Health Systems and Public Health
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- ItemThe social terrain of endemic tuberculosis in and around Cape Town(Stellenbosch : University of Stellenbosch, 2010-12) Murray, Emma Jane; Marais, Ben; Bond, Virginia; University of Stellenbosch. Faculty of Health Sciences. Dept. Interdisciplinary Health Sciences. Community HealthENGLISH ABSTRACT: Global control of the tuberculosis (TB) epidemic remains one of the greatest health challenges of the 21st century, despite the availability of effective treatment over the past 50 years. The rising incidence of transmitted (primary) drug resistant TB threatens the very fabric of conventional TB control efforts, which are already strained by a rampant human immunodeficiency virus (HIV) epidemic. Ongoing transmission of Mycobacterium tuberculosis is a key factor that sustains the TB epidemic in endemic areas 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 to ongoing transmission and the potential that it holds for enhancing TB control efforts. Analyses of qualitative data from eight township research sites in and around Cape Town show that pragmatic and novel approaches are required to pierce through the enormity of TB as a political and economic problem. Broadening the current biomedical focus on treating individual patients, to include more holistic community-based interventions, can and should be developed. Data were collected as part of qualitative pre-intervention community surveys conducted in 2005 and 2006 for a public health intervention trial (ZAMSTAR) performed in Zambia and South Africa. Twenty-four communities were selected as research sites and this study draws on the survey data collected in the trial’s eight South African sites. Although the data were collected for the ZAMSTAR trial, the aims and analyses presented in this study - which seek to improve our understanding of how the social terrain is meaningful for TB control - remain independent of ZAMSTAR. Through a retrospective analysis of the South African data, I inductively present three distinctive ways in which the social terrain is meaningful for TB control. First, the interaction between social cohesion and social diversity may be an important variable that predicts community response to public health interventions aimed at reducing the prevalence of TB in these endemic areas. This is demonstrated by triangulating ZAMSTAR’S adaptation of a social systems model with further analysis of the research sites. Second, the study identifies a common discourse running through the sites that stigmatizes TB as both a dirty and HIV-related disease. It is argued that this may be significantly contributing to TB diagnostic delay and I call for more holistic approaches to TB control that can reduce perceived marginalization and TB-HIV stigma. Third, congregate settings emerge as noteworthy visible features of social terrain that clearly have the potential to facilitate TB transmission within communities. The pre-intervention surveys qualitatively described public spaces within each research site and the use thereof. 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” that may serve as focal points for targeted interventions, such as adjustments that increase ventilation or encourage TB suspects to seek urgent medical diagnosis and treatment.