South Africa is a country located at the southern tip of Africa. It is rich in natural resources and cultural and ethnic diversity, but its recent history is marred by disease, poverty, and conflict, including many years of apartheid—official racial segregation and white minority rule—which ended in 1994. South Africa is also known for its high rate of HIV-AIDS, which makes people more susceptible to developing active TB.
These photographs focus on South Africa’s gold mining population, among whom the TB incidence rate is among the highest in the world. These miners are particularly vulnerable to contracting TB because of the small, poorly ventilated areas in which they live and work, their high rates of HIV, and their high rates of silicosis—a lung disease caused by silica, a dust formed during mining. Silicosis, similar to HIV, weakens the immune system and makes it easier to contract TB.
The miners come from a largely migratory workforce, with the men traveling from their homelands to spend 10–12 months at a time working in the mine. When they are working they may have access to health care, but this care is often inadequate. Furthermore, because TB can lay in a person’s body for decades before becoming active, many miners have already returned home and are far away from any health facilities when the disease begins to cause damage. TB becomes a health issue that they often have to deal with for the rest of their lives.
Tuberculosis (TB) is a preventable and treatable lung disease, but the infrastructure to deal with the problem doesn’t exist in much of South Africa. Among certain populations, such as the country’s gold miners, the disease has reached epidemic proportions. This story aims to convey the stress and pressure inflicted by the disease and show how TB affects not just those who carry it, but also the communities in which they live.
Here, miners pray for their safety before beginning a work shift 6,500 feet underground at the Great Noligwa Mine in Orkney, South Africa. The miners have high rates of silicosis and HIV, both of which make miners vulnerable to contracting TB.
Because HIV is a disease that affects a person’s immune system, people with latent TB are much more likely to develop active TB if they are also infected with HIV. People who are HIV positive and infected with TB are up to 50 times more likely to develop active TB in a given year than people who are HIV negative.*
* World Health Organization, Frequently asked questions about TB and HIV
Underground at the Great Noligwa Mine, run by AngloGold, a global gold mining company. Silica dust is present in mines and quarries where quartz concentrations are high, as is the case in many gold mines in South Africa. When silica dust is inhaled, it can cause scarring in the lungs, which reduces the ability of the lung to function normally. Often there are no symptoms of silicosis, but in some cases, it causes severe breathlessness and coughing, and it can predispose an person to the development of TB.* To attempt to lower rates of silicosis among its miners, AngloGold installed a dust reduction system.
* AngloGold Ashanti 06 Annual Report, Silicosis
M.M. worked at a gold mine for 24 years before being released in 2008, after a medical exam showed he had TB and HIV. In South Africa, TB is the biggest killer among people with HIV. Here, a priest at the African Gospel Church in M.M.’s hometown of Bakuba prays for M.M. to get better.
A worker at the National Institute of Occupational Health prepares the hearts and lungs of former mine workers for examination. Every bucket in this room is filled with the organs of deceased mine workers, which will be examined to determine if the workers had TB or any other occupational lung disease. Families of the miners are often entitled to compensation if it is found that the miner had occupational lung disease.
While every worker has the right to have his or her organs examined, the large majority do not do it, as there are no trained medical personnel nor proper facilities in the workers’ home communities to carry out the autopsies.
Women sing during a service at the African Gospel Church in Bakuba. TB is very contagious, and it can be dangerous for miners carrying the disease to go home untreated, as they may pass it on to their family members.
Miners and their friends drink and play pool inside a tavern in Khutsong, a poor mining community outside of Johannesburg. Miners often have very little understanding of lung disease, referring to any chest problem as “TB.” Misinformation and lack of education about the disease make it more difficult for miners to spot the symptoms of TB and seek treatment. Even those who know they have TB often have no way to begin (or to continue) receiving treatment.
T.M., 53, worked in the gold mines for 26 years until 2005, when a medical exam showed that he had HIV and TB and he was released. According to the WHO, as of 2009, 58 percent of South Africans who tested positive for TB were co-infected with HIV. However, only 49 percent of South African TB patients know their HIV status, so in reality, that number of co-infections could be a lot higher.* HIV and TB are sometimes considered a “dual epidemic” because of the links between the diseases. T.M. left the mines to return home and receive treatment for TB. His wife currently has TB as well, possibly contracting it from T.M.
* World Health Organization, Frequently asked questions about TB and HIV
K.N. was released from his job at a gold mine after 19 years when a medical exam revealed that he had TB and HIV. He is currently unemployed and tries to support his wife and children by working a small plot of land outside their home in Mnceba.
