Healthcare Needs of Immigrants in London - Article Example

Healthcare Needs of Immigrants in London 2008 Introduction In any multi-cultural community, health differences and hence healthcare requirements are determined by the cultural, social and economic parameters. Analysis of determinants of health differences between communities is then essentially one of studying the materialist conditions resulted by the social inequalities in terms of environmental factors. However, social hierarchies may not always obviate the differences in health attainment. Although health researchers accept the fact that socio-economic status - the most obvious and obtainable data - is the bedrock of studying public health, there may be various levels of differences in the socio-economic strata that complicate the matter. To explore the matter, the materialist approach that is by studying the absolute differences in absolute poverty, is different from the psycho-social approach, that is studying differences in relative poverty that affects public health and healthcare requirements also through differences in relative value perceptions of socio-economic status. In this paper, I will analyze the healthcare requirements of the immigrant communities in London. To begin with, I will discuss the effect of urban poverty – both absolute and relative - on health will follow since a large section of the immigrant population is poor. Then, I will discuss in detail the composition of the immigrant population in the city of London and peculiarities of health and healthcare requirements of these communities. I will then detail the risks of epidemics and contagious diseases originating from the immigrant population. This will be followed by a discussion on cultural health of different communities and the implications for nursing. The paper will be rounded up with listing of scope for future research. Urban Poverty and Health Not only does absolute poverty result in various public health problems, income inequalities and relative poverty aggravate many diseases. Hence, it is important to understand the sociological backdrop in order to properly tackle public health problems, particularly in urban areas like London. Malnutrition, overcrowding, lack of hygienic sanitation and living near industrial premises have severe effects on the health of the urban poor. They, particularly the children, are prone to work-related diseases and environmental hazards. Not only does lack of income inhibit their access to proper medication, the subsistence income and casual nature of jobs do not allow them to take leave from work even when they are ill (World Bank). In the social approach, differences in health among groups of population can be explained through socio-economic differences, that is differences in income, social stratification, access to social capital, social connectedness, gender and other such social parameters (Philips, 2005). Income inequalities between different groups of people are found to result in differences in life expectancy and mortality rates (Fiscella & Franks, 1997). The relationship between income inequality and mortality rate is found in differences in investment of social capital, that is investments in social trusts and membership of voluntary groups for health matters (Kawachi et al, 1997). In this approach to public health, social cohesion is seen to be a more important factor than individual lifestyle parameters for establishing the basis for public health and epidemiology. As a corollary, interventions strategies to improve community health needs to be targeted towards the social parameters. Treatment approaches then focus towards building the “social capital” rather than “individual treatment”. Hence, the political environment that ‘sensitises” the social divide and income inequalities are more important than individual causal model (Lomas, 1999). In the social approach to health, differences in health are not attributed to biology alone. This also incorporates the difference between sex and gender, as differentiated in the social sciences, to percolate health studies. That is, although the biological differences between male and female bodies are apparently unchanging over time, roles and expectations from men and women that depend on the social differences across time and space also explain the gender differences of health. Hence, barriers to access to food, education and medical care to disadvantaged women among immigrant communities affect women’s health more acutely than men’s while powerless and lack of control over sexual decisions result in the high incidence of HIV/AIDS among African women (Philips, 2005). Occupational differences as a social explanation of health, however, are also emphasized through differences in income, health insurance coverage, health habits, job characteristics and prestige related to the occupation (Sindelar et al). Among other social determinants of health are housing and early childhood development (Maier). The debate on absolute versus relative poverty has had ramifications on issues of public health. It is not the lack of social capital per se, that is absolute poverty that results in physical diseases but relative poverty, that is the perception of relative depravity vis-à-vis other social groups that result in perceived bias regarding health, which in turn affects physical health. Negative psycho-social comparisons of the self with the other social groups, in terms