Introduction

One hundred and twenty years after the discovery of gold on the Witwatersrand in 1886, mining remains a major force in the South African economy. Despite policy and legislative reform, partly informed by extensive research, 16 years into a democratic South Africa, gold miners in particular face an epidemic of occupational lung diseases. This provides an occupational health context in which to examine the impact of research on policy implementation and occupational health systems performance. This article outlines the gold mining environment, presents disease burdens, describes initiatives to reduce disease, and concludes with factors that may have impeded effective interventions, some common to other countries.

The Gold Mining Industry

Although well below the half million employed in the 1990s, South African gold mines still employ approximately 160 000 people.1 The industry is characterized by male cross-border and internal rural-urban migrants who leave their families and live mostly in single-sex mining compounds, returning home for variable periods.2 Until 1975, work contracts were temporary and short, but labour arrangements stabilized thereafter and duration of service increased.3, 4 These social circumstances and stabilization have contributed to serious inter-related epidemics of silicosis (silica dust-induced scarring of the lung),5 tuberculosis (TB), and HIV infection in miners, in surrounding communities and in labor-sending regions.2 Post-apartheid reforms deracialized legislation, but race remains an important determinant of occupation, salary, housing, and disease burden.

Surveillance and Research

In South Africa, surveillance of occupational exposures and diseases is weak notwithstanding efforts of the Department of Mineral Resources to maintain registers such as the South African Mining Occupational Diseases database, initiated in 1998.6 The Pathology Automation System (PATHAUT), an electronic database of approximately 100 000 autopsies of deceased miners, dating back to 1975, is a striking exception. Although provision for compensation for occupational lung diseases to current and former miners and their families in life and after death has been in place since 1911, the Occupational Diseases in Mines and Works Act of 1973 catalysed the development of the database by the South African Medical Research Council.7 PATHAUT provides a rich data-source for research and monitoring disease trends.8, 9 Universities and research entities, some partially funded by the state or from levies on industry administered by the state, filled gaps in data, on black miners in particular, in the 1990s and 2000s, showing rates of disease previously unappreciated. Silicosis demonstrates these aspects well. Importantly, the proportion of black gold miners found to have silicosis at autopsy increased from 3 per cent in 1975 to 32 per cent in 2007. Key studies describing silicosis prevalence in gold miners (Table 1) show substantial disease burdens into the late 2000s, with no evidence that interventions have reduced these to acceptable levels.

Table 1 Silicosis prevalence in gold miners, 1940–2007
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Biologic and social factors combine to create a ‘perfect storm’ for the interaction among silicosis, TB, and HIV. Thus, integrated, multifaceted remedies are required to control these epidemics. Silicosis substantially increases the risk of TB19, 20, 21, 22 to a magnitude similar to that of HIV infection.23 Importantly, silica exposure is associated with TB even in the absence of silicosis20, 24 and the increased risk is lifelong.24 Risk factors such as migrancy25 and single-sex compounds increase high-risk sexual behaviour,26, 27 and thus HIV rates, which are close to 30 per cent among these miners.28 The TB risks of silicosis and HIV infection combine multiplicatively.23 Consequently, the highest recorded rates of TB worldwide have been reported in South African gold miners.29 Mortality from TB is higher than that from mine accidents.30, 31 The prevalence of TB in gold miners has increased from 806 per 100 000 in 1991 to 3821 in 2004.32 HIV prevalence rose from less than 1 per cent in 198733 to 27 per cent in 2000.28 More recent data, after the roll out of antiretroviral treatment in 2003, are not available.

There is a large body of research on the control of TB in South African mines that addresses the use of isoniazid therapy to prevent TB in people with HIV;34, 35, 36 the spread of TB in the mining environment;37, 38, 39, 40, 41 and TB case finding.42, 43, 44 Studies have evaluated clinical management,45, 46, 47 and delayed, missed, or inaccurate diagnosis of TB in life28, 48 that have added to TB transmission. Drug resistance37, 49, 50 and recurrence of TB41, 51, 52, 53 have also complicated control. Researchers and occupational health practitioners have developed materials to assist mine health-care workers with TB management.54, 55 The Mine Health and Safety Council, a tripartite body formed under the Mine Health and Safety Act of 1996, and comprising representatives from the Department of Mineral Resources, the mining industry, and trade unions, funded and published the work. Neither the Council nor any other organization has formally measured the uptake of the materials but anecdotal evidence suggests that they are not widely used.

