It's from Royal Prince Alfred Hospital in Camperdown and it can mean only one thing. I tear at the envelope and pull out a single sheet of cheap A4. As I unfold it, I remember my visit to the hospital a few days ago: a radiologist, saying, "If you hear from us again, that's bad news". Bitterly, I rewind the scene a few seconds further. I'm peering into the radiologist's dimmed inner sanctum, attempting to glimpse the two ghostly negative images of my lungs that she's just clipped into a light-box on the wall.
"You're nosey," she says.
"I'm just a bit worried," I say. "I wasn't expecting all this. I don't want to be deported."
She stands in the half-dark frowning at the glowing, ghoulish photos.
"Well I can't see anything to worry about," she says. "I think you're all clear. Probably, nothing will happen now. But if you hear from us again..."
And so I have. Which means, like the seemingly pristine waters of Iron Cove, I too am actually dangerously polluted. As I'd whistled my way along the cycle path, wondering what was going to happen next, I'd been carrying an evil passenger. That I've been sent this scrappy letter means that a possibility even I thought too calamitous to be true has been realised. Somehow, I've caught Tuberculosis, a lethal disease I'd assumed existed only in Edwardian novels and the wretched hospices of the third world.
These are the things I don't know as I fumble at the letter, trying to convince myself there's been a mistake: tuberculosis infects nine million people every year and kills almost two million. According to the World Health Organisation, the earth's currently under attack from a "global pandemic" of lung-hungry tubercule bacillus; with an estimated one third of humanity infected, it's the only disease to be afforded this calamitous status. TB bacteria spread like the common cold, but only one in twenty people who host the germ actually develop 'active' TB - a healthy immune system is usually enough to keep it sleepy. Australia, however, is lucky: despite the fact that half the world's new TB cases are contracted within our neighbouring countries in South East Asia and the Western Pacific, it has one of the lowest infection rates in the world, with between five and six cases per 100,000 people, or roughly 1,000 per annum. But many of these infectees are immigrants - people, in other words, like me.
If I wasn't British, and if my partner Farrah and I hadn't decided at the start of 2007 that a radical change of climate might be beneficial to our happiness levels, I might, by now, have started feeling the symptoms. I'd be wondering why I can't shake this jagged cough, and why my handkerchief is freckled with blood. I'd be irritated by the night sweats and pleased about the weight loss - the sins of a thousand pizzas miraculously absolved - but not overly worried, because I'm never ill: at my last address in London, where I lived for more than three years, I hadn't even bothered registering with a GP.
This is why I consider it to be just another pesky hurdle when, during our application for four year Temporary Resident Visas, we're asked to provide the Department for Immigration and Citizenship [DIAC] with chest x-rays to demonstrate we're TB free. We book in at the private Princess Grace hospital in central London one evening and as an afterthought, whilst the credit card machine is dialling out, I ask the nurse if they look alright.
"It's supposed to be a secret," she says. "Strictly speaking, it's between us and DIAC." She winked. "But as far as I'm concerned, they're fine."
So I don't worry.
Actually, that's not true: I do worry. It's in my nature. I worry constantly, about everything. I spend my days pacing up and down inside my head, assailed by the dreads and expecting trouble to come at me violently and from any direction. I sniff potential crises everywhere. I glimpse them behind fleeting facial expressions and I sense them crawling between weird timings and revealing phrases. And when I catch them, which is often, I grasp at them as if they're treasure. So that evening, when the nurse said, "As far as I'm concerned, they're fine," it wasn't the word "fine" I seized upon, but the phrase "as far as I'm concerned".
"It implies that it's not up to her, doesn't it?" I said to Farrah over a post x-ray plate of hummus and kebabs. "So we're not in the clear."
"You'd know if you had TB," Farrah said. "You'd be dying. Plus, who gets bloody Tuberculosis?"
She was right. I relegated it to a grade three worry. It became a tiny concern, buried under a hillock of troubles that were suddenly to become mountain.
Because leaving your job, your friends, your family and your flat to come to a city 10,000 miles away where you have none of the above is not easy for the pathologically wonky-minded. The fact that, six weeks into our arrival, our visas mysteriously haven't been cleared doesn't help. One afternoon, a solicitor calls and tells me that mine will be granted on condition that I sign a 'health undertaking'; a legal agreement that I'll contact the Department of Immigration and Citizenship [DIAC] and be re-x-rayed.
