased from 2,309 to 3,450, which represents an increase of approximately 50% (Adams 2010). This paper identifies tuberculosis as an urban public health issue in Newham, London. The paper is organized into a number of areas which include, the rationale why tuberculosis is an urban public health issue, the urban context and determinants of tuberculosis, public health consequences and implications of tuberculosis, the strategies and interventions for addressing tuberculosis as an urban health problem, and a conclusion and recommendations on the issues that should be taken into account in order to overcome the public health issue.
The rationale why Tuberculosis is an urban public health issue
Reversing the high rate of urbanization is a major challenge facing many countries across the world. The challenge posed by urbanization is that it is proceeding at a rate that is considerably high compared to the implementation of essential hygiene and health services (Hargreaves et al. 2011). The World Health Organization (WHO) intends to reduce the rate of death as a result of tuberculosis by 95% and the incidence of tuberculosis by 90% between 2015 and 2035 (Prasad et al. 2016). Hargreaves et al. (2011) assert that people living in urban areas have access to better healthcare services compared to people living in rural areas. However, WHO might experience a major challenge in achieving this goal because of the high rate of urbanization. Urbanization has resulted in to increase in the number of people living in overcrowded and poor housing conditions. Moreover, the high rate of urbanization especially in big cities might lead to the development of slum areas. The number of people living in slum areas is estimated to increase from the current rate of 1 billion to 2 billion by 2050 (Kim et al. 2017). Most people living in overcrowded areas experience difficulty in accessing quality healthcare services, which increases the burden of tuberculosis (Prasad et al. 2016). According to Hargreaves et al. (2011), social inequalities such as socioeconomic inequalities, population growth rate, and rapid urbanization comprises key structural determinants of tuberculosis epidemiology. The UK is characterized by a complex trend of internal migration with citizens migrating to different parts of the country annually. However, the rate of migration to urban areas is considerably high. Melissa (2016) asserts that London’s population is increasing by approximately 100,000 people annually. This has led to the transformation of the city into a megacity status. It is projected that London’s population will increase to over 9 million between 2014 and 2024, which represents a 13.7% growth (Melissa 2016).
The high population growth coupled with poor living conditions, especially amongst marginalized groups such as refugees, the homeless, migrants, and prisoners presents means that the high incidence of tuberculosis in London may pose a remarkable public health risk. Therefore, it is imperative for stakeholders in the UK public health sector to consider implementing measures that will successfully eliminate the risk posed by tuberculosis within London. Some of the issues that the UK government should take into consideration entail improving the resident’s living conditions and reducing overcrowding across London boroughs.
Urban context and determinants of tuberculosis; New ham borough
Increase in the rate of population and housing crisis
In Europe, tuberculosis has often been considered to be a past health problem where it was associated with 20% to 30% of the total mortality rate between the 17th and 19th centuries (Melissa 2016). However, the UK has experienced an increase in the incidence of tuberculosis over the past three decades. Urban areas are characterized by the highest incidence of tuberculosis. This view is supported by Hargreaves et al. (2011) who assert that urban areas have more incidence of tuberculosis than rural areas because of the dismal living conditions that favor its development and transmission.
The World Health Organization and United Nations Human Settlements Program (2010) assert that some urban areas are characterized by overcrowding and poor-quality housing, which is evidenced by the emergence of slum areas and neighborhoods characterized by poor living conditions. These aspects increase the incidence of tuberculosis. The high inequalities that characterize the people living in overcrowded urban areas increase the health risk posed by tuberculosis. A study conducted in Europe in 2000 showed that on average the rate of tuberculosis in low-incidence European countries was 2.5 times higher in big cities compared to national rates (Prasad et al. 2016). This variation arose from the fact that the big cities were characterized by high-risk groups among them the homeless people, alcohol, and drug users, and migrants (Prasad et al. 2016). Dhuria, Sharma, and Ingle (2008) assert that urban areas are more attractive to migrants compared to rural areas because the immigrants can easily access different facilities. A report released by London Health Committee in 2015 affirmed that tuberculosis presents a considerable health challenge (Prasad et al. 2016). The report revealed that 25% of London boroughs are categorized as high TB incidence areas by the World Health Organization, which makes some parts of London to be classified among high-incidence countries such as Iraq and Algeria.
