South Africa's gold mines are estimated to have the highest number of new tuberculosis (TB) cases in the world, making the disease a leading export to neighbouring countries. IRIN takes a look at the declaration meant to change this situation.
In August 2012, heads of state from the Southern African Development Community (SADC) agreed to sign the SADC Declaration on TB in the Mining Sector, following endorsements by their national ministers for health, labour and justice.
According to Swaziland’s Minister of Health, Benedict Xaba, he and South African Health Minister Aaron Motsoaledi, and Lesotho’s former Minister of Health, Mphu Ramatlapeng, began pushing for the declaration in 2010. Xaba, the son of a miner, admitted that he has lost members of his family to TB.
South Africa is supporting the declaration and related initiatives, including a 1,000-day campaign to meet TB and HIV targets in the region, but the country has not yet officially signed the declaration, according to Lynette Mabote, regional HIV, TB and human rights advocacy team leader at the AIDS Rights Alliance of Southern Africa (ARASA), a civil society body that has been heavily involved in the declaration and advocacy around TB in mines.
How big a problem is TB in the mines?
The South African Department of Health estimates the country's gold mining industry has the highest number of new TB cases annually in the world - up to 7,000 cases per 100,000 people per year - according to its TB Strategic Plan for South Africa 2007-2011.
Data collected from autopsies on formers miners have also shown a prevalence of latent and undiagnosed TB as high as 90 percent, according to a 2009 study.
Why is TB a problem on the mines?
While many people may carry latent TB infection, active TB infection will usually only occur in a small number of them. However, those with compromised immune systems and HIV co-infection are up to 30 times more likely to develop active TB.
In South Africa, where HIV prevalence is about 18 percent, many miners are no doubt living with HIV but face additional occupational risks, according to Rodney Ehrlich from the Centre for Occupational and Environmental Health Research at University of Cape Town. He describes these risks as:
• A high burden of silicosis, a respiratory disease that develops due to inhaling silica dust during the mining process and could be viewed as an immune deficiency illness;
• Silica dust load in the lungs and previous lung damage;
• Poor living conditions, including overcrowding;
• Circular migration between neighbouring countries and South Africa, leading to interrupted TB/HIV treatment and poor access to care.
The mines have also not escaped the growing epidemic of drug-resistant tuberculosis, which in the absence of wide access to molecular testing has not only been harder to diagnose but also to treat. Research released in 2010 estimated that that almost four percent of the national multidrug-resistant TB (MDR-TB) burden, where TB is found to be resistant to both the commonly used first-line drugs isoniazid and rifampicin, may reside on the country's mines.
Falling employment figures indicate that the mines now employ considerably fewer miners than in the late 1980s, Ehrlich added. Commodity prices dropped in 2008 and 2009, leading to further lay-offs, which may greatly complicate addressing the needs of affected miners who are no longer employed and will be relying on already stressed health systems in rural areas or home countries for treatment.
What did countries commit to in the declaration?
Countries agree to taking tangible actions like establishing independent mining ombudsmen to handle health-related complaints, harmonising treatment protocols related to addressing HIV, TB and silicosis on the mines, and - controversially for some - classifying TB and silicosis acquired in the mines as such.
At a meeting of SADC health ministers in April 2012, mining companies were reluctant to classify TB and silicosis, a respiratory disease linked to exposure to silica dust produced during gold mining, as occupational diseases. In addition, the responsibility of mining companies to ensure treatment of mine workers with these diseases even after employees have left the company was a sticking point, according to David Mametja, head of South African Department of Health's TB Control and Management Programme.
The document now calls on employers to take full responsibility for the management of all occupational diseases, including TB associated with silicosis post-employment.
However, activists have cautioned that national legal frameworks must be changed to ensure TB is treated as an occupational disease. This would have to include provisions for mine workers who have left employment but later developed active TB.
"The history around the issue of occupational health is littered with companies not taking responsibility," activist Gregg Gonsalves told IRIN at South Africa's 2012 TB conference. "It has to be about regulation - states have to regulate their business practices. Only in jurisdictions where that has happened has that problem been solved. It has to come through statues and regulation."
The declaration also calls for the development of a minimum package of services to facilitate cross-border care.
"Our referral systems do not take into consideration the dynamics that are experienced in the region as far as TB in the mines is concerned," said Stephen Sianga, SADC secretariat director for social and human development and special programmes. "There are challenges regarding standard treatment, both between countries and within countries, where you find that the system used in the mines is different to that used in the public health system."
While TB treatment regimens across the SADC are largely already harmonized, activists have long been calling for the same to be done regarding HIV treatment. This would also facilitate the use of health passports, which would enhance cross-border care, as would the standardization of a minimum package of HIV, TB and silicosis services.
What happens next?
In the run-up to the August 2012 signing of the declaration, civil society groups like ARASA called for a five- or 10-year action plan, with concrete steps to be taken to implement the declaration. Now, SADC will be looking to operationalize the declaration at national level through a code of conduct.
According to Mabote, the draft code was dismissed by ministers of health at a SADC meeting in Angola in July 2012. An SADC technical working group reworked the document in November, but a final version of the document has yet to be released.