Tuberculosis: South Africa’s forgotten killer : New Frame
At a 1982 tuberculosis conference in Pretoria, one of the medical presenters pointed out that, “if one maintains a high index of suspicion for tuberculosis, one should not forget that there are other conditions which can present themselves in a similar way”. Forty years later, this omen seems to have been cruelly reversed.
A persistent cough. High fever. Night sweats. Not long ago, patients with these symptoms in South Africa were sent straight for TB testing. This has not been the case since the start of the Covid-19 pandemic. The similarity between TB and Covid-19 symptoms, and the resulting failures to rule out TB in patients who present with them, is one of the reasons why untreated cases of Africa’s most chronic killer of the South have probably increased under the cover of the containment.
Another has to do with the nature of South Africa’s approach to TB, which is passive and does not involve active case finding. The country’s public health system does not search for tuberculosis. He waits for tuberculosis to come through the door. But the hard closures have prevented people from doing just that. Meanwhile, large parts of the country’s health infrastructure were reallocated to treating Covid-19 – particularly during waves of infection, when outpatient departments were closed and surgeons reassigned.
The likely and devastating outcome, according to some leading TB experts, is that we have missed swathes of new infections, and possibly even deaths. Bavesh Kana, director of the Center of Excellence for Biomedical Research in Tuberculosis, said the past two years have “seriously undermined the gains we had made with tuberculosis”. South Africa’s long battle with the disease, he said, has been set back “five to seven years”.
At Sizwe Hospital for Tropical Diseases, Gauteng’s only hospital for drug-resistant tuberculosis, the sentiment is much the same. Xavier Padanilam, the hospital’s chief medical officer, said ‘TB has been sidelined’ during the Covid-19 lockdowns, leading to a ‘dramatic drop’ in diagnoses and delayed referrals to specialist units like Size. The later a patient is referred for treatment of drug-resistant tuberculosis, the greater the risk of developing often life-threatening complications.
It is difficult to measure the extent of the resurgence of tuberculosis. But there are definite signs that it is happening. Pediatric TB cases in Sizwe dropped dramatically during the Covid-19 lockdowns, for example. “We didn’t see any children,” said Rianna Louw, CEO of the hospital. “They weren’t allowed anywhere.” Padanilam added that “there is simply no way” the number of children getting sick could drop so drastically while adults are still sick.
More than a private matter
Tuberculosis is incredibly contagious through the air – much more so than Covid-19. Viable TB, coughed up in a room, will live there years later. Missing diagnoses mean cases can go undetected for years, infecting along the way. “It’s a crisis,” said Gary Maartens, who heads the clinical pharmacology division of the University of Cape Town’s department of medicine. “And it’s not just a problem for the individual. It is a public health crisis. »
Missed diagnoses mean missed opportunities to get patients on treatment, contain new infections and interrupt onward transmission. This will probably lead to an increase in excess mortality. Kana, who thinks a “massive amount” of TB deaths is already likely linked to the excess deaths commonly attributed to Covid-19, said “we missed many people we could have saved”.
He added that lockdown disruptions in the treatment of TB patients likely mean that TB is building up resistance and “creating a very frightening breeding ground for future outbreaks of drug-resistant TB”.
The proportion of drug-resistant cases is a good indicator of the effectiveness of a country’s TB control programme. By this metric, South Africa had been headed in the right direction. Starting from scratch – drug-resistant tuberculosis was virtually a death sentence when it first emerged in the mid-2000s – Sizwe had achieved cure rates of around 85%. “We were very excited about how the country was going,” Louw said.
These gains may now be at risk. As confinement measures are relaxed, the number of patients admitted to Sizwe is already starting to increase. There are many readmissions among these patients, suggesting that there have been interruptions in their treatment. With the resulting complications, the hospital’s death rates also began to climb. There was a time when Louw and his staff were convinced they would never see a 20% death rate again. This figure recently reached 25%.
Killer as old as time
Once referred to as “captain of all these men of death”, tuberculosis is as old as time. The spines of Egyptian mummies have been deformed by disease. Hindu physicians observed it some 2,000 years later. In Deuteronomy, Moses warned that “the Lord will strike you with consumption, and with fever, and with inflammation” and, of all diseases, Hippocrates described phthisis (pulmonary tuberculosis) as “the most difficult to cure, and the more deadly.
But while the disease’s origins are, in the words of a group of medical historians in the 1980s, “shrouded in the mists of antiquity”, the destruction it wrought in South Africa has been resolutely modern. Colonial occupation, the discovery of minerals and industrialization allowed tuberculosis to thrive in South Africa, which, like the rest of the continent, had until then escaped the worst ravages of the “White Death”. The lungs of miners housed in cramped enclosures and sent down underground shafts every day were virgin ground for disease. The same was true for those of their families in the ancient homelands, who cared for them once they fell ill.
After a century of devastation, tuberculosis in South Africa was on the decline. Until HIV. Working in tandem, one death the other destruction, TB and HIV have woven an epidemiological web that has proven incredibly difficult to unravel. South Africa has become the home of the world’s worst pandemic collision of the two. In the two years between 2005 and 2007, at the height of the AIDS crisis in the country, cases of drug-resistant tuberculosis tripled.
Since those dark days, however, South Africa has experienced a difficult recovery, spurred by tremendous advances in new diagnostic technologies, successes in getting patients started on treatment on time and, above all, ensuring that they remain on treatment. On the one hand, TB services tend to be shielded from the broader issues of the primary health care system. On the other hand, the South African TB program is written in pencil while others around the world tend to be written in stone – it is adaptable and changes quickly. When bedaquiline, now indispensable in the treatment of drug-resistant tuberculosis, was still a scary new drug, it was made available here long before the rest of the world.
There is every reason to believe that South Africa’s recovery has suffered a serious blow over the past two years. Kana warned that for the country to get back ahead of the disease, “TB cannot remain a poorer cousin of Covid, or HIV, or anything else.” Important lessons will have to be learned from the Covid-19 pandemic, he said. A disease can be brought under control if huge resources are invested in the health system, for example, or if the development of a vaccine can be done when it is taken seriously.
While South Africa has missed new TB diagnoses, the main drivers of the disease – HIV and community transmission – have not gone away. At almost every level, TB kills slowly. Breathe it in and it will remain viable in your body for years waiting for the ideal drop in immunity – an operation, an HIV infection – before it strikes. As a result, TB epidemics unfold over decades, not the weeks we have become accustomed to with Covid-19. What the next decade of our fight against TB will look like now hangs in the balance. In Louw’s words, “TB has a long history, but it’s not over yet”.