TB in South African mineworkers demands cross-border response, say advocates

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The AIDS and Rights Alliance for Southern Africa (ARASA) launched a campaign to address TB in gold miners in Southern Africa at the Fourth South African AIDS Conference in early April. Gold mines in South Africa have the world’s highest tuberculosis (TB) incidence of around 300 to 700 per 100,000 per year, according to the South African Department of Health.

The main aim of the campaign is to create a system to improve the prevention, diagnosis and treatment of TB in gold miners. This includes setting up a cross-border referral network between countries across the region for migrant mine workers, and improving access to compensation for miners with occupational TB.

The extent of the TB crisis in mineworkers

Numerous reports and studies have documented the extremely high prevalence and incidence of TB in the gold-mining population and the failure of clinicians to diagnose TB in gold miners. However, there has been little response to the high burden of TB among mineworkers by the Departments of Health or Mines and Energy.

The Milner Commission Report, written in 1903, described the extent of TB in miners and warned that preventative measures were a matter of great urgency. The Leon Commission Report, written 93 years later in 1996, outlined similar concerns, following a dramatic increase in TB incidence as the HIV epidemic began to grow in South Africa during the 1990s.

Glossary

pulmonary

Affecting the lungs.

 

referral

A healthcare professional’s recommendation that a person sees another medical specialist or service.

hazard

Expresses the risk that, during one very short moment in time, a person will experience an event, given that they have not already done so.

active TB

Active disease caused by Mycobacterium tuberculosis, as evidenced by a confirmatory culture, or, in the absence of culture, suggestive clinical symptoms.

occupational exposure

Exposure to HIV as a result of work (job) activities. Exposure may include accidental exposure to HIV-infected blood following a needlestick injury or cut from a surgical instrument

The rate of active pulmonary TB in black miners at autopsy has risen from approximately 45 per 1000 in 1975 to 350 per 1000, according to the National Institute of Occupational Health 2008 Report. Clinicians failed to diagnose pulmonary TB cases of miners who died in 1999 who had TB on autopsy.

HIV has contributed significantly to the high TB rates. According to a 2000 study by Prof. Churchyard, the presence of HIV was significantly associated with the increase in the case fatality rate. A deceased miner was 15 times more likely to be HIV-positive (95% CI: 7.4- 30.6).

The presence of silicosis, caused by the dust that is created in the mines from extracting gold, has been shown to be a significant contributing factor to the development of TB in mineworkers. The same study showed that the odds of silicosis being present in those who died of TB was three times higher (95% CI: 1.4-6.3).

The risks of silicosis and HIV infection combine multiplicatively. Hence, TB has become an occupational hazard for miners because of the HIV epidemic and the lack of dust control in mines.

TB and HIV in migrant mineworkers from neighbouring countries are also highly problematic. At least 25% of Lesotho’s drug-resistant TB cases are made up of mineworkers who formerly worked on the gold mines in South Africa.

Migrant mineworkers are often left with little access to health care when they return to their home countries, which they are often forced to do if they are too ill to work. Cross-border referrals are non-existent, making continuity of care impossible. Miners who begin TB treatment may receive no further treatment if they go home, or may be lost to medical care if they are discharged from service after a TB diagnosis.

The lack of compensation for gold miners who died of TB due to occupational exposure is also well documented. Only 400 of the over 28,000 claims received by the Compensation Commissioner for Occupational Diseases (CCOD) from mineworkers who have active TB were paid out in the 21 months leading up to December 2003.

Receiving compensation is especially difficult for migrant mineworkers from countries neighbouring South Africa. Although all mineworkers are entitled to Medical Benefit Examinations (MBE), the necessary technologies are often not available in their home countries. Even if eligible, there are complex procedures that need to be followed to access compensation, resulting in very few migrant mineworkers receiving compensation.

Responses

In May 2008, ARASA held a meeting with representatives of the Lesotho and South African health and labour sectors, the mining industry, mining unions, activist groups and public health specialists with the aim of creating policy and programmatic interventions for cross-border control of TB between Lesotho and South Africa.

The meeting recommended that the diagnosis, treatment and care of miners with TB needs drastic improvement in the South African mines and that referral networks between the TB and HIV programmes in both countries need to be established.

In March 2009, a memorandum from ARASA, the Treatment Action Campaign and Solidarity was sent to the South African Departments of Health, and Mining and Energy, calling for the immediate implementation of the TB Programme Review Tool in the mining industry. ARASA is involved in consultations and soliciting input from partners on the Southern African Development Community (SADC) Draft Policy Framework for Population Mobility and Communicable Diseases.

ARASA is also working with mining communities and the unions to capacitate them to carry out their own advocacy interventions around the improvement of the diagnosis and treatment of TB and issues of occupational compensation. This includes training and awareness raising. ARASA is also partnering with a range of stakeholders such as other NGOs, human rights organisations as well as the mining unions.

References

Akugizibwe P Mines, TB and migration in Southern Africa. Presented at the Fourth South African AIDS Conference, Durban, 2009.

Trapido AS et al. Prevalence of occupational lung diseases in a random sample of former mine workers, Libode District, Eastern Cape Province. Am J Ind Med 34: 305-313, 1998.

Churchyard G et al. Factors Associated with increasing case fatality rate in HIVinfected and non-infected South African goldminers with pulmonary tuberculosis. Int J Tuberc Lung Dis Aug: 4 (8): 705-12, 2000.

Murray J et al. A clinico-pathological study to reduce the rate of missed and misdiagnosis of pulmonary tuberculosis in the South African mining industry. SIM Health 611, 2000.

ARASA. The mining sector, tuberculosis and migrant labour in southern Africa. July 2008. Download here. Date accessed : 20 April 2009.