TB epidemic - South Africa, apartheid

TB Epidemic in South Africa

By the time apartheid started in 1948 the TB epidemic in South Africa was raging out of control. The South African health system for black people was ill equipped and lacked any commitment to TB control. The inadequate health services were directly responsible for the under treatment of TB patients. For many years standard TB treatment consisted of a 12 or 18 month period in hospital taking the TB drugs para acid, isoniazid and streptomycin.

TB services in the apartheid era

In South Africa during the apartheid era there effectively was a dual health system, with a highly sophisticated service for the urban mainly white people which consumed 97% of the health budget. There was then a primitive health centre system for the majority black population.¹Jinabhai C, “Socio-medical indicators of health in South Africa”, Int J Jealth Serv 1986 www.ncbi.nlm.nih.gov/

Even when TB care in South Africa became “ambulatory” (out patient care) to save hospital costs and supposedly make it easier for TB patients, services were still generally hospital based. This meant that TB patients had to travel long distances to facilities making TB treatment inaccessible and unaffordable. In addition TB drug supplies were erratic in many areas. All of this contributed to a lack of cure for TB patients and the risk of them developing drug resistant TB.²“Tuberculosis in South Africa”, Health Systems Trust Update Issue no 56, October 2000 www.healthlink.org.za/publications/394

TB Incidence in South Africa in the 1970s

TB incidence in South Africa rose steadily peaking first in the 1960s with an incidence rate of over 350 cases per 100,000 population. There was then supposedly a decline in TB in South Africa which was probably due to the exclusion of data from the black homelands. ³Compion, Sara Ruth,”Tuberculosis discourse in South Africa: a case study”, University of Pretoria, 2008 http://repository.up.ac.za/handle/2263/27459

By the 1970s TB had been all but eliminated among white people in South Africa. However it remained a major cause of morbidity and mortality among black people. In 1979 the Medical Officer of Cape Town estimated that the incidence of TB among white people was 18 per 100,000 whilst that for black people was a staggering 1,465 per 100,000.

A prevalence survey conducted in the Transkei in 1977 estimated that 4.3 percent of the population had active TB, a figure that ranked amongst the highest in the world.

A Major TB Epidemic

As the Nationalist government supposedly gave the homelands their “independence”, the high disease rates suffered by their “citizens” were credited to the homelands. As a doctor in Durban said in the early 1980s:

Half the patients we used to admit had TB. We were always witnessing and being involved in the TB epidemic. At the time, it was not acknowledged by government because of the way statistics were collected. The patients came from a section of Natal which was a quasi-independent state, so it didn’t feature in the Durban City Council statistics. But if you worked in a Black hospital, you were well aware of a major TB epidemic.

TB in South Africa - after the end of apartheid

After apartheid came to an end in 1994, South Africa for the first time called on international help and established a revised National Tuberculosis Control Programme (NTCP). It was based on the Directly Observed Short Course (DOTS) strategy of WHO. It’s aim was to gradually replace the non standardised short-course chemotherapy that had been applied throughout South Africa for several years.⁴“Mobilising against Tuberculosis: South African Plan for TB Control”, Department of Health (The Government of South Africa), 2001 www.westerncape.gov.za/eng/your_life/4502‎ But there were occasions when patients with AIDS and TB weren’t even given the TB medication available in South Africa. A doctor recalls looking after a patient with AIDS when he was working in a military hospital in 1995.

“At that stage we didn’t do anything in the military, nothing; we tested for opportunistic infections, but no definite treatment [for TB]. It was depressing, because we knew he wouldn’t make it; and we knew we couldn’t give him definite TB treatment. ”

In 1995 the Leon Commission was the first enquiry after the end of apartheid to hear the testimony of black miners. It was said in evidence that the mines had played a major role in the spread of TB. There is more about TB and Mining.

The 1996 Joint TB Programme Review

This review carried out with the help of the World Health Organisation, found that with an estimated population of 41.4 million and an estimated 130,000 TB cases in 1995, South Africa had one of the highest annual TB incidences (311 per 100,000 population) in the world. The TB incidence did however vary dramatically by both geographical region and population group. It was also found that the proportion of TB cases that were also HIV positive, was alarmingly high, particularly in the South Africa provinces of Kwazulu Natal and Mpumalanga.

Annual TB case rates per 100,000 population for different population groups 1995

Following the review a number of major recommendations were made including that the Department of Health should publicly declare the seriousness of the TB epidemic in South Africa and the urgency of the necessary response. Some comments were also made about the lack of advocacy and public awareness.