Newham is one of London’s boroughs that is characterized by a considerably high incidence of tuberculosis. In 2012, over 366 Newham residents were diagnosed with tuberculosis, which translates into 117 residents per 100,000 of the borough’s population (Melissa 2013). The report further showed that the treatment completion amongst Newham residents diagnosed with tuberculosis is below the London average. One out of 10 patients fails to complete their treatment hence developing drug resistance (Heathwatch Newham 2015). This poses a major problem in the treatment of tuberculosis.
New Ham is characterized by a considerably high degree of inequality, which increases the likelihood of the residents suffering from tuberculosis. One of the notable aspects entails an increase in the rate of homelessness. Badiaga, Raoult, and Brouqui (2008) emphasize that ‘homelessness is an increasing public health problem because people living in poor living conditions have limited access to healthcare systems’ (p. 1353). The United Nations has categorized homelessness into two main categories, viz. absolute and relative homelessness. Absolute homelessness entails a condition in which one lives without physical shelter. Conversely, relative homelessness involves a situation in which a person has physical shelter but the shelter does not meet the basic standard safety and health requirements. Epidemiological studies on the relationship between homelessness and the prevalence of communicable diseases show that the prevalence rate for tuberculosis amongst the homeless ranges between 1.2% and 6.8% (Badiaga, Raoult & Brouqui 2008).
Newham has experienced a remarkable increase in the number of homeless people over the past few years. A report by Shelter, a charity organization in London that focuses on helping the homeless categorized Newham as one of the boroughs with the highest rate of homelessness. According to the report, over 12, 246 people out of Newham’s total population of 334, 218 people in 2016 were homeless (Melissa 2016). Between 2009 and 2014, the rate of homelessness increased from 1.1 per 1000 households in 2009 to 7.9 per 1000 households as illustrated by the graph below. The graph further shows that homelessness in Newham has increased remarkably compared to the London borough.
In 2016, the rate of homelessness in Newham increased substantially. According to statistics from Local Authority Homeless Statistics, the rate of homelessness has increased to 11.89 per 1,000 households compared to 2.52 per 1,000 households in England and 5.44 per 1,000 households in London, The rate of homelessness in Newham is expected to grow due to an increase in population. It is estimated that Newham’s population will increase to 381,000 by 2024 (Melissa 2016). Some of the factors that are likely to contribute to increase in the rate of homelessness entail increase in birth rate and rate of immigration. According to Badiaga, Raoult, and Brouqui (2008), homeless people have been exposed to a myriad of communicable diseases amongst them tuberculosis. Currently, it is estimated that approximately 5,000 children in Newham are homeless (Hakim 2015). Shelter (2014) asserts that homeless children are amongst the most vulnerable groups of people likely to suffer different airborne diseases amongst them tuberculosis. This view is supported by findings of a study conducted by Shelter (2014) which revealed that 32% of children living in overcrowded houses in England are likely to suffer from asthmatic wheezing compared to children living in good housing. This underlines the health risk that overcrowding poses.
Housing crisis
Farrar and Manson (2013) emphasize that Newham is experiencing an increase in the rate of overcrowding. The high population growth rate in Newham is likely to contribute to increase in the rate of homelessness. This outcome will arise from the fact that the high population growth will constrain housing, hence leading to an increase in housing prices and rent. According to a report by the Office of National Statistics 2016, rental prices across the UK increased by 2.6% between 2015 and 2016. Subsequently, the cost of renting a house whose price was £500 in 2015 increased to £ 513 (Melissa 2016). The increase in the price of rent is likely to further worsen the housing problem that characterizes most boroughs in London. Currently, Newham is characterized by the highest level of overcrowding in the United Kingdom. It is estimated that 20% of London’s 100,000 households live in houses that are too small and overcrowded (Caritas Anchor House 2017). In 2015, housing enforcement officers in Newham discovered a group of 26 people living in a 3-bedroom house in Newham. This underlines the prevalence of overcrowding in London (Butler 2015).
