An epidemic uncurbed: tuberculosis in Cape Town, South Africa, 1910–2010

Abstract

Cape Town is unique among currently high-TB-burdened settings because detailed records are available, which span 100 years of public health attempts to bring the disease under control. Over the century, public health TB interventions were implemented which contemporarily mirrored those implemented in the industrialised cities of the Northern Hemisphere. Longitudinal observational data allow an exploration of associations between observed epidemiological changes and specific interventions. TB was never truly generalised but was consistently linked to socio-economic disadvantage. In the first half of the century TB treatment was focused on sanatorium treatment. While patients were observed to clinically improve immediately after admission, no long-term individual or public health impact was discernible. Following the introduction of chemotherapy in the 1950s, case fatality declined markedly but with less impact on non-European TB notifications. TB remains the commonest cause of natural death in the city. TB meningitis, a particularly pernicious form of the disease, frequently affecting children, peaked in the 1940s followed by a 100-fold decline and remains at low levels. In contrast, childhood TB also peaked in the 1940s but has returned to rates higher than those reported 100 years ago. High childhood TB rates are indicative of ongoing transmission and the recent HIV epidemic has further exposed failure to control TB transmission. While Cape Town TB has waxed and waned over the decades, TB rates remain among the highest in the world and are at levels recorded 100 years ago. A fundamental question is, why have public health measures failed to control TB?

Keywords:

• Cape Town
• tuberculosis
• tuberculous meningitis
• notification rate
• mortality rate
• sanatorium
• mass radiography

ACKNOWLEDGEMENTS

We gratefully acknowledge the Health Department, City of Cape Town for the access to TB notification data and ongoing collaborative efforts to understand the TB epidemic in Cape Town, and the University of Cape Town Medical Library for access to the City of Cape Town Medical Officer of Health Historical Reports.