7.0 - COMMISSION 2: HEALTH REMEDIATION AND COMPENSATION

7.1 - Health Service Provision

7.1.1 - Background
7.1.2 - Findings

7.1.2.1 - Diagnosis of ARDs
7.1.2.2 - Treatment of ARDs
7.1.2.3 - Services Available in the Greater Kuruman Area
7.1.2.4 - Barriers to Medical Care
7.1.2.5 - Training of Health Service Providers
7.1.2.6 - Disease Surveillance

7.1.3 - Conclusion
7.1.4 - Recommendations

7.2 - The Compensation System

7.2.1 - Background
7.2.2 - Barriers to Compensation

7.2.2.1 - Confusion and Lack of Information
7.2.2.2 - Access to Health Services and Diagnosis 7.2.2.3 - Corruption
7.2.2.4 - Labour History
7.2.2.5 - Inefficiency

7.2.3 - The Legal Framework

7.2.3.1 - Exposure to Industrial Contamination of the Environment
7.2.3.2 - Fragmentation of Responsibility for ARDs
7.2.3.3 - Post-Mortem Requirement
7.2.3.4 - Age Limits on Inheritance
7.2.3.5 - Using Workers' Wages to Calculate Compensation
7.2.3.6 - Individual versus Collective Compensation

7.2.4 - Conclusion
7.2.5 - Recommendations

7.3 - Health Education and Promotion

7.3.1 - Background
7.3.2 - Findings

7.3.2.1 - Role of Local Activists
7.3.2.2 - Role of Non-Governmental Organisations
7.3.2.3 - Participatory Research on ARDs
7.3.2.4 - Public Outreach on Rehabilitation
7.3.2.5 - Role of Trade Unions in linking ARD Education to Skills Development
7.3.2.6 - The Role of Hospitals and Clinics in Education about ARDs
7.3.2.7 - The Role of Public Schools

7.3.3 - Conclusion
7.3.4 - Recommendations

7. 0 COMMISSION 2: HEALTH REMEDIATION AND COMPENSATION

7.1 Health Service Provision

7.1.1 Background
Improvement of the quality, of and access to, health care has been a major priority of the new South African government. The White Paper on the Transformation of the Health System(74) proposes a legislative framework to facilitate the formation of a national health and safety agency for occupational health, which will bring all primary care services under the jurisdiction of the district municipality(75). The national government will retain responsibility for health policy, while the provincial governments are to provide secondary and tertiary medical care through provincial hospitals. The South African health system is currently in transition while responsibility for comprehensive health service provision is being transferred to the district level. Because of the different characteristics of each province, including financial resources and proportion of rural/urban population, progress has been uneven. While some provinces have reached the goal of decentralisation, "the reality is that at present some municipalities cannot even provide water and electricity, let alone immunisation service"(76). In cases such as the Northern Cape, therefore, health care will continue to be administered by the provincial government until the local administrations build the necessary capacity to reach in an efficient and cost-effective manner small rural villages spread over a vast geographical area.

In addition to the White Paper's broad proposals to improve the nation's health system, the national DoH has undertaken a number of initiatives to improve access to health services and compensation among ex-miners. One of the main programmes in the department involves expanding the availability of BMEs through ex-miner's clinics that have been established in the provinces. These examinations are a point of intersection between the health care and compensation systems, as they both provide medical care and form the first step in the compensation system. The DoH has also initiated a number of nurses' training programmes in particular provinces. These programmes offer training in occupational health and safety(77). According to a senior official at the Medical Bureau of Occupational Disease (MBOD), these training programmes will increase access to BME's for ex-miners.

We met numerous dedicated practitioners who are working hard to cope with the problem of ARDs. In this section, we discuss the progress made and the work that remains to be done in reaching the government's goal of improving diagnosis, treatment, and training of practitioners, specifically as it pertains to health services in the Kuruman region.

