UK Urban Health Issue

¶ … incidence tuberculosis as an Urban Health issue among ethnic minority group in Canning Town, Newham Borough of London. Large scale incidence of tuberculosis (TB) has been a major concern for public health planners in the UK. The report is structured as follows to enhance a greater understanding of the TB rate in Newham and strategies to reduce the TB rates in Newham London.

First, the report explores the TB rates in the entire UK. Moreover, the report provides the rational the TB cases in an urban health issue since Newham is a part of London. Moreover, the paper provides overall urban health issues and their implications to urban residents. The paprt explores the TB incidents in London and narrow the incidents to the Newham in London. Moreover, paper compares the TB rates of all important cities in the UK to enhance a greater understanding of urban health issues. Finally, the report recommends strategic intervention to reduce the TB rates in Newham.

Rationale of Tuberculosis is an Urban Health Issue

Large-scale environmental problems due to urbanization have been the major cause of health problems among the UK residents. A recent report presented by Public Health England, (2013) reveals that the UK has highest rates of the TB (tuberculosis) in the western countries, however, the TB is unevenly distributed because certain sub-groups such as minority groups, and new migrants have higher rates of TB incidence in the UK. In 2012, the UK recorded 8,751 TB cases revealing an incidence of 13.9 per 100,000 people. Although, the incidence of TB is relatively stable since 2005, however, majority of people with TB cases are people from high burden countries, born outside the UK. Half of the TB patients were already diagnosed at their countries of origin five years before entering the UK.

Moreover, "7.3% of TB cases had at least one social risk factor (history of homelessness, imprisonment, drug or alcohol misuse); only 43% of these were reported to have started on directly observed therapy." (Public Health England, 2013, p 8).

Similarly, London has approximately 3,426 of TB cases, which is a rate of 41 per 100,000 people. Although, the rate of the TB in London stabilizes after two decades of TB high rates, however, majority of the TB cases are among people born outside the UK, however, TB case is higher among non-UK born ethnic groups such as Somalia, India, and Pakistan. While TB rates continue to increase among the Indian population in London, the TB rate is declining among black Africans. Despite the rate of TB rate in London, "the highest numbers and rates were reported among residents of Newham (366 cases, 117 per 100,000) and Brent (313, 100 per 100,000) local authorities, followed by Ealing (253 cases, 75 per 100,000)" (Public Health England, 2013 p 9).

As being revealed in Table 1 and Fig 1, the average TB rate is very high in Newham compared to TB rates in London in general. When comparing the TB rates in London to the average TB rate in the UK, it is revealed that the TB rate in London is 200% higher than TB rate in the entire UK.

Table 1: TB Rates per 100,000

UK

London

Newham

13.9

41

Fig 1: TB Rates per 100,000 in the Nehman and London

Urbanization has been the major health problem in London, and explosive growth of urbanization in the UK is a major concern to public health planners. Typically, rapid growth of urbanization has been the cause of public health hazard such as water and air pollution, overcrowding, acid rain, which consequently lead to other environmental health problem such as tuberculosis. (Tsouros,1997). Studies have revealed that major cause of death is from communicable disease such as tuberculosis, and other respiratory disease. (Tsouros, 1997, Leeder, Ward and Wilmoth, 2006). Consequently, there is an inverse relationship between chronic diseases and environmental hazard in the urban settings such as London.( City of London, 2008 ),

Newham in London is the most deprived area in England with the population of 308,000. Newham historically has the highest rates of tuberculosis in England, which is "8 times higher than the national average and three times than the London average." (Newham, London, 2012 p 30) . In 2011, over 90% of Newham residents were notified the risks of tuberculosis, while 20% of the residents were born outside the United Kingdom, with approximately 50% of the residents have just arrived in the United Kingdom within the past five years. The figures show that the risks of cases of TB are very high in Newham. In 2011, the notification of tuberculosis for Newham residents increased from 77 cases to 381 cases representing 25% increase compared to the previous year.

