The statistics are startling. While Cape Town is often rated as one of the top destinations in the world, thousands of mostly poor people in the suburbs are being infected or affected by a TB epidemic that is not only curable, but in many instances preventable.
Maps compiled by Schalk van Lill, Geographic Information Specialist at Stellenbosch University, starkly highlights the inequities between two examples – Uitsig and Bothasig.
TB is an almost foreign concept in Bothasig, but in nearby Uitsig the disease is ravaging a community already reeling from high unemployment rates, an unskilled labour force, extremely poor housing and more often than not overcrowding.
While thousands of unaffected Cape Town residents have grown accustomed to reports on high TB rates in the province, fact is it is causing thousands of unnecessary deaths leaving families bereft and destitute.
Two factors in particular, overcrowding and under-nutrition, are consistently associated with very high TB rates.
According to the maps many people in Uitsig are unemployed, a factor that would impact directly on the nutritional status of the community.
While the overwhelming majority of Bothasig residents enjoy separate housing, Uitsig residents living in tiny, dilapidated houses.
These statistics suggest that a strategy to combat the TB epidemic might only be successful if it is combined with other measures that ensure food security and adequate housing for vulnerable groups.
Historical literature shows that in the long term, as housing and diet improve, the TB death rate falls.
In an attempt to ensure a fairer distribution of resources such as housing and jobs (which in turn leads to food security and good nutrition), the Equity Gauge has been introduced to the Cape Town Unicity.
Dr Mickey Chopra senior lecturer at the University of the Western Cape’s School of Public Health and one of the driving forces behind the introduction of the Equity Gauge, says the gauge could provide an active approach to monitoring equity (fairness) in health and health care.
“The graphs clearly show how TB for example is related to poor social and economic circumstances,” Chopra points out.
In fact TB was almost completely controlled in Europe before antibiotics and vaccines were discovered because of the improved housing, nutrition and economic circumstances of most people.
In this way the different rates of TB across the city is an accurate reflection of the different social, nutritional and economic situations.
“This is not to say that successful treatment is not important. Good functioning health systems that ensure the monitoring and follow up of patients so that they complete treatment can control TB even in the most difficult circumstances. So TB cure rates is also a very good measure of the quality of health services,” says Chopra.
“Once again there is a great deal of variation across the city and this needs to be addressed.”
Nulda Beyers, Associate Professor at the Department of Paediatrics and Child Health, Stellenbosch University and Tygerberg Children’s Hospital says there is a good reason why a Bothasig resident should be concerned about the startling TB rates in Uitsig, a few kilometers away.
“Two reasons, one humanitarian, the other totally selfish. The humanitarian reason is that there are many, many people in South Africa who still suffer as a result of the forceful removals, subsequent crowding, poverty, etc. and are now suffering from diseases of poverty.
“The other reason is that people do not live on islands and the people with TB often get into contact with people without TB in for example shopping centers, public transport or the workplace.”
Beyers says it is difficult to unravel the precise contribution of each of the many factors driving a TB epidemic in a suburb such as Uitsig.
“Most of the factors are related to poverty. TB is transmitted as an airborne disease and as soon as people live under crowded conditions, the chances of transmission are greater than when conditions are not so crowded. And of course crowding goes with poverty, as does poor nutrition and heavy alcohol intake.”
Beyers points out that the immune system is essential in combating TB – poor nutrition and heavy alcohol intake decreases the immunity and hence leads to poorer coping mechanisms with the infection and disease.
The biggest danger to the immune system is infection with HIV, but Beyers does not think that HIV is as yet a driving force in Uitsig.
Beyers says there is not much that can be done in the short term to improve the situation except job creation. “In the meantime if people with TB are treated in a humane way by non-TB people it will mean a lot to them.”
One area in Cape Town that appears to be winning the battle against TB is the South Peninsula, which is currently recording cure rates of 85%.
“Look, people do live in small houses, it is overcrowded, the winters are damp and people are poor. If we were able to sort out our social problems we wouldn’t have TB, but the fact of the matter is that we have to do what is within our reach now and that is to improve the treatment of patients,” says Dr Virginia Azevedo, manager of the TB programme in the South Peninsula.
“There is no excuse not to cure patients. We have got all the resources,” says Azevedo.
She admits that patients do initially struggle with the idea of having to report to the clinic every day to take their medication.
“That is how we operate. Sometimes we do make exceptions and allow the supervisors at work to administer the medication, but we prefer people to come to the clinic,” says an adamant Azevedo.
“Some people, especially those who are well off don’t want to be seen around other TB patients. They see it as a disease of poverty and dirtiness, but it is not.”
Chopra added the final comment: “TB is a powerful indicator for the quality of health services across the city. But it can also monitor the progress all the different departments of the new Unicity are making in reducing inequities in poverty and living conditions.”
* Beyers and her team at Tygerberg Hospital and Stellenbosch University do research into TB through the GlaxoSmithKline Action TB Programme. They have established a Job Creation Centre in collaboration with the Unicity, Stellenbosch University, Safmarine and GlaxoSmithKline. “None of this would have been possible if people and sponsors didn’t choose to get involved in something that provides some immediate relief to TB,” says Beyers. See related stories: “TB becomes part of Uitsig family’s lives” and “Cape’s new health director grapples with equity issues”
See related stories: “TB becomes part of Uitsig family’s lives” and “Cape’s new health director grapples with equity issues”