7.1.2 Findings

7.1.2.1 Diagnosis of ARDs
Diagnostic services are stipulated by law for former mine workers as part of the compensation system and are offered by doctors in the Kuruman area. Proper diagnosis of ARDs in rural settings is often difficult, because of a lack of necessary equipment. To confidently diagnose any ARD, a chest X-ray is needed. Lung function testing is extremely useful and is required for certainty in borderline cases. However, while an X-ray and lung function test are sufficient to diagnose asbestosis, the diagnosis of mesothelioma can be complicated, requiring a histological sample or a clinical diagnosis by an experienced doctor.

7.1.2.2 Treatment of ARDS
"Asbestos is a serial killer-that's how we look at it. Child, young, old-no mercy." -Ncweng resident

"There is no cure for asbestos. The only cure is death and for death there is no compensation." Ga-Mopedi resident

Most people in the Kuruman region with ARDs are never treated for their disease. In our interviews, we were repeatedly told about people who had died while waiting to see a doctor. Although there is no cure for asbestosis, lung cancer, or mesothelioma, palliative care, especially pain relief and treatment of symptoms, can make a major difference in the quality of life for people suffering from ARDs. People specifically complained that medical care was often insufficient to combat the pain of ARDs. When asked if going to the doctor helps people with ARDs, the people of Ga-Mopedi said "No. We go to the doctor, but we don't get any better." The people we spoke with were well aware that curing ARDs is highly unlikely, and this dissuades people from even seeking medical care. Representatives of the CPAA in Prieska suggested that many people would rather not know they have ARDs, because there is no cure and they see it as a death sentence.

7.1.2.3 Services Available in the Greater Kuruman Area

Occupational health
Patients are entitled to medical care at any public hospital or clinic free of charge, or at any private doctor for a fee. There are several specified providers, both public and private, who have contracts with the MBOD to provide BMEs for former mineworkers. These examinations are free for the patients as they are financed by the MBOD as required by the ODMWA. A complete BME includes a clinical examination, a chest X-ray, and a lung function test.

There is an Occupational Health Centre in Kimberley. Although it is not yet fully operational and is greatly under-resourced, the practitioners are well-trained and the unit is equipped to handle people with ARDs, to provide them with the appropriate treatment, to help patients with compensation claims, and to follow-up with the MBOD and Compensation Commissioner on their behalf.

The Occupational Health Unit at Batlharos Hospital is the only provider of BMEs in the Kuruman region with all the necessary equipment. A private doctor we spoke to in Kuruman who provides BMEs stressed the need for lung function testing at his practice to assist in diagnosis of borderline ARD cases, but said that buying the equipment is prohibitively expensive. Providers we spoke with agreed that lack of lung function testing results in under-diagnosis of ARDs. There is no occupational health unit at Kuruman Hospital.

Primary health care
Medical services beyond BMEs, including diagnosis and management of disease, are inconsistent and largely dependent on the knowledge and interest of the practitioners involved. While the Occupational Health Unit at Batlharos Hospital assists people in compensation matters and perform BMEs, the Unit does not diagnose disease or provide medical care for patients presenting with ARDs. Responsibility for diagnosis is left to the MBOD and does not occur at the time of the BME. Patients with ARDs are referred to Kimberley or Klerksdorp for more specialised care, such as chemotherapy and surgery. There is also a flying team of doctors from Kimberley, who come to Kuruman Hospital once a month and provide services which would otherwise only be available in Kimberley. Their presence in Kuruman, however, is not regular and the people who come to the clinic vary greatly in their health needs. Because BMEs are provided only for former miners, people with ARDs due to environmental exposure must depend exclusively on their primary care physicians for diagnosis and treatment.

7.1.2.4 Barriers to Medical Care
At every level, we found that people suffering from ARDs encounter obstacles to the necessary diagnostic and treatment services. These barriers range from logistical problems resulting from their rural location, to the social and economic inequality that is the legacy of apartheid. The obstacles to health services that we uncovered through our interviews in the Kuruman area are summarised below.

