Those Who Don’t Return: Improving Efforts to Address Tuberculosis Among Former Miners in Southern Africa

Abstract

Despite increasing awareness regarding the role of oscillating migration in the mining industry as a major driving force in the spread of tuberculosis (TB) throughout southern Africa, very little work has focused on the historical and contextual factors which may contribute to former migrant miners’ present-day risk of TB. Most research regarding migration-related and occupational influences on TB has been done on current miners still employed by the mining industry. Through both a historical and contemporary lens, this paper explores and elucidates the need to address the TB epidemic among former migrant mine workers and provides considerations to improve current interventions among this critical population.

Keywords

gold mining South Africa tuberculosis silicosis

The search [to overcome tuberculosis in the South African mining industry] has always been on ways of interrupting this relentless cycle of new labor, short contracts, recruit more, examine them, and so on. And all of the time, the real problem was not the people who came back [to the mine], but the people who didn’t. And we have no knowledge of what happens to them.—Dr. Tony Davies, Professor Emeritus, University of the Witswaterand, 2012¹

Introduction

In the 1974 South African film The Last Grave of Dimbaza, G.F. van L. Froneman, the apartheid government’s Deputy Minister of Justice, Mines, and Planning, brusquely illustrates the government’s devaluation of migrant families within southern Africa by explaining, “Black workers must not be burdened with superfluous appendages like wives and children.”^2,3 This characterization of poor Black African families was hardly a metaphor, as targeted segregation and discriminatory laws had been imposed since South Africa’s colonization in the seventeenth century. Formal apartheid laws further formalized this ideology through additional state-imposed mechanisms such as Influx Control, the Group Areas Act, and the homeland system of government, all of which perpetuated deliberate impermanence for Black laborers.^4,5

Such mechanisms had a tremendous impact on the family structure for migrant mine workers in the region. Families attempting to maintain the familial unit by traveling to the urban mines together risked being evacuated from their new homes immediately if the miner passed away. This was clearly articulated in parliament in 1968 when a Liberal member stated,

If an urban African woman loses her husband … she can be ordered to vacate the house in which she and her family are living. Usually the woman has small children dependent on her and must fill the role as breadwinner. But the local authority may order her to give up her house.⁶

Since families migrating together had previously sacrificed their rural home to make such a move, these families would be forced into a state of limbo: cut off from both the urban and rural communities, placed in “relocation camps,” and left with virtually no means of economic survival.⁶ As a result of these policies, the majority of women and children remained in the rural home areas, while men of suitable working age traveled long distances to work in the mines.

This migrancy was the explicit goal of many apartheid policies. In a 6 February 1968 statement to parliament, van L. Froneman clarified this motive in no uncertain terms: “We are trying to introduce the migratory labor pattern as far as possible in every sphere. That is in fact the entire basis of our policy as far as white economy is concerned, namely a system of migratory labor.”⁶ This system exploited Black labor in order to drive the white economy while concomitantly forcing the black African economy to be almost entirely dependent on the migrant labor system. Although these formal policies dissolved alongside the apartheid regime in the 1990s, the economic dependency created or exacerbated by such policies continues to characterize much of modern-day southern Africa’s rural interior.

Migration was by no means a new phenomenon in the region, and such political mechanisms exploited existing patterns of circular or oscillating migration of the region’s mining workforce that have existed since the late nineteenth century when gold and diamonds were first discovered in the region. Apartheid legislation simply served to concretize these migration patterns and solidify the fate of hundreds of thousands of men destined to spend the majority of their lives traveling between their family homes and the distant mines.⁷

However, from the 1970s to the end of apartheid, recruitment patterns shifted dramatically. During the 1970s, rising gold prices and increased international attention to employment practices in South Africa led to higher wages in the mining industry.^8,9 In a period of five years, the Chamber of Mines (now the Minerals Council South Africa) and the mining houses increased wages elevenfold, which attracted considerably more workers.⁸ Intra- and international political forces, such as the rise in other mineral prices and the independence of Mozambique from Portugal, led to more consistent employment patterns in the migrant labor force.

While employment stabilization and higher wages were key advancements toward improved employment practices, such developments had important implications for the future of the tuberculosis (TB) epidemic in the mining community. More miners were exposed to occupational hazards, such as silica dust, and prolonged family separation contributed to an environment of high-risk sexual behavior for sexually transmitted diseases, particularly emergent HIV. Both silica exposure and HIV increase one’s susceptibility to TB.^10,11 With the emergence of HIV in the 1980s, the mines soon became an industrial nidus (i.e., breeding ground) of disease. TB grew exponentially, with a sevenfold increase in the number of mine workers with TB upon autopsy from 1975 to 2011.¹² Coupled with entrenched migration patterns, the stage was set for a deadly and overwhelming co-epidemic of TB and HIV throughout the entire subcontinent.

Although migrancy and occupational lung diseases are characteristics of all mining commodities, the consequences of oscillating migration and the TB and HIV epidemics are most profound within the gold mining industry. Gold miners in South Africa are exposed to exceptionally high concentrations of silica dust compared to miners in other commodity sectors, which greatly increases their susceptibility to TB.^13–15 There is an abundance of epidemiological literature on gold mining, gold miners, their oscillating migration in the southern African region, and its contribution to the spread of both TB and HIV.^7,16–20 These studies, however, tend to investigate miners who have recently participated in or are currently participating in the migrant labor system. Unfortunately, little is known about the burden of TB and its ongoing effects among men who remain in the rural countryside long after working in the mine and who never reenter the migrant labor system. These individuals are no longer exposed to daily occupational TB risk factors at the mine, but there are several additional factors that may contribute to an increase in TB incidence among this important bridge population, including the development of silicosis (or retained silica dust in the lung in the absence of clinical silicosis), a high HIV prevalence and incidence throughout the region, and the advancing age of these former miners.