of assets, income and social status, results in lower self-esteem, higher anxiety and depression, which affects the physical health and often results in diseases like those of heart, back pain and diabetes (Ellaway, et al, 2004). A stressful psychosocial work environment also increases the depressive tendencies, particularly in men. Hence public health intervention through psycho-social factors to reduce alcohol dependence has also been recommended (Head et al, 2004). However, although adverse psycho-social exposure, that is “misery” is usually related to physical disease, the causation is not necessarily direct. Misery erodes the quality of life, thereby affecting the psychology of people, psycho-social interventions have not resulted in much positive results (McLeod and Smith, 2003). Psychosocial approach to public health is difference to the material or social approach to the extent that the former analyses the indirect psychological effects of deprivation on physical health while the latter analyses the direct deprivation for the same. However, it must be noted that the perception of misery is to a large extent dependent on real deprivation. So, public health intervention requires tackling the absolute socio-economic conditions more strongly without undermining the psychological aspects as well. In the United States, it has been seen that African Americans, Hispanics and Asians are less likely to receive coronary angioplasty, bypass surgery, advance cancer treatment, renal transplant or surgery for lung cancer than white patients with similar level of income, insurance cover, age, morbidity, type of hospital or any other parameter (Geigger). The same is true for immigrants, particularly Asians, in London. Besides the actual surgery, the differentiation is noticeable in basic care, laboratory tests, physical examination or pain reduction strategies. Racial biological differentials have long been discarded and alternative explanations like discriminatory healthcare practices, patients’ mistrust based on past experiences, lack of cultural competence on the part of physicians and other healthcare personnel are now offered. Explicit or implicit stereotyping often affects clinical decision-making. The role of race, gender and language is really a matter of clinical decision as much as it is a sociological interest. Darzi (2007) finds that “there are stark inequalities in health outcomes across London, and the quality and safety of patient care is not always as good as it could, and should, be” (cited in Wilson). Access to healthcare in London is difficult for blacks and ethnic minority communities (Wilson). Research on areas like breast screening is also limited for ethnic communities, resulting in lack of sufficient information on health problems suffered by them. However, it is recognized that “’Ethnicity’ is useful for public health if it can help to differentiate between cultural groups with different health care needs, lifestyles and attitudes. This ‘ethnicity’ is multi-dimensional and included information that can be collected such as birthplace, cultural heritage, and skin colour, but also more tacit and intractable dimensions such as social networks and other wider dimensions of identity” (Petersen 2007, cited in Wilson). Yet, all the information that is available on ethnic patient population is that it is identical to the resident population, which is not the case. All ethnic patients are not even registered with NHS. The lack of sufficient patient care for immigrant and ethnic communities is seen from the lower proportion of breast screening, which can prevent breast cancer, done for such women. Although ethnicity is not generally associated directly with breast screening, there is a low awareness of the need for screening among the immigrants. This is seen from the table below that shows the screening status in Lambeth, Southwark and Lewisham. Source: Barter-Godfrey & Taket 2005 Source: Trouton & Jani 2007 From the second table, it is evident that the proportion of screening is lower than the desired for all communities but less so in deprived areas. Further, screening is reduced on account of inconvenience in travelling, low income or temporary work, and language and literacy barriers (Wilson). Typically, African-origin women are less likely to attend breast screening among all minority communities. Further, fewer number of newly arrived immigrants go for breast screening. Immigrant Demographics of London and Differences in Health The two South Asian communities, Indians and Pakistanis, who are predominant in London, are broadly similar in culture while there are obvious religious differences, India being a secular country with predominantly Hindu population and Muslims as the second largest population group while Pakistan is an Islamic state. In the present times, immigrants are more trans-cultural in nature, retaining cultural affiliations and connections to the country of origin, than earlier when immigrants adapted to the culture of the adopted country. Hence, requirements for developing cultural competence on the part of healthcare workers are all the more crucial. Similar to Indians, Pakistanis are at high risk of coronary heart diseases and diabetes mellitus. In addition, Asian women are at risk of dyslipidemia and cardiovascular diseases than white women. Other health problems of Asians include tuberculosis, hypertension, oral submucous fibrosis as a result of tobacco