The social terrain of endemic tuberculosis in and around Cape Town

[摘要] ENGLISH ABSTRACT: Global control of the tuberculosis (TB) epidemic remains one of the greatest healthchallenges of the 21st century, despite the availability of effective treatment over thepast 50 years. The rising incidence of transmitted (primary) drug resistant TB threatensthe very fabric of conventional TB control efforts, which are already strained by arampant human immunodeficiency virus (HIV) epidemic. Ongoing transmission ofMycobacterium tuberculosis is a key factor that sustains the TB epidemic in endemicareas such as the socio-economically deprived townships of Cape Town, South Africa.My research explores the disease context, or social terrain, of TB in this endemic setting.It is primarily concerned with how the social terrain of endemic TB may contribute toongoing transmission and the potential that it holds for enhancing TB control efforts.Analyses of qualitative data from eight township research sites in and around CapeTown show that pragmatic and novel approaches are required to pierce through theenormity of TB as a political and economic problem. Broadening the current biomedicalfocus on treating individual patients, to include more holistic community-basedinterventions, can and should be developed.Data were collected as part of qualitative pre-intervention community surveys conductedin 2005 and 2006 for a public health intervention trial (ZAMSTAR) performed in Zambiaand South Africa. Twenty-four communities were selected as research sites and thisstudy draws on the survey data collected in the trial's eight South African sites. Althoughthe data were collected for the ZAMSTAR trial, the aims and analyses presented in thisstudy - which seek to improve our understanding of how the social terrain is meaningfulfor TB control - remain independent of ZAMSTAR.Through a retrospective analysis of the South African data, I inductively present threedistinctive ways in which the social terrain is meaningful for TB control. First, theinteraction between social cohesion and social diversity may be an important variablethat predicts community response to public health interventions aimed at reducing theprevalence of TB in these endemic areas. This is demonstrated by triangulatingZAMSTAR'S adaptation of a social systems model with further analysis of the researchsites. Second, the study identifies a common discourse running through the sites thatstigmatizes TB as both a dirty and HIV-related disease. It is argued that this may besignificantly contributing to TB diagnostic delay and I call for more holistic approaches toTB control that can reduce perceived marginalization and TB-HIV stigma. Third,congregate settings emerge as noteworthy visible features of social terrain that clearlyhave the potential to facilitate TB transmission within communities. The pre-interventionsurveys qualitatively described public spaces within each research site and the usethereof. Basic principles of TB transmission are applied to these descriptions,developing a novel method of mapping the relative transmission risk possibly posed.Innovative use of similar approaches could identify likely transmission 'hot spots thatmay serve as focal points for targeted interventions, such as adjustments that increaseventilation or encourage TB suspects to seek urgent medical diagnosis and treatment.

[发布机构] Stellenbosch University