A limited number of studies among former miners refer to the high prevalence of occupational lung disease such as silicosis and chronic obstructive pulmonary disease among former miners, both of which are risk factors for the development of TB.^21–24 In a 2009 prospective cohort conducted after retrenchment from a South African mine, Park et al.²⁵ demonstrate that the incidence of TB among former miners one year after returning home was roughly the same as in current miners and approximately four times that of the general population during that time period.^25,26 The study also reveals that the risk of contracting HIV was over twice as high in the mining cohort compared to their nonmining contemporaries.

Although more work is needed to further measure the risk of TB among this population, particularly the present-day risks for miners who left the mining industry decades ago, such evidence suggests that labor-sending areas of the rural southern African countryside have large numbers of former miners at an increased risk for both developing clinical TB and transmitting the disease to the general public. This paper examines the historical and contemporary evidence of this claim by describing the change the migrant labor system has undergone in this time period and the complex interactions between TB, silicosis, and HIV that persist throughout the present day. We present a case for the immediate need to tailor public health programs that will target TB interventions specifically at this overlooked population.

The Stabilization of the Mining Workforce

A critical factor in the development of occupational diseases and other adverse social factors was the changing nature of the mining industry during the mid-1970s toward stabilization of the migrant workforce. In the context of this paper, “stabilization” refers to contracts of longer duration and the ability for miners to return to their previous employer (in contrast to shorter contracts at multiple mines). This led to more consistent and reliable employment for mine workers in the industry. In the early era of mining in South Africa, contracts were primarily short-term contracts of three to five months.²⁷ Initially, short contracts were preferred by the miners themselves, as they were a dependable source of income for land purchases, replacement of cattle herds, or other cash-based needs such as food and goods.²⁸ However, the gradual deterioration of the rural economy ultimately made shorter contracts more advantageous to the employers. They served to justify low wages, maintain a low level of skill among the employees, and allow for the easy dismissal of ill or aged miners. These short contracts also perpetuated persistently poor living and working conditions for the miners. As mining reached its peak in the latter part of the twentieth century, between 60 and 80 percent of men in sub-Saharan Africa migrated, with the majority of these men traveling to the South African mines.^29,30 The population of migrant workers who originated from neighboring countries steadily grew, peaking at almost 80 percent of the migrant gold miner workforce in 1973, followed by a sharp decline over the next five years to roughly 50 percent.^31,32 As the number of migrants grew, so did the rural economy’s dependence on remittances by the migrant family members. In the mid-1930s, income farming had accounted for 40 to 50 percent of all rural family income, but by 1970, that figure had dwindled to a mere 10 percent. Meanwhile, by 1980, remittances from migrant workers to their families back home accounted for 75 percent of all household income.^33,34

While short-contract migration was at its peak, a number of both external and internal motivating factors led the industry and government to reexamine its labor recruitment practices. For instance, on 4 April 1974, a group of seventy-five migrant Malawian gold mine workers returning home from work in South Africa tragically died when their plane crashed in Francistown, Botswana.^35,36 As a result, the Malawian president temporarily banned all labor recruitment practices in Malawi, and 119,000 miners under contract with the member mines of the Chamber of Mines (Minerals Council South Africa) were ordered to be repatriated, as well as an additional twelve thousand employed by other mines and industries.³⁶ The next year, on 25 June 1975, Mozambique gained independence from Portugal, which subsequently interrupted the flow of this critical labor pool due to political and economic considerations.¹¹ These and other external pressures, such as rising gold prices, were mirrored by issues within South Africa’s borders. Drought, deteriorating conditions in the homelands, and internal pressures on the industry from the apartheid government spurred the industry and government to give preferential employment to rural unemployed men from inside South Africa’s borders, and for longer periods of time.^10,37,38 During this time, the average length of a miner’s contract tripled, growing from an average of 4.5 months to 13.4 months.³⁹ Consequently, the need for skilled labor and longer contracts increased the average age of the workforce. For instance, in 1980, only about 10 percent of miners at Anglo American, one of the major gold mining companies in South Africa, had worked in the mine for at least five years compared to roughly 63 percent in 1990; approximately 37 percent of these men had worked in the mine for greater than ten years.¹⁰

Stabilization’s Impact on the Occupational Hazard Exposure Profile of Miners During Service

Stabilization during this specific time of industry growth exposed migrant miners to sustained adverse living and working conditions and has three important implications for understanding the present-day TB epidemic. First, susceptibility to TB is directly related to the extent of exposure to the silica dust found in high concentrations in the gold mines. The effects of silica dust retained in the lung are lifelong with or without the development of clinical silicosis. Second, high-density hostel-style housing and poor living conditions exacerbated the exposure to TB bacilli. Though the focus of medical surveillance is typically on active TB cases, the likely increase in new latent TB infections (LTBI) during this time is of particular importance to the former miner population. LTBI may progress to active disease later in life due to silicosis or retained silica dust in the lung, HIV infection, or increasing age. Third, longer periods of renewed contracts resulted in migrants spending increasingly more time away from their family. Coupled with adverse working and living conditions, this created social interactions and sexual networks conducive to HIV infection.

Silica dust exposure

During the latter half of the twentieth century, the mining industry’s preventative measures for occupational exposures such as silica dust—including risk assessments, training, maintenance of equipment, and the use of personal protection equipment—were seldom in compliance with international occupational standards.^40,41 Compliance with these standards was so rare that a 2008 audit on mining health and safety described the industry as having “a pervasive culture” of noncompliance and that “the list [of inadequate preventative measures] goes on and on.”^40,41 Although a reduction of respirable silica dust concentrations may have taken place over the last half of the twentieth century, in 1999, only eight out of forty-eight (17 percent) of gold mines had dust concentrations below the current occupational standard of 0.1 mg/m³.⁴² Research suggests, however, that this may be nonprotective: even if the current occupational standard for dust (0.1 mg/m³) is met, such a significant risk of silicosis and, by implication, other silica-related diseases would remain.^14,43 In 2016, the United States Occupational Safety and Health Administration recognized the insufficiency of the current standard and established a new silica dust exposure limit of 0.05 mg/m³ for an eight-hour time-weighted average,⁴⁴ but it is not an international standard.

