Return of an old enemy: Tuberculosis

Return of an old enemy: Tuberculosis

By Adam James

LONDON: Disadvantage and deprivation are far removed from the life of Ali Khaleeli. With his background, there seemed little risk of him catching tuberculosis, which is known as the disease of poverty. Born to a wealthy family in southern Iran, Khaleeli was educated at an English public school and vaccinated against TB (tuberculosis) when 16.

And by 1991, when he started suffering a dry cough, he was a healthy, badminton-playing 45-year-old diabetes consultant living in a village in affluent Cheshire, England.

Certainly he had come into contact with TB patients during his career - but so had tens of thousands of other medical staff. When an X-ray revealed a shadow on his lungs, therefore, both his radiologist and chest physician felt there was only one conclusion - Khaleeli had lung cancer. "You do not see a lot of tuberculosis nowadays," the radiologist replied, when Khaleeli suggested he might have that disease.

It was only one day later, when a groggy Khaleeli awoke from a biopsy operation, that he was told that, indeed, he did not have cancer but tuberculosis. "Although I was still under the effects of the anesthetic, I shouted with relief," Khaleeli recalls. "The anesthetist said he had never seen anyone so happy to be told they had tuberculosis."

TB is usually easily treatable with antibiotics - so Khaleeli had reasons to be thankful. Nevertheless, his diagnosis fitted into the bigger picture causing concern to TB doctors - that this highly infectious disease is returning to Britain at an alarming rate. Moreover, hospitals up and down the country are under- prepared for its resurgence.

According to British Public Health Laboratory Service figures, TB cases have been growing rapidly over the last 10 years. In one year alone, 1998-1999, cases in England and Wales rose 20 per cent, from 4,659 to 5,658. The disease is most prevalent in poor, deprived areas such as east London, which has the highest rate of TB in the country.

This rise has evoked so much apprehension that, last year, TB Alert was formed, making it the first British TB charity since the 1960s. "It is true to say that tuberculosis is a slow timebomb in the United Kingdom," warns Peter Davies of the Liverpool tuberculosis research unit at University Hospital, Aintree, north England. "If it continues to increase at the present rate, the incidence of TB will, in two or three generations' time, be five or ten times what it is now."

Before the introduction of effective drugs in the 1950s, TB thrived in the poor social conditions during and after the industrial revolution. The bacteria killed one in four white Europeans and Americans. But now it is mostly non-whites, like Khaleeli, who are coming down with the disease in this country.

More than half (56 percent) of cases are in people born outside Britain, particularly sub- Saharan Africa and Asia where TB can be rife and treatment poor.

Despite opinion that poverty remains the most significant underlying cause of TB in this country, Davies, who treated Khaleeli, places more emphasis on biology.

"My hypothesis, which is highly contested, is that white European and Americans who survived TB passed on a genetic resistance to the disease to their children," he says. "Asian and African people may not necessarily have this innate resistance.

Therefore I think the rise of TB in the UK is down to migration, pure and simple."

Aware that such scientific speculation may be seen as having racist overtones, he adds: "We can get around claims of xenophobia by remembering that TB is essentially a European export. So, in a sense, it is a disease which is coming home."

Above all, it is British doctors' lack of familiarity and expertise in dealing with TB that worries specialists such as Davies. World Health Organization guidelines specify that, in order to tackle TB effectively, there must be an efficient system of diagnosis and thoroughness in ensuring patients complete their course of treatment. Yet last year the British Thoracic Society reported that only 14 percent of 43 health districts had minimum staffing levels necessary to treat TB.

"It is down to individual doctors to recognize tuberculosis - but we now have two generations of doctors who have not, in their professional lives, seen tuberculosis," says Davies. "Training is just not adequate, and this is something that, over the last 10 years, has driven me to distraction."

Tight treatment procedures are all the more urgent when ineffectively treated strains of the disease can mutate to become "multi-drug resistant" (MDR), making it difficult - and expensive - to fight.

One case of MDR tuberculosis can cost US$360,000 to treat. When New York suffered an MDR outbreak 11 years ago, it cost $158.40 million over four years to control it. In Britain, MDR cases were unheard of five years ago. But now, according to Davies, one in 50 is MDR. "All the more reason to pay attention to the rise of TB," he emphasizes.

"We have just seen Prince Charles and other celebrities put their support behind an anti-bowel cancer charity. If only we could get that kind of publicity for tuberculosis. But it is not an issue people want to raise because it is seen as a problem for other countries. Well, it is not."

A fully recovered Khaleeli, who is convinced he caught TB from one of his patients, is one doctor who has learned the lesson.

Each year, he presents a lecture on tuberculosis to staff at Halton General Hospital, near Runcorn, Cheshire, where he works. He is also considering researching the proportion of Asian and African doctors and nurses who have been infected with TB, possibly from patients.

"The treatment of tuberculosis and other infectious diseases was one of the things that made the British health system so good," he says."But tuberculosis has reared its head again, and it is particularly important we are on the look-out for it among Asian and African people. Surveillance is so vital to prevent its spread."

--Guardian News Service