The family of Somisewu Mookozo (center) sits in a small mud hut that also serves as the family’s kitchen. Mookozo left his job at a gold mine in 2007, after 16 years of work, because a medical exam showed that he had contracted TB. He began a six-month treatment plan, but he stopped when he started to feel better, instead of completing the full course of treatment. This is a common problem in rural areas, where treatment cannot be monitored and there is little education about or awareness of the disease. If patients prematurely stop treatment, they can develop multi-drug resistant TB (MDR-TB). Bacteria that are exposed to but not eliminated by the antibiotics meant to kill them can evolve to resist the killing effects of the medicine. MDR-TB is a strain of the disease that has high mortality rates and is very difficult and costly to treat. While the typical six-month treatment for regular TB can cost $20, treatment for MDR-TB can cost tens of thousands of dollars and take several years.
Johannes Khumalo sits on his bed inside his home in Wadela, a small, impoverished mining community a few hours outside of Johannesburg. Khumalo worked in the gold mines for 27 years until 2002, when he was released after an exam showed that he had TB. This is the third time he has been diagnosed with TB. Khumalo is barely able to get out of bed and is almost entirely dependent on health care workers.
E.M. worked in the gold mines for 12 years, but when a medical test showed that he had TB and HIV, he was released. Since HIV weakens the immune system, it makes those infected with TB more likely to develop active TB. E.M. is now very weak and gets assistance from home health care workers, though he says the workers do not bring him enough medicine for his daily dose. To treat TB, patients need to take medicine daily. It’s important that they take the right medicines at the right time and for the full duration of treatment. E.M. is unable to get to the health clinic on his own and is totally dependent on the workers.
Martha Malefo, 78, a bedridden patient, gets a sponge bath from home health care workers. The sick and elderly are at high risk of becoming infected with TB if they are exposed to the disease.
Malefo’s daughter works at the mines. Once a miner has contracted TB, the disease can lie in wait for more than 10 years until the patient’s immune system is weakened and the disease becomes active.
A cross made of stones sits on a hill near Carletonville, a gold mining community. In South Africa in 2009, 52 people out of every 100,000 died from TB.* By contrast, in the United States, that rate is 0.16 per 100,000.†
* The Kaiser Family Foundation, TB Deaths per 100,000 population, 2009
† World Health Organization, Tuberculosis Profile: United States of America, 2009
Knumbizile Nkisimane (center), an ex-miner with TB, stands during the funeral of Sindiswa Sakubona, a woman who died of TB. Her husband, a former mine worker, also passed away from TB in 2001. The couple leave behind seven orphaned children, none of whom have ever been tested for TB. Sindiswa’s father, also an ex-miner, currently has TB, and her brother used to have the disease.
Family and friends watch as the casket of Sindiswa Sakubona is lowered into the ground.
Thembinkosi Nodyontylo, 50, worked in the mines for 30 years; he was released in 2004 after a medical exam showed that he had TB. His wife died of TB in 2007 at the age of 31, and he regularly visits her grave to pray.
A patient gets a chest x-ray at the Chris Hani Baragwanath Hospital in Johannesburg. X-rays are one of the main methods used for initial diagnosis of TB, though most rural clinics do not have access to x-ray machines. Furthermore, x-rays alone are not sufficient for diagnosing TB. Because of the complexity of TB, it can sometimes be difficult to get an accurate diagnosis. An accurate diagnosis of TB requires a complete medical evaluation, including a physical examination, a medical history, chest x-rays, and sputum smear analyses. Many people remain undiagnosed, unaware that they have TB, even as their health deteriorates. .
The most effective diagnostic tests are done by looking at mucus from the lungs (sputum). Until recently, there were only two different tests used to diagnose TB: a smear test, in which the sputum is smeared on a slide and examined for TB bacilli, and a more accurate laboratory test. The smear test is relatively quick to do, but isn’t accurate enough to identify everyone with active TB. The laboratory test takes the sputum and grows live cultures from it in the lab. However this test can take up to eight weeks to complete. Both of these tests require lab equipment and trained staff. However, scientists have developed new diagnostic methods that are much faster at detecting TB, and organizations such as the WHO are working to provide funding and equipment so that these tests are available in the countries where they are most needed.*
* World Health Organization, New rapid test for MDR-TB recommended by WHO/TDR expert panel, 30 June 2008
A miner with TB takes his medication at an on-site AngloGold health clinic after working an underground shift. AngloGold has one of the most advanced TB treatment and prevention programs in South Africa, but, as of 2008, when this picture was taken, the company had still been unable to bring its TB rate below the industry average. This is indicative of the difficulty in treating TB without also managing and treating HIV and silicosis, both of which make people more susceptible to developing active TB.
Nthshngose Pumelelo waits to receive treatment for TB at Mnceba Clinic. This is the second time he has had TB, and his mother has also had the disease. This clinic provides free treatment to its many patients with TB.
Doctors at the Chris Hani Baragwanath Hospital in Johannesburg look at the chest x-ray of a former miner who is believed to have TB. Because TB can lie dormant for many years before becoming active, miners often develop active TB after they have left the mines and returned to their rural homelands, where accessing health care is very difficult. This miner is fortunate to have access to a large hospital that is able to take a chest x-ray. With accurate diagnoses, access to quality treatment, and increased education about the disease, TB is both preventable and curable, and patients can make full recoveries.