Men at the stope (the working face of mining extraction) worked long hours underground in labor-intensive positions, in a seam often only two to three meters wide.⁴⁵ Dust levels were high, and temperatures averaged 32.4°C (90.32°F) with an average of 92.3 percent humidity.⁴⁶ Such uncomfortable conditions led to a reduction in the proper use of personal protection equipment, which in turn increased miners’ exposure to silica dust. South African gold mines, in particular, utilize a single shaft to mine for gold in which air is pumped down the shaft to the underground working surface of the mine, but this air has no way to be removed unless it travels up the working shaft.⁴⁷ Thus, miners may be exposed to silica dust and possibly Mycobacterium tuberculosis throughout the entirety of the shaft and not only at the working surface of the mine.

The problem of silica dust exposure should not be seen as solely one of inadequate occupational standards or compliance but also as a product of the political economy of the time. Economic necessity is likely to outweigh education about silica dust reduction and exposure. Miners are acutely aware that their family’s and community’s economic survival depends almost entirely on their remittances and that the loss of a job would place their loved ones in severe economic distress. Such responsibilities often deterred workers from taking measures that would reduce their exposure to silica dust, such as changing mining positions or reporting occupational disease, for fear of job loss. As Robert Cowie, a leading researcher on TB in the mining industry, explained in 1987,

It proved to be quite exceptional for a man with silicosis to elect to have compensation, or repatriation, or a change to a non-mining occupation. In general, the men [black miners] were obsessed with continuing their work, were unaware of and unconcerned about silicosis and continued to believe that a decision to report their disease for compensation was punitive, no matter how diligently the matter was discussed with them.^39,48

This attitude was believed to be so pervasive and reporting seen as so punitive that the mining hospital had in fact ceased the routine reporting of men with silicosis approximately five years prior to the start of Cowie’s study.⁴⁸

Furthermore, mining supervisors had little impetus to control silica dust in the era before HIV. Despite a century of research from leading investigators arguing to the contrary, silicosis was often perceived by South African mining leaders as a mostly harmless disease.^49–53 This perception was initially shaped by research in the 1970s among miners in Western countries which claimed silicosis was considered to have “little or no disturbance in health” and was “shown to be a benign disorder with little dysfunction and no disability.”⁴⁹ The inappropriate generalization of this work to Black South African mine workers overlooked the improved dust control measures and more successful TB prevention measures in Western countries. Research by Cowie and other researchers in the 1990s continued to demonstrate the seriousness of silicosis among Black southern African miners.^{15,19,48,50,54} Moreover, in 1982, the National Union of Mineworkers was founded and also played a critical role in advocating for reduction of silica dust levels throughout the 1980s and 1990s: the 1995 Leon Commission of Inquiry into Safety and Health in the Mining Industry (herein, the “Leon Commission”) was brought about in part because “…the pleas for urgency in adopting remedial action to reduce the scale of death, injury, and disease, made on behalf of the National Union of Mineworkers, were well founded.”⁴⁰

The relationship between exposure to silica dust and occupational diseases, particularly silicosis and TB, has been thoroughly described, and the association between silica dust exposure and increased active TB is widely accepted.^{10,15,19,23,55–57} There is a strong exposure-response relationship for silica dust exposure and morbidity and mortality associated with TB, clearly indicating that increased exposure is correlated with an increased risk of TB.^15,58 Depending on the extent of exposure, the lung tissue may not be able to rid itself of the dust particles, and thus, the consequences of silica dust exposure may be cumulative, gradual, and persistent throughout the duration of one’s life even if exposure to dust ceases.

Living conditions

Stabilization coupled with the booming market of the later twentieth century meant that large numbers of men needed to be housed in a relatively small geographical space. The majority of men lived in cramped, high-density, single-sex hostels where between twelve and twenty men lived in each dormitory; on average, there were 14.7 men per room with only 5.1 square meters of personal space.⁴⁰ Conditions were exceedingly poor and unsanitary; inspectors for the Leon Commission, upon assessing living conditions in and around the hostel, were “shocked by the conditions in which food was prepared” and with facilities “so squalid as to shock the most hardened.”⁴⁰ The Leon Commission also found that the buildings’ ventilation systems, originally designed to allow air to escape via rooftop ducts, had been replaced with closed ceilings, effectively eliminating ventilation from all of the rooms.⁴⁰

These accounts leave little to the imagination as to the ease of TB transmission in the hostels and the high risk of TB infection. However, while clinical TB disease was noticeable and often described in epidemiological reports, LTBI—where the TB bacilli persist in a dormant state and may reactivate later in life—was rarely given attention. LTBI is of particular importance to the present-day former miner population. As this population ages and the detrimental effects of silica dust exposure progress, former miners who worked in the mines decades ago may be at an increased risk of reactivation of their LTBI. In a detailed cross-sectional survey of 429 retrenched gold miners conducted in 2009, the prevalence of LTBI was 89 percent among workers.⁵⁹ Other studies show that miners with silicosis have an LTBI prevalence of up to 99 percent, suggesting that silica dust exposure increases the likelihood of LTBI as well as active disease.^19,59 Although several mines have recently included LTBI testing and treatment as a routine part of their HIV and silicosis programs for current miners, asymptomatic LTBI often goes unnoticed and unattended until many years after the individual has left the mine. As a result, former miners who left the mine before benefitting from these current preventative measures continue to be at risk for reactivation of their latent TB. Given the extent of LTBI described in this population, targeted measures seeking to find and treat LTBI among former mine workers may prevent both the progression of active disease within the individual and the subsequent transmission of TB to the community.

