Some 30 years ago, word seeped out of the United States of a strange new disease that affected gay men. South Africans paid little attention. In 1985, around the time when actor Rock Hudson admitted he had Aids, the apartheid government was preoccupied with declaring the first State of Emergency.
Both political upheaval and the initial belief that HIV and Aids would affect only a small slice of the population were massive distractions and lost the country valuable time in tackling the epidemic.
If we had known that HIV was easily transmissible in a heterosexual population, we could have made a better guess at how bad it would get and started an effective fight far sooner, says Dr Thuthula Balfour-Kaipa, head of the health department at the Chamber of Mines. Even so, we missed some crucial red flags.
"We in South Africa could see HIV marching down the continent, but we woke up very late to the fact that it would affect us badly," she says. Caught up in the whirlwind of political change and lulled by an HIV and Aids prevalence in 1994 of below 5%, South Africans failed to realise that the country possessed three key factors that would eventually be seen as crucial drivers of the epidemic.
First, South Africa had a 100-year-old tradition of using migrant labour from neighbouring countries in the mines that werethen still a dominant element of the economy. Second, South Africa's political system promoted migrant labour within the country's borders - for example, men moved from "homelands" such as Transkei to work in the mines of Egoli, leaving families behind. Third, South Africa already had a history of less than ideal control of tuberculosis (TB). All these factors formed part of an endless Möbius strip that would power the epidemic in southern Africa.
Away from home alone
Migrant labour is an acknowledged driver of the epidemic. Lucia Corno and Damien de Walque, in an article called "Mines, Migration and HIV/Aids in Southern Africa" and published in the Journal of African Economics, March 15 2012, found that "migrant miners aged 30–44 are 15 percentage points more likely to be HIV positive and having a migrant miner as a partner increases the probability of infection for women by 8 percentage points."
Migrant miners leave their homes and partners for long periods; they work in some of the most poverty-stricken areas in the country where desperately poor women seize the opportunity to make money through sex work.
The first inkling of HIV infection in mining demonstrated the crucial role of migrancy. When prevalence was very low in the general population, surveys showed levels of HIV infection among some miners, mostly from Malawi.
Miners were repatriated in a move that triggered outrage and was in the end futile: migrant labour was a fact of life in southern Africa and the virus was steadily moving south into untouched terrain.
Along the paths followed by migrant labour across the subcontinent, HIV encountered opportunities to expand its range: multiple-partner sex around mines, followed by a chance to jump thousands of kilometres to a virgin population in rural Eastern Cape or Swaziland.
The infection rate among miners rose exponentially and the impact on communities close to mines has been huge.
The Benchmarks Foundation reported in a 2007 study titled "The Policy Gap: A review of the corporate social responsibility programmes of the platinum mining industry in the North West Province", that: "In an interview with a medical doctor working at the world-famous Tapologo Aids Hospice serving informal settlements such as Freedom Park it was claimed that the HIV infection rates at these informal settlements are currently between 50% and 57%. The high rate of infection is as a result of the interaction between mineworkers and sex workers in the surrounding informal settlements."
The wasting disease
TB and HIV are marching companions. Such is TB's prevalence in South Africa that most South Africans have been exposed to the TB bacterium somewhere along the line, but those with HIV are far more likely to develop active TB.
TB and mining have been connected for centuries. The exposure to silica dust in gold and coal mines impacts on the lungs and amplifies the effect of TB.
"Since the early 1900s, TB has been recognised as an occupational lung disease in the mines," says Balfour-Kaipa.
TB was a foreign disease to southern Africa, so it took a toll during the years before the arrival of effective antibiotics and has never been well controlled in the country.
The living conditions of miners - single-sex hostels in their day, or crowded informal settlements - compound the problem because densely populated areas provide perfect opportunities for TB to spread. The cherry on top is poverty, which, through malnutrition and other factors, also drives TB infection.