“Considering the severity of South Africa’s tuberculosis epidemic, awareness of the problem among policy-makers is surprisingly low. The same interest which exists among journalists, government officials, and NGOs for addressing the AIDS epidemic or childhood immunisations does not currently exist for controlling the TB epidemic”

In the public hospitals, changes as a result of the AIDS epidemic, and because of TB and HIV co-infection, were becoming increasingly apparent. As one doctor said:⁵Oppenheimer, G, “Shattered dreams?”, Oxford University Press, 2007

The TB epidemic & the deaths continue

“The TB ward has increasingly become a place where people come and die. The TB ward used to be somewhere that patients came, they had TB, but they were relatively well. They were given their medications; they then went home to take their medications.

Now, what we are finding is that people come to the TB ward, and then they stay a long time and then they die. Or they go home and take their medications and then come back to the hospital to die.”

The review also found that there were both strengths and and weaknesses in the South African Tuberculosis Control Programme (TBCP).

Among the strengths

were the acceptance by the provinces of the use of the DOTS strategy being incorporated into the South African national policy guidelines, excellent human and financial resources and health infrastructure, and a reliable TB drug supply.

Among the weaknesses

were the failure of the national and provincial Department of Health to respond adequately to the TB epidemic, an incomplete implementation of the DOTS strategy, inadequate investment in TB management, and the absence of an appropriate TB microscopy service.

TB in South Africa 1996 - 2000

Between 1996 and 2000 the South African government continued to implement many of the recommendations made by WHO, in their report of 1996. Action focused on the provision of DOTS, improving the TB cure rate to at least 80%, and improving the TB microscopy services. However the number of TB cases continued to rise. ⁶“Tuberculosis Strategic plan for South Africa”, 2007 - 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011

TB cases reported in South Africa 1996 to 2000

From 109,328 reported TB cases in South Africa in 1996, there had been an increase to 151,239 reported cases of TB in 2000. The TB cure rate also declined from 53.9% to 53.8% whilst the TB treatment completion rate fell from 72.7% to 63.0%.

The South African Plan for TB Control 2002 - 2005

The South African government responded to the increasing numbers of TB cases by developing in 2001, the 2002 to 2005 National TB Control Programme’s Medium Term Development Plan for 2002 - 2005. The objectives of the plan, to be reached in 2005, were:⁷“Mobilising against Tuberculosis: South African Plan for TB Control”, Department of Health (The Government of South Africa), 2001 www.westerncape.gov.za/eng/your_life/4502‎

These objectives are an example of how discussion about TB became increasingly focused on the biomedical aspects of the disease. There was little mention or consideration of other issues surrounding TB, such as the social factors of poverty, inequality, migration etc.

It was also at this time that discussion of TB became directly linked to the issue of HIV/AIDS and the control of TB became inextricably tied to the control of HIV/AIDS.⁸Compion, Sara Ruth,”Tuberculosis discourse in South Africa: a case study”, University of Pretoria, 2008 http://repository.up.ac.za/handle/2263/27459 In 2003 the Mbeki government finally decided to provide antiretroviral drugs for free in public health services. You can read more about HIV in South Africa.

However even as the rollout of the HIV drugs started, the TB epidemic continued to grow and the number of TB cases continued to increase.

TB cases reported & incidence rate South Africa 2001 to 2005

In just ten years the country had gone from a reported number of TB cases of 109,328 and a TB cure rate of 53.9%, to 302,467 reported TB cases and a TB cure rate of 57.7%. There was considerable variation among the South African provinces as to how well they were doing. The best performing province, the Western Cape, had a TB cure rate of 71.9% and a TB treatment completion rate of 79.7%, whereas the KwaZulu-Natal province had a TB cure rate of just 45.2% and a successful TB completion rate of just 64.2%. ⁹“Tuberculosis Strategic plan for South Africa”, 2007 - 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011

In 2005 TB is declared to be a national emergency

A DOTS worker checks that a TB patient has taken their medication ©WHO/TBP/Gary Hampton

In 2005 the government declared TB to be a national crisis and a TB crisis management plan was developed.¹⁰“Tuberculosis Strategic plan for South Africa”, 2007 - 2011, Department of Health (Government of South Africa), 2006 National Strategic Plan for South Africa 2007-2011 The aim of the TB plan was to firstly address the four districts with the highest TB disease burden and poor treatment outcomes and to turn the situation around within a year by increasing the smear conversion and the TB cure rates by more than 10%.

These four districts were in three provinces, Gauteng, the Eastern Cape and one, eThekwini district, was in KwaZulu Natal. This district had reported 29,724 TB cases in 2005. So why were the figures for KwaZulu Natal so high?

Drug Resistant TB (XDR TB) in KwaZulu Natal

In 2005 some South African and US clinicians and researchers identified a large number of cases of XDR TB at the Church of Scotland Hospital at Tugela Ferry. Tugela Ferry is a rural and extremely poor part of Kwa_Zulu Natal. It was found that out of about 200 patients with multi drug resistant TB, 53 had XDR TB. XDR is a form of TB that is extremely difficult, although not impossible to treat. You can read more about XDR TB at Tugela Ferry.

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You can read more about what is happening now with TB in South Africa.

References