Divided families and changing patterns of risk behavior

The adverse effects of stabilization and the living and working conditions to which miners were subjected extend well beyond their physical surroundings. As the terms of the miners’ contracts continued to lengthen, so did the time spent away from their families and home communities. During the 1970s, for example, contracts for Basotho miners ranged between 10.6 and 14.4 months, but more than two thirds of the men accepted another contract within six months of returning home.⁶⁰ Consequently, during this time period, the actual length of time a Basotho miner spent outside of Lesotho and away from his family averaged between thirteen and sixteen years, depending on if he migrated from the lowlands or highlands, respectively.⁶⁰ Furthermore, these years away from the family were concentrated in the early and middle stages of the miner’s life when he would be particularly sexually active. In 1976, 77 percent of males aged twenty to thirty-nine in Lesotho were absent migrant laborers.⁶¹ Such separation carried with it an intricate development of social and sexual risk behavior practices that would prove to be detrimental to the health of miners.^62,63

This removal from social and family networks and placement in a harsh setting provided a multitude of adverse contextual experiences, including hazardous working conditions, discrimination and oppression, violence, victimization, isolation from family, and threats to masculinity, all of which have implications for TB and HIV risk behavior.^64–66 For instance, it has been shown that regular exposure to hazardous conditions such as fear of a mine collapse may make migrant men more preoccupied with such immediate health threats and thus view TB and/or HIV risk factors as a distant concern.⁶⁷

In addition, alcohol abuse evolved as a sort of subculture at the mine, as described by social scientist Anne Mager: “Prevented from living with their families, and deprived of the status of household head, migrant workers in bachelor quarters saw themselves as having little option but to while away their leisure hours at the bar.”⁶⁸ As one miner described, “This [drinking alcohol] is part of my job.”^68–70 Drugs and alcohol were powerful yet addictive tools used to dismiss the stress of work and separation from family. Such substances, however, transformed the potentially therapeutic or supportive notion of a miner’s social life into a superficial and isolating experience, undermining the establishment of meaningful relationships with other miners, such as hostel roommates and shaft workers.⁷¹ Regarding such relationships, Mager explains that miners were “adamant” that such acquaintances failed to compensate for the loss of female partners and children at their rural home.⁶⁸ She ultimately concludes that “absent families were never far away in [miners’] accounts of their lives and their health.”⁶⁸

Migrancy and its role in sexual relationships on the South African gold mines has a rich and complex history discussed in depth elsewhere (see Moodie,⁷² Moodie et al.,⁷³ and Morrell,⁷⁴ among others). In brief, migration placed exceeding strains on relationships and throughout generations promoted a norm of extramarital relationships. This often took the form of the migrant miner adopting a “town wife” or “junior wife” whose role lies anywhere from a sex worker, a mistress, or to a proper “second wife,” supplementing the “senior wife” in the rural home.^72,73,75 In a study of Mozambican migrants, 37 percent had wives in both South Africa and Mozambique.²⁹ A robust and thriving commercial sex industry existed. Approximately one third of miners were engaging in transactional sex or had multiple casual relationships, yet only 15 percent of these men were regularly using a condom.⁶² The use of sex workers and multiple partners by migrant mine workers became fundamental in the spread of HIV in the 1990s and up to the present day.^{18,45,63,66,76}

Adverse experiences and vulnerability to HIV

Extensive attention has been devoted to documenting the prevalence of HIV and the frequency of sexual risk behaviors among present-day migrant miners, with a smaller body of literature aimed at understanding the determinants of their sexual risk behavior.^25,77–80 Most of this research, however, has solely focused on individual-level factors of sexual risk behavior (e.g., awareness of HIV, intentions to use condoms). Such a narrow focus fails to consider long-term effects caused by adverse migration experiences as well as the behavior patterns resulting from such experiences (e.g., depression, alcoholism). These long-term effects can, in turn, potentially influence former miners’ HIV risk behavior—and subsequent vulnerability to TB—regardless of when their service at the mine ceased.

Presently, there are limited studies on such relations, and data remain circumstantial. A recent study of South African men in the Eastern Cape demonstrated that alcohol use, increased number of lifetime sexual partners, and increased number of adverse experiences were shown to be associated with an increase in transactional sex throughout the duration of one’s life.^63,81 All of these factors are generally associated with mining; however, the study did not specifically clarify its definition of “mining experience.” Another study of migrants and sexual health in India demonstrated that migrant men abusing alcohol, even if they were no longer mobile, were the group most prone to lifelong as well as more recent sexual risk behavior.⁸² An additional study investigating trauma exposure and sexual risk behavior among labor migrants in Tajikistan concluded that current HIV sexual risk behavior was associated with higher previous indirect trauma exposure.⁸³ This study included trauma indicators such as workplace accidents and separation from family members. Such research highlights the potential long-term effects that migration and the contextual factors caused by separation of family have on continued vulnerability to HIV among miners who are long since removed from the mine.