chewing habits, cancer, particularly resulting from smoking or submucous fibrosis. Asian immigrant women are also at higher risk of breast cancer than those at home (Periyakoil, n.d). Many of these diseases are related to poor nutrition, lifestyle patterns including smoking and tobacco chewing, early marriage or marriage between first cousins putting them at risk of thalassemia or infection carried at the time of immigration or during travels to home country. The traditional health beliefs of Asian Muslims are based on Unani, which is a kind of therapy based on mind-body unanimity. According to Unani, the environment, food & beverages, movement & rest, sleep & wakefulness, eating & evacuation and emotions determine the state of health (Periyakoil, n.d). Diseases are caused when any of these factors are obstructed, according to the traditional beliefs. Many Muslims believe that the religious priests may cure diseases and that diseases may be tests imposed by God. Hence, there is often a resistance to formal western therapy. Religious beliefs of Muslims affect the lifestyle as well. For example, most religious Muslims follow the routine of five namaaz (prayer) a day and the Friday special namaaz. The month of the Ramadaan is meant for fasts during the day when drinks, food, smoking or sexual relationships are not allowed during daylight. Muslims eat only Halal, or sanctified meat, and are not allowed to eat blood, porcine or Haraam, or unsanctified meat, including all forms of pork like bacon and ham (Periyakoil, n.d). There may be resistance to using porcine insulin as well. Traditional Muslims prefer same sex nurses and particularly women prefer women nurses for X-rays, physical examination, mammogram, etc. There are specific cultural norms regarding treatmentt of Asian elders. For example, elders are shown great respect in the Asian community hence they expect similar treatment from healthcare workers. Most Asian families prefer not to communicate end of life states to the patients and even when there are no possibilities of success in clinical therapy, religious beliefs are held on to. Language is a common barrier to patient-nurse communication. Typically, elder Asians and new immigrants have limited English language skills. Employment of Asians in the healthcare profession in areas that are dominated by Asians are required to break the communication barrier. Many Pakistanis may wear religious accessories like amulets and skull caps. These should not be removed without the consensus of the patient. Besides, sensitive issues like sexuality, political inclinations and cultural peculiarities should not be enquired upon since these might affect the patients’ sensibilities. Following the accession of eight East European countries into the European Union in 2004, there has been a large influx of immigrants from these countries into the United Kingdom. Although most of such immigrant inflows have been outside the major cities – the total number being about 500,000 -s there is also a large number of East European immigrants in London (Stickler, 2007). As a result, pregnancies and abortion requests have risen. Since the new immigrant women are mostly young and fertile, one in five abortion requests in the UK are from East European women. According to official figures, 579,000 Polish people have migrated to the UK since 2004 and 5,000 babies have been born to Polish mothers (Martin, 2007). Besides Asians and East Europeans, Irish are a white ethnic community. In fact, the Irish is the largest white immigrant community in the United Kingdom and most of them live in London and other big cities. The Irish community suffers from mental health problems because of racial stigma, negative stereotypes, poverty, homelessness, unemployment, poor living and social support, lack of faith on the criminal justice system, all of which gives rise to a high incidence of depression, suicide and alcoholism. Because of lack of knowledge on services available and stereotyping, Irish immigrants, usually, men delay asking for help. Hence, there is an urgent requirement of mental health professionals to step up services and information in Irish-dominated areas (actiondre). A BMJ study found that new immigrant mothers are less likely to smoke during pregnancy and more likely to breast-feed but with longer stay in the UK, immigrant pregnant women take to unhealthy behavioral practices. Interviewing 8588 immigrant mothers twice between 2000 and 2005, when their children were nine months and three years old, the study found that for first and second generation immigrant women, the rate of smoking increased and that of breast-feeding declined with the duration of stay in the UK. With each additional five years in the UK, the rate of smoking during pregnancy increased by 31 percent and that of breast-feeding decreased among immigrant women (Reuters, 2008). Epidemics & Contagious Diseases There has recently been an increase in the incidence of tuberculosis (TB) in London, with about 8,500 cases reported in 2007, highest since 1987 (Harvey, 2008). The disease is closely connected with poverty and most of the cases have been found in areas dominated by immigrants from poor countries who live in over-crowded, unsanitary accommodation and live on limited nutrition and often with limited sunlight as well. Many immigrants into the UK also have to live on poor wages and hard work. Such people are most vulnerable to TB, which is an