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It could have been consigned to the history books, but instead tuberculosis is on the rise. Is a lack of political will going to allow levels of the disease to 'drift up'?

Queen Anne was the last English ruler to touch subjects for scrofula, the 'King's Evil' which monarchs were thought to be able to cure in the middle ages.

Rationalism shattered faith in the healing touch of the monarch - but scrofula, or tuberculosis of the lymph nodes, never went away.

Two years ago, Sam Higgins, then aged two, contracted the disease. His mother says the first sign was a lump on his neck that did not unduly worry her GP. It was only when Sam 'woke up screaming' one night that he was rushed to hospital. But it took eight weeks to work out what was wrong.

A new charity, TB Alert, argues that TB should have been consigned to the history books. A relatively cheap and effective cure has been recognised since the first-ever randomised controlled trial was carried out in 1959.

It showed that 200 Madras TB patients living in slum conditions could be effectively treated at home with drugs discovered a decade earlier.

Yet TB is on the increase again. TB Alert says 2 billion people are infected and 10 million a year develop the active disease, of whom 3 million die.The charity predicts that TB could kill 4.5 million people a year by 2005.

In Britain, infection rates have risen since 1987, and there are now about 6,500 new cases a year. In London, about 50 people a week get the disease, and two die. Of particular concern is the emergence of drug-resistant strains of TB.

Dr John Moore-Gillon, chair of the British Lung Foundation and a consultant at Bart's and the Royal London trust, says this is not a major concern in Britain.

'But in terms of finance it is a huge problem. We estimate it can cost£55,000 to treat one patient.'

The average cost of dealing with a TB case is£5,000-£6,000. So, 'if we had another three drug- resistant cases a year, we would bankrupt the department'.

The World Health Organisation declared TB a 'global emergency' six years ago. TB Alert says 'getting proper treatment to everybody who needs it, anywhere in the world' is a matter of urgency.

So does Dr Moore-Gillon, although he is 'gloomy' about how likely this is to happen.

'The problem is political will. There can be a reluctance to admit your country has a problem with this old-fashioned disease when the country next door claims it has no problem.'

Dr Moore-Gillon expects the number of cases in Britain to 'drift up' because of increased mobility. 'As people move around the world, they bring the disease with them,' he says. To tackle the disease in this country, he says, research is needed to develop new diagnostic tests and drugs.

He says commissioners need to draw up clear guidelines for treatment and 'put their money where their wishes are'. Patients need to be treated by specialists, not 'doctors who might see TB every three to five years', he says.

And there needs to be specialist nursing and health visiting support 'to help people through treatment that takes at least six months. It is a difficult regime, and it is difficult psychologically. There is still a lot of stigma attached to the disease,' he says.

Ms Higgins agrees. After Sam's story was told on local television last month, some parents refused to let their children go to school with him - even though the only reminder is a scar on his neck.

The NHS Executive's London regional office is already looking at TB control. A discussion paper sent to public health directors in December says that 55 per cent of confirmed cases of TB occur in people born outside the UK.

But 20 per cent are due to recent transmission rather than old cases being reactivated, or TB being imported from elsewhere. Social deprivation, homelessness and HIV infection are major risk factors.

The report says that at least 50 per cent of patients are not in paid employment, 5 per cent have lived in hostels for the homeless and 1.5 per cent 'have a recent history of imprisonment'.

Such patients can find it difficult to get access to health services - and are hard to monitor if they do. This is made worse by what the report admits are 'fragmented' services.

A recent survey found that only 56 per cent of London health authorities had specific contracts in place for TB treatment and control, 31 had too few staff to screen immigrants, some of whom could be carriers, or trace known cases. And only 31 per cent had active case-finding programmes for homeless people.

Worryingly, the report - subtitled 'the need for change' - says the overall level of TB, and the rate of increase in cases, is similar to that seen in New York 10 years ago.

The US city 'experienced a major epidemic' of TB in the late 1980s and early 1990s, with 'many outbreaks of drug-resistant disease in hospitals and prisons'.

Dr Sue Atkinson, London's director of public health, says the situation is not directly comparable. Unlike New York, London has a public health system and free healthcare at the point of delivery which means the people most at risk of TB are less likely to 'fall completely through the net'. But 'we cannot just say, 'oh well, there you are' and leave it at that,' she says.

'We need a more co-ordinated system, common standards throughout London, a way of monitoring treatment completion, and to make sure it is not passed from one person to another.'

The capital also needs to find resources for TB services.

Why should all this happen now when it has not happened before? Dr Atkinson says the new high profile of public health, emphasis on joint working and standards and the London-wide regional office should help.

'It is a key part of our modernisation plan, and while I am not saying words on a piece of paper mean something will happen, our intention is to get improvement here.'

TB: return of a killer. TB Alert, 22 Tiverton Road, London NW10 3LH. Free.

Tuberculosis Control in London: the need for change. NHS London region, 40 Eastbourne Terrace, London W2 3QR. Free.