How did modern London become “the tuberculosis capital of Europe”?

The Royal London Hospital in Whitechapel, in London's East End. Image: Getty.

Poverty, overcrowding, poor housing conditions... All these things, we learnt from a London Assembly report published last week, are contributing to an increase in the incidence of tuberculosis in the city.

The fact this most Victorian of diseases is on the rise is not exactly new information, either. In 2005, the BBC reported that the capital had 20 times the TB rate of the rest of the UK, and in 2010, the Telegraph described the city as “the TB capital of Europe”.

But how bad can it really be? The Tackling TB in London report is fairly explicit:

There were over 2,500 new cases of TB in London in 2014, making up approximately 40 per cent of all cases in the UK. One third of London’s boroughs exceed the World Health Organisation “high incidence” threshold of 40 cases per 100,000 population. And some boroughs have incidence levels as high as 113 per 100,000 people – significantly higher than countries such as Rwanda, Algeria, Iraq and Guatemala.


Tuberculosis is caused by the mycobacterium tuberculosis bacteria, and mostly affects the lungs. The symptoms include persistent coughing, fever and tiredness. It's spread by coughing and sneezing, but don't start getting righteous on tube snifflers - you'd need to be in prolonged contact with an infected person to contract the disease.

It's not incurable, but patients can need to take antibiotics for up to six months – more if the strain of TB turns out to be one that’s resistant to drugs. The other danger is from latent TB - where a person is a carrier but doesn't actually have the symptoms.

TB had already been eradicated in the UK – but the disease has made a slow and steady return, thriving on overcrowding in deprived boroughs, poverty and Dickensian housing conditions. As Dr Onkar Sahota, chair of the Greater London Authority’s health committee, explains:

"The causes are complex and far from simply medical. TB affects those who most need our help: migrants, the elderly, prisoners, homeless people and those who are marginalised from society. TB has a relationship with deprivation as well as clinical causes.

“We know TB disproportionately affects prisoners, homeless people and people with substance abuse issues, and high quality TB care services are not universally available to all Londoners."

As to where the disease is on the increase, some boroughs are beset by far more cases than others. Here's a chart showing the 10 boroughs with the highest rates of infection:

Given the unfailing reliability with which some sections of the media crowbar the words “migration” and “ticking time-bomb” into their tuberculosis stories, it's no surprise that a lot of people think migrants are bringing the disease to the UK. But the World Health Organisation (WHO) refutes this, stating that there's “no systematic association” between migration and infectious diseases, adding that “communicable diseases are associated primarily with poverty”.

The writer of the report alluded to by the Telegraph, Professor Alimuddin Zumla of University College London, has made the same point. He noted that, while the increase in TB cases has been mainly among people born outside the UK, they appear to have been infected here rather than in their country of origin. With many migrants to London living in poverty, sleeping rough or in poor quality, overcrowded homes, it's hardly a surprise that they are more at risk.

Crucially, WHO advise against limiting access to medical assistance for immigrants, legal or otherwise. Suddenly, charging migrants to use the NHS doesn't seem like quite such a clever idea.

The homeless, another high risk group, are finding help in Hackney. The council has partnered with Homerton University Hospital to reduce what was once the highest rate of TB infection in London. Any homeless person with TB is given accommodation for the duration of their treatment, even if they're not actually eligible for housing in the first place.

The result? The borough's infection rate has dropped, and in July this year, the Homerton Hospital team won an award for their work.

In Newham, the borough with the current highest rate of infection (and, not coincidentally, one of London's most deprived), the council has partnered with the NHS Newham Clinical Commissioning Group to screen for latent TB when residents register with a GP. Newham was also one of the first councils to introduce a crackdown on “slum” landlords to try and tackle overcrowding.

The London Assembly's recommendations include a city-wide education programme, extending Hackney's housing plan to other boroughs and universal provision of the BCG vaccination. With around 1m people living in poverty, and with housing conditions as poor as they are, Londoners' health is also falling through the inequality gap.

You can read the report here (PDF).

Beth Parnell-Hopkinson is a senior editor at Londonist.


Uncertainty is the new normal: the case for resilience in infrastructure

Members of the New York Urban Search and Rescue Task Force One help evacuate people from their homes in Fayetteville, North Carolina, in September 2018. Image: Getty.

The most recent international report on climate change paints a picture of disruption to society unless there are drastic and rapid cuts in greenhouse gas emissions. And although it’s early days, some cities and municipalities are starting to recognise that past conditions can no longer serve as reasonable proxies for the future.

This is particularly true for America’s infrastructure. Highways, water treatment facilities and the power grid are at increasing risk to extreme weather events and other effects of a changing climate.

The problem is that most infrastructure projects, including the Trump administration’s infrastructure revitalisation plan, typically ignore the risks of climate change.

In our work researching sustainability and infrastructure, we encourage and are starting to shift toward designing man-made infrastructure systems with adaptability in mind.

Designing for the past

Infrastructure systems are the front line of defense against flooding, heat, wildfires, hurricanes and other disasters. City planners and citizens often assume that what is built today will continue to function in the face of these hazards, allowing services to continue and to protect us as they have done so in the past. But these systems are designed based on histories of extreme events.