Shelter (2014) asserts that living in overcrowded houses increases the risk of the spread of tuberculosis. One of the factors that have contributed to increase in the rate of overcrowding in Newham entails the growing rate of inequality. Manor Park, Green Street, and East Ham are some of the regions in Newham characterized by a high level of poverty, which is evidenced by overcrowding and poor housing. According to Malone et al. (2009), approximately 70% of tuberculosis cases in Newham are recorded in East Ham, Green Street, and Manor Park. The high rate of tuberculosis in these areas is mainly evident amongst the economically deprived groups, which is evidenced by an increase in the number of people living in poverty. This shows that tuberculosis poses a significant challenge to communities living in the urbanized areas in Newham.
Public health consequences and implications of tuberculosis
The prevalence of tuberculosis in Newham poses a significant health threat to the general population. Studies conducted by the World Health Organization show that tuberculosis is associated with the highest number of deaths recorded annually. It is projected that tuberculosis will remain one of the top 10 causes of adult mortality until the year 2020 (Kim et al. 2017). Approximately 2 million tuberculosis-related deaths are recorded annually (Badiaga, Raoult & Brouqui 2008). On the basis of this aspect, the health consequence of tuberculosis cannot be underestimated. Thus, it is imperative for stakeholders in the UK public health sector, particularly Newham borough to consider addressing the high incidence of tuberculosis.
The World Health Organization estimates that individuals suffering from active tuberculosis who are not adequately treated may infect between 10 and 15 individuals annually. Treatment of tuberculosis usually takes up to 6 months during which the patient is subjected to a long period of medication. Failure to adhere to the treatment may lead to the patient developing resistance. Ahlburg (2000) asserts that developing resistance to tuberculosis treatment is associated with relatively high mortality. The cost of treating patients who have developed drug resistance is relatively high. This poses a major challenge to the public health sector. A study conducted by the WHO in 2000 estimated the cost of treating TB to amount to £ 150,000 (Ahlburg 2000).
The high incidence of tuberculosis in Newham, London presents a considerable public health issue not only to London’s public health sector but also to other parts of the UK. For example, London is ranked as the leading trade center in Europe, which is evidenced by the fact that it acts as an entry point into the UK and other European countries. The unvaccinated immigrants and tourists who use London as a transit point to other parts of the UK may contribute to the spread of tuberculosis. The undocumented immigrants and the poor living in urban areas showing symptoms of tuberculosis may delay or be unable to seek specialized healthcare (Tomas et al. 2013). As a result of these challenges, the patients may result to self-medication, which increases the risk of the patient developing a drug-resistant strain of tuberculosis.
In addition to the above implication, the likelihood of poor people living in overcrowded areas developing active tuberculosis may be increased by the fact that they may not have the capacity to access proper nutrition (Kim et al. 2017). According to Kim et al. (2017), people living in poverty are three times more likely to self-medicate compared to higher-income groups. This means that the high incidence of tuberculosis in Newham might pose a public health risk not only to Newham but to the country in general.
In addition to the above implications, the high prevalence of tuberculosis in Newham may lead to an increase in the rate of death amongst HIV-positive patients. Kim et al. (2017) postulate that ‘while non-HIV infected persons with TB have a 5-10% lifetime risk of developing TB disease, HIV infected persons with TB have a 5-10% annual risk of progressing to active disease’ (p.5). It is estimated that TB accounts for approximately 33% of all AIDS-related diseases. The high incidence of tuberculosis in Newham may thus result in to increase in the burden faced by health services.
The prevalence of tuberculosis in Newham may further lead to deterioration in the economic well-being of the residents. Kim et al. (2017) emphasize that tuberculosis halts the progression of formal and informal economies and hence the household’s economic situation. Individuals suffering from tuberculosis may lose between 3 to 4 months of work annually, which translates into a 20% to 30% reduction in household income. Additionally, families of persons who die as a result of tuberculosis lose approximately 15 years of income (Kim et al. 2017). Therefore, tuberculosis may lead to a general loss of productivity, which means that it results in increased social costs.
Strategies and interventions for addressing tuberculosis as an urban health problem
The analysis reveals that tuberculosis poses a remarkable public health implication in Newham, London. To minimize the health risk posed by tuberculosis, it is imperative for stakeholders in the public health sector in the UK to implement effective strategies. One of the most viable intervention strategies that should be taken into account relates to controlling the transmission of tuberculosis. In the process of controlling the spread of tuberculosis, the UK government should establish a TB screening program. Prasad et al. (2016) assert that the risk of a person being infected and contracting tuberculosis is considerably high for people living or come into close contact with people suffering from tuberculosis. This category of individuals should be promptly identified. The screening program should be optimally designed by taking into consideration different aspects that include baseline testing, serial testing for mycobacterium tuberculosis infection, serial screening for TB signs and symptoms, and training and educating the public on tuberculosis (Joint Commission on Accreditation of Healthcare Organizations 2007).
