Tuberculosis in immigrants

217

LEADING

ARTICLE

Tuberculosis in Immigrants T h e recent arrival of refugees from H u n g a r y has again focused attention on the question of tuberculosis in immigrants and the best means of dealing with the problem. As well as the Hungarians, tile mounting influx from the West Indies (2,ooo in x952 and 29,ooo in I956 ) and the steady intake from Eire (about 2o,ooo per annum) have been the main sources of concern, though there are also considerable numbers of Indians and Pakistanis in the Midlands and of Cypriots in the t w o London boroughs of Islington and St. Pancras. Factual evidence, which is essential to assess accurately the extent of the problem~ is still meagre. Information from London and the Midlands suggests that so far amongst West Indians the incidence of disease is no higher than amongst the nativeborn British population; and the concern expressed in The Times1 in 1954 regarding the risks of population movement from a tropical island to the metropolis has diminished. T h o u g h largely derived from Negro stock the people of the West Indies have been exposed to tuberculous infection for over 3oo years and the inherited resistance of the present generation appears to be m u c h the same as ttmt of most Europeans. T h e y do, of necessity, often have to live in overcrowded conditions; but full employment and their own well-developed sense of hygiene appear to have compensated for this; and the fact that there are few in the susceptible I5-25 year age-groups has also been an advantage. T h e situation with regard to Irish immigrants is less reassuring; here the breakdown rate appears to be appreciably higher than amongst the native-born British. Thus in the North West Metropolitan Region 8 per cent of those notified for tile first time in I956 were born in Ireland. While the exact proportion of Irlsh-born in the general population of the Region is not known, it is unlikely to be so greatly in excess of the 2. 5 per cent quoted for Greater London in the I95Z Census, especially as a considerable rural area outside Greater London is included. T h e percentage of notifications was noticeably high in the older built-up areas, particularly Willesden (i8.8 per cent), Paddington (I6. 3 per cent), St. Pancras (I3.8 per cent) and H a m m e r s m i t h (x2. 5 per cent), reflecting the higher concentration of Irish in these areas but possibly suggesting also a greater liability to breakdown in an urban environment. No doubt living conditions are in part accountable, but it seems difficult to escape the conclusion that amongst the Irishborn there exists a higher proportion of people who are susceptible to breakdown with tuberculous disease under urban conditions. M a n y of the immigrants come from the more remote rural parts of Ireland; and the presumption is that not only are m a n y of them tuberculin-negative on arrival but that there are also a considerable n u m b e r who after infection go on to develop active disease. Exact figures of the percentage of immigrants who have active tuberculosis on arrival in this country are not available; but some light is cast on the subject by the North West Metropolitan Board's 1956 enquiry which showed that just over 30 per cent of the total immigrants found to have tuberculosis were notified within one year of their arrival. It seems likely that the majority either had disease which was active when they disembarked or that the additional stress experienced during the first arduous twelve months resulted in breakdown. At first sight this would appear to lend support to the demand for a pre-immigratlon radiograph; but .this seemingly simple theoretical solution is not easy to put into practice. Immigrants come to Britain from all over the world and it would be an extensive undertaking

~218

TUBERCLE

to insist that all be x-rayed before, or even on, arrival; and to impose such a restriction would invite a similar retort from other countries with regard to Britons entering their domains. The complexity of the procedure and the ill-feeling it might generate would be out of all proportion to the results achieved, the n u m b e r of immigrants with active tuberculosis from any one country being for the most part quite small. T o attempt to select countries whose nationals should be subjected to x-ray would be more invidious still; moreover, as regards countries within the Commonwealth, such as the West Indies, their inhabitants have as much legal right to come here without further health restrictions as, for instance, a citizen of Edinburgh has to go to London. There is also free passage between the Republic of Eire and Great Britain, with over 75o,ooo journeys per a n n u m in each direction. Compulsion in the circumstances would scarcely appear desirable or practicable; and even in theory it is less satisfactory than at first appears because it would completely fail to discover the tuberculin-negative susceptibles, who are p r o b a b l y a greater problem than the already diseased. T h e fact remains, nevertheless, that voluntary x-ray examination of intending migrants either before arrival or as soon after it as possible would be advantageous from both their own and the country's point of view; furthermore, with both efficient therapy and ample beds available there seems little need to aim at adopting the rigidly exclusive policy employed by Australia, Canada and the United States with the hardships of family separation it is liable to cause. O n the other hand, while respecting the rights of others, it is only reasonable to expect that precautions be taken to safeguard the health of ourselves. Fortunately the two are far from b e i n g irreconcilable. T h e essentials would a p p e a r to be that tile presence of active tuberculosis be ascertained radiologically as soon as possible; and that where BCG can afford protection it should be given. We must realize too that the problem is not the concern of this country alone; it is a sobering thought that approximately 300 individuaI~ with known tuberculosis return from Britain to Eire each year 2 and that no less than IO per cent of cases on their register arise in this way. M a n y minor epidemics m a y have been created among tuberculin-negative near-relatives and others in Eire by bacilli imported from Great Britain. Furthermore, the Irish authorities, by giving BCG to increasing numbers of their young population, will not only give them greater protection individually but also help towards diminishing the incidence of tuberculosis in British cities. BCG could also be given after arrival here; but it would obviously be better given earlier. In this country certain other lines of approach could be tried. It is important in the first place not to exaggerate the danger; the greater part of the country has no immigrant problem to speak of; it is only in London, some large ports and certain Midland cities that the numbers are sufficient to cause concern and even then only relatively small areas are affected. London has the most cases, but a p a r t from certain central boroughs in the North-West the numbers are surprisingly small. The problem therefore is to a considerable extent geographical and indeed local and the areas where it is most obtrusive are in general the very areas where there is also a high incidence of tuberculosis among the other members of the community. I t would appear logical, therefore, to search intensively for the disease in such districts, bearing in mind the experience of the recent campaign in Glasgow, which has already disclosed over 8,0o0 cases of p u l m o n a r y tuberculosis requiring observation or treatment. Such an approach would have the advantage of avoiding singling out for special attention any particular section or group; a regular, even annual, 'sweep' of such areas would seem desirable. T h e possibility of a preemployment x-ray might also be considered in certain industries and routine radiography of workers in the catering trade would be advantageous, though difficult to enforce in the absence of a specific regulation (see p. 222). T h e question of tuberculosis in immigrants cannot be separated from that of