In Newham, 121.4 out of the 100,000 residents suffered from tuberculosis in 2011 compared to the London residents having of 43.1 out 100,000 people suffering from tuberculosis. However, the TB is not evenly distributed across the Newham because 70% of Newham residents suffering from TB reside the north and east - Manor Park, Green Street, and East Ham. Consequently, low economic status of Newham residents contributes to high rates of tuberculosis in the area. The data presented by the Newham London Borough Council show that Newham is among the most 5% most deprived place in the UK. Typically, the residents suffer from poverty low level of education, and poor health. Moreover, 17% of the working population in Newham is suffering from long-term illness. Thus, tuberculosis continues to be a serious health problem in Newham. Alcoholism, drug misuse, homelessness, mental health issues, and imprisonment are the social risk factors of tuberculosis. At London Borough Newham, one out of 10 tuberculosis patients face these social risks. Moreover, a tuberculosis patient is more likely to develop a disease highly resistance to treatment and drug.

Despite the high rate of tuberculosis at Newham Borough in London, the incidence of tuberculosis is higher among minority ethnic group in the UK. Typically, approximately 90% of tuberculosis patients are born outside the UK, and the incidents of tuberculosis are 10 times greater among minority ethnic group than majority ethnic group in the UK. Essentially, TB is one of the most deadly diseases in the UK, and a leading killer of people infected with HIV.

Health problems associated with TB in Newham make public health planner in London to make TB as one of the important health priorities because the TB is urban health issues. In 2013, London has the population of 8.03 million, and since 2001, the population of entire London continues to increase by 12%. The data from Office of National Statistics show that approximately 145,000 people arrived in London in 2009 representing 2% increase in London population, however, 178,000 people across the UK moved to London in 2009. The increase in London population in the last 10 years leads to the growth of urbanization which assists the spread of TB. Typically, there is a correlation between high TB incidence and urbanization. Urbanization leads to overcrowding which is a factor that leads to a spread of communicable disease such as tuberculosis. The high rates of TB in Newham and London makes the TB to become a public health priority among health planners given that TB is a communicable disease that can spread to other people within a short period. Overcrowding is one of the features of urban setting because of overcrowding assists in spreading TB among urban residents. Essentially, overcrowding in urban setting also affects physical health of the population. (Office of the Deputy Prime Minister, 2004). As being revealed in Fig 2, the number of non-UK born receiving the TB notifications is significantly higher than the number of the UK-born receiving TB notifications. The data reveal that the TB incidence is higher among foreign-born UK residents.

Figure 2 -- London TB notifications rates based on place of birth, 2004 -- 2010

In the next section, the paper discusses the implication and consequences of TB in urban context.

4) Identification and Public Health Issues Newham Borough of London

The report focuses on Newham to enhance a greater understanding of urban health issue in London. Newham is an area of exceptionally complex in London having high level of cultural and ethnic diversity. Essentially, Asian, Black and other minority ethnic groups constitute over 60% of the total population of Newham, and the area is the third fastest growing population in England. Newham has the highest rate of TB in the country, which contributes to the factor making Newham resident to have high level of mortality and morbidity. Many stakeholders such as academic institutions, trusts, Council, and the voluntary organizations have collaborated to improve the health outcomes in the areas. Despite their continual efforts to improve health outcomes in Newham,

"health outcomes remain poor owing to a number of factors including delayed access to care, socio-economic deprivation, structural barriers to making healthy lifestyle choices, poor health education and maternal and childhood malnutrition." (University of East London (2010 p 2).

Public Health England (2013) released the health profile of Newham residents in 2013, and the findings reveal that general health status of Newham residents is the worst in England. Typically, the resident of Newham is currently experience high level of deprivation making Newham recording highest rates of tuberculosis in England. Moreover, the life expectancy is lower in Newham compared to national average. Deprivation is higher in Newham than the national average. Typically, 86% of Newham's "residents live in areas classified" (Mayho, 2003 p 2) as the most fifth deprived areas in England. Moreover, Newhman receive the highest notification of TB in England with 15% increase in population since 1981, however, the rest of the cities and towns in the UK record a slower rate of population increase of only 4.3%. The increase in the Newham population is attributed to the increase in the number of ethnic minority groups settling at the place. Overview of the Newham's population shows that

"Newham has the most diverse ethnic minority population in the UK with 61% of the population from non- White ethnic groups. Data suggests that the population of ethnic minority communities has grown considerably between 1991 and 2001" (Mayho, 2003 p 2).

