JOHANNESBURG, March 8 -- While most of the world celebrates a decline in TB rates, the disease is firmly, and worryingly, on the rise in some countries in Southern Africa. Thought to be driven by infections of miners, this trend has focused regional attention on the long-hidden scandal of mine workers’ health.
For more than a century, TB control in this sector has been beset by inertia as governments, mining companies, and workers’ organizations rehash old debates about who is responsible and who should pay. With no easy answers, there has been no resolution, so the arguments continue and TB spreads.
However, a new partnership, led by the Southern African Development Community (SADC) involving the World Bank, Stop TB Partnership and the International Organization for Migration, is attempting to resolve some of the issues that have hampered TB control efforts before now.
Recently, the organizations brought long-divided interest groups together for a Stakeholders Consultation on TB in the Mining Sector, under the auspices of SADC, with World Bank support. The meeting alone was an achievement, but a further triumph is that they thrashed out a consensus for high-level commitment to loosen TB’s grip on the mines.
Why now, when TB has thrived, unobstructed, for so long? A sudden realization that with the rampant spread of HIV in Southern Africa – and the more rapid onset of active TB this infection confers – the crisis of mine workers’ TB has become an impending disaster for population health.
A long and difficult history
TB was first brought to Africa in the 19th century by British immigrants looking to trade their coal mining skills for a share of South Africa’s newly discovered gold and diamonds. It found a niche in the lungs of the African workforce.
Housed in cramped unsanitary hostels, these workers, often already harbouring dust-related lung damage due to long days at the rock face, became a reservoir of TB. And their periodic movements from rural homes to mine sites, and back again, ensured this contagion was spread far and wide.
It was 1903 when the first official investigation into miners’ TB concluded it was “an urgent necessity” to control the epidemic, and labelled the extent of workers’ suffering “a matter of keen regret.”
Nearly 100 years later, the concerns – and causes – remain. With one added dimension: while mine workers’ TB has historically struck down older men, tired and sick from a life spent down in deep, dangerous shafts, HIV is giving the disease a new youthful face. The unwritten story of this shift makes the public-health risk of unchecked disease an economic, environmental, social, and moral, concern.
The convergence of risks for the mining work force – poor housing, occupational hazards, and risky sex lives – makes them highly vulnerable.
Numbers reveal the scale of the problem: TB incidence has doubled in the SADC region since 1990 (defying global trends), and in South Africa alone it has tripled. But mining has an amplifying effect. A miner is five-to-six times more likely to get TB than a non-miner, and research suggests that each TB-positive miner will infect a disproportionate number of peers compared with a TB-positive non-miner.
With mining a regional economic pillar – Citibank estimates there are 2.5 trillion dollars in mineral reserves in South Africa alone, and burgeoning industries in many other SADC countries – the business case for action is clear. An economic study of the cost of TB control in the mining sector in South Africa (done by the World Bank and requested by SADC) suggests that intervention, which could save US$300 million a year, is cheaper than maintaining the current hodgepodge of control efforts.
A complex problem
Addressing the problem is no simple feat, and there are complex reasons for why this long-standing problem has not been solved.
TB is a health issue, but just one among many competing diseases. Mines, where it is most prevalent, are in the private sector, so governments don’t have jurisdiction to intervene. And regulations are fuzzy about whether the disease can truly be considered “occupational,” so companies will not act on their own.
Patrick Osewe, lead health specialist for the Africa Region Technical Health Unit of the World Bank said combating the disease will require input from several sectors.
"Tuberculosis among miners and ex-miners in southern Africa poses a multi-sector challenge, so the solution must bring together ministries of health, labor and finance along with the private sector and civil society,” he said. “The status quo results from fierce disagreements about responsibility, culpability, and financial obligation, leading to fragmented and uncoordinated responses that blight miner’s lives.”
The fact that migrant workers often come from across borders adds a level of complexity: multiple sectors must be coordinated in multiple countries to achieve meaningful results.
Building consensus for action
It is with this background that high-level officials from SADC’s 15 member states met with industry, civil society, academics and development partners last week.
After listening to the evidence on TB and mines from appropriate expert sources – the World Health Organization, the World Bank, industry representatives, academic contributors, and high-burden countries all took the floor – meeting participants worked in groups to pin down key challenges and possible solutions before tackling areas of contention in a draft Declaration on TB in the Mining Sector. A key focus of debate was an associated implementation plan – Code of Conduct in SADC terminology – which will set the scene for follow-up action. It is this document that development partners hope to build on in the coming year.
A refined Declaration, molded by last week’s debate, will be presented to SADC Health Ministers at an Extraordinary Ministerial Meeting on TB in the Mining Sector, April 25-27, 2012. Approval in this forum will see the document forwarded to Heads of State for signature in August.
Although the meeting marked the start of a SADC-wide process, it is the result of sustained advocacy dating back to 2010, when the Ministers of Health of Lesotho, Swaziland and South Africa – three countries with large populations of migratory mine workers coupled with huge burdens of TB – called on the Stop TB Partnership Coordinating Board to act.
Dr Llang Maama, head of the national TB program in Lesotho, said "Lesotho is particularly hard hit by the issue of TB and mines but clear leadership has been shown by the ministers of health of South Africa, Lesotho, Swaziland and SADC. I congratulate SADC for leading the regional response to this issue which has been affecting Africa for a century. Enough talking has been done. It's now time for action. I hope that the declaration will help us in Lesotho achieve our vision of zero TB deaths."
SADC’s attention, and that of journalists who attended a linked training session run by the Stop TB Partnership, are bringing the issue the crucial regional recognition it needs. But if the Declaration is endorsed, the important work to enact its provisions begins.
Ruth Kagia, World Bank country director for South Africa, Swaziland, Namibia, Lesotho and Botswana, all of which have active mines and workers, said the meeting is a major step toward fighting TB in the mining sector.
“Mining is a critical and rapidly growing economic sector in our region but the disease is presenting a new and serious public health challenge,” she said. “We welcome SADC leadership in organizing the regional stakeholders’ consultation which has forged a shared vision among industry and workers’ representatives on how to tackle the disease. This meeting, and the ongoing process to gain Heads of State approval for a Declaration on TB in the Mining Sector, has created a unique opportunity to generate political ownership and support for the implementation of the proposed activities.”
- The draft Declaration on TB in the Mining Sector will be discussed by senior officials and Health Ministers of SADC Member States in April 2012
- The SADC Heads of State Summit will endorse the Declaration in August 2012
- Development partners are collaborating to facilitate drafting of an action plan that builds on the provisions of the Declaration to improve TB control in this sector