A brief examination of the problem’s historical origins
Gold mining began at the Witwatersrand in 1886, where in the immediate decades after several reports were made public that blatantly described the health impact of miner’s “phthisis,” an antiquated term used to describe silicosis associated TB (silico-TB). In 1902 the Weldon Commission was appointed to investigate the cause of phthisis, determined silica dust was the primary underlying cause, and recommended dust elimination by methods still universally applied today1. In 1903, another commission report concluded,
“The extent to which Miners’ Phthisis prevails at the present time is so great that preventive measures are an urgent necessity, and that such a large number of sufferers in our midst is a matter of keen regret2.”
During this time, the investigations done by the Miner’s Phthisis Commission on the Union of South Africa were considered so thorough and absolute, that the 1912 report was universally regarded as, “one of the most notable contributions to the knowledge of a question which is of worldwide importance [phthisis], wherever dust-producing occupations are carried on” by the United States Bureau of Labor Statistics3. These early reports clearly delineated silica dust as a major health concern and as a factor for increased TB in the mining industry, and made the cause for silico-TB globally known. Moreover, the report goes on to state, “The disastrous experience of the last 15 years, involving the loss of countless useful lives, is suggestive of the conclusion that if silicosis… were recognized as an industrial disease, entitling that person to adequate pecuniary compensation, a material reduction in death rate would soon be a matter of time3.”
At this time the prevalence, incidence, and rate of silico-TB were higher on the Witwatersrand, South Africa than at any other mining center in the world1. Though epidemiological reports are limited, in 1919 the prevalence of silico-TB in South African gold mines was 1140 per 100,000 population, whereas the prevalence of uncomplicated TB was 255 per 100,000 population3. These rates, however, were only recorded amongst white miners, as disease in the black population was generally disregarded.
In the 1920s, the annual incident rates of TB amongst gold miners from Botswana, Lesotho, and Mozambique were 2350, 1340, and 1490 per 100,000 respectively4. Even during this era, the public health impact on the general population of these high rates in the South African gold mines was noted; during this time, the circular migration of mineworkers was estimated to attribute an average of 1000 new cases to rural areas of southern Africa each year5. In a 1924 study of TB amongst miners, of 112 patients who had returned home, over half (65) were dead by the time of follow up five years later, and only half of the survivors were capable of working again6. So it is to little surprise that at the beginning of the century, a leading journal was quoted as saying, “phthisis has killed such a large number of young, strong laborers, that many miners in Europe and America prefer to stay in their own countries, earn lower wages, and live, rather than come to the Rand [South Africa], earn a higher wage, and die1.’
Thus, for over a century there was a clear and demonstrated understanding for the etiology of silico-TB, the risk it poses to miners, the public health impact in the general population, and ways to prevent the development of the disease. With adequate measures in place and willing regulatory authorities, the scourge of TB and silicosis in South Africa could have been reduced or prevented. Illustrated in the United States during this same period (1930s), deaths from silicosis and tuberculosis were recognized in the Vermont granite mines and vigorous dust control measures were issued shortly thereafter by the Vermont Division of Industrial Hygiene. These dust control measures, using only basic technology during that era, dramatically reduced and even eliminated death from silicosis and tuberculosis7. Important to note, is that this timeframe predates the development of tuberculosis chemotherapy.
However, in 1996, well over half a century later and with modern chemotherapy, the Leon Commission Report declared, “The failure to control tuberculosis in the mining industry must be a matter for grave concern8.” Over a decade later, a 2007 health and safety audit9 found that TB rates in the mines continue to be the highest in the world. The audit could not have been more blunt about the cause:
“There is a pervasive culture of non-compliance to legislative requirements. Inquiry after inquiry makes findings to the effect that risk assessments are not conducted, training is not done, early-morning examinations are not done, equipment is not maintained and the list goes on and on.”
The audit continues to state that the system of administrative penalties for non-compliance failed to serve as a deterrent.
“Provision is made in the Act for referral of cases to the director of public prosecution where negligence has resulted in death or serious injury. Every year referrals are made, but no prosecution has ever taken place.”
Furthermore, in 2009, a letter addressed to the Minister of Minerals and Energy and the Minister of Health, signed by 16 of the most prominent TB, HIV, and silicosis researchers associated with the mining industry, requested urgent attention to TB in the mining sector, going so far as to call it a “human rights crisis.10”
Despite this awareness and demonstrated overcoming of silico-TB in the 1930’s, as well as the historical warnings from both the research community and presidential commissions, today gold miners in South Africa experience an incidence rate of TB higher than anywhere else in the world, three times higher than the highest burdened countries. At 3000-7000 cases of TB per 100,000 miners, the South African gold mines produce TB at rates up to twenty-eight times the measure for a declared emergency by the World Health Organization, ten times the rate of the general population of South Africa, three times higher than the highest burdened countries, and 1,400 times higher than Western countries11,12.
1Katz, Elaine. The White Death: silicosis on the Witwatersrand gold mines 1886-
1910. Witwatersrand University Press. 1994.
2South African Native Affairs Commission. Report: 1903-1905. 1905. Cape Town
Limited Printers.
3Hoffman, Frederick. The problem of dust phthisis in the granite-stone industry.
United States. Bureau of Labor Statistics. 1922.
4DOPH. Department of Public Health: Annual Report. 1990. cited in Anderson (1990).
5Anderson, N. “Tuberculosis and social stratification in South Africa” Int J of Health
Services. 1990;20:141–165.
6Allan, P. Report of Tuberculosis Survey of the Union of South Africa. Government
Printer, Cape Town. 1924 .(cited in Anderson, 1990)
7Costello, J. and W. G. Graham. “Vermont Granite Workers’ Mortality Study.” Am J of
Ind Med 1988;13(4):483-497.
8The South African OHS Commissions. “LEON: Report Of The Commission Of Inquiry Into Safety And Health In The Mining Industry, vol 1 and 2.” Leon
Commission. 1996.
9Department of Minerals and Energy, Republic of South Africa. “Presidential Mine
health and Safety Audit.” Mine Health & Safety Audits, 2008.
10Letter to DME and DOH, “Re: Calling for Urgent Action on TB in the South African
Mining Sector.” 26 March 2009.
11Ministry of Health, Republic of South Africa. Tuberculosis Strategic Plan for South
Africa 2007-2011. Durban: 2007.
12World Health Organization. Global Tuberculosis Control – Surveillance, Planning,
Financing. WHO; 2008.