Refugee constitutes approximately 8% of the total population and the place constitutes the second largest asylum seeking areas in London. Wide concentration of ethnic diversity in Newham makes the place to be very unique in London, and the most deprived borough in London. In Newham, TB continues to be increase among ethnic India minority. Although, TB rate is declining among black population, however, black still account 21% of TB patients notified in 2012. However, approximately 14% of all TB cases have just entered Newham in the last two years. In recent years, half of the TB patient has pulmonary disease and a sputum smear results are identified with 76% of TB patients. Many ethnic minorities in Newham continue to live in overcrowded conditions and poor housing. Since Newham has the highest notification of TB cases in London, there is a correlation between poverty, poor housing and TB incidence.

Essentially, TB is very important for public health planner in the UK based on the strategic location of London. Newham is a part of London metropolis, and London is one of the most important world trade centers with 7.4 Million habitants. London economy and life shapes global economic forces particularly flow of capital, trade and labor. Moreover, London serves as major destination for students, investment fund and workers. London is also a gateway to all part of the UK through London airports, raid and road links. Moreover, London serves as an important destination for world tourists. In 2002, 108.6 Million people flew through London airports at Heathrow, the increase in mobility of people into London metropolitan leads to spread of tuberculosis. Thus, Newham in London is highly vulnerable to TB cases because the area is the destination of Asian, African and Latin American immigrants entering the UK. Media reports across London blames immigrant bringing TB disease into Britain. Some people suggest that the UK government should screen all visa applicants for TB before issuing the business or tourist visa.

Social-economic factor contributes to high incidence of tuberculosis in Newham in London. The fig 2 compares economic status of the Newham residents to the residents of Westminster and Chelsea boroughs in London.

Fig 3: Economic Status of Newham and Westminster and Chelsea in London

Comparative analysis of social economic factors of Newham borough, Westminster and Chelsea boroughs reveal that that there are wide social-economic disparities between the residents of Newham and residents of Westminster and Chelsea boroughs. The illustration in fig 3 reveals that Westminster is a London economic powerhouse, the place is the UK third most prosperous borough. The average income of people in Westminster is very high and the place is the residents of some of the wealthiest people in the UK. The data in Fig 3 reveal that nearly 30% of Westminster households earn income above £60,000 per annum, and average of 5% of the population earn below £15,000. Most of the resident of Westminster is White British background with 56% born in the UK. Contrary to Newham borough that has higher percentages of minority ethnic group, however, minority ethnic group is significantly lower in Westminster. Similarly, residents of Chelsea earn second highest income in London. The data in Fig 3 reveal that more than 25% of households in Chelsea earn more than £60,000 pounds per annum with average of 9% of the population earning below £15,000 per annum.

Contrarily, less than 10% of Newham households earn above £60,000 pounds while nearly 30% of households in Newham earn less than £15,000 per annum. The average household income in Newham makes many of the TB patients in the areas unable to afford the costs of TB treatments. Based on the data presented in the Fig 3, there is a correlation between socio-economic status and TB rates in London. Typically, residents of Westminster and Chelsea boroughs hardly have TB because of their socio-economic status. Their economic status will assist them to have access to the best medical assistances compared to the Newham households whose majority are living below the poverty line. Lienhard, (2001) argue that socio-economic factor is correlated with the rate of tuberculosis. The UK data reveal data areas with higher rate of poverty record high rates of tuberculosis compare areas enjoying higher standard of living.