infectious disease and may develop into a drug-resistant one. Since TB is more related to poverty than to immigration from countries where the disease is prevalent, screening immigrants for TB at entry points would be ineffective. Instead, in-country healthcare facilities and increasing the number of healthcare professionals so that the disease can be diagnosed and treated early is required. In London, the incidence of TB has been rising since 1987 and it is more predominant in the more deprived areas. The highest rates are found in Newham, Tower Hamlets and Brent and in many London burroughs, the rate doubled over the 10 years since 1999. Of the population in 1993, 40 percent of the cases were from Indian subcontinent, 31 percent from non-white and 29 percent from others. The rate of reported TB increased more for the “other non-white” category, mostly Africans (Hayward and Coker, 2000). However, most London hospitals do not collect data on the origins of patients so accurate data is not available. Yet, at least 55 percent of reported TB is from foreign-born people. London has a large number of homeless people. Although data on homelessness among immigrants is not available either, it can be assumed that the incidence of TB is high among them since they suffer from acute poverty. Prevention and control mechanisms for TB are limited in the UK. In some areas, screening is done at entry points selectively and chemoprophylaxis is rarely used except for children (Hayward and Coker, 2000). The number of patients who complete treatment in London is not known but is less than the total number. An audit in a London hospital showed that about 19 percent of the patients did not complete the treatment (Hayward and Coker, 2000). Another study among the homeless people showed that as much as 43 percent did not complete the treatment. In a study by Cooke et al (2007), it was found that immigrants were presented with a wider range of infectious diseases than UK-born patients. Primary infection was most highly associated with those who had asylum/ refugee status, followed by a new migrant, and those who have been in the UK for less than five years. New arrivals into the UK are encouraged to register with the National Health Services (NHS), which is more active in the immigrant-dominated areas. Migrants are found to lack healthcare facilities both at arrival and also in-country because of language and cultural barriers, lack of knowledge of the local healthcare system and poverty. Livingstone et al (2002) found from an interview of 1085 people above the age of 65 that access to mental healthcare was limited for older immigrants. However, Africans and Caribbeans, who have poorer mental health, have greater access to mental health service. Cost to National Health Services In the United Kingdom, all patients have free healthcare from the National Health Services but newly arrived immigrants and asylum-seekers have limited access to the service because of language and information barriers. Many also have difficulties in getting access to prescriptions because of lack of proper resident documents. Because of immigration, NHS spending on maternity care has increased from GBP200 million a year 10 years ago to GBP 350 million now (Easton, 2008). A decade ago one in eight babies born was of a foreign-born mother, now the figure is one in four. The number of babies born to foreign-born mothers has increased by 64,000 over the 10 year, marking a 77 percent rise, the number of babies born to British mothers is down by 44,000. As a result, the overall birth rate is 26 percent. In Central London, one in 10 babies are born to foreign-born mothers. In Some parts of Greater London, the figure is 7 out of 10 babies. Since there is a higher incidence of diabetes, TB and HIV among immigrants mothers, these births are often more dangerous and expensive. The high birth rate is the highest among the Indian community (a rise of 11,000) followed by African (8,000 more in 10 years). This has necessitated transfer of nurses and midwives to hospitals in the predominant immigrant localities. The highest rise has been among the East European communities. While there were only three babies born to East European mothers in 2000, the number increased to 200 in 2006. Cultural Differences and Implications for Nursing Developing culturally competent care services imply acquiring the knowledge, skills, attitudes and personal traits of the particular group of people differentiated by religion, race, ethnicity or community. In an increasingly diverse society, cultural competence in healthcare is essential to provide effective services. For best patient outcomes, nurses need to be sensitive to the cultural mores, religious beliefs, lifestyle and family patterns. It is essential for nurses to continually acquire cultural competence so that they may incorporate the cultural aspects of care in all the domains of operation. The professional nursing associations, education institutes and the healthcare fraternity on the whole is responsible for assessing the cultural competence of nurses as well as to continually educate them about client needs in a changing society. Typically the literature on cultural competence in healthcare emphasize less on race than on sub-groups related to the elderly, homeless, women, mentally ill and so on. ). As a result of lack of trans cultural education, nursing care has not been meaningful for these ethnic communities. Nursing