The Impact of the Former Miner Population on the Present-Day TB Epidemic

In the 1970s and 1980s, the gold mining industry was thriving, and demand was at one of its highest points in history, with the gold mining workforce at its peak of 480,000 workers in 1988.⁸⁴ As described above, these hundreds of thousands of men faced a series of adverse working, living, and social conditions that seeded in them a lifelong predisposition to TB well beyond their years at the mine. However, in the late 1980s, production fell and the value of gold dropped dramatically, resulting in large-scale retrenchments throughout the industry. Between 1986 and 1992, one out of every three miners was retrenched and sent back to their rural home,³³ and in 2006, the industry had been reduced to 160,000 miners.⁸⁴

Today former gold miners far outnumber active miners,⁸⁵ and their lungs are vulnerable to developing TB. Both silica dust and HIV independently increase one’s susceptibility to TB, but the risks of silicosis and HIV infection combine multiplicatively.⁵⁷ Thus, HIV-positive silicotic miners have considerably higher TB incidence rates than their HIV-positive nonmining contemporaries.⁵⁷ In one study, 85 percent of TB cases among former miners were diagnosed with silicosis after leaving mine service, with an average of eight years passing between their last exposure to the mine and their initial diagnosis.¹⁵

Previous cross-sectional studies have shown that former miners who have returned to their rural home have a higher prevalence of silicosis than in-service miners,^13,22,23 remain at a similar risk of HIV infection,²⁵ and have a similarly high incidence of active TB.^25,86 Almost 90 percent of returned miners have LTBI.²⁵ A 2008 prevalence study assessing the burden on pulmonary complications among former Basotho mine workers found that 91.9 percent of miners had been exposed to either medium or high dust exposure positions at the mine, and almost half of the men suffered from either silicosis, past or present TB, airflow obstruction, or chronic productive cough.²¹ Previous studies by Steen et al.²² and Trapido et al.²³ corroborate such findings and show the prevalence of clinical silicosis among former miners to be between 20 and 30 percent.

These factors place former miners at a much higher lifetime risk of developing active TB disease while living in their home community long after they left the mine. Recent studies have estimated the number of former miners to be as high as two million;⁸⁷ thus, it is a plausible hypothesis that the former mining population may contribute to the ongoing TB epidemic in the general population. Unfortunately, although numerous studies have sought to characterize the risk of TB among current mine workers, little research has specifically sought to estimate the contribution of former mine workers to the general TB epidemic. A 2011 modeling study demonstrated that mining production was associated with substantially higher TB incidence in the general population, but the study did not investigate associations between former miners and incidence independent of current production.⁸⁸ Another modeling study in 2018 found that individual gold mine workers contribute approximately 1.6 times as many new infections compared to the general South African population.⁸⁹ However, while such disproportionate transmission was found on an individual level, the authors also found that the mining industry as a whole contributed only marginally to the overall TB epidemic in the country. Unfortunately, there is insufficient evidence to determine and quantify the contribution of former mine workers to the general TB epidemic.

Recent Progress to Address TB in the Mining Sector

The connection between mining and lung disease is not new, and efforts to address this issue have long been a point of emphasis in South Africa. However, momentum in recent years suggests that the region may be in the process of achieving the goal of reducing TB in the mining industry through evidence-based interventions and mobilization of key stakeholders. In this section, we first provide a brief review of recent progress made in efforts to control TB in the mining sector as a whole; we then identify overlooked needs that may improve interventions specific to former miners.

Recent Policy Recommendations and International Political Progress

Contemporary policy recommendations are abundant and generally focus on reducing the risk of TB transmission at the mine, improving continuation of care for migrants, and improving working conditions. For instance, both Basu et al.⁹⁰ and Dharmadhikari et al.⁹¹ delineate interventions which target reducing the biological risk of TB through improved living and working conditions, more effective diagnosis and treatment, and political coordination. In 2008, the advocacy organizations AIDS and Rights Alliance for Southern Africa, working in partnership with governmental, industry, and civil society partners, delineated specific policy and programmatic interventions that sought to prioritize resources and improve cross border management of TB among migrant miners and their families traveling to and from Lesotho.⁹² Later, AIDS and Rights Alliance for Southern Africa and RESULTS UK further identified a series of actions that civil society could take, such as reaching out to specific ministers and pressuring international governments to address these issues.⁹³

In November 2011, the Ministers of Health for South Africa, Swaziland, and Lesotho brought the issue of mining and TB to the Southern African Development Community, ultimately leading to the Declaration on Tuberculosis in the Mining Sector (herein, the “Declaration”), which is perhaps one of the strongest displays of political will to address the crisis in the history of the region.⁹⁴ The Declaration highlighted key priorities for addressing TB in the mining sector and coordinated political will at the highest levels. A code of conduct was also developed that sought to operationalize the Declaration, provide accountability, and secure financial commitment from Southern African Development Community members.⁹⁵

On behalf of Southern African Development Community and in response to this growing awareness, the World Bank (WB) began a series of integrated projects that sought to explore the impact of interventions and to mobilize stakeholders. In April 2013, in collaboration with regional governments, civil society, and industry, the WB formed the South Africa Knowledge Hub (“Hub”).⁹⁶ The hub began to establish a mechanism for countries to share best practices, scale-up implementation, and recognize and resolve challenges in addressing TB in the mining sector. In 2014, the WB initiated a study estimating the economic benefit and cost of TB prevention and control measures and further demonstrated a profound economic benefit from implementation of these policies resulting from reduced cases and increased productivity.^91,97 Later in 2014, the WB also published A Framework for the Harmonized Management of Tuberculosis in the Mining Industry (the “Framework”), which, among other suggestions, provided a coordinated protocol for TB diagnosis (including drug resistant TB), treatment, and care among mining populations.⁹⁸ In 2016, the WB provided an additional US$122 million to develop programs that improve occupational lung services and TB control programs in Zambia, Lesotho, Mozambique, and Malawi, as well as improve the ability of these countries to handle the increased TB burden.⁹⁹

In 2016, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (“Global Fund”), in collaboration with the WB, Stop TB Partnership, and the United Kingdom’s Department for International Development, provided a US$30 million grant to support initiatives that target TB in ten southern African countries.¹⁰⁰ This grant in part established the “TIMS Project”—TB in the Mining Sector in Southern Africa—which coordinates a regional response to TB among current and former miners and their families and communities. This includes TB care and prevention, health information, mobilizing communities, and program management in ten southern African countries.¹⁰¹ The grant is currently composed of two phases. Phase 1, which ran from January 2016 to December 2017, conducted studies that established infrastructure, evidence, and regional support. Phase 2, running from January 2018 to December 2020, will use the evidence from Phase 1 to operationalize the integration and improve the quality of TB care systems.