Public Health Consequences and Implications to Urban Health

Urbanization refers to the percentage of population living in an urban area. In the UK, annual rate of urban growth is 0.7%. Since large number of people settle in urban centers to search for jobs and improve their lifestyles, this decision consequently leads to overcrowding in urban setting. Lienhardt (2001) argues that overcrowding is one of the major factors that lead to the spread of tuberculosis in urban setting and TB notification is two times higher in urban setting than rural setting.

Bothamley, Kruijshaar, Kunst, et al. (2011) present the data to reveal a correlation between urban setting and the rates of tuberculosis in the UK. As being revealed in Table 2, the growth of urbanization increases the rate of TB in the UK. From the data in Table 2, London has the highest number of population out of the all the cities listed in the Table 2. The London population is more than 8.7 million and the TB cases in London are 3,440 in 2009 with 44.4 cases of TB per 100,000. Birmingham is the second largest city in the UK with the population of approximately 2.3 million in 2009, and TB cases in the same year are 509. Manchester has population of 2.24 million and the city has 248 number of TB cases in 2009. Comparatively, areas such as Coventry that has lower number of population has 92 cases of TB. Leicester with 304,598 total populations has 212 cases of Tuberculoses. The data in Fig 4 reveals that the UK has the highest number of TB rates among the cities in UK based on its large number of population.

Table 2

Major UK conurbations and smaller cities having high TB burden

City

Population

Population density

(person per

hectare)

"Actual population by TB clinics in 2009"

TB cases in 2009

Incidence

per 100, 000

London

8, 278, 251

51.0

7, 747, 748

3, 440

44.4

Birmingham

2, 284, 093

38.1

2, 284, 093

22.3

Manchester

2, 240, 230

40.3

419, 628

248 (196)

59.1 (40.5)

West Yorkshire

1, 499, 465

40.5

Leeds: 762, 461

Bradford: 467, 363

15.7

38.3

Glasgow

1, 168, 270

40.5

866, 379

24.2

Newcastle

879, 996

41.7

268, 751

43

16.0

Liverpool

816, 216

43.9

433, 333

52

12.0

Nottingham

666, 358

42.0

909, 836

86

9.5

Sheffield

640, 720

39.5

530, 000

106 (80)

20.0 (14.6)

Edinburgh

448, 624

37.7

452, 514

81

17.9

Leicester

441, 213

43.4

304, 598

69.6

Coventry

300, 848

31.1

312, 925

92

29.4

Source: Bothamley, Kruijshaar, Kunst, et al.(2011)

Fig 4 -- TB notifications in the UK major cities in 2009

The incidence of tuberculoses has been a major concern to both government and resident in London since data reveal that 84% of TB incidents is prevalent among people born outside the UK, the disease is also common among people susceptible to social risk factors such as homeless, alcohol and drug dependency. Typically, TB is a major concern since it is considerable expensive to diagnose and treat acute TB. The costs of treating drug sensitive to TB can range between £1,100 and £4,000. Although, the cost of initial treatment may not be more than £1,100, however if a TB patient is required the follow up treatment the cost of treatment can be as high as £4,000. Contrarily, there are cases of multi-drug resistance TB that are very difficult to treat, which the costs of treatment can exceed £18,500. (NHS, 2011).

However, a report from House of Parliament (2012) provides contrary results by revealing that the costs of treating TB are approximately £5000 per patient. However, if a patient is required a second line of treatment, the costs of treatment can range between £50,000 and £70,000 per patient. (House of Parliament, 2012). Although, the UK government has been implemented several funding programs to eradicate tuberculosis in the UK, for example, the UK government claimed that it has contributed $200 million through Global Funding to eradicate TB in the UK. (Washington Times, 2001). However, the shortcoming of this approach is that the UK government has not focused on the root cause of TB in Newham London. Overview of the costs of treating a TB patient is very high in the UK, and many of the TB patients are people born outside the UK and many of them may not be able to afford the cost of TB treatment. Moreover, largest percentages of TB patients reside in Newham where employment rates are the lowest. Typically, employment rates in Newham are 56.2%, which are significantly below London average of 62.7%. (A2D, 2011). This report provides intervention program to reduce the TB rates in Newham London.