The migrant labour system has weakened incentives to control dust and disease by externalizing costs of disease, moving them away from the gold mining industry to communities and the State.2, 56, 57, 58, 59, 60, 61 South Africa requires multifaceted public policies to address this negative impact of migrancy that is common to many low and middle-income countries. Bilateral agreements between countries to provide industry-funded health services for former miners in labour-sending areas is one example. Another is patient-retained medical records to improve continuity of care for migrant workers.62 Accompanying this are failures of the occupational disease compensation system. Barriers to compensation are considerable and the majority of qualifying claimants have not received awards (Table 2), thus reducing the substantial financial incentive to control dust that would be brought about by compensation payments and hence increased levies on mines. Trapido et al63 estimated the unpaid occupational lung disease compensation for gold miners to be 10 billion South African rands (US$1.4 billion; $1=R7) in 1996, closer to 20 billion rands (US$2.9 billion) today. Even in poor countries, investments in compensation systems should bring greater returns in reduced disease burdens and their attendant costs to the public health system, provided that compensation costs are borne by industry.

Table 2 Studies of occupational disease compensation processes and outcomes in miners employed on South African mines
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Policy, Legislative and Service Initiatives

Although the history of disease reduction initiatives dates back to the early 1900s, these cannot be seen in isolation from South Africa's apartheid history of racial discrimination.67 We describe attempts to achieve control of silica dust, reduced impact of migrancy, improved housing, and better TB management and compensation systems necessary to reduce disease burdens. In 1973, the Occupational Diseases in Mines and Works Act (ODMWA) provided compensation for occupational diseases for miners, but benefits were substantially higher for white miners than other groups. The 1993 Amendment to ODMWA established racial parity in compensation benefits but access to benefits is unsatisfactory (Table 2). In Table 3 we summarize key initiatives in the last two decades and comment on their outcomes.

Table 3 Policy, legislative and service initiatives affecting miners in South Africa: 1993–2010
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The 1994 Leon Commission of Inquiry into Safety and Health in the Mining Industry, whose recommendations were informed by evidence presented by the National Union of Mineworkers, researchers, and activists, has had far-reaching consequences. The inquiry led to promulgation of a modern and comprehensive Mine Health and Safety Act with ancillary tripartite structures (representation of labour, government, and industry), such as the Mine Health and Safety Council (MHSC), to promote, develop, and oversee policy, standards, and encourage relevant research. However, neither the state, academics, nor trade unions have evaluated the impact of this law on practice.

Government has not implemented its long-standing policy of improving compensation benefits for miners (under the auspices of the Department of Health), in line with those available to non-mining workers (under the auspices of the Department of Labour), probably because of the increased and unfunded costs.

Numerous initiatives have sought to address living conditions of miners, but progress has been slow.68 A substantial body of applied research to reduce silica dust and disease69, 70 coincides with widely published targets (milestones),71 the establishment of task teams to disseminate good practice, and campaigns by stakeholders. There is, however, limited evidence of sustained reductions in silica dust levels.72, 73 Translation of research into practice has been patchy; for example, MHSC-sponsored research-based materials to raise awareness and skills among practitioners, miners, health and safety representatives, and managers71 have not been disseminated by the MHSC, mining houses, or trade unions.

Efforts of mine medical services to control TB in the mines have had limited impact.62 Although the mining industry has made substantial progress in developing HIV and AIDS programmes for miners,74 there is little evidence of declining HIV rates. Despite research and numerous policy initiatives, South Africa's mining industry falls short of compliance with health and safety legal requirements, as demonstrated by the Department of Health,73 the AIDS and Rights Alliance for Southern Africa,75 and a Presidential Audit of compliance76 reports.

Barriers to Translating Research into Action

The mining industry, the state, trade unions, and academics have done scant formal critical analysis of factors that have impeded effective interventions to reduce disease.77 In the absence of this analysis, we have identified financial, social, and organizational factors with face-validity that might explain much of the failure to implement translation of research and policy into action (Table 4). Many of these factors could apply to other countries.

Table 4 Factors influencing translation of research findings and policy initiatives into effective interventions to reduce disease
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Conclusion

Scientific studies have motivated and informed many sound policy decisions and legislative reforms, and have identified strategies for strengthening practice and health systems. South Africa has adopted some recommendations, but very few studies seem to have fostered sustained remedial action. There are clear gaps between research, policy, and implementation in occupational health practice in the South African mining industry.

Mining is growing in southern Africa and in many low- and middle-income countries. Other countries could avoid the high levels of occupational diseases experienced in South Africa through an enhanced understanding of the implications of the failure to use research evidence. Key messages to other countries are to: monitor dust and disease levels reliably, evaluate the impact of policy and regulatory reforms, and define the roles and responsibilities of individual government departments and other agencies clearly.