Though these recent political and programmatic advances are encouraging and represent a reinvigorated commitment to addressing TB in the mining sector, it is important to maintain scrutiny regarding their success in actually reducing morbidity and mortality among former miners. There is a danger that such commitments and actions are useful for making little more than headlines; as these programs are relatively new, we currently lack the critical distance to accurately evaluate their effectiveness in preventing and treating TB among former miners. It is reasonable for miners and their advocates to be leery: for well over a century, miners and former miners have heard similar rhetoric and have made similar promises. In 1903, the Miner’s Phthisis (TB) Commission report on mining and lung disease led by Lord Alfred Milner stated that, “preventative measures [for occupational TB] are an urgent necessity, and that such a large number of sufferers in our midst is a matter of keen regret.”^51,102 Almost a century later, the Leon Commission of 1995 concluded that the “… failure to control tuberculosis in the mining industry must be a matter for grave concern.”⁴⁰ Although recent political interest is uniquely reinforced with unprecedented international financial commitment, procuring funds must not be mistaken for success. True success must rest on the effectiveness of the programs implemented in reducing the incidence and prevalence of TB among former miners and their families. This highlights the continued need for evaluative studies identifying evidence-based policies and interventions to ensure that resources are used effectively, and recent commitments do not fall victim to the same fate as prior responses to this epidemic.

Recent Progress in Occupational Lung Disease Compensation Schemes

The South African legal framework for compensating occupational TB or silicosis among current and former miners is outlined in the Occupational Diseases in Mines and Works Act (ODIMWA). Unfortunately, the abject failure of ODIMWA in providing adequate compensation to former miners and their communities has been well known for many decades and has long been the topic of discussion; a more in-depth review of ODIMWA can be found in the online supplemental appendix (see also Ehrlich and Rees,¹⁰³ Ehrlich,⁸⁵ and Boyko et al.,¹⁰⁴ among others). Briefly, one of the most notorious challenges with ODIMWA is the arduous process for miners to submit claims (Figure 1). As a result, only a fraction of those miners or their families who have claims in the system receive compensation—as low as 1.4 percent in some audits—and among those who do, the time to disbursement may be years down the road and have little impact on the miner’s ability to seek and receive TB-related care (see online supplementary appendix).^104,105

Figure 1.

Process to submit a compensation claim for occupational silicosis and/or tuberculosis under ODIMWA for living former mine workers.

Although the current ODIMWA system has been criticized as functionally incapable of providing meaningful compensation to mine workers,^85,103,104 recent legal advances have provided an alternative route for former miners to access compensation for their occupational lung disease. In 2011, the South African Constitutional Court unanimously agreed that mine workers had the right to directly sue mining houses for adequate compensation under common law.¹⁰⁶ The result was a series of lawsuits, the latest being a class-action lawsuit representing potentially hundreds of thousands of miners and former miners. On 3 May 2018, a R500 billion (US$400 million) settlement was reached between miners and six South African mining companies is awaiting court validation. If confirmed, this settlement will provide former miners employed at eligible mines from 1965 to the present with an additional source of funds for compensable occupational lung disease, as well as broadens the categories of eligible claimants (Table 1).¹⁰⁷ An extensive informational campaign has accompanied the settlement, which includes a streamlined website with clear and specific information, a call center, and printed guides in at least six languages to date.¹⁰⁸

Table 1.

Classes of Claimants and Eligible Benefits for Former Mine Workers or Their Families From the May 2018 Class Action Settlement.¹⁰⁷

Disease	Claimant	Definition	Amount (ZAR)
Silicosis	Living miner
	Class 1	Lung function impairment ≤10 percent (no ODIMWA equivalent)	R70,000
	Class 2	Equivalent of first-degree silicosis defined in ODIMWA	R150,000
	Class 3	Equivalent of second-degree silicosis in ODMWA	R250,000
	Class 4	Defined special aggravated medical condition; available “…to a small number of claimants who are suffering from extraordinary disease conditions which exceed most other silicotic claimants” (no ODIMWA equivalent).
	Deceased miner
	Dependent of a deceased miner	Died between 1965 and effective date^a; primary cause of death is silicosis	R100,000
	Dependent of a deceased miner, with ODIMWA determination	Died between 2008 and effective date^a; certified with first- or second-degree silicosis before death or at autopsy	R70,000
Tuberculosis^b	Living miner
	First degree	Diagnosis of first-degree TB within a year first shift (per MBOD definition)	R50,000
	Second degree	Diagnosis of second-degree TB within a year first shift (per MBOD definition)	R100,000
	“Historical” TB	(1) Must have worked in an eligible mine^b for two years between 1965 and 1994 and (2) issued a TB certificate (without degree) within a year of working first shift	R10,000^c
	Deceased miner
	Dependent of a deceased miner	(1) Must have worked in an eligible mine for two years, (2) died within a year of working at least one shift at an eligible mine^b, and (3) TB was primary cause of death	R100,000

Note. ODIMWA = Occupational Diseases in Mines and Works Act; MBOD = Medical Bureau for Occupational Diseases; TB = tuberculosis.

Effective date not yet determined at time of writing.

Must be a miner working at one of the six eligible mining companies: African Rainbow Minerals, Anglo American SA, AngloGold Ashanti, Gold Fields, Harmony, and Sibanye-Stillwater.

If medical certificate indicates proof of degree of TB, miner will be awarded commensurate to degree (R50,000 or R100,000).

