MARCH 2014 OVERVIEW 86202 Benefits and Costs of Reducing Tuberculosis Among Southern Africa’s Mineworkers Today, there are about 500,000 mineworkers and 1.5 to 2 million Key Messages ex-mineworkers across four n At 2,500-3,000 cases for every 100,000 people, tuberculosis (TB) countries in southern Africa—South incidence among mineworkers in South Africa is the highest Africa, Lesotho, Mozambique among any working population in the world. This is ten times the and Swaziland. Mineworkers in level that the WHO classifies as a health emergency. South Africa have the highest n The World Bank is working with national health ministries, the incidence rates of tuberculosis Stop TB Partnership, mining companies, mineworkers’ and ex- (TB) of any working population mineworkers’ associations and other partners to help resolve the in the world; at 2,500-3,000 per 100-year-old problem of TB among mineworkers. 100,000 individuals (see Table 2). n The spread of TB by migrant mineworkers is a serious public They are three times more at risk of contracting TB than the general health problem and financial burden across four countries—South population, where the rate is 948 per Africa and its labor-sending neighbors Lesotho, Mozambique and 100,000 people. The TB incidence Swaziland. rate among mineworkers is ten n Mineworkers are more susceptible to TB because many live with times higher than the level of a HIV and/or develop silicosis. Gold mineworkers are particularly at health emergency as defined by risk for silicosis with prolonged exposure to silica dust. the World Health Organization n While migrant mineworkers help to reduce poverty and increase (WHO). The World Bank is working national income when they send money home, they also closely with the governments of increase the TB burden in their communities. This has long-term South Africa, Lesotho, Swaziland implications that work against productivity and prosperity. and Mozambique, the Stop TB n Preliminary findings from a study commissioned by the World Partnership, mining companies, Bank on the economics of TB prevention and control in these mineworkers’ associations, and four countries suggest that the cost of testing and treating all other partners to help resolve the mineworkers is significant (about R330 million or US $33 million 100-year-old problem of tuberculosis a year), but would result in considerable long-term benefits, as (TB) among mineworkers and their productivity increases and fewer people require treatment. home communities. n The study will recommend a three-pronged approach to reduce TB Top-level regional action is among mineworkers: gathering momentum on – Test and treat all gold mineworkers for TB over two years, TB and TB-HIV co-infection followed by all mineworkers. in the mining sector. Fifteen – Set up a cross-border tracking and referral system to reach all Southern African Heads of former mineworkers. State pledged to address the TB – Improve working/living conditions to reduce the risk of epidemic among current and occupational lung disease. ex-mineworkers, their families and affected communities in August 2012. The World Bank is providing policy and analytical done as part of the Government put in place for harmonized support to enhance knowledge of South Africa/World Bank management of TB across the of the drivers of the epidemic, Knowledge and Solutions Hub. mining sector, and preliminary generate expert consensus, and In March 2014, with high-level economic analysis by the World mobilize political and financial support from the four affected Bank is helping to inform the support. This work is being countries, a framework is being way forward. Why are mineworkers South Africa. Mineworkers are areas and surrounding countries, separated from their families for particularly Lesotho, Swaziland, and at high risk of Mozambique (see Table 1). Due to long periods and have high levels contracting TB? of HIV infection. the high risk of infection among The risk of contracting TB is mineworkers and transmission to high among mineworkers for a South Africa’s large mining their families and communities number of reasons: i) Silica dust industry, which started with the across these countries, TB is a exposure which increases the risk first mine in Witwatersrand in 1886, regional public health problem. of pulmonary TB; ii) Occupational consists of over 2,000 mines today, Further, the countries from which conditions as mineworkers live contributes to nearly 9 percent the mineworkers come already and work in crowded and poorly of GDP on a nominal basis, and have among the world’s highest ventilated houses and shafts, accounts for 38 percent of the rates of TB incidence and HIV-TB co- iii) High-risk behaviors among country’s merchandise exports (as infection (see Table 2), and all have migrant mineworkers who move of 2011). It has historically relied cases of extremely drug-resistant between countries and within on migrant workers from rural TB (XDR-TB). Table 1: Cumulative number of workers recruited, terminated, and returned home, by region, 2003-2013 Workers medically Workers medically Labor-sending Workers employment Workers recruited boarded, in home- boarded, in TB Country terminated based care program program Botswana 692 3,777 35 6 Lesotho 55,997 61,654 2,381 24 Mozambique 47,601 56,856 1,072 6 Swaziland 4,308 7,469 230 6 Total 108,598 129,756 3,718 42 South African province Eastern Cape 173,384 87,689 2,440 18 Free State 81,268 45,793 158 2 Gauteng 130,594 80,656 151 1 KwaZulu Natal 27,801 18,915 700 10 Limpopo 52,954 31,663 73 3 Mpumalanga 26,782 14,128 44 — Northern Cape 6,831 4,328 41 1 North West 184,422 95,060 201 3 Western Cape 830 502 1 — Total 684,866 378,734 3,809 38 Note: This does not include contract workers. Source: TEBA data Table 2: High TB incidence among the general population; higher still among mineworkers Population TB Incidence Rate/100,000 people TB/HIV Co-Infection (%) Lesotho, general 633 77 Mozambique, general 347 66 South Africa, general 948 70 Swaziland, general 1,317 84 South Africa, mineworkers 2,500-3,000 — 2 Preliminary million) a year. An approximate 40 offers significant benefits across to 1 benefit-cost ratio is estimated, all types of mines, benefits are findings and implying that the benefits to particularly high in PGM mines recommendations society of this investment would that take in larger numbers of ex- from a forthcoming exceed R13 billion. gold mineworkers. economic study The foremost benefit is reduced GeneXpert is the diagnostic An ongoing World Bank study deaths due to TB and reduced