Pumps, for example, are sized based on historical precipitation events. Transmission lines are designed within limits of how much power they can move while maintaining safe operating conditions relative to air temperatures. Bridges are designed to be able to withstand certain flow rates in the rivers they cross. Infrastructure and the environment are intimately connected.

Now, however, the country is more frequently exceeding these historical conditions and is expected to see more frequent and intense extreme weather events. Said another way, because of climate change, natural systems are now changing faster than infrastructure.

How can infrastructure systems adapt? First let’s consider the reasons infrastructure systems fail at extremes:

  • The hazard exceeds design tolerances. This was the case of Interstate 10 flooding in Phoenix in fall 2014, where the intensity of the rainfall exceeded design conditions.

  • During these times there is less extra capacity across the system: When something goes wrong there are fewer options for managing the stressor, such as rerouting flows, whether it’s water, electricity or even traffic.

  • We often demand the most from our infrastructure during extreme events, pushing systems at a time when there is little extra capacity.

Gradual change also presents serious problems, partly because there is no distinguishing event that spurs a call to action. This type of situation can be especially troublesome in the context of maintenance backlogs and budget shortfalls which currently plague many infrastructure systems. Will cities and towns be lulled into complacency only to find that their long-lifetime infrastructure are no longer operating like they should?

Currently the default seems to be securing funding to build more of what we’ve had for the past century. But infrastructure managers should take a step back and ask what our infrastructure systems need to do for us into the future.

Agile and flexible by design

Fundamentally new approaches are needed to meet the challenges not only of a changing climate, but also of disruptive technologies.

These include increasing integration of information and communication technologies, which raises the risk of cyberattacks. Other emerging technologies include autonomous vehicles and drones as well as intermittent renewable energy and battery storage in the place of conventional power systems. Also, digitally connected technologies fundamentally alter individuals’ cognition of the world around us: consider how our mobile devices can now reroute us in ways that we don’t fully understand based on our own travel behavior and traffic across a region.

Yet our current infrastructure design paradigms emphasise large centralized systems intended to last for decades and that can withstand environmental hazards to a preselected level of risk. The problem is that the level of risk is now uncertain because the climate is changing, sometimes in ways that are not very well-understood. As such, extreme events forecasts may be a little or a lot worse.

Given this uncertainty, agility and flexibility should be central to our infrastructure design. In our research, we’ve seen how a number of cities have adopted principles to advance these goals already, and the benefits they provide.

A ‘smart’ tunnel in Kuala Lumpur is designed to supplement the city’s stormwater drainage system. Image: David Boey/creative commons.

In Kuala Lampur, traffic tunnels are able to transition to stormwater management during intense precipitation events, an example of multifunctionality.

Across the U.S., citizen-based smartphone technologies are beginning to provide real-time insights. For instance, the CrowdHydrology project uses flooding data submitted by citizens that the limited conventional sensors cannot collect.

Infrastructure designers and managers in a number of U.S. locations, including New York, Portland, Miami and Southeast Florida, and Chicago, are now required to plan for this uncertain future – a process called roadmapping. For example, Miami has developed a $500m plan to upgrade infrastructure, including installing new pumping capacity and raising roads to protect at-risk oceanfront property.

These competencies align with resilience-based thinking and move the country away from our default approaches of simply building bigger, stronger or more redundant.

Planning for uncertainty

Because there is now more uncertainty with regard to hazards, resilience instead of risk should be central to infrastructure design and operation in the future. Resilience means systems can withstand extreme weather events and come back into operation quickly.

Microgrid technology allows individual buildings to operate in the event of a broader power outage and is one way to make the electricity system more resilient. Image: Amy Vaughn/U.S. Department of Energy/creative commons.

This means infrastructure planners cannot simply change their design parameter – for example, building to withstand a 1,000-year event instead of a 100-year event. Even if we could accurately predict what these new risk levels should be for the coming century, is it technically, financially or politically feasible to build these more robust systems?

This is why resilience-based approaches are needed that emphasise the capacity to adapt. Conventional approaches emphasise robustness, such as building a levee that is able to withstand a certain amount of sea level rise. These approaches are necessary but given the uncertainty in risk we need other strategies in our arsenal.

For example, providing infrastructure services through alternative means when our primary infrastructure fail, such as deploying microgrids ahead of hurricanes. Or, planners can design infrastructure systems such that when they fail, the consequences to human life and the economy are minimised.

The Netherlands has changed its system of dykes and flood management in certain areas to better sustain flooding.

This is a practice recently implemented in the Netherlands, where the Rhine delta rivers are allowed to flood but people are not allowed to live in the flood plain and farmers are compensated when their crops are lost.

Uncertainty is the new normal, and reliability hinges on positioning infrastructure to operate in and adapt to this uncertainty. If the country continues to commit to building last century’s infrastructure, we can continue to expect failures of these critical systems, and the losses that come along with them.

The Conversation

Mikhail Chester, Associate Professor of Civil, Environmental, and Sustainable Engineering, Arizona State University; Braden Allenby, President's Professor and Lincoln Professor of Engineering and Ethics, School of Sustainable Engineering and the Built Environment, Ira A. Fulton Schools of Engineering, Arizona State University, and Samuel Markolf, Postdoctoral Research Associate, Urban Resilience to Extremes Sustainability Research Network, Arizona State University.

This article is republished from The Conversation under a Creative Commons license. Read the original article.