While the unprecedented effort that has led to this beneficial settlement should not be discounted, critical challenges remain. The process remains reactive: former miners must first present with a certified diagnosis of lung disease before the compensation process can initiate. Thus, compensation will likely be too slow to have any impact on miners who are already actively suffering from TB. The envisaged settlement trust from this class-action suit has only twelve years to identify and track eligible claimants, facilitate Benefit Medical Examinations, and conduct other administrative duties. Because many former miners reside in remote rural areas and have incomplete work histories and medical records, it could take much longer than this settlement’s time frame allows to accurately identify all eligible claimants. In addition, despite a substantially better compensation process through the settlement compared to ODIMWA, payouts remain in the form of a lump sum (as opposed to a pension). Lump sum payments are discouraged by the International Labor Organization as they often cannot be expected to support former miners and their families for more than a few years.¹⁰⁹ A 2007 report of a similar settlement among asbestos miners states, “further compensation payouts resulted in the vast majority of claimants having exhausted their awards within relatively short periods of time.”¹¹⁰ As such, while the settlement is certainly a welcomed step, it is unlikely to reduce TB transmission, morbidity, and mortality among former miners and their families. The settlement does not suffice as a replacement for comprehensive legislative reform, nor is it a sustainable, long-term solution to a systemic problem that will likely continue to plague the region for decades to come.

Toward Improving Efforts Among Former Mine Workers

With the recent political and legal progress alongside other international goals, such as the Global Plan to Stop Tuberculosis,¹¹¹ increased attention has been given to the goal of eliminating TB in the mining sector. Labor organizations, international organizations, and governments have worked alongside industry leaders to improve many aspects of TB detection and treatment at the mine. While most of this effort has rightly targeted reducing the risk of TB and silicosis among current miners, the ambitious goal of overcoming TB in the mining industry cannot be achieved without significantly more attention being given to former miners. This is a far more difficult challenge, as the former miner population is not only significantly larger but also distributed throughout remote parts of the region. Labor organizations do not have the capacity to reach across the entire subcontinent and must largely concentrate their efforts to issues at the mine, individual governments have their own objectives and ambitions that complicate negotiations, and international aid organizations often struggle to implement sustained and lasting interventions.

Despite these challenges, we are in an era of remarkable international support to address this issue, and many of the multilateral projects, initiatives, and strategies include both current and former miners in their target population. However, these two populations are not the same. The current suggested policies and interventions may obscure the specific needs relevant to the former mining population. In this section, we seek to highlight critical observations that may improve the ongoing efforts from the numerous international stakeholders directed at reducing TB in the mining industry. They include conceptualizing the risk profiles of former miners as a spectrum, accurately locating former miners, providing an active role for former miners in intervention efforts, and investigating adverse migration experiences and HIV high-risk sexual practices.

Conceptualizing Former Miners Along a Spectrum

Former miners are often referred to as a single group or population, though this population is likely more heterogeneous than previously assumed. A recent project by the University Research Council and the United States Agency for International Development seeking to identify former miners found that the age of former miners ranged from thirty-five to seventy years, and their experience ranged from one to over thirty-one years in the mine.¹¹² These findings are even more remarkable considering that the study was conducted among a small number of miners within a single Swazi community. Such differences imply the need for varying approaches to finding and preventing TB among former miners.

We argue that the TB and silicosis risk profile of former miners may be better viewed as a continuous spectrum with partially overlapping areas of heterogeneity as a complex function of time, work history, past and current living situations, mental health, familial support, and other factors. Two functional consequences follow this conceptualization. First, it supposes that current population-level interventions targeting former miners will be more effective when targeting the higher end of the risk spectrum. This approach may also serve as a bellwether for intervention success, as interventions that succeed among the higher risk population will likely also hold among the medium to lower risk groups (or conversely, fail). Second, a better understanding of the risk spectrum allows for the development of new, targeted interventions specific to the varying risks that may be present within this spectrum. Such information would be particularly useful in the context of improved geospatial and epidemiological data, which may facilitate estimating disease burden and projections, directing intervention programs, and improving access to compensation.

Unfortunately, very little research has focused explicitly on the former mining community. While the University Research Council/United States Agency for International Development study found that 38 out of the 231 (16.5 percent) former miners in their study screened positive for pulmonary TB, to our knowledge, no research exists that seeks to tease out varying levels of TB and silicosis risk among former miners. While an enormous amount of effort has been put forth in recent years to address TB among former miners, it may be met with limited effectiveness if this population is reduced to a single risk group. The knowledge that someone is a “former miner” does not suffice; future research is needed to characterize the varying types of TB risk profiles among the former miner population.

Accurately Locating Former Miners

Parallel with better understanding diversity in the former mining population, addressing TB among former miners cannot be accomplished without first having accurate data regarding the location of former miners. Currently, accurate and independent data are lacking on the location and density of living former miners at risk of developing TB. Although some postemployment health surveys are conducted, they are woefully inaccurate.⁸⁵ Data given by TEBA Ltd., historically one of the mines’ largest recruiting agencies and now a private company, remain one of the primary resources for mapping former miners. Several studies have used TEBA data to perform geospatial mapping exercises. In 2014, the WB, University Research South Africa, and Bay Technologies established density maps of former miners and locations of health clinics in in Lesotho, Swaziland, and South Africa. In 2017, Ehrlich et al.¹¹³ analyzed over ten million TEBA records from 1973 to 2012 and reported extensive mapping of the distribution of recruits during this time frame. This enormous work established epidemiological and spatial patterns of mining recruitment and trends and will likely prove useful in the planning of future programs. Also in 2017, the WB, in collaboration with TomTom and Riskscape (mapping and geographical information service firms), conducted extensive mapping exercises that sought to map locations, routes, and health facilities of miners in ten southern African countries.¹¹⁴

However, although these studies are undoubtedly useful, all are predicated on TEBA-provided data. TEBA is a private recruiting company, and their data are not collected for analytic research. TEBA does not represent the entire mining workforce and has been shown to underrepresent mining employment;¹¹³ the 2014 WB report notes that “TEBA data will only represent approximately 50 percent of the problem statement regarding ex-mine workers and families.”⁸⁷ Few independent, academically rigorous studies have sought to generate empirical data to actively locate, quantify, and describe former mining populations in their home communities.

