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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

Dialogue between Science and Society series looks at forgiveness and reconciliation
2013-03-24

 

Taking part in the discussion on forgiveness and living reconciliation, were from left: Olga Macingwane, a survivor of the Worcester bombing of 1993; Dr Juliet Rogers, a Scholar on Remorse from the University of Melbourne in Australia and Dr Deon Snyman, Chairperson of the Worcester Hope and Reconciliation Process.
Photo: Mandi Bezuidenhout
24 March 2013

How do you, as a mother who lost her only daughter, forgive the man who claimed responsibility for the attack that killed her?  How do you forget his crime while travelling with him across the world?  

These were some of the questions posed to Jeanette Fourie at a Dialogue between Science and Society series on forgiveness and living reconciliation. Jeanette, whose daughter Lyndi was killed in an attack on the Heidelberg Pub in Cape Town in 1993, was one of three people telling their stories of forgiveness while dealing with traumatic experiences. 

Sitting next to Letlapa Mphahlele, the man who owned up to the attack that killed her daughter, Jeanette spoke about their story of forgiveness traveling the world together, spreading the message of forgiveness and conciliation. 

"Don't ever think you can forget, because that’s not possible. What you do with the pain is to find peace, and that's what forgiveness does. Forgiveness allows you to stop all the dialogue in your head on why he did it. You don't forget, you confront it and you deal with it." 

Letlapa, Director of Operations of Apla, the military wing of the PAC at the time of Lyndi's death, spoke about dealing with the response to his crime. "Sometimes you wish that you were not forgiven, because now you have the great burden of proving that you are worthy of forgiveness."

Also telling her story of forgiveness was Olga Macingwane, a survivor of the Worcester bombing of 1993 in which four people were killed and sixty-seven others injured. Four people were sent to prison. In 2009 Olga met one of the perpetrators, Stefaans Coetzee, and what came out of that meeting, is her story. 

"When I met Stefaans I was very angry, but when you sit down with somebody and listen to him or her, you find out what the reasons were that made him or her do something. I can say that I forgave him." 

Facilitating the conversation, Prof Pumla Gobodo-Madikizela, Senior Research Professor on Trauma, Forgiveness and Reconciliation, said the seminar was meant to get in touch with the truth that forgiveness is possible. 

"Before we had the Truth and Reconciliation Commission (TRC) in South Africa, the experts always said that forgiveness was not possible in these stories of the past. And then the TRC came into life as a response to mass atrocities. For the first time in the history of these traumatic experiences, of political traumas, we witness something that we have never seen.  Even us on the TRC, although it was framed as reconciliation, we never imagined there would actually be stories of forgiveness emerging out of that process, and then we witness that this too is possible." 

Others who took part in the two-hour-long seminar, were Dr Juliet Rogers, a Scholar on Remorse from the University of Melbourne in Australia and Dr Deon Snyman, Chairperson of the Worcester Hope and Reconciliation Process. They spoke about the dynamics behind the processes of engagement between victims/ survivors and perpetrators. 

The Dialogue between Science and Society series was co-hosted by the Institute for Reconciliation and Social Justice. 

 

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