Jonathan P Smith, an American epidemiologist, is making a film about the kind of scenario mentioned in yesterday's blog post: South African miners and their families being infected with TB as a result of living and working in appalling conditions, and the failure of crumbling health services to offer the level of treatment that would cure people of the disease, prevent it from spreading and avoid drug resistant strains developing.
Smith follows four former gold miners who have contracted resistant TB while working at a gold mine. The gold mine's hospital has failed to treat the men and they are now being sent home. It is likely they will die from TB, but also that they will infect a number of other people first. As they have a resistant strain, they can also transmit this resistance. Treatment will therefore be difficult, very expensive and unlikely to be available. Their immediate family will probably be most at risk.
Mine owners are under no obligation to treat miners infected with TB. But government programs to eradicate the disease are unable to influence the working and living conditions that result in TB spreading rapidly and resistant strains of TB from developing and spreading. Eradication programs are often separate from other health services, because health services are unable to cope even with far less threatening diseases, and funding levels mean that TB eradication often amounts to little more than free drugs.
Squalid living and working conditions ensure that a disease like TB will remain endemic, and that people will remain highly susceptible. Circular migration from home to work and back ensure that TB will be spread widely. Intermittent health services ensure that resistant strains will develop and be spread, to infect and reinfect people of all ages. Add to this a high disease burden and an underfunded health sector, and you have a production line of sick people, packaged up to receive whatever pharmaceutical companies have to offer.
The figures Smith cites are staggering: TB rates among South African gold miners are 1,400 times rates in western countries. Western countries may be willing to send money and drugs for TB eradication programs, but we also enjoy cheap consumer goods, which depend on costs for raw materials being kept as low as possible. As a result, conditions in mines remain hazardous and miners and their families suffer the consequences. Even HIV, which attracts more funding than any other disease, is rampant in mining areas.
Smith notes that those infected with HIV are very vulnerable to TB but he doesn't mention if those with TB are more likely to be infected with HIV. TB has always infected poorer people in higher numbers whereas HIV has often been more closely associated with wealthier, better educated people. But HIV prevalence also tends to be higher among employed people, especially those in formal employment, such as mining. The received view of HIV transmission, that it is mainly a result of unsafe heterosexual sex, would suggest that employed people take more sexual risks. But perhaps employment related health facility conditions may play a role here?
People working in mines do have access to health services, but those services tend to be basic. It is unlikely that safe healthcare is a high priority. Miners suffering from diseases that are common in terrible living and working conditions, such as TB, respiratory infections, intestinal parasites, nutritional deficiencies, water-borne diseases and sexually transmitted infections (STI), may face additional risks in health facilities. Do those facilities have enough basic supplies, such as gloves, injecting equipment, sterilizing fluid, gauze, etc? Are there enough well-trained personnel? Can safety be guaranteed? Or are mining hospitals as unsafe as most hospitals in high HIV prevalence countries?
Some of the highest TB figures are found in countries that have significant mining interests, and in countries that supply the migrant labor. But some of the highest HIV figures are also found in these countries. Much has been written about the role of sexual behavior in an effort to explain these epidemics. But a lot less has been written about the possible role of unsafe healthcare. There is a great fondness for writing about and reading about sexual behavior, but this could mask the elevated levels of non-sexual risk that miners and others must face.
TB spreads easily among people who live together, especially in overcrowded slums. It also spreads easily among people who work in badly ventilated mines. But HIV does not spread so readily through unsafe sex alone. Perhaps transmission through unsafe healthcare could help to account for some of the worst epidemics in the world? Perhaps unsafe healthcare could explain why many infants are infected when their mother is not and why so many people with a HIV negative partner become infected where there is no obvious sexual risk?
Smith writes: “What is the point of public health research if there is no public health benefit? We, as researchers, have an ethical obligation to not simply perform epidemiological research, but advocate a positive change in our research population... [T]o conduct research without the intention of betterment within that population makes a mockery of our public health researches.” This could equally be applied to all research, such as human rights, development, anthropology, even industry related research.
[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]