I phone DIAC instantly, the mental pacing now at such a frenzy that I feel as if I'm about to stride out the front of my own forehead. What have they found? Obviously it's not TB. TB doesn't exist anymore, except perhaps in countries where leprosy, witchcraft and child soldiers are considered everyday threats to life. Besides, I'm not ill. Back in London, I cycled twenty miles a day - I have the lungs of a blue whale! Of an astronaut!
"Have they found something on my lungs?" I ask the operative. "Cancer? Might it be cancer?"
"Probably the original x-ray wasn't clear enough and they just need to get it done properly," she answered.
Of course! I'm reassured further by the placid nature of the letter I receive from the hospital. When it arrives, the appointment it announces isn't until October and I'm even given a number to call if the date is 'not convenient'. I know it's not TB - that would just be stupid. And if it was cancer, I reason, they'd see me straightaway. Clearly, all this grief is over a duff x-ray.
***
I stride through the invalids, separated from them by the illusory invisible screen that divides the healthy from the sick, and saunter up to the hospital's eleventh floor where I'm given a green form to take to Radiology on the fifth. Descending in the lift, I peruse the piece of paper. There's my name, my address, my date of birth, the purpose of X-Ray: 'TB?'.
TB?
In the time it takes for the lift to drop less than two millimetres I've deduced the following. I have caught tuberculosis. I have infected half of Sydney and all of Farrah. I am going to be deported, possibly tomorrow, by vengeful immigration officers wearing face masks and carrying billy-clubs. The move back to the UK will send Farrah and I into debt. We will be unemployed. We will lose our flat. We might even die - in penniless, hacking agony, in a filthy ward in the ructious bedlam of a south London hospital.
***
When Lady Strife upends her witchbag over my head, I usually react by creating waves of action - any action at all, it doesn't matter - in an effort to repel the doom. Thus, I track down the phone number for the hospital's chest clinic and dial it without having the first idea of what I'm going to say to the person who answers.
I get an answer machine. "The chest clinic is open between nine am and five pm, Monday to Friday." I look at the clock on my computer. 'Fri 17.02'.
This sends me into fluster-mode two. I try to sate the sensation of approaching doom by gathering facts on the internet. Of course, throwing hastily assembled knowledge down the throat of a problem usually only serves to heighten it's appetite. It creates more uncertainty and multiplies the ruinous possibilities.
Naturally, I forget all this as I frantically click through webpages. First I go in search of the secrets of my enemy in this festering war for my life. Bacteria. Everyone knows we have a lot to thank bacteria for - not least cheese and the ability to digest it - but did you know that, if it wasn't for the legions of teeming invisibles that thrive in the layers and creases of every place you look (and even more places you don't), the entire ecosystem would collapse?
The more I discover, the more I begin to doubt the hubris of humans: any objective survey of the facts would surely conclude that the world really belongs to them, not us. They've already staged five hostile takeovers of the earth, each of which took millions of years to recover from (in one, the 'late Permian mass extinction', they turned the oceans stagnant and poisoned the entire planet). Scientists tells us that bacteria were earth's dominant species for 3 billion years. But what with there being roughly ten times more bacterial cells in a human body than actual human ones, who are we to say they still aren't? They're certainly tougher beasts than us, having been found in the north pole at minus 85 degrees centigrade; on deep-sea hydrothermal vents in 106 degree water and living on radioactive waste. Some spend their entire lives bouncing around the clouds whilst others thrive 1500 metres underground inside solid rock. They power themselves like batteries and can move at speeds which, relative to their size, are equal to a human running 100 metres a second. Most, I'm sure, are charming and many, I know, are essential. But quite a few really do want to kill every last one of us. These are the pathogens. And they're winning.
Tubercule Bacillus look like tiny sausages and a single microscopic one of them is enough to set-up a devastating colony in your tubes. An 'active TB' sufferer expels 40,000 teeming droplets every time they sneeze and the moment one arrives in the warm, windy catacombs of your lungs, it begins it's slow multiplication, dividing every 16-20 hours. TB is a catabolic disease, which means it steals your resources to live. And when the immune system begins it's violent attack - the collateral damage of which devastates the lungs - the sufferer can become doubly, fatally weakened.
The skirmish in my lungs, I discover, is part of a war that's been boiling for many millennia. Prehistoric remains of TB-ravaged humans have been found and it was still killing one in four Londoners in 1815. It's variously been known as 'king's evil', 'white plague' and 'consumption' and - ironically, given it's catabolic nature - is said to be the cause of European vampire myths. Many took note of the waxy pallour; the sore, light-sensitive eyes; the constant fatigue and the coughing-up of blood and concluded that the deathly-looking consumptive had been up all night sucking on necks. When other family members started to appear as if their lives were being drained from them, the original victim was blamed.
