Tuberculosis: A syndemic of structural violence, by Emmanuella Ngozi Asabor

South Africa has one of the highest incidence rates of tuberculosis.¹ According to a 2017-2019 estimate from the first national tuberculosis prevalence survey, the overall case rate of TB in South Africa is 852 per 100,000 with even higher rates in certain subpopulations including men, people over 65, and people living HIV.^2,3 With a disproportionately high rate of mortality, South African miners offer an instructive case study on the social mediation of tuberculosis.^4,5 They encounter a syndemic of silicosis – a lung disease linked to the inhalation of high concentrations of the silica found in mines, HIV infection, and tuberculosis.^6,7 Access to antiretroviral treatment had improved survival for many miners, but miners suffer an increased risk of mortality compared to the general population even after cessation of work.^4,9

Racial disparities in health pervade the South African mining community.⁸ Black miners have a mortality risk that is over three times higher than that of white miners, after adjusting for other variables including occupational category, commodity mined, length of time in employment, and age at exit from the mining industry.⁴ Racial differences in housing conditions, income, nutrition, job description, silica and tuberculosis exposure, and the likelihood of family living in close proximity to the mines likely underlies these disparities.⁵ Yet, epidemiologic research has only begun to address the persistent health effects of apartheid, a system of land dispossession and state-sponsored discrimination which established a racial hierarchy in South Africa that sequestered resources for white people and placed indigenous, Black Africans at the bottom of the social order.^5,10

South Africa boasts a rich tradition of community and social agency. Black South Africans have addressed structural racism on the health and wellbeing of their communities through self-advocacy and collectivism.^11,12 Still, post-apartheid racial gaps persist in contemporary South Africa in educational, employment, housing, nutritional, healthcare, and wealth indicators, among others, and continue to affect the wellbeing of miners.^13,14  For example, even today Black miners are less likely to have access to high quality health care upon losing eligibility for employment-linked health services.⁵ They also return to home communities with disproportionately high incidences of accidental injury and violence.⁴ Structural racism confers upon them a disproportionate mortality risk, exacerbating the ill effects of their occupational exposures.⁵

Far across the Atlantic in the United States, a distinct but common history has unfolded. Tuberculosis incidence has been on the decline down to 2.4 cases per 100, 000 in 2021 from the surge of 10.4 cases per 100,000 in 1991.^15,16 However, up to four-fold higher rates are documented in communities facing structural vulnerabilities due to homelessness, overcrowding, and recent migration to the United States.¹⁷ A rural American setting offers an instructive case study on an understudied epidemiological risk profile of tuberculosis in the context of an outbreak .¹⁸

In 2016, the Alabama Public Health Department identified 47 people with TB in Perry County, a rural community of about 9200 residents. Between 2014 and 2016, the city of Marion (population ~3300) lost 3 people to TB during an outbreak.¹⁹ At the height of the breakout, Marion had an incidence of 253 cases per 100 000, rivaling the rates of TB infection in some of the world’s highest-burden countries.²⁰ The situation was not entirely unpredictable.¹⁸

Marion’s population is 63% Black and characterized by generations of poverty and limited access to healthcare.²⁰ Life expectancy in the area is less than the national average by more than 7 years and there is only 1 clinic providing X-rays.²⁰ Since 2000, 18 hospitals have closed in the state impacting rural areas the most. When the Affordable Care Act (ACA) was enacted in 2010, the Alabama state government chose not to expand Medicaid.²¹ Turning away the federal support to expand Medicaid which serves as a fundamental resource to low-income Black and other people of color signifies structural racism at the highest level, consistent with a demonstrated history of racial bias in the allocation of social welfare in the United States.²²

In the early 20^th century, African Americans would have constituted a “key population” in the language of modern epidemiology of TB with Black American communities, along with white immigrant communities, suffering and dying disproportionately from the disease.²³ While the current epidemiological context of TB in the United States has changed since the early 20^th century, TB continues to tell stories about the socio-structural position of the communities it disproportionately impacts.¹⁸ TB in the early 20^th century was an expression of contested politics in the Jim Crow era. In his book, Infectious Fear: Politics, Disease, and the Health Effects of Segregation, historian Samuel Kelton Roberts, Jr. follows the political history of TB among African Americans in the United States and traces the ways in which Black health moved from a place of “absolute neglect to qualified inclusion based on specific notions of care, expertise, public utility, citizenship, social control, and responsibility . The neglect of African Americans suffering from TB was a consequence of Jim Crow era policies of racial segregation along with contemporaneous scientific ideas of biological racial difference which cast Black bodies as inherently and inevitably more susceptible to TB, among other diseases. In the setting of mainstream neglect, Black communities made demands on government for increased public health and sanitary resources in their communities, formed community aid initiatives, and organized their own professional societies.²⁵ Black health advocacy eventually became somewhat integrated with mainstream public health, and entangled with various, often competing political expediencies. For example, there was an increase in Black public health professional inclusion in public health efforts in the 20^th century. This increase was due not only to Black health advocacy or progressive white allyship but also due to utility– Black people were best positioned to effectively surveil other Black people and manage infectious, stigmatized Black bodies in a highly segregated society as recognition of the contagious nature of TB blended with humoral and racial notions of disease susceptibility.²³ The transition from “absolute neglect” of Black health to the “qualified inclusion” of Black people in the public health conversation reflects the Critical Race Theory of interest convergence when socio-political expedience for white America and apparent benevolence towards structurally marginalized Black communities intersect and appear as progressive policies.^23,24

At the start of Marion’s TB epidemic, Black residents delayed seeking care. A commonly cited reason was a desire to keep others from “knowing [their] business.”²¹ Fractured relationships between communities and health officials are not only historically rooted, but they continue to be rearticulated through the deliberate state and local policies and practices that reinforce poor health in Black communities like Marion, Alabama.¹⁸  A well-founded concern for surveillance, endemic poverty, and limited access to quality healthcare services can nurture transmission in the context of systemic racism,  even within countries with a low burden of disease.¹⁸

South Africa and the United States are different national contexts with unique histories and particular local realities. As a physician-scholar in training and a student of social medicine, I intentionally compare them to articulate TB as a syndemic of structural violence. TB in the present, as in the past, tells stories about the socio-structural position of the communities it impacts. The contribution of structural violence to public health devastation and crisis is unmissable in high and low resource countries because of the inequitable stratification of economic and political resources across race, class, and gender lines.²⁶ The story of efforts to eradicate TB must be told alongside stories of the political and economic contexts of the settings where TB continues to have potential for harm.

About the Author

Emmanuella Ngozi Asabor is a physician-scholar in training who immigrated to New York City from Lagos, Nigeria in her early childhood. She is a joint MD Candidate and PhD Student in Epidemiology at Yale University Schools of Medicine and Public Health. Her research sits at the intersection of social medicine, epidemiology, and health policy. She writes about TB in South Africa as a student of the role of the legacy of Apartheid in shaping the present-day health of Indigenous, Black Africans after having lived and conducted community health research in Tugela Ferry, Msigna in rural KZN, South Africa. Her dissertation research brings the impact of post-Apartheid segregation on the HIV epidemic in rural South Africa into conversation with the impact of post-Jim Crow segregation on the COVID-19 epidemic among ethnoracial minority communities in the US. She earned her bachelor’s at Harvard University where she studied the history of medicine and global health. She also holds a master’s degree in African Studies from the University of Cambridge.

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