In employing this strategy, stakeholders in the public health sector should target the groups that are characterized by a high incidence of suffering from tuberculosis.
The control mechanism should emphasize early detection of tuberculosis, especially among the people living in overcrowded areas and the homeless. The UK government through the public health department should undertake periodic screening of people living in the overcrowded neighborhoods across Newham. This move will aid in limiting the likelihood of people who come into contact with people suffering from tuberculosis spreading the disease, for example, household members of tuberculosis patients. This means that stakeholders in the public health sector should prioritize screening high-risk groups. This approach will minimize the likelihood of diverting resources by screening low-risk groups.
In addition to the screening program, the UK government should integrate Directly Observed Therapy (DOT) (Kim et al. 2017). The rationale for employing the DOT strategy is to enhance the efficacy of controlling the spread of tuberculosis. The DOT strategy is based on five main aspects which entail improvement of the government’s commitment to establishing activities aimed at controlling tuberculosis, case detection through sputum smear microscopy amongst individuals who have depicted tuberculosis symptoms, and integration of standardized treatment regimens that last for approximately 6 to 8 months for all individuals positively confirmed to be suffering from tuberculosis. Additionally, the UK government should ensure that individuals diagnosed with tuberculosis should be provided uninterrupted supply of the relevant anti-tuberculosis drugs.
The DOT approach also recommends the incorporation of a standardized recording and reporting system. The purpose of the reporting and recording system is to provide the relevant authorities an opportunity to progressively evaluate the effectiveness of the tuberculosis control program. On the basis of this approach, public health workers and volunteers will establish a close bond with the patients. Subsequently, the public health workers will ensure that the patients adhere to and complete their tuberculosis treatment program. The appropriateness of employing the DOT strategy is not only hedged on the fact that it aids in effectively controlling tuberculosis but is also a cost effective approach (Kim et al. 2017).
In addition to this approach, it is imperative for stakeholders in the UK public health sector to focus on improving the living conditions for the economically deprived groups and improving housing conditions for people living in overcrowded areas. This intervention will play a remarkable role in minimizing the risk associated with contracting and spreading tuberculosis amongst these groups. One of the groups that the government should take into account entails the homeless. The UK government should improve access to social housing in order to minimize the probability of the homeless contracting communicable diseases amongst them tuberculosis as a result of dismal living conditions.
Conclusion and recommendations
The case study identifies tuberculosis as a significant urban public health issue in Newham borough in London, UK in spite of the UK being categorized as a low-incidence country. The borough has over the past years been characterized by an increase in the number of new cases of tuberculosis. The high prevalence of tuberculosis in Newham arises from a number of factors amongst them an increase in the rate of immigration and population growth, which have led to overcrowding in some regions across Newham. Moreover, the borough is characterized by an increase in the number of economically deprived groups such as the homeless. Considering the high prevalence of tuberculosis within the borough, these factors increase the health risk posed by tuberculosis. The study showed that tuberculosis is associated with significant public health consequences and implications such as an increase in the level of poverty and death rate. Thus, it is imperative for stakeholders in the public health sector to implement the relevant measures in order to minimize and completely eliminate the public health risk posed by tuberculosis. To achieve this outcome, there are a number of measures that the UK government should take into consideration. Some of the fundamental issues that should be taken into consideration are outlined herein.
i. The UK government should establish comprehensive tuberculosis screening program that targets high-risk groups such as individuals living in overcrowded homes and the homeless. The screening program should focus on diagnosing individuals suffering from tuberculosis in order to incorporate them into a tuberculosis treatment program.
ii. The UK government in collaboration with the public health sector should focus on improving the living condition of people living in economically deprived areas and the homeless. One of the ways through which this outcome can be achieved is by developing an effective social housing program that should target high-risk groups.
iii. An effective treatment program such as the DOT program should be incorporated in order to ensure that individuals diagnosed with tuberculosis are successfully treated in order to minimize the risk of spreading tuberculosis.
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