education requires guidelines in the planning of curriculum carefully developed for greater cultural competence. According to the literature on cultural competence of nurses, the following themes emerge (cited in Jirwe et al, 2006): Awareness of diversity – awareness of one’s own identity as well as the patient’s so that the nurses are aware that each one has a cultural background. This would diminish the tendency of cultural stereotyping Ability to care for individuals – this requires cultural knowledge about the individuals to whom care services are provided. Cultural knowledge about nutrition, childbirth, pregnancy, death rituals, spirituality, traditions, family values, etc. are essential for providing appropriate care. This knowledge stems from not only educational cultural knowledge but also from world view, documented cultural knowledge and encounters with people from different cultures. Educational cultural knowledge may be imparted through training courses but nurses may also enhance their cultural knowledge through interactions with people from different cultures. Developing world views on care would familiarize nurses with different attitudes towards illnesses, diagnosis and care. This would make the nurses more responsive to patients’ problems. Cultural encounters between nurses and patients are also essential since nursing culture is very important to the patient, being dependent for the time being on the patient. Non-judgmental approach – Nurses must realize that each culture has different notions about health, illness, diagnosis, care and lifestyles. A non-judgmental approach makes communication between healthcare professionals and patients more effective. Skills in cultural assessment – Nurses’ cultural assessment of patients and themselves are based on collection of data during the process of care. The data collection relates to various types of lifestyle issues of different cultures. Developing cultural competence continually – Cultural competence is not a static skill but needs to continuous updates related to the changes in the society as well as world developments. The most important nurse-patient interaction is through communication skills. Although language skills may not be so easily acquired by nurses from different cultural backgrounds, there are various nuances that may be picked up. Evaluating on the basis of these communication skills need to be done to develop effective training modules. For example, nurses may need to begin with small talk with the patients to overcome the initial communication resistance on the part of the latter. The use of colloquialism may create artificial barriers with the patients. The nurse needs to understand the verbal and body language of the patient for better care. For example, if the patient avoids eye contact, it may be more because of shyness than mistrust for the nurse. Also, it may also be the case that the patient nods his head and says “yes” out of respect for the physician or the nurse even when he does not comprehend what is being told. Respect for cultural beliefs on health and illness: The staff needs to be evaluated on his or her respect for the patients’ cultural beliefs on health and illness. It should be recognized that the traditional religious and cultural beliefs of Pakistanis are widely different from the western cultural beliefs. The nurse should be evaluated on the basis of his or her ethnicity, recognition of differences and the respect that she or he has for other beliefs. The care provider may ask the patients the following questions to understand their beliefs (Periyakoil, n.d): What do you think is the problem? Why do you think this illness or problem has occurred? What do you think the illness does? What do you think is the natural course of the illness? What do you fear? How do you think the sickness should be treated (what alternative therapies are you using currently), How do want us to help you? Who do you turn to for help? Who should be involved in decision-making? The nurses may be evaluated on the basis of answers that the patients give. For example, the patient may feel that a disease is created by God when the nurse knows that it is inherently caused by the lifestyle. The illness may also be perceived as part of penitence and the patient may turn to prayers instead of formal therapy. The patient may be unduly fatalistic or hopeful and the nurse needs to understand the parameters of cultural psychology. The patient may simultaneously use alternate therapy that might hinder the clinical care. The nurse must deal with this in a sensitive manner to dissuade from the practice if it is perceived harmful. Pakistanis have close family links and often the families are intricately involved with the clinical process as the patients. The staff may be evaluated on the basis of following case strategies: 1) What would the nurse do when a female elderly Asian patient refuses to undertake a mammogram by a male nurse? 2) What would the nurse do if a Asian Muslim patient fails to turn up for a repeat clinical test on an appointed date that happens to be a Friday? 3) What would the nurse do if a diabetic Asian refuses to use a particular type of insulin? 4) What would the nurse do if a cancer patient who is undergoing radiological treatment uses a kind of religious balm that results in dermatological scalp problems? 