Famous consumptives include George Orwell, Immanuel Kant, Florence Nightingale, Emily Bronte, Kafka, Chopin, Alexander Graham Bell, Cardinal Richelieu and Charles Bukowski (TB was the only thing powerful enough to stop the beserk LA writer drinking), and cures have included puncturing a lung, 'the flesh of a she-ass' and - oh, beautiful irony - emigration to Australia.
But out of all the information I find over those dawdling, anxious weeks, these are the ones that worry me most: TB is the only illness which automatically triggers refusal of a visa to Australia; the antibiotic regimen lasts at least six months and is free, in New South Wales, to all except those holding a '457' visa - the type held by Farrah and I. According to the BBC website, it costs at least £6000 [$13500] to treat.
As I spent all my money relocating to Australia, I conclude the only solution is to fly home, pick up my free antibiotics from the National Health Service and then hop on a Qantas to resume my joyful bicycle rides in the lucky country. I ask my Dad to double-check this impermeable plan by speaking to a nurse on the UK's free health helpline NHS Direct. He returns my call an hour later, sounding delighted.
"They were wonderful!" he says. "The nurse said she didn't know but would call me back - then five minutes later a TB specialist called!"
"That's great," I say. "What did she say?"
"She'd be amazed if any GP would be irresponsible enough to let you walk away with six months worth of antibiotics."
"Oh."
Meanwhile, word of the doom has spread. The phone and email have been hysterical with two generations of Farrah's family worrying at great length if I infected any of them or 18 month old Findlay on their recent visit. My mother has emailed to wonder if I put my two year old niece Beth in danger when I saw her six months ago. She then calls to check if Farrah's alright. Healthwise, she is, but the threat of deportation and a $13,500 medicine bill has her uncharacteristically moody. I spend a Sunday evening stalking the corridors, the family vampire, whilst Farrah talks endlessly on the phone about 'infectious' and 'checked out' and 'I'll get him to ask the doctor'.
The shame of a highly infectious disease is something sheer and unforgettable. It's like confessing you're a criminal to your most loved and trusted. When they discover your secret, they become gripped with this expression of quiet horror: you're not the person they took you for; you're something else, something dangerous. You can sense them wondering, "Has he got me?"
It's a lonely business, too. You really are doing it solo, for a start, and where you'd receive emotional support for suffering a busted spine or cancer, when there's a possibility that others will be forced to join you, they're understandably more concerned for their own wellbeing. This is natural, of course, and perfectly reasonable and satisfactory. It's still a shock. More than anything else, though, it's the isolating net of guilt that gets you. Farrah's brother, I learn, has cancelled his visit to Australia because of all this. And what can I say? The whole truth is painful and it's dirty and it's this: I've pushed everyone I love into the path of danger and there's no way I can manoeuvre myself blameless, even in my own thoughts.
***
"Ah," I say.
It's a typically wet Sydney morning and my appointment hasn't started well. The doctor is an hour late, which gives me plenty of extra time to sit in the waiting room and fantasise about calamities. Last week, I called a government helpline, explained my situation and was told that a panel of officials would weigh the cost of my treatment against the benefit to the nation of my presence. That's when I really started panicking. Next I spoke to a solicitor who told me the health authority would expect my private medical insurance to cover the treatment. And I said, "Private what?". I contacted a leading provider who advised me that even if I'd signed-up the day I arrived, my TB would've been considered a 'pre-existing condition' and I'd be entitled to naught. By now, I'm as sure as rock: they're going to ask me for $13500, I'm going to show them my bank statements and they're going to send me home in a sterilised cage.
I wobble into the doctor's surgery, soused in anxiety, and plonk the big, damp, rain-smeared pile of internet research that for some reason I've brought with me onto her desk.
"Can-I-just-ask-something-I've-been-really-worried-well-we-both-have-me-and-my-girlfriend-I-know-this-treatment-is-really-expensive-are-we-going-to-be-deported-we-don't-have-any-mon..."
"We're not here to talk about immigration issues," she says. "Our principal concern is your health."
"But!"
"I can tell you that TB treatment is free."
"But!"
I show her the internet document that says 457 visa holders have to pay.
"I know about that and I'm telling you it's free to all."
"But!"
"Look, even if we wanted to, we couldn't send you back. People with active tuberculosis aren't allowed to fly. And if we find it's latent TB you don't even have to have treatment."
"But!" There's a silence. "What... really?"
