Before Covid-19, Dr Farzana Hussain says, it was rare for her to see a case of scabies at her GP surgery in Newham, east London, but since the pandemic, the number of patients with the parasitic skin infection has increased dramatically.
“By the time a patient comes to me for advice, everyone in the family has it, including all the children,” she says. “The itch is maddening. People demand immediate treatment.”
Transmitted by tiny mites that burrow and lay eggs under the skin, scabies is a disease associated with squalor and overcrowding. Spread by close personal contact, it is so infectious that during the Victorian period, workhouses maintained separate “itch” wards so those infested with the mites could be segregated and treated before being allowed into the workhouse proper.
According to the Royal College of General Practitioners (RCGP), scabies cases are now running at three per 100,000 of the population in England, double the five-year seasonal average. That translates into approximately 2,000 cases of scabies a year. However, in the north, the worst affected region of England, GPs are seeing rates as high as six per 100,000.
Scabies is not the only disease that appears to be making a comeback in Rishi Sunak’s Britain. In 2022, 423 patients were admitted to English hospitals with rickets, a disease caused by lack of sunlight and inadequate levels of vitamin D. The same year, 188 people were treated for scurvy, a condition caused by not eating enough fresh fruit and vegetables, leading to a deficiency in vitamin C.
Both scurvy and rickets are often seen as proxies for malnutrition, hospital admissions for which are running at about 10,000 a year in England, four times the level of 12 years ago. Little wonder that Dr Clare Gerada, the former president of the RCGP, has warned the UK is in danger of “going back to the Victorian era”.
Sir Michael Marmot, director of the Institute of Health Equity at University College London, agrees. “The idea we are starting to suffer the same diseases that in Victorian times people on long ocean voyages suffered because of the shortage of citrus fruits is simply horrendous,” he said recently.
For Marmot, the surge in infectious diseases reflects the cost of living crisis and decade-long cuts to social services and public health, which have left Britain with one of the poorest and most vulnerable populations in Europe.
According to a recent report by the Joseph Rowntree Foundation, 14.4 million Britons – or one in five people – were living in poverty in 2021-22 and 6 million people – or four in 10 of those in poverty – were in “very deep” poverty, with an income way below the poverty line.
Poverty and disease are closely correlated: according to the Royal College of Paediatrics and Child Health, children living in deprived neighbourhoods are twice as likely to die of infections as those living in the least deprived neighbourhoods. These health inequalities are mirrored by adult mortality rates, with nearly 11,000 more excess deaths occurring in the most deprived areas of the UK in 2020 than in the least deprived 20%, according to Marmot’s most recent review of the state of the nation’s health.
But are poverty and worsening social and economic conditions the only factors? According to the UK Health Security Agency (UKHSA), cases of measles – a disease for which there was no vaccine in Victorian times – are also increasing, with 1,603 suspected cases last year, more than four times the number in 2021.
Britain is also seeing alarming increases in sexually transmitted diseases, such as syphilis and gonorrhoea. The latter is up 50% from 54,961 cases in 2021 to 82,592 in 2022. That’s the highest number since records began in 1918. And syphilis is up 15% to 8,692 in 2022, the highest number since 1948.
Some of this increase in STDs may be explained by more diagnostic testing – during the pandemic, the government encouraged people to use home tests, as half of UK sexual health clinics were closed. However, the scale of the increase also suggests more infections in the community, leading to more demand for sexual health services.
According to the Local Government Association, in 2022 STD clinics conducted 4.5m consultations, a third more than in 2013. But because of cuts to frontline services and a shortage of sexual health counsellors, getting an appointment at a clinic can take weeks, and patients who succeed in getting one can face waits of up to four hours before being seen.
“If people can’t get in when they want to, the risk is they may not come at all,” says Prof Matt Phillips, president of the British Association for Sexual Health and HIV.
But this is by no means the whole story: the increase in STDs may also reflect fewer people taking precautions than in the 1980s and early 90s, when the fear of Aids persuaded people to adopt less risky sexual behaviour. By contrast, today, the availability of pre- and post-exposure prophylaxis for HIV means that gay and bisexual men have less incentive to use condoms.