5) What would the nurse do if the elderly female Asian does not understand the physicians’ instructions made in English? The nurses should be evaluated on theirs cultural comprehension, communication skills and sensibilities. In particular, new immigrants may have difficulties in understanding instructions hence the speed and mode of communication is essential. Conclusion and further research In London, as in most urban cities of the world, health and healthcare demographics is closely related to the socio-economic status. Although free healthcare is available through the National Healthcare Services, the access to the services is limited for immigrants primarily due to cultural and language barriers as well as lack of proper resident documents. Health services in London suffer from severe inequalities although the needs are substantially higher for the immigrants, a large proportion of whom live in poverty. Healthcare needs are very closely related with lack of income, unemployment or temporary work, malnutrition, over-crowded and unhygienic living conditions, lack of proper sanitation and so on. There is a larger incidence of epidemic diseases like tuberculosis among the immigrants. Besides, lifestyle differences account for a higher incidence of diseases like diabetes and cardiac problems among immigrants from South Asia. Yet, preventive measures like screening for breast cancer is limited for them. As a result of a large influx of immigrants from the European Union over the recent past, there has been a pressure on maternity health services since a large proportion of new entrants are young women. Pregnancy rates and abortion requests have increased as a result. Healthcare access is also limited by cultural barriers between the immigrants and patients. From the perspectives of nursing, developing cultural competencies is essential for providing improved healthcare facilities to immigrants. Works Cited Jirwe, Maria, et al (2006). The Theoretical Framework of Cultural Competence. Journal of Multicultural Nursing and Health. Fall 2006. Retrieved from http://findarticles.com/p/articles/mi_qa3919/is_200610/ai_n17194975/pg_7 Geiger, H. Jack (n.d). Racial Stereotyping and Medicine: The Need for Cultural Competence. http://www.cmaj.ca/cgi/content/full/164/12/1699 Periyakoil, Vyjeyenthi S et al (n.d). Health and Health Care for Pakistani American Elders. Stanford University. Retrieved from http://www.stanford.edu/group/ethnoger/pakistani.html Cox, Melissa, A, Welfare Dependence and Dynamics in Britain, Presented at “Women Working to Make a Difference”, IWPR’s Seventh International Policy Research Conference, June 2003, retrieved from http://www.iwpr.org/pdf/Cox_Melissa.pdf Ellaway, Anne et al, Are social comparisons of homes and cars related to psychosocial health?, International Journal of Epidemiology 2004 33(5):1065-1071 Fiscella, K and P Franks, British Medical Journal, 1997, Jun 14;314(7096):1724-7 Geiger, H. Jack (n.d). Racial Stereotyping and Medicine: The Need for Cultural Competence. http://www.cmaj.ca/cgi/content/full/164/12/1699 Head, J et al, The psychosocial work environment and alcohol dependence: a prospective study, Occupational and Environmental Medicine 2004;61:219-224 Kawachi, I et al., Social capital, income inequality and mortality American Journal of Public Health, 1997 Sep; 87(9):1491-8 Lomas, Jonathan, Social capital and health: Implications for public health and epidemiology, Social Science and Medicine, Volume 47 Issue 9, November 1998 Macleod, J and G Davey Smith, Journal of Epidemiology and Community Health 2003;57:565-570 Action DRE, Mental Health and the Irish Community, http://www.actiondre.org.uk/positivesteps/irish_community.html Cooke, Graham et al, Impact on and use of an inner-city London Infectious Diseases Department by international migrants: a questionnaire survey, Health Serv Res. 2007; 7: 113. Harvey, Evelyn, The no-blame Game, Society Guardian, January 28, 2008, http://www.guardian.co.uk/society/2008/jan/28/tb.london Stickler, Angus, Immigrant pregnancies stretch NHS, BBC News, 26 March, 2007, http://news.bbc.co.uk/1/hi/health/6494651.stm Reuters Health, Immigrant women to the UK adopt unhealthy maternal behaviors, April 10, 2008, http://www.thejobcure.com/reuters_article.asp?id=20080410clin001.html Livingstone, G et al. Accessibility of health and social services to immigrant elders: the Islington Study, The British Journal of Psychiatry, 2002, 180: 369-373 Martin, Daniel, Immigrant baby boom puts NHS under strain, Daily Mail, 27 March, 2007, http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=444801&in_page_id=1770 Barter-Godfrey, S. and A. Taket, Women and Health: Views of Women Aged 50-64 Living in Lambeth, Southwark and Lewisham: Final Draft. London South Bank University. London, Institute of Primary Care and Public Health, 2005. Darzi, A., A Framework for Action: Summary. Healthcare for London. London, NHS London, 2007 Petersen, J., Breast Cancer Screening Uptake: Analysis of Ethnicity, Birthplace and Name Origin Southwark PCT 2003-2006 DRAFT. Southwark Knowledge Transfer Partnership. London, 2007 Trouton, A. and N. Jani, Draft: Health Equity Audit of Breast Screening Uptake 11/02/2003- 26/01/2006 (Unpublished). London, Southwark Primary Care Trust, 2007 Wilson, Kristin, Uptake and Ethnicity: The London Perspective, The Cancer Screening Programmes, NHS Hayward, Andrew C and R C Coker, Could a Tuberculosis Epidemic Occur in London as it Did in New York, Emerging Infectious Diseases, Vol 6 No 1, January-February, 2000 Read More