South Africa: Tuberculosis, A Forgotten Disease Still Endemic in Cape Town

Zanyiwe Mavebenwane, from Cape Town in South Africa, hasn’t seen her eldest daughter in two months. It’s the fifth time she has had tuberculosis, and is receiving long-term care in hospital. The unemployed mother of five runs a soup kitchen a few times a week and is taking care of her one-year-old grandchild, who also has TB.

“We buried her partner, the father of her daughter, two weeks ago. She gave TB to him and he died,” says Mavebenwane, a resident of Masiphumelele Township in Cape Town.

She hopes that her daughter will finally be cured, as her latest bout of TB has been especially traumatic.

According to the World Health Organisation, tuberculosis is the leading cause of death in South Africa. Some 58,000 people died of TB in 2019, and more than half of those who died were HIV positive as well.

“One in five children who start school at the age of five will already be infected with TB, and by the time they reach their 15th birthday, it’s one in two,” says Dr. Linda-Gail Bekker, the CEO of the Desmond Tutu Health Foundation in Cape Town.

Almost every single person in the townships where the Foundation works will have been exposed to TB by the time they reach adulthood, she adds.

“In other words, we live in a sea of tuberculosis.”

An ancient disease

TB is caused by a bacterium called Mycobacterium tuberculosis, which usually attacks the lungs, but can also be found in the brain and the spine. Although the bacteria was discovered in 1882, scientists estimate that the disease has been around since ancient Greece.

Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection (LTBI) and TB disease,” according to the US Centers for Disease Control and Prevention.

Since efforts were more recently geared towards handling the Covid-19 epidemic, TB has regained the top spot as the world’s biggest infectious killer, according to Mel Spigelman, president of the non-profit TB Alliance.

TB Alliance, which works for drug access for TB in poorer countries, estimates that based on the annual death rate, TB kills 4,109 people a day.

The disease was once New York City’s biggest killer, but effective laws, including window requirements, improved building codes and preventing children from working and coming into long-term contact with adults helped to stem the tide of infection.

In places like Masiphumelele, TB is rampant, in part due to poor and cramped housing. The latest population estimate shows that some 38,000 people live in less than one square kilometre.

Mavebenwane showed RFI her home in the township, smaller than a shipping container, where 11 people live and sleep.

“We see TB a lot because the houses are overcrowded,” she says. “We have four people sleeping in the bedroom.”

Pill fatigue and other problems

The current treatment for TB, particularly drug-sensitive TB, includes six months of daily antibiotics, a regimen that has not changed since the 1950s.

In an effort to find alternatives, Dr. Melissa Le Fevre is working on a TB treatment study at the Desmond Tutu Health Foundation in Masiphumelele that would treat all types of TB.

“It would cover not just drug-resistant or drug-sensitive TB but a Pan-TB regime that could be taken for four months instead of six months,” she says.

Part of the challenge to combat TB stems from pill fatigue, as witnessed in the case of Mavebenwane’s daughter.

“The patient starts feeling better after a couple of weeks, and they don’t understand that they need to carry on taking the treatment and if they stop early they are at risk of a relapse or re-infection of TB,” says Le Fevre.

The tuberculosis bacteria hides in the lung tissue, so even though an infected person is not coughing any more, the six months of medication is necessary to kill the bacteria completely.

A slightly compromised immune system due to co-infection with HIV or drinking alcohol, malnutrition or poor diet and stress can also make treatment a challenge.

While people tend to go to a health clinic if they feel symptoms, there are residents who resist getting tested, says Le Fevre.

“Some in the community don’t want to get tested, and they’re reluctant to interact with the health clinics, due to poor experiences in the past, and discrimination,” she says.

Ongoing research

Robin Wood, professor of medicine at the University of Cape Town, sees parallels in the TB epidemic in New York City at the turn of the last century and townships like Masiphumelele. He also works in TB research at the Desmond Tutu Foundation.

His research has measured the amount of air people swapped with each other, and he made a machine that measures the carbon dioxide levels to determine if and how TB is transmitted, even through people who are not visibly ill.

Wood co-authored a study published earlier this year showing that although cough is assumed as the main way of transmission of TB, tidal breathing, or inhaling and exhaling while a person is relaxing, could also be a significant contributor to TB transmission.

“We know the circumstances which are particularly hazardous for acquiring TB, and for political, social other reasons, we haven’t actually addressed them,” he says.

“I’m hoping that by measuring these things better that we’ll re-ignite interest in the social control of TB, besides just the treatment,” he adds.

Lessons from Covid

Dr. Linda-Gail Bekker says that curbing TB as a whole involves not only scientific research, but political will and social resources.

“We haven’t got the whole suite of opportunities and we are not bringing to bear everything we need to be doing for TB,” she says.

However, she maintains that healthcare workers have learned a number of valuable lessons from the Covid-19 pandemic that could be applied to TB today.

“We are now relying on antibiotics and we are not going to treat our way out of this epidemic because we’ve never treated our way out from any epidemic,” she says.

“We’ve always needed prevention, a break in transmission, protection for those who are vulnerable, and treatment for those who are already infected – Covid-19 taught us that,” she says.

“You can’t just think about the people who need oxygen in the hospital,” she says, referring to oxygen given to the worst hospitalised cases.

“You need to think about the people in the community who are vulnerable.”

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