Tuberculosis in South Africa – reflections on how social perspective, cognitive biases and risk perceptions mask an avoidable horror.
We humans misunderstand a lot of things. Our subjective interpretation of established facts is often found wanting. We get things directionally wrong, fail to understand causality or appreciate the magnitude of effects – we often misjudge interconnectivity.
It is the systematic element of our cognitive biases that plagued me as I sat staring at my screen, startled at the predictability of my own ignorance. The fact that I did not know that tuberculosis was the leading cause of death in South Africa in 2018  is not a function of my education, but, in part, because of it. Quite simply, well-educated, middle-class people do not worry about dying of TB.
I was reading through a number of articles on TB in South Africa, some quite technical and others aimed at the general public. I stumbled across a short piece by Justine Fargher , a young South African medical doctor who, I noted, studied at Wits, my alma mater. It was entitled, “The Inequality of the Tuberculosis health crisis in South Africa”.
I read on. She describes hiking in the mountains of the Cape, when an acquaintance asked what she did for a living. When she said that she was working in the field of drug-resistant TB, he replied, “TB? Here? In South Africa?” She struggled to understand how a well-educated, 50-year-old man (who happened to be white) could not know about the scourge of TB in our country. My passport shows that I was born in 1971, and the gnawing intensified.
I actually have a fairly good grasp of the disease biologically, its treatment, issues with drug resistance, and the correlation between tuberculosis, poverty and social conditions . But I had massively, grotesquely, underestimated the extraordinary magnitude of it. How could a “curable” disease, which has brought about so much misery, occupy so little of the public discourse – amongst the vulnerable and less vulnerable alike?
As of 2018, South Africa contributed approximately 3% of the global cases of TB , the highest rate per capita in the world. Over 95% of TB cases globally occur in developing countries . People with HIV are eighteen times more likely to contract TB, and South Africa has the fourth highest incidence of HIV/AIDS (17.3% of the adult population) . Those suffering from undernutrition are three times more at risk (one in four children in SA are stunted through malnutrition) . Environmental factors such as alcohol abuse and smoking, which is more prevalent in poorer communities in the developing world, are both risk contributors. As an airborne illness, the bacteria thrives in South Africa’s densely populated slums and shanty towns.
Perhaps our atavistic threat responses, which served our palaeolithic ancestors so well, are not well attuned to threats that are not proximal and visceral for a specific individual. People are more terrified of sharp things and precarious high places, it seems, than statistics. The field of behavioural finance is replete with cognitive biases and how we respond suboptimally to abstract threats. Perhaps we are not well-engineered either to appreciate benefits that are stretched out over time or accrue to us indirectly.
When we misjudge scale, we miscalibrate our responses. Decisions are based on perceived costs and benefits, and scarce resources are allocated to competing demands. The maths of optimisation fails and, with that, the integrity of our prioritisation.
It is not good enough that epidemiologists have medical strategies for prevention and cure. If it turns out that the true etiology of the TB epidemic lies in deep-rooted inequality and poverty, then the costs need to be understood more broadly across policy-making disciplines, and more publicly (perhaps more emotively too). So too do the benefits. Politicians aim to please voters and businesses allocate CSR expenditure to themes that are trending and topical. Maybe we need to start talking to hearts and not just minds.
When I started my MSc at Edinburgh, I thought scientific innovation would dominate finding solutions to global challenges. Instead, the most intractable problems seem to be perceptual and behavioural. Covid vaccine hesitancy in South Africa underscores that point. It is clear that we were preoccupied with procurement, roll-out and facts. Social context and issues of trust were underestimated.
South Africa is a country of stark inequalities and grinding poverty, a consequence of colonialism and exploitation. Our tuberculosis tragedy needs to be understood within the context of eradicating a vestige of Apartheid and discrimination – perhaps then it will receive the same attention as the other emotive social and political issues that are a product of our turbulent history.
 Stats SA (2017) ‘Mortality and causes of death in South Africa: Findings from death notification’, Statistical Release, P0309.3. Available at: https://www.statssa.gov.za/publications/P03093/P030932017.pdf
 Fargher, J. (2019) ‘The Inequality of the Tuberculosis health crisis in South Africa’. Blog site for Rebecca Richards, University of Edinburgh Law School. Available at: https://www.ghe.law.ed.ac.uk/the-inequality-of-the-tuberculosis-health-crisis-in-south-africa/
 Murdoch, J et al. (2021) ‘Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study’, Infectious Diseases of Poverty 10, 67 (2021). https://doi.org/10.1186/s40249-021-00840-5
 Osman, M., Karat, A.S., Khan, M. et al. (2021) Health system determinants of tuberculosis mortality in South Africa: a causal loop model. BMC Health Serv Res 21, 388 (2021). https://doi.org/10.1186/s12913-021-06398-0
 World Health Organisation (2020) ‘Tuberculosis’, Fact Sheets. Available at: https://www.who.int/news-room/fact-sheets/detail/tuberculosis
 World Population Review (2021) ‘HIV rates per country’, Accessed 2021/10/10. Available at: https://worldpopulationreview.com/country-rankings/hiv-rates-by-country
 Stoltz, E. (2021) ‘South African children suffer the ‘slow violence of malnutrition’, Mail & Guardian, 18 February 2021. Available at: https://mg.co.za/news/2021-02-18-south-african-children-suffer-the-slow-violence-of-malnutrition/#:~:text=South%20Africa%20has%20a%20%E2%80%9Cdouble,and%20overweight%20children%20is%20increasing.
3 replies to “Tuberculosis in South Africa – reflections on how social perspective, cognitive biases and risk perceptions mask an avoidable horror.”
Thanks for this! Great insights on how often our knowledge and understanding is clouded by our position in society – far off issues really are hard to grapple with. I loved your point about speaking to hearts, not just minds. I think this is really valuable. Humans are story-tellers and we certainly resonate more with stories than we do with statistics. Would be really interesting to hear if you have any ideas of what this could look like.
Hi Brandon – I hope you are doing well. Thanks for the highly reflective blog on TB in SA. I am really pleased that you emphasised the role of inequality as a driver of TB and indeed other diseases – sadly I think SA is still considered one of the most unequal countries. It seems to me there is an element of fatalism in the poverty-stricken areas, no doubt nurtured from Colonialism and Apartheid. Do you feel there is some level of acceptance of illness and death or is this just me – perhaps being very naive? I can only imagine how Covid-19 must be exacerbating the problem and I can certainly see why there would be a reluctance for vaccination, with feelings of neglect and so much mistrust. This reminds of some of the examples/case studies from the Development courses with the social and cultural factors not being considered when the well-meaning foreigners with medical aid come in to day save the day – in their own way!
All the best,
Hi Brandon, this is a great blog! Thank you for sharing your personal viewpoint on TB in South Africa. It is shocking to see that obvious inequalities and poverty issues are so easily ignored and blinded by cognitive biases.