This is fabulous news. Latent tuberculosis is what they call it when you've caught and fought the disease. Latent patients are frequently asymptomatic, and the first thing they know about TB is a chest x-ray that shows lesions - battle-scars from the silently fought war. They're people who've had the precisely the same experience as me. I've decided, therefore, that it's pretty-much self-evident that I'm latent. If I've had TB at all, that is. Which I doubt.
"You certainly look healthy enough," agrees the Doctor. "You haven't been losing weight?"
"I've put weight on!" I cry. "And I've been dieting. Honestly, doctor, I never even get the sniffles. I really, really think it's impossible that I have TB. There's just no way."
"Have you been to Asia in the last few years?"
I think for a moment.
"I've been to Hong Kong," I begin. "Three times, on assignments. And India, three or four times. And China - rural China. And Pakistan."
"Did you go into the countryside in Pakistan?"
"Yes. And I was in rural Colombia. And Venezuela, in the barrios. And Belize."
"Eastern Europe?"
"Russia twice. And Poland in April."
"Sub-Saharan Africa?"
"Uganda in February. And Tanzania and Mauritania and South Africa. Do they have TB in South Africa?"
The doctor glances up from her notes and hits me with a look that I'll never forget and that I probably don't need to describe.
"Try not to worry too much," she says. "We're trying to disprove TB, not prove it. Look..."
She shows me another of those green treatment cards - this one for a CT scan. Where it says, 'Purpose of scan', she's written 'Disprove TB'.
I grin and sag in my seat.
***
Of course, you know you're really in trouble when the gap between your hospital summons is reduced to four hours.
"How soon can you get back in?" says the nurse on my mobile, just after lunch.
"Is it my scan?" I ask.
"It's active TB."
Words travel faster than feelings; when you hear bad news, there's often a curious of moment of stillness before your emotions catch up with what you've been told. Held in that crystalline moment, you can view your situation with a clarity and distance that's almost amusing. Observing the fist in motion, you think, "Oh wow - this is going to be shit" And then it hits. Reeling from the force of the nurse's words, I end the call and cycle to the hospital in a manner so beserk that it imperils my life more than exposure to the deadliest bacteria known to science.
The next medical specialist to see me does so from behind a protective face mask, in a sealed room that has a special air outflow to ensure my breath doesn't kill anyone.
"I didn't say this was going to be pleasant," she's saying, as I'm gagging into a small pot.
I've been ordered to breathe warm, salty air until my lungs suffer seizure and vomit up sufficient phlegm for three samples. This is an 'induced sputum' test. And, she's right, it's not pleasant. When the results come, they're negative, which demonstrates that I'm not infectious. However, my doctor is sufficiently convinced that the small cloudy area at the top of my right lung is active tuberculosis in its early stages that I'm to start a course of antibiotics that'll last at least six months and will include four different drugs at eighteen pills per dose. I'll be required to swallow them in hospital, under the supervision of a nurse. I'll also need my blood and eyesight tested regularly, as this combination of pills puts me at risk from liver failure and blindness (not to mention deafness and nerve damage). They're so noxious, in fact, they make you cry orange tears.
If I'd have known how they'd make me feel, I would never have accepted the invitation of the Society of Travel Writers' Christmas Lunch. I arrive at the hotel restaurant in Sydney's Rushcutters' Bay just as they begin to take effect. I suffer the first attack as I'm collecting name badge. It's like someone's dropped a buffalo on my head. I lurch as a wave of prickles passes through me and my blood suddenly quadruples it's speed. I try to focus. My palms sweat and I get the strange feeling that parts of my face are being pulled in bad directions; suddenly my left eye is half a metre in front of the other one, then my right cheek is stretched to the floor, then a spot on my brow is pushed inwards. Then the sensation that my brain and eyes are extremely tiny but my head is huge. As I reach for my name-badge, I twitch and jump at a darting, black hallucination that, just for an instant, I take for some sort of creature.
I'm bracing for another surge when two elves rear up at me.
"You've been a naughty boy," says the first. She's got a blue face and a bell on her hat. For some reason, I focus on the sweating, painted wrinkles by her eye in repulsive, magnified detail. "We're going to make you stand in corner."
"God, no!" I think.
"We're going to spank you!" says the one with the green nose and angry buttons. "Spanky! Spanky! Spanky!"
I force myself to understand that these are actually 'comically' decorated middle aged women, before staggering to a toilet cubicle where I fall asleep.
***
"We've divided the world up by risk, that ranges from 'low', such as the United Kingdom, to very high, such as most of Africa. How long you're coming for and where you're coming from will determine what sort of medical examination you'll undertake."
