Thoko Mngoma clinic is situated in the outskirts of Alexandra Township in Johannesburg in an area called Marlboro. Just outside the clinic is a whole lot of litter as the surrounding community in this informal settlement has turned the pavement into a dumping site for rubbish.

The smell of the dirty sewage water running down the street is unbearable. Children seem oblivious to this abnormal state as they play here. The community is living in abject poverty with a high unemployment rate.

By the end of last year, the Thoko Mngoma clinic had about 330 TB cases in their records. Most patients here are required to come in and take their treatment on a daily basis. TB nurse at the clinic, Helen Mookeletsi, says the majority of their patients adhere to treatment, with only a few exceptions.

‘€œFor those who are not employed and are able to walk, they come to the clinic every day, except for Saturday and Sunday. They really do come. You will have those who default at some stage, but the majority come to the clinic’€.

Mookeletsi says there is a range of reasons why some patients default on their treatment and that these include cultural beliefs.

‘€œMostly, there are Africans here and they believe in ‘€˜amaloyo’€™, so others you’€™d find that they thought they are bewitched and go to traditional healers. Although others will refer them back to the clinic, people have different information and they don’€™t come back causing them to default. When they come back they are very sick. Some give you the wrong address or a non-existent address. Another reason is unemployment. We have a high rate of poverty, so, maybe sometimes when the patient wakes up the first thing they think of is getting a job instead of coming to the clinic because they are hungry’€, says Mookeletsi.

But the clinic says that about 75% of those who default on treatment are traced and put back on treatment, thanks, largely, to the help of a network of DOT supporters who work with the clinic.  However, the clinic could not tell its defaulter rate.

‘€œWe have DOT supporters – Directly Observed Treatment.   For those who cannot come to the clinic, they go and give treatment at home. We have a good system in place. All the files are filed according to the return dates.

This means we can identify the defaulters within three days. We immediately’€¦ within three days’€¦ send our community health workers to trace those patients’€, says Daphne Mohube, co-ordinator of the clinic’€™s TB programme.

The problem, though, is that there is still a lot of stigma attached to TB, mainly because of its association with HIV. Mohube says they are trying hard to work with communities and traditional healers to educate them that TB is curable.

‘€œIn our area we are working well with the traditional healers because most of them encourage these patients to finish the treatment. I find the stigma issue very serious. For example, you will find that someone living next to Thoko Mngoma clinic opts to go to a clinic further away from home. And, remember, in the township there are still those who believe if you have TB you are HIV-positive, so the stigma is there and that’€™s one of our focuses when we educate the community. We are trying to move them away from those beliefs’€, says Mohube.

Bridget, a TB patient at the clinic, is now on the fourth month of her six month treatment programme. She was very ill in October last year and could hardly walk or lift a spoon ‘€“ but now, she says she is healthy, happy and has negative sputum because of the good support she got from the staff. She urges anyone with TB to adhere to treatment.

‘€œIt is very important. Look at me now. I am recovering. I wasn’€™t able to sweep, cook or wash myself. These days I do everything. I even walk to the clinic instead of using a taxi because I want to exercise. If you see someone coughing for a long time, it means there is something wrong and they should go get checked’€.

Meanwhile, the City of Johannesburg’€™s Health Department says the average defaulter rate in the city has ranged from five to eight percent over the last couple of years. In 2009, it was 6.9%. Deputy Director for Communicable Diseases in the City of Johannesburg, Antonia Barnard, says it is not easy to decrease the defaulter rate to reach the national target of less than 5%.

‘€œIn Johannesburg, we have managed to decrease our defaulter rate, but there are some areas like the inner-city which have higher defaulter rates than others. People there live on a temporary basis. They relocate to other areas and they default. We try to explain to patients why they have to follow treatment. We are still struggling to get to less than five percent’€, says Barnard.