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24 March 2023 | Story Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht | Photo Supplied
Prof Christo Heunis, Prof Michelle Engelbrecht, Prof Gladys Kigozi-Male
From the left, Prof Christo, Prof Michelle Engelbrecht, and Prof Gladys Kigozi-Male.

 Opinion article by Profs Gladys Kigozi-Male, Christo Heunis, and Michelle Engelbrecht, Centre for Health Systems Research and Development, University of the Free State.


Each year on 24 March, the world commemorates World TB (Tuberculosis) Day. This date coincides with the day in 1882 when Robert Koch announced his discovery of the Mycobacterium Tuberculosis, the germ that causes TB. This infectious disease is transmitted through airborne droplets when an infected person coughs, sings, shouts, or sneezes. TB primarily affects the lungs (i.e., pulmonary TB), but other organs in the body such as the pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, or meninges (i.e., extra-pulmonary TB) can also be affected. TB can be cured; effective anti-TB drugs have been available for almost eight decades. Despite this, TB continues to wreak havoc across the world and in South Africa. According to a report released by the World Health Organisation (WHO), an estimated 304 000 new TB cases were reported in South Africa in 2021 and 56 000 people succumbed to the disease in the same year

A world without TB

In 2014, the sixty-seventh World Health Assembly endorsed a global strategy and targets for TB prevention, care, and control. The strategy envisions a world without TB, aiming to end the epidemic by 2035. By this target date, a reduction in TB deaths of 95% and new infections of 90% – compared to the respective levels in 2015 – are anticipated. Further to this, the United Nations’ Stop TB Partnership was mandated to drive activities to end the global TB epidemic. In 2015, the partnership launched the 90-(90)-90 targets; to reach at least 90% of people with TB and place them on appropriate treatment, including at least 90% of vulnerable populations such as people living with HIV, and to ensure that at least 90% of people with TB are successfully treated. Despite commendable progress, persisting high TB infection and death rates are adversely affecting global and national efforts to end the TB epidemic. With a treatment success rate of only 78% in 2020, South Africa is sorely challenged to attain the global target of 95%.

TB with mental health illness

One of the challenges confronting TB control is the frequent comorbidity of TB with mental health illness. There is compelling evidence linking TB to common mental health problems such as depression, anxiety, and alcohol misuse. Research indicates that TB patients can experience mental health problems at any time during the course of their TB treatment. Undiagnosed mental illness among TB patients may result in poor health-seeking behaviour and non-adherence to treatment, subpar quality of life, and negative treatment outcomes. The WHO's Global End TB Strategy thus recommends integrated patient-centred TB care. This implies that TB care should be provided in close collaboration with other primary health-care (PHC) programmes such as mental health. However, in many countries – South Africa included – efforts to integrate mental health and TB care are confronted by challenges such as limited capacity, nonrecognition of mental health as a problem, insufficient resources, and TB-related social stigma. Consequently, mental health conditions in TB patients are often un-/under-/mis-diagnosed.

Taking depression as a compelling example, a scoping review reported the prevalence of depression as high as 84% among people with TB in studies conducted internationally. However, little is known about the prevalence of depression among TB patients in South Africa. Using a nine-item Patient Health Questionnaire, we assessed probable depression among a sample of TB patients attending PHC facilities in the Free State. We found that almost half (46,1%) of the 208 patients interviewed had probable depression, with 22,6%, 18,8%, and 4,8% having mild, moderate, and severe symptoms, respectively. Probable depression was almost four times more likely among patients diagnosed with extra-pulmonary TB compared to pulmonary TB patients. HIV-infected TB patients undergoing antiretroviral therapy were more than twice as likely to experience symptoms of depression compared to their counterparts who were not undergoing such therapy. This could possibly be attributed to non-adherence to antiretroviral therapy. Studies elsewhere have established a significant association between depression and ART non-adherence. We further found that the longer patients were retained on TB treatment, the less likely they were to display symptoms of depression.

Important to monitor TB patients for depression

Based on these findings, it is important to monitor TB patients for symptoms of depression – particularly those with comorbid HIV – in PHC settings. At the same time, ensuring that patients stay on treatment by providing adequate support for treatment adherence may help to mitigate depression during TB treatment. 

The theme for this year’s World TB Day is ‘Yes! We can end TB’. It is a call for concerted multi-sectoral collaboration between governments, civil society, communities, academia and technical partners, international aid and scientific organisations, the private sector, and disease control programmes in the country to eliminate the TB epidemic. To this end, TB patients attending PHC facilities in South Africa need to be routinely screened for mental health illness. Given the critical shortage of mental health specialists, screening for mental illnesses could be undertaken by trained and well-supervised non-specialist healthcare cadres such as community health workers.

News Archive

Self-help building project helps to change lives
2017-12-15


 Description: Eco house read more Tags: Anita Venter, Start Living Green’, Earthship Biotecture Academy, construction skills 

Anita Venter, lecturer in the Centre for Development Support, with the residents of
the eco friendly house. Photo: Supplied

UFS PhD student Anita Venter did not know it in the beginning, but her doctoral research would eventually change her life and the lives of many others. 

The research was whether South Africa’s housing policies were socially and culturally responsive to grassroots reality in informal settlements. Venter agreed her research approach might have raised a few eye brows, but it was a journey she holds had more benefits than failures. 

Green living
For her case studies, Venter looked at ‘Start Living Green’ as a concept and further examined the implementation models of Earthship Biotecture Academy in New Mexico and Central America and the Long Way Home non-profit organisation in Guatemala. 

These groups train people with no specialised construction skills in applying and managing environmentally sound self-help building projects. Furthermore, their primary objectives were not building-related, but people-centred, with an advocacy role to create social, environmental and educational change through utilising the building technologies. 

It resulted in Venter signing up for a course in Guatemala to get the skills to implement her case studies here at home in Bloemfontein. 

An experimental mud, straw and waste material structure in her back yard grew into similar houses built in informal settlements, through the transfer of knowledge of indigenous building methods.  

Are rickety corrugated iron shacks only alternative?

Her case studies, one in Freedom Square in the Mangaung Metro Municipality, highlighted, among others, baffling tenure insecurities and “tangible conflicts” entrenched between Westernised and African perspectives on home ownership.

Venter says her thesis, in essence, did not oppose existing housing strategies but did challenge the applicability of an economically inclined model as the most appropriate housing option for millions of households living in informal settlements. 

The main findings of the case studies were that self-help building technologies and skills transfer could make a significant contribution to addressing housing shortages in the country; in particular in geographical locations such as the Free State province and other rural areas.

Venter’s own words after her academic endeavour are insightful: “These grassroots individuals’ courage to engage with me in unknown territories, gave me hope in humanity and inherent strength to keep on pursuing our vision of transforming informal settlements into evolving indigenous neighbourhoods of choice instead of only being living spaces of last resort.”

Positive results 
The study has had many positive results. The City of Cape Town is now looking at new innovative building technologies as a result. Most importantly Venter's study will open further discussions that necessarily challenge the status quo views in housing development. 

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