Davies tells me that 10,000 'health undertakings' of the type I had to sign, are issued annually. "Only Commonwealth doctors can approve an undertaking," he says, "and if we put someone on one we're satisfied they don't have active TB".
Incidents of immigrants that are issued undertakings and turn out to have active TB are, apparently, rare. "Nobody that we know of comes to Australia with active TB," says Davies. "From time to time we do come across someone - but more often than not it's an Australian citizen returning from overseas. When an immigrant is diagnosed with active TB we're notified, not so we can take punitive action against them, but simply so we can look at the medical clearance we gave in the first place and see what was missed."
I'm also curious to discover why, as the radiologist in London claimed, the results of these x-rays are kept secret from the patient.
"That was probably a misunderstanding," he says. "Doctors and radiologists are under instruction not to return the documents to the client because we don't want somebody substituting medicals. But the normal doctor-patient rules still apply".
Indeed, a great deal of the information I've been told - from radiologists, government helplines, legal professionals and even the BBC - turns out to be untrue. When I speak to Dr Cathy Hewson, an adviser on tuberculosis to global health charity MSF, she tells me that the course of antibiotics I'm taking doesn't cost $13,500, but "between 30 and 60 Euros ($50 - $100). It's cheap. They are old drugs. That's part of the problem."
Hewson tells me that I'm taking a combination of four antibiotics - Isoniazid, Rifampicin, Pyrazinamide and Ethambutol - some of which kill the bacteria by attacking their cell walls and some of which prevent from them from replicating, which gives my immune system a chance to kick them to death.
These drugs were developed more than 60 years ago. She goes on to tell me that the diagnostic test, for which my sputum was induced, only identifies around 50 percent of infectees and was developed in 1882. Because TB isn't seen as a priority in the developed world, virtually no work has been done on new drugs since the 1960s.
"There was a paper recently that said the chance of having a new tuberculosis drug by 2010 is less than one percent," she says. "What's worse, because of drug-resistant tuberculosis. which is becoming more and more of a threat, we don't need just one, we need a combination of new drugs".
Tuberculosis is, says Hewson, a "very clever bacteria" and has learned how to combat several of our best modes of attack. According to the World Health Authority, 300,000 unfortunates annually are now catching 'Multi-drug-resistant TB' [MDR], which can overcome two of the first-line medicines whilst others are being diagnosed with 'Extensively-drug-resistant' TB [XDR], which can also beat some second-line drugs.
The WHO say that 50 million people currently have drug resistant TB. One in ten new infectees turn out to have it. It's savaging China, Africa, India, eastern Europe and the former Soviet Union, and the treatment for it is barbarous.
"MDR patients have to take 13 tablets per day," she says. "And that's without the drugs for side effects. It's really tough - nausea, vomiting, gastritis, diarrhoea, major effects on your kidneys, your liver, your thyroid gland, joint pain. You can have problems sleeping, psychiatric side-effects - important ones like depression, psychosis, convulsions. We've had patients suicide under treatment. And that isn't even XDR. For XDR we're forced to prescribe every drug we can think of. Most of them we've pulled out of the rubbish bin where they were put fifty years ago because they're so extremely toxic."
And this is when the bad thing happens; when, once again, my attempts to sate the pangs of uncertainty serve only to make it grow ever deeper.
By now I've almost become accustomed to the thrice-weekly underwater coshing that my medication gives me and have been looking forward to the days when I won't have to pass through airport security checkpoints with hundreds of pills in my hand-luggage. I've got the measure of my problem. I've felt all along it's perimeter; it's ceased being frightening and progressed to being merely annoying. I was even wondering if I might've actually been crawling back to the perfect, untroubled state that I experienced in the sunny hours before all this began. Until I ask the Dr Hewson next question. I do this because it seems clear that I sniffed-up my particular pathogen whilst away on an assignment. And, since 2000, my work has taken me to every one of the places Dr Hewson says MDR and XDR are currently "savaging". So I say, "How will the hospital know if my TB is drug resistant?"
"Well, you only know if you can grow the bacteria, and they can't grow your bacteria because your sputum test was negative. There weren't any bacteria in it, so they can't test to see if it's resistant. So they don't know."
I experience that moment, again. That curious distance as you fall through space towards a brand new exploding new crisis.
"But that's not likely, is it?" I ask.
"Well," says the doctor. There's a silence as she measures her words. "It's less unlikely than you think."
And when the interview ends I put down the phone, rest my chin in my hand and spend a long time just sitting there.
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Words & photos copyright 2005-2010 Will Storr