And when it comes to measles and other preventable diseases, the increases are probably due to a similar array of factors, including fears about vaccines, fatigue with childhood vaccine schedules and the difficulty of accessing jabs for households where both parents are in full-time work.
The result is that in Birmingham, where last month doctors treated more than 50 measles cases, prompting the UKHSA to declare a “national incident”, only 80% of children had received two doses of the measles, mumps and rubella (MMR) vaccine by their fourth birthday (the national target is 95%). And in Hackney, east London, the figure is just 56.3%.
Little wonder some experts believe Britain is facing a severe challengefrom infections from the past. One thing that might make a difference is employing more health visitors. But due to local authority cuts, this workforce has fallen 40% since 2015.
“We do not have enough health visitors to meet rising levels of need,” says Georgina Mayes, policy and quality lead at the Institute of Health Visitors. “As a result, too many families are missing out on essential health visitor reviews.”
Helen Bedford, professor of children’s health at University College London, believes the shortfall is one of the factors driving the low uptake of the MMR jab and other vaccines.
“It means those visits where mums got to ask questions about their baby’s health are not taking place or happening in the same way as in the past,” she says. As a result, parents are less likely to take on board medical advice to vaccinate their children.
Bedford argues that this hesitancy was compounded by the pandemic, when people were encouraged not to visit GP surgeries unless necessary, even though most surgeries never suspended their vaccination services.
“The message should have been, stay at home, but you can still get your child vaccinated,” says Bedford.
Hussain says another factor is fatigue: “During the pandemic, people took on board the message to get the Covid vaccine, but now don’t feel it’s necessary – or that they have the time – to get the measles jabs for their children. If you’re on a zero-hours contract and you’re struggling to make ends meet, you’re less likely to take time away from the office to get a vaccine.”
Bedford agrees, which is why she would like to see more mobile vaccination centres.
Another factor driving the upsurge in measles infections is misinformation and conspiracy theories about vaccines. In 2018, 93% of people thought vaccines were important for children. Today, just 72% think that, according to the London School of Hygiene and Tropical Medicine’s vaccine confidence project.
For some groups, these views may reflect religious and cultural taboos – that vaccines containing gelatine are forbidden for Muslims, even though alternative vaccines not containing gelatine are also available.
For others it reflects the continuing influence of the disgraced gastroenterologist Dr Andrew Wakefield, who suggested there was a link between the MMR jab and autism. Although Wakefield’s theory has been comprehensively debunked, it continues to feature on scores of anti-vax sites, as well as on the WhatsApp chats where many parents get their medical information.
The danger now, argues Hussain, is that the “Wakefield cohort” – people who due to Wakefield missed their MMR jabs in the 1990s – are having babies themselves, increasing the chance of further outbreaks in both unimmunised adults and children. Such outbreaks are serious. Measles is extremely contagious – in a susceptible population one measles carrier can infect between 12 and 18 people, and for every 1,000 children who get measles, one to three will die.
But is there a danger that in comparing today’s situation with the Victorian period we may be getting things out of proportion? For instance, one of the key reasons scabies cases are increasing, according to the British Association of Dermatologists, is a shortage of treatments such as permethrin and malathion. And not every case of scurvy is due to parents being unable to afford fresh fruit and vegetables – sometimes, a vitamin C deficiency may be due to children being picky eaters.
Similarly, the incidence of rickets is far below the rate seen in the 1800s, when London was blanketed by smog, blocking UV radiation, and it is estimated that the condition affected 60% of children living in the capital.
That is not to say we should be complacent, however. Dr Benjamin Jacobs, an expert on rickets at the Royal National Orthopaedic Hospital in Stanmore, Middlesex, says that whereas in the 1980s it was unusual to see a case of rickets, today, sadly, the condition is no longer a rarity. “I see at least three children with rickets each year; each case is a heartbreak,” he says.
“The NHS has provided free vitamin supplements for some children for almost 20 years, but the vitamins often don’t get to the children who need them most. It is shameful that the NHS has not made more progress preventing these severe diseases.”
