"It's complex" is a phrase that crops up frequently when asking health specialists to explain why South Africa is struggling to control tuberculosis.
Poverty, the prevalence of HIV/Aids, the legacy of apartheid, and individual health-seeking behaviour are among the factors that Professor Nulda Beyers, director of the Desmond Tutu TB Centre at Stellenbosch University, cites when discussing the TB epidemic in South Africa.
In contrast to a decrease in TB levels in other countries in the region, and despite South Africa's status as a middle-income developing country and substantial spending on health, TB levels in South Africa continue to rise.
"When something is out of control it's exactly that - one can't get away from it. Here in the Western Cape one in every three minibus taxis has a person with infectious TB in that taxi. Once it has reached those proportions it's very difficult to unravel what was the reason the figures got so very high," says Beyers.
"I think the question is, why doesn't everyone in South Africa have TB?" Beyers asks and then answers her own question, explaining how a healthy immune system manages to overcome TB.
"Even if people are infected, 90 percent will never get TB because we have a good immune system. But that is where HIV comes in. If the immune system goes down, then TB can flare up."
Public health officials often describe TB as HIV's "twin". HIV has been rampant in South Africa for the past two decades, exacerbated by prevarication in the late 1990s and early 2000s when former president Thabo Mbeki questioned the link between HIV and Aids, and his health minister denied the efficacy of antiretroviral medication.
After these tragic delays in combating the HIV/Aids pandemic, South Africa now provides antiretroviral therapy to some 1.7 million citizens - one of the world's largest public health Aids treatment programmes.
Besides the effect of HIV, poor nutrition, or other factors in weakening the immune system, poverty is a key factor in explaining the prevalence of TB. A classic public health study of Victorian England shows how TB levels declined throughout the 19th century in direct correspondence with improved living conditions and a reduction in poverty.
While Beyers is at pains to point out that wealthy, middle class people also contract TB, particularly given its widespread prevalence in South Africa, she says there are many reasons why poor people are more vulnerable to the airborne disease.
Crowded living conditions with poor ventilation are ideal conditions that assist TB to spread. Poor nutrition and malnourishment, which can cause obesity or emaciation, also undermine our immune systems.
Smoking and other risk-taking behaviours are additional factors that increase vulnerability to TB, says Beyers. "Educated people are smoking less and less, but in their marketing of cigarettes, tobacco companies are now targeting the poor people who are not well educated."
Health-seeking behaviour is also a factor. "If I cough for two weeks, I go to the doctor," says Beyers. "Whereas if people are poor, there are often so many other pressing emergencies - 'where will food come from, will I be safe tonight, will my children be safe?' so that a little cough is the least of one's problems."
Beyers acknowledges that while many factors within poverty make the treatment of TB complex, progress could be made against the country's TB epidemic if the South African government delivered the basic services it promises.
"While we researchers tackle why people behave in a certain way and exactly how poverty and TB interact, the health authorities should step up to the plate and implement what should be implemented, and it's just not there," Beyers says.
These basic services include proper recording and monitoring of TB, a reliable and consistent delivery of TB medication to clinics, as well as more efficient and effective systems within clinics.
One of the reasons the epidemic isn't broken, says Dr. Pren Naidoo, a public health specialist attached to the Desmond Tutu TB Centre, is because there is a "continuous infected pool in the community" - people who are infected with TB, who are not on treatment and who continue to spread the disease.
Key challenges are to be found in the laboratory system - how effectively and efficiently TB tests are processed - and the health system in terms of how patients are followed up and treated. There are also challenges among patients themselves regarding their attitudes and behaviour.
"We need a more active approach. There are a lot of deep-seated problems in our health service," says Naidoo. "I don't know if it's just apartheid or whether we have poor management, and poor accountability overall. I think poor accountability contributes quite substantially. At the end of the day, if somebody misses something, or doesn't get a patient on to treatment quickly, nobody makes a fuss about it."
A key challenge caused by these inefficiencies is the phenomenon of "initial default", where a patients comes to a clinic, is tested and found to have TB, but never starts treatment.
"One in five, or between 20 to 30 percent of people in this country who are diagnosed with TB don't start treatment and are not registered [as having TB]," says Naidoo. This happens often as a result of health workers not wanting to initiate the process of putting a patient on treatment in case the patient defaults, and then it will show up in the system as a "failure". The reasons for default vary. Some patients do not return to the clinic to get their results, or the clinic fails to trace them at their given address.
"This is a reality, it's what happens because clinics don't want their outcomes to look bad," says Naidoo. She describes the scenario: "A patient comes in, you don't draw a folder for them, you just send them through to have their sputum taken. When the results come back and the patient is not there, the results get put in a bottom drawer somewhere, but nobody makes an effort to track down the patient. That's just a lack of motivation and efficiency."
According to a spokesperson from the City of Cape Town, of those TB cases that are registered, "approximately 10-15 percent of patients who test positive do not return for their results", although the city says efforts are made to trace those patients.
Naidoo says there are some glimmers of hope, however. A new programme to "reduce initial default" or "TB-RID" is having some success in reducing the number of people who don't initiate treatment. The process sends a red flag to clinics alerting them to patients who've tested positive for TB and requires health workers to respond with the patient's registration information.
"It is possible to change these things, but you've got to identify the problem, you've got to develop a solution, you've got to implement it, and you've got to hold people accountable," says Naidoo. "This is not always easy to do."
"We've been doing interviews with patients and there are so many things from a patient's side that gets in the way of them starting treatment," says Naidoo. This includes the attitude of staff who are often more renowned for scolding patients at public health facilities than caring for them. It's a far cry from the South African health department's commitment to the principle of "batho pele" or "people first".
"I think that our health systems could be a whole lot friendlier," says Naidoo. "People are not as motivated as they need to be. The whole idea of the caring profession has just dropped by the wayside. We've had reports of patients going to a health facility three or four times before getting a result. Sometimes the results are not available, but often it's just laziness on the part of the staff to make a phone call or go onto the website and try to find the result."
A study among patients at clinics in South Africa's Western Cape province showed that by far the top complaint among people with TB symptoms was the waiting time at health facilities.
Whether employed or unemployed, nobody likes to wait for a long time, especially if there isn't a caring attitude among health staff, says Beyers. She advocates a triage system to care for TB patients as quickly as possible, particularly when they are waiting in an enclosed health facility where they can easily infect other people.
"People who cough simply cannot sit in a big waiting room and cough for hours on end," she says. "There needs to be a fast track to get those who've been coughing for a long time seen quickly and get them out of the clinic."
"So I think it's complex," concludes Beyers. "It is about health-seeking behaviour - where do people go to when they are sick, what are their belief systems, what do people think about sickness and disease? Do they have an understanding of the germ theory of disease or do they believe that illness comes because they've done something wrong and it's a form of punishment?"
"It is complex from the patient's point of view and because of the complexity of poverty," she says. "And I don't think those things can be fixed in a minute or two. I think we need much more research to really understand behaviour and how to fix poverty."