~TAKING TIIE CURE'

2i 9

tuberculosis in general and intensification of already proved methods of dealing with the general problem should go a long way to solving the particular one; for the rest, active co-operation with the health services of those countries, particularly Ireland, from which the immigrants mainIy come, will prove beneficial both to them and to us. 1 The Times, Nov. lo, x954, Correspondence.

-* Report of the National BCG Committee, St. Ulstan's Hospital, Dublin, x955.

HERE

AND

THERE

'TAKING THE CURE' T h e practice of sending tuberculous patients on a sea voyage or advising a change of scene is referred to by most of the ancients. T h e manuscript of Celsus's 'De Aledicina', the only surviving part of an encyclopaedic work written about A.D. 30, ` remained unknown until the fifteenth century, when it was discovered and printed at Florence in I478. Celsus w r o t e 'But i f there is more serious ilbzess and a true phthisis, it is necessary to counter it forthwith at the very commencement; for when of long standing it is not readily overcome. I f the strength allows of it a long sea voyage is requisite with a dmnge of air, of suclz a khzd that a denser climate should be sought than that which a patient quits; hence the most suitable is the voyage to Alexandria from Italy . . . . I f the patient's weak state does not allow of the above, the best thhzgfor him is to be rocked in a ship without gobzgfar away. I f ato, thhzg prevents a sea voyage, the body is to be rocked bz a litter, or in some other way.' From Celsus : De Medicina, with an English translation by W. G. Spencer, 3 vols., z935-3& z, p. 329, Heinemann. "k "tr ~r In 1756 Ebenezer Gilchrist published a work in which he related case-histories of several patients who apparently recovered after taking a sea voyage. T h r e e English editions were published between 1756 and 177I, and a French translation appeared in x77o. 'A young nobleman.., was seized with a spitting of blood from the lungs, which reduced hhn to the greatest extremity . . . . As the case seemed to me a very bad one, I did not hesitate a moment hz advising his gohlg to sea with all possible expedition. His pulse was necer below ninety when at rest, and it rose to a hundred or upwards after eathzg or moving. His cough and expectoration were considerable;... Streaks of blood htdeed were often observed, and somethnes snzall quantities of pure blood were brought up, he was frequently let blood, and his blood was sizy . . . . he was costive, mudl emaciated, and it was with difficulty he could walk across his bed-dmmber ; his spirits were nevertheless good. The ffteenth of February we [sic] sailed from ~larseilles, and the second of Mardl arrived at Malta. Durhzg this short navigation we had fresh gales of wind, whiclz abnost daily produced sickness, and vomithzg of bile in large quantities. The pulse came down to eighty, and never rose to nbzety ; he gah2ed strength, his appetite grew sharp, and his sleep sound and refreshing, hz a word, never was a vo)'age attended with more remarkable success.' From The Use of Sea Vo.)'ages b~ Medicine; And particularly hz a Consumption: With Observations on that Disease, by Ebenezer Gilchrist, London, z77I , p. 3o2, 7-. Cadell. ~c ~r ~r Sir James Clark's detailed study of climate, with particular reference to its value in consumption was influential in popularizing the South of Europe as a resort for pulmonary invalids. H e pointed out, however, that much depended on the state of the patient's health on setting o u t -