Future research that provides more accurate and contemporary geospatial distributions and descriptions of former mine workers, their proximity to the healthcare system, and their migration patterns is paramount to the success of any intervention or public health program. Such information also may provide insight into additional barriers to care, such as ease in accessing health clinics. An accurate representation of the geospatial distribution of former miners will allow public health programs to provide services more accurately and efficiently.

Promoting Interventions Led by Former Miners

Many community health interventions do not adequately involve former miners in the implementation of the intervention. A 2017 ethnographic study of former miners by Adams et al.¹¹⁵ revealed a widespread lack of knowledge and disregard for TB support systems despite health interventions and activities in their communities. The authors found that, while this phenomenon was attributed in part to entrenched stigma and knowledge gaps found in the general population, it was also “an articulation of symbolic and structural violence” among miners.¹¹⁵ Although former miners have varied backgrounds, cultures, and perspectives, they maintain a shared brotherhood found only at the mine. In most cases, as healthcare workers, physicians, and community members likely do not have the lived experiences of a miner, the well-intentioned interventions may be met with only limited success as programs are likely missing the critical rapport needed to affect this population.

Several studies have shown that peer-led interventions have succeeded in other high-risk populations in improving HIV testing, treatment, and care.^116,117 Thus, it is plausible that interventions that integrate and which are led by former miners would be more effective in achieving their goals. We advocate for the active integration and true participation of former miners in multilateral efforts to address TB among this population. The explosion of international interest in recent years provides an unprecedented opportunity to create a sincere and productive collaboration between health officials and former miners, a population uniquely suited to both contribute to and benefit from these interventions.

Investigating Adverse Migration Experiences and HIV High-Risk Sexual Practices

It is unreasonable to discuss TB among former miners without recognizing the role of HIV. HIV is a well-known risk factor for TB, and migrant miners are more than twice as likely to be infected with HIV than their nonmining contemporaries.⁸⁰ While evidence has been established for active migrants, little is known about the sexual risk behavior of men once they leave the migration system. Given evidence from other migrant populations, we hypothesize that adverse migration experiences may have a lifelong effect on the high-risk sexual behaviors of miners after they leave the industry.^82,83 Understanding the impact of adverse migration experiences on miners’ continued high-risk sexual behavior throughout their lifetime is important to our understanding of both TB and HIV infection in former miners. By elucidating such factors, programs that are contextually specific to the root cause of such behavior (e.g., alcoholism and depression) may prove vital to a comprehensive effort to control TB and HIV. To date, research on the full range of adverse experiences faced by migrants and the influence of such adverse experiences on sexual risk is minimal. Without such research, it is difficult to conceptualize context-specific interventions for former miners that address these needs.

Conclusion

The issue of TB and mining in South Africa is almost as old as the industry itself. Although advancements have been made in the past decade, the modern-day discussion of addressing TB among former miners must be viewed through the prism of South Africa’s beleaguered history of oppression and exploitation. The implications that this history has on TB vulnerabilities place former miners at a much higher lifetime risk of developing, and potentially disseminating, TB after returning to their home communities. Although the detection and treatment of TB among former miners has indeed improved in recent years, many of these efforts overlook the complex history relevant to the former mining population and thus may not reach their full potential for impact. Success among the many policies and programs should not be viewed in dollars or headlines, but instead be framed in the context of their ability to actually reduce morbidity and mortality among former miners and their families. Unfortunately, despite many of these programs’ substantial positive press, most are too nascent for a true evaluative study. We argue the need for independent, methodologically rigorous evaluations to ensure the implementation of sustained and evidence-based programs and interventions that truly achieve their goal of reducing TB among former miners.

Solomon “Sol” Plaatje, a prominent South African journalist and political figure in the early twentieth century, provided perhaps the best description of the complex relationship between mining, miners, and TB when in 1914 he discussed the

two-hundred thousand subterranean heroes who, by day and by night, for a mere pittance, lay down their lives to the familiar fall of rock, and who…in the bowels of the earth, sacrifice their lungs to the rock dust which develops miner’s phthisis and pneumonia.¹¹⁸

These men and their families are indeed heroes. They have sacrificed more than most could ever imagine in shaping South Africa into the country it is today. Ensuring that the recent international enthusiasm translates into meaningful, sustained improvement of TB detection, treatment, and care among former miners and their families is thus both a public health issue and a matter of social justice.

Supplemental Material

Supplemental material for Those Who Don’t Return: Improving Efforts to Address Tuberculosis Among Former Miners in Southern Africa

Supplemental Material for Those Who Don’t Return: Improving Efforts to Address Tuberculosis Among Former Miners in Southern Africa by Jonathan Smith and Paul Blom in NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy

Footnotes

Authors’ Note

Jonathan Smith is also affiliated with Yale University School of Public Health, New Haven, CT, USA.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Jonathan Smith is a PhD candidate in the Department of Epidemiology at Emory University’s Rollins School of Public Health and a Lecturer in Health Policy and Management at the Yale School of Public Health. His research focuses on the intersection of tuberculosis epidemiology, law, and migration dynamics of migrant mineworkers. For his work in this field, he has been awarded the Lowell Levin Award for Excellence in Global Health from Yale University and the Tuberculosis Survival Prize from the Lily MDR-TB Foundation.

Paul Blom is a PhD student and teaching fellow in the Department of English and Comparative Literature at the University of North Carolina-Chapel Hill. His research focuses on the political and ethical implications of trauma in literature. His research has involved extensive work with vulnerable and underserved populations, and since he 2015 has worked with former mineworkers in South Africa and Swaziland.

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