TB technology cost used in the is currently estimating the incidence among mineworkers analysis, with the GeneXpert economic benefits and costs and their communities. It is cartridge procured at reduced of TB prevention and control estimated that about 3,000 public cost. Privately procured and implications for the mining lives could be saved over a 15- cartridges cost R480 to R700 (US industry and mineworkers and year horizon (2015-2030), with $48-70) whereas the public sector their communities in South roughly two-thirds of this positive cost is just R100 (US $10). Making Africa, Lesotho, Mozambique, and impact seen in South Africa. the cartridges available to mining Swaziland. The study will detail the Other benefits include increased companies at public cost would economic returns (benefit-cost productivity among these ratio) of a program of expanded vastly reduce the cost of testing. individuals, which contributes Such a program would also testing and treatment of gold and to poverty reduction, and lower platinum-group metals (PGM) include provision of treatment by treatment and morbidity costs. existing mining company health mineworkers in South Africa and a These benefits would then scaled up treatment program for facilities in remote locations where complement the positive effects mining communities and labor- public sector facilities are weak or of migrant worker remittances sending areas. non-existent. to their home communities and The results of the economic countries. Left uncontrolled, high Nearly 42,000 mineworkers in analysis are intended to TB transmission among workers South Africa have TB, and about inform expert discussions on and their communities takes away 70 percent of occupational TB policy, financing, and program from the long-term benefits of cases go undetected. While South interventions in the region. Based remittances. African mineworkers are eligible on preliminary findings, the to be tested for occupational Workers in gold mines are benefits from a comprehensive disease once a year and can at particularly high risk for approach to testing and treatment claim compensation for this, the occupational lung diseases in mines significantly outweigh drawback is that there are only 187 such as silicosis (with greater the costs. The report will suggest accredited test providers. Further, exposure to silica dust) and a three-pronged approach to migrant mineworkers from the pneumoconiosis, further raising the problem: (i) Testing and other countries are not covered their risk of TB infection. Large treating mineworkers (ii) Setting by these service providers, even numbers of gold mineworkers are up a cross-border tracking though they are legally eligible for medically boarded in a home- and referral system to reach all compensation if they are found based care program—nearly former mineworkers in the labor- to have occupational disease. The 5,400 workers between 2003 supplying provinces in the four incentive to report occupational and 2013, in contrast to 1,700 countries, and (iii) Improving disease is thus reduced. If in PGM mines. Therefore a key working/living conditions to workers could gain access to the recommendation is to roll out a reduce the risk of occupational Medical Bureau of Occupational testing and treatment program lung disease. among gold mineworkers first, Diseases (MBOD) claims process over a period of two years, in Swaziland, Lesotho and TESTING AND TREATING ALL and then extend the program Mozambique, this would create MINEWORKERS to all mineworkers, with the an incentive to come in for The preliminary analysis shows objective of reducing their risk testing at regular intervals, and that testing and treating all to at least the level among the would be more economical than current mineworkers would general population in the four trying to trace them in remote cost about R330 million (US $33 countries. While such a program communities. 3 SETTING UP A CROSS- is becoming more difficult. In themselves—a trans-boundary BORDER TRACKING AND previous years, most mineworkers pooled TB fund would result in REFERRAL SYSTEM from Swaziland were recruited efficiency gains. Such a fund could More often than not, the public through The Employment Bureau operate, for example, with a one- health system in labor-sending of Africa (TEBA), but today many time cost of R120 million (US $12 countries is unaware of the health approach mine employers directly million) and recurrent draw of R250 profile or needs of returning without going through TEBA. million (US $25 million) a year, with mineworkers—for example, contributions from all sources. Such A tracking system across all four whether they have been diagnosed a regional initiative would cover TB countries is therefore critical with TB or occupational lung tracking, testing, and treatment for to transmit health information disease, whether they have current and former mineworkers across national borders in two received treatment in the past, or in Lesotho, Mozambique, South directions—as mineworkers any future needs that they might Africa, and Swaziland. return home, and as they return have. A returning mineworker with to the mines (exposure to MDR- a history of multi-drug resistant REDUCING OCCUPATIONAL TB could have occurred in home TB (MDR-TB) could enter his home LUNG DISEASE RISK provinces as well). To further country without his need for future strengthen the public health Occupational lung diseases raise treatment being made known to systems in these countries, the the risk of TB among mineworkers. the public health system. tracking and referral system Although unrelated to testing To take the example of Swaziland, a should not be restricted to and treatment, broad measures June 2013 tracking survey showed TB alone, but should cover all to improve working and living that of about 250 ex-mineworkers, occupational diseases and conditions and reduce dust 38 showed TB symptoms and 12 HIV/AIDS. exposure among mineworkers were found to have TB. These ex- would greatly reduce the risk of mineworkers also had high rates In addition, given the multiple silicosis and pneumoconiosis and of MDR-TB and XDR-TB.1 Further, sources of funding for TB hence of contracting TB. tracking mineworkers in Swaziland diagnosis and treatment among mineworkers—national Further analysis is necessary to 1 Dlamini and Calnan, Tracking Survey. Ministry governments, donors, the mining explore the interventions that of Health and University Research Consortium, Swaziland. June 2013. industry, and mineworkers would yield the best health results.