How London became the tuberculosis capital of Western Europe

View of London. Image: Robert Lamb/Creative Commons.

I was recently diagnosed with tuberculosis, which was quite the shock since I’d assumed it to be a disease left behind in Victorian slums – only briefly making a comeback to kill off heroines in old Westerns. But there I was being prescribed strong antibiotics by a very serious nurse, realising that despite my naivety, the disease has made a big comeback in London in the past 15 years.

A 2015 report from the London Assembly found that one third of London’s boroughs exceed the World Health Organisation's (WHO) ‘high incidence’ threshold of 40 cases per 100,000 people. The boroughs of Newham, Brent, Ealing and Hounslow have some of worst rates in the country, comparable with significantly less developed countries such as Rwanda, Algeria and Guatemala. It is no wonder that the capital has picked up the rather unsavoury title of ‘TB capital of Western Europe’.


Varying TB rates across London. Image: London Assembly

Having TB means being infected by ‘Mycobacterium tuberculosis’, which manifests in one of two ways within a person. If ‘active’, the bacteria is damaging your body and you can infect other people. Symptoms include a loss of appetite, weight loss and a persistent cough that may bring up blood. If treatment cannot be accessed it can lead to death.

Luckily for me, and everyone forced to commute with me on the Victoria Line, my tuberculosis is ‘latent’. This means that I’m both symptomless and not infectious. If untreated, latent TB has around a one in ten chance of becoming active, but a three-month course in antibiotics takes this down to one in 100.

Anti-immigration groups like the now-obsolete BNP were quick to claim a connection between TB’s resurgence and London’s high immigrant population. But this doesn’t tell the whole story: although 74 per cent of cases in London do occur in people born abroad, it is highly unlikely they could have brought active TB into the UK. People applying for visas from countries with high incidence rates are required to get medically screened.


The disease instead ‘activates’ here, particularly in areas that are strongly linked with deprivation and the associated poor housing, poor nutrition and general ill health. Newham is in one of the poorest boroughs in London and comparable levels of poverty can be seen in the other ‘high incidence’ areas.

Health inequality plays a big part in TB getting a foothold in the city, with many affected having inadequate access to inadequate services. If it wasn’t already, this means limiting access to healthcare for migrants would be a terrible idea. The restrictions around healthcare imposed under the ‘hostile environment’will likely deter people from receiving treatment that they need. Untreated carriers of active TB spread the disease and drug-resistant strains are on the rise.

The WHO estimates that two billion people across the world are infected with tuberculosis. Although I’m soon to be TB-free, London is still very much under threat. A co-ordinated approach is needed; not just improving outreach programs among vulnerable demographics, but also tackling the socio-economic causes. This Victorian disease should be resigned to history and not allowed to become a feature of modern London.

 
 
 
 

What’s killing northerners?

The Angel of the North. Image: Getty.

There is a stark disparity in wealth and health between people in the north and south of England, commonly referred to as England’s “north-south divide”. The causes of this inequality are complex; it’s influenced by the environment, jobs, migration and lifestyle factors – as well as the long-term political power imbalances, which have concentrated resources and investment in the south, especially in and around London.

Life expectancy is also lower in the north, mainly because the region is more deprived. But new analysis of national mortality data highlights a shockingly large mortality gap between young adults, aged 25 to 44, living in the north and south of England. This gap first emerged in the late 1990s, and seems to have been growing ever since.

In 1995, there were 2% more deaths among northerners aged 25 to 34 than southerners (in other words, 2% “excess mortality”). But by 2015, northerners in this age group were 29% more likely to die than their southern counterparts. Likewise, in the 35 to 44 age group, there was 3% difference in mortality between northerners and southerners in 1995. But by 2015, there were 49% more deaths among northerners than southerners in this age group.

Excess mortality in the north compared with south of England by age groups, from 1965 to 2015. Follow the lines to see that people born around 1980 are the ones most affected around 2015.

While mortality increased among northerners aged 25 to 34, and plateaued among 35 to 44-year-olds, southern mortality mainly declined across both age groups. Overall, between 2014 and 2016, northerners aged 25 to 44 were 41% more likely to die than southerners in the same age group. In real terms, this means that between 2014 and 2016, 1,881 more women and 3,530 more men aged between 25 and 44 years died in the north, than in the south.

What’s killing northerners?

To understand what’s driving this mortality gap among young adults, our team of researchers looked at the causes of death from 2014 to 2016, and sorted them into eight groups: accidents, alcohol related, cardiovascular related (heart conditions, diabetes, obesity and so on), suicide, drug related, breast cancer, other cancers and other causes.

Controlling for the age and sex of the population in the north and the south, we found that it was mostly the deaths of northern men contributing to the difference in mortality – and these deaths were caused mainly by cardiovascular conditions, alcohol and drug misuse. Accidents (for men) and cancer (for women) also played important roles.

From 2014 to 2016, northerners were 47% more likely to die for cardiovascular reasons, 109% for alcohol misuse and 60% for drug misuse, across both men and women aged 25 to 44 years old. Although the national rate of death from cardiovascular reasons has dropped since 1981, the longstanding gap between north and south remains.

Death and deprivation

The gap in life expectancy between north and south is usually put down to socioeconomic deprivation. We considered further data for 2016, to find out if this held true for deaths among young people. We found that, while two thirds of the gap were explained by the fact that people lived in deprived areas, the remaining one third could be caused by some unmeasured form of deprivation, or by differences in culture, infrastructure, migration or extreme weather.

Mortality for people aged 25 to 44 years in 2016, at small area geographical level for the whole of England.

Northern men faced a higher risk of dying young than northern women – partly because overall mortality rates are higher for men than for women, pretty much at every age, but also because men tend to be more susceptible to socioeconomic pressures. Although anachronistic, the expectation to have a job and be able to sustain a family weighs more on men. Accidents, alcohol misuse, drug misuse and suicide are all strongly associated with low socioeconomic status.

Suicide risk is twice as high among the most deprived men, compared to the most affluent. Suicide risk has also been associated with unemployment, and substantial increases in suicide have been observed during periods of recession – especially among men. Further evidence tells us that unskilled men between ages 25 and 39 are between ten and 20 times more likely to die from alcohol-related causes, compared to professionals.

Alcohol underpins the steep increase in liver cirrhosis deaths in Britain from the 1990s – which is when the north-south divide in mortality between people aged 25 to 44 also started to emerge. Previous research has shown that men in this age group, who live in the most deprived areas, are five times more likely to die from alcohol-related diseases than those in the most affluent areas. For women in deprived areas, the risk is four times greater.


It’s also widely known that mortality rates for cancer are higher in more deprived areas, and people have worse survival rates in places where smoking and alcohol abuse is more prevalent. Heroin and crack cocaine addiction and deaths from drug overdoses are also strongly associated with deprivation.

The greater number of deaths from accidents in the north should be considered in the context of transport infrastructure investment, which is heavily skewed towards the south – especially London, which enjoys the lowest mortality in the country. What’s more, if reliable and affordable public transport is not available, people will drive more and expose themselves to higher risk of an accident.

Deaths for young adults in the north of England have been increasing compared to those in the south since the late 1990s, creating new health divides between England’s regions. It seems that persistent social, economic and health inequalities are responsible for a growing trend of psychological distress, despair and risk taking among young northerners. Without major changes, the extreme concentration of power, wealth and opportunity in the south will continue to damage people’s health, and worsen the north-south divide.

The Conversation

Evangelos Kontopantelis, Professor in Data Science and Health Services Research, University of Manchester

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