Initially, Teba Limited (the Employment Bureau of Africa), which provided labour for the mines, developed an HIV awareness campaign, but by 1989 prevalence was still fairly low, as was the sense of urgency.
Then a few surveys showed a rapid rise in infection rates. The next decade or so saw a flurry of action by the Chamber of Mines, the unions, the state and individual mining companies, with Anglo American leading the charge.
During the 1990s, most major mining companies introduced HIV and Aids programmes that included elements such as awareness campaigns, training peer educators and nurse counsellors, free condom distribution in the workplace and voluntary counselling and testing (VCT).
At a series of meetings during the early years of the 21st century, mine health and safety, with specific emphasis on HIV and Aids, were discussed and agreements hammered out.
"Companies could see that the virus would have a serious impact," says Balfour-Kaipa. "Once they started offering VCT, it made sense to provide the treatment as well, especially as antiretrovirals were coming down in price."
Today, with a three-in-one pill available, compliance is better and the treatment success rate is high.
"HIV is really just another serious chronic disease," says Balfour-Kaipa. "If you think about it, treating diabetes is just as expensive." With medical schemes coverage, it was possible to extend care and treatment beyond the worker to his or her immediate family.
So, for example, Implats has invested substantially in medical aid schemes as well as in first-class healthcare facilities. And some companies, such as Xstrata Coal SA, have begun to see the benefits of working within the communities surrounding its operations.
Miles to go
"I think that there are some real models of tackling HIV in the mining industry," says Mark Heywood of Section27, which has a long history of activist engagement with the virus.
But, says Balfour-Kaipa: "We could have more joint action between employers and employees in the form of the unions." Heywood agrees.
Another Achilles's heel, says Balfour-Kaipa, is the many smaller companies that are contractors to the industry and do not necessarily follow the HIV policies that major companies have agreed to.
In addition, Heywood says, the industry has not really got to grips with the determinants that drive HIV and Aids, the two most important being migrant labour and the sex industry.
That may not happen without a push from outside the triangle of mining stakeholders - unions, mining companies and government - say David Stuckler, Sanjay Basu and Martin McKee in their 2010 paper called "Governance of Mining, HIV and Tuberculosis in Southern Africa."
The authors acknowledge the progress mining companies have made in providing comprehensive anti-retiroviral treatment to employees and in expanding activities, especially for ex-miners and their families in rural areas.
But, they say, "neither voluntary self-regulation by mining companies, nor pressure from miners' representatives has been sufficient to establish systems of governance that effectively respond to mining-related risks of HIV and TB.
"The ability of states to address these risks is undermined by the cross-border flows of miners, vested interests, and dispersion of responsibility across state institutions.
"To spur adaptations of the mining governance system, we argue that international and regional agencies, together with academics and NGOs, have a crucial role to play in monitoring progress, setting norms, and establishing cross-border treatment protocols."
In other words, things will not get substantially better unless civil society and other agencies take action.
They offer recommendations that include "establishing cross-border systems of care" (also mentioned by the Aids and Rights Alliance for Southern Africa in its 2008 publication "The Mining Sector, Tuberculosis and Migrant Labour in Southern Africa").
A portable record of treatment migrants can carry with them and integration of HIV and TB-related health-care available across the SADC region make good sense.
In addition, they call for a reform of miners's living environments. Although single-sex hostels are largely (but not by any means completely) a thing of the past, family housing is only available in limited areas and it should be a major focus. Family housing would reduce some of the perils inherent in migrant labour, such as risky sexual activity and multiple partnerships.
Stuckler and his colleagues suggest that such interventions for improved mining conditions could follow in the footsteps of the blood diamond campaign.
"Mining companies have yet to face the same pressure, even though there is - at least in relation to gold, platinum, and diamond mining - a huge gulf between the image conveyed by the marketing of their products and the reality for those who produce them."
With much mine-related migration happening within South Africa's borders, a concerted effort to provide sufficient family housing close to mines could be a significant factor in fighting the virus in South Africa.