Andrew Hinderaker for Al Jazeera America

Funding cuts may leave New York City vulnerable to tuberculosis

‘Forgotten’ disease continues to hit poorest immigrants as prevention resources drop and clinics close

NEW YORK — Eradication had been the idea. But two decades after health care workers turned the tide on tuberculosis in New York City, no one in the few remaining TB clinics can celebrate its demise.

For the first time in a decade, the number of confirmed cases in the city has gone up, according to the New York City Health Department's 2013 report, and the once declining rate of active infection has slowed to a constant. Even if the current infection numbers remain low, budget cuts could result in the city being ill prepared for any future outbreaks. New York’s last wave of TB, in the 1980s and 1990s, killed thousands of people.

Facing funding cuts, some clinics have closed, and at least one has started charging for TB screenings. With TB most common among the homeless, immigrants arriving with little money and the immune-compromised, the $30 that is sometimes needed to be tested is often hard to come by.

Lillian Agyei injects tuberculin in Ibrahim's arm.
Andrew Hinderaker for Al Jazeera America

At the African Services Committee (ASC) clinic in Harlem, workers at times waive the fee for patients at risk of TB, such as Ibrahim, a man in his late 20s, who asked that his real name not be used. After he arrived in New York from Burkina Faso two years ago, it was determined that he was a potential candidate for TB. With no health care, his case might have gone undetected if he’d had to pay the full price. 

Lillian Agyei, testing coordinator at ASC, said that since the clinic started charging most patients, the number of visits had dropped dramatically. In 2009, about 4,500 people were tested for tuberculosis. Last year, only 534 clients sought the service, according to internal statistics. Agyei said these were mostly people who needed the test for administrative reasons related to employment or study, not individuals who found themselves at risk of infection.

The ASC director, Kim Nichols, said the dramatic fall in people being tested could hamper efforts to battle the disease. “There will be those few cases that we would have treated or screened in previous years who will not be picked up on until they have active TB, or have already infected other people in their households,” she said. “You lose the opportunity to intervene before a person develops active symptoms.”

Nichols said the drop in screenings at ASC is the result of municipal and federal budget cuts, which have been enforced despite confirmed cases in the New York area rising from 651 in 2012 to 656 in 2013, according to the latest figures.

"You hope it’s not a trend,” Lee Reichman, executive director of the New Jersey Medical School Global Tuberculosis Institute and former New York City health director, told Al Jazeera.

Reichman oversaw the city's response to the TB outbreak of the late 1980s and 1990s, in which more than 12,000 people died. At the time, authorities scrambled to spend $1 billion to quell the epidemic. Now, he said, the numbers are still in their “early stages.”

“If we don’t do something about it, [this] may increase more. It may actually affect the rate. It’s a warning sign,” he said.

Even though some experts fear cases could increase, the New York City Health Department's Bureau of Tuberculosis Control reduced operating hours at two chest clinics in 2013. The NYC Health Department did not respond to Al Jazeera’s request for comment, but according to the 2013 annual report, the hours were cut “due to decreased use and financial constraints."

At the Charles P. Felton National Tuberculosis Center at Harlem Hospital, operations have been discontinued and testing resources diverted to other clinics in New Jersey, Florida, Texas, California and Minnesota.

Bill Bower, former director of education and training at the center and an assistant professor at Columbia University, said the decision by the Centers for Disease Control and Prevention (CDC) was taken in response to local rates nearing national averages. From a case rate of 220 per 100,000 residents in 1991, exceeding that of many developing nations, central Harlem now registers 4.8.

“TB incidence in Harlem … had been reduced considerably. It was time to spread state-of-the-art TB care, training, materials and medical consultation across the country," he said in an email.

But health care professionals at ASC said community organizations like theirs are left to pick up the slack while government providers take “a back seat.”

U.S. cities with highest case rates

Metropolitan area State(s) Total cases Case rate per 100,000
Urban Honolulu HI 96 9.8
San Jose-Sunnyvale-Santa Clara CA 176 9.3
McAllen-Edinburg-Mission TX 72 8.9
San Francisco-Oakland-Hayward CA 382 8.6
San Diego-Carlsbad CA 234 7.4
Jacksonville FL 99 7.2
Los Angeles-Long Beach-Anaheim CA 862 6.6
Stockton-Lodi CA 44 6.3
Houston-The Woodlands-Sugar Land TX 340 5.5
Washington-Arlington-Alexandria DC-VA-MD-WV 321 5.5
Jackson MS 31 5.4
New York-Newark-Jersey City NY-NJ-PA 1029 5.2
Memphis TN-MS-AR 66 4.9
Dallas-Fort Worth-Arlington TX 300 4.5
El Paso TX 37 4.5

At the national level, Reichman pointed to an oft-ignored group buried in public health statistics. While touting the record on national TB rates, the administration may be neglecting the plight of immigrants, who remain disproportionately affected by the disease.

Despite the number of TB cases in the U.S. reaching historic lows of 3 per 100,000 people, the rates among foreign-born people (15.6) remain around 13 times higher than those of U.S.-born individuals (1.2), according to the CDC.

Budget cuts have also been a source of concern for advocacy networks such as Treatment Action Group, an HIV/AIDS think tank. In 2013, sequestration forced the CDC to reduce TAG’s research budget, TAG said in a statement, setting back plans to conduct research that could shorten the length of TB treatment. TB research funding at the United States Agency for International Development (USAID) fell from $19.8 million in 2010 to $12.2 million in 2012, it added.

“[The] cuts jeopardize our ability to eliminate TB in the U.S. and especially in the context of the global epidemic that has been unabated,” said Mike Frick, a TB/HIV project officer at TAG. “As long as TB remains a problem globally, we can expect it to be a problem here in the U.S. A lot of people have a sense that the situation here is under control, but ultimately eliminating it will require looking outside borders.”

Tuberculosis is an airborne disease that can take years to develop before a patient becomes sick. Many with TB walk around not knowing they’re carrying the disease. Worldwide, TB is believed to have killed more people than all wars and famines combined.

In 2012, around 8.5 million people developed TB and 1.3 million died from the infection, according to the 2013 report by the World Health Organization. The rates have been falling worldwide for about a decade, but the rate of decline remains slow — too slow, said the organization, which called the number of deaths “unacceptably large given that most are preventable.” The majority of cases worldwide in 2012 were in Southeast Asia.

The cramped conditions that await some Asian immigrants coming to the U.S. also help explain why New York areas such as Sunset Park, West Queens and Flushing have some of the highest TB rates in the country.

“I have heard that some live in apartments with more than 10 people, tenement-like situations,” said Vivian Huang, a former tuberculosis clinic resident physician with the NYC Health Department and current hepatitis B director at the Charles B. Wang Community Health Center in New York's Chinatown.

A lingering stigma, she added, and, among undocumented immigrants, fear of deportation further discourage patients from seeking timely treatment for a disease many in the U.S. have forgotten.

“You don’t think you can get it, but it happened to me. I’m a normal NYC guy,” said Kareem Ali, a 32-year-old financial analyst, who moved to the U.S. from Pakistan in his childhood and requested that his name be changed.

He went on to recount a painful 18-month battle against multidrug-resistant TB in the mid-2000s, which left him coughing up blood, battling depression, losing some of his hearing and experiencing dramatic weight loss.

With reduced budgets for clinics and research, some compare the current funding cuts to those of the Reagan era, when officials dismantled prevention programs as TB rates dropped, only to watch them flare up again in the late 1980s and 1990s with devastating consequences.

“We can’t afford to not be vigilant. In NYC, we’ve already seen what the consequences are of letting down our guard,” said Frick.

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