Cost of Medical Care
"Our concern is our medical bills" -Kuruman resident

"The worst occupational hazard is not to have a job." -Reed Street Clinic, Cape Town

"The company must take responsibility. They must pay the medical bills." -Kuruman resident

"As soon as you're diagnosed with asbestosis, there must be some sort of a fund that will help you with all the medical costs" -Kuruman resident

"I got a claim, because I was working for a mine, but what about my children? They only lived in a town that asbestos was blown into." -Kuruman resident

Many people who have been exposed to asbestos are very concerned about the price of medical care. While BMEs are free of charge for former miners and most services are free for everyone at state hospitals and clinics, proper management of ARDs can be quite expensive for patients and their families. Private doctors are too expensive for people in rural areas. When severe disease sets in, the price of hospitalisation, even at the public hospitals, adds up quickly. People we interviewed, both from the villages and in town, told us that cost sometimes prevents them from seeking treatment or is a large financial burden.

Because most of the entitlements available for ARDs result from implementation of the ODMWA, people exposed through industry's contamination of the environment are excluded from services provided for former miners. Although all people are entitled to free examinations at state hospitals, patients who are not exposed through their occupation must pay for any X-rays taken. Therefore, people suffering from non-occupational ARDs often go undiagnosed because of the patient's financial constraints. Similarly, private doctors charge a fee for X-rays in addition to the price of an appointment. Patients without MedicalAid often cannot afford the extra charge and do not get X-rays taken, even when it is likely they are suffering from ARDs, as we were told by a doctor in private practice in Kuruman. Moreover, many of those with ARDs from industrial environmental exposure are women, who may have worked in the mines, but do not appear on the official record. Also affected are those who played on the mines as children and who lived in these villages their entire lives.

Information
Many people are uninformed about the services to which they are entitled. A private doctor in Kuruman told us that he relies on word of mouth to spread information about BMEs to rural villages, a relatively unreliable mechanism, which has led to poor dissemination of information. While some doctors are well informed about asbestos issues, others have very little knowledge about ARDs. This discrepancy can result in misdiagnosis or lack of appropriate treatment, although it is impossible to fully evaluate the extent of these problems without more in-depth study. A practitioner who performs BMEs in the Kuruman area did not realise that further forms for compensation are necessary after a patient receives a letter of certification from the MBOD. Although the health service provider is supposed to receive a copy of the certification letter, this practitioner claimed not to have received any letters about patients whom he had examined.

Transportation
Transportation to health care facilities poses a serious problem for people in rural villages. The villages most affected by asbestos-those closest to the mines-are located up to 20km away from health centres on untarred roads. Many of those affected by ARDs are poor, elderly, and dependent on an old-age pension. They find the cost of transportation to and from the local hospitals prohibitive. Because histological diagnoses for mesothelioma and many of the treatment services for ARDs, such as chemotherapy and surgery, are available only at the larger provincial hospitals, patients must often travel up to four hours to receive the necessary care. We were told by a doctor at Kimberley Hospital that, while this centre is of great help to those who can access its services, it cannot reach the people of Kuruman, because of distance and the expense of travel.

Language
Most of the people in the villages surrounding Kuruman speak Setswana whereas most of the doctors speak primarily English and Afrikaans. The people with whom we spoke at Ga-Mopedi felt that they often did not understand what was going on at their medical appointments and that doctors did not make enough of an effort to explain the results of X-rays and other tests. They felt that having a single centre for ARD concerns, with translators available, would help ease the language barrier that prevents people from understanding their diagnosis or prognosis.

Equipment/Facilities
There are several places that offer diagnostic services for ARDs in the Kuruman area, but only Batlharos is equipped with a lung function machine. While unnecessary for recognition of severe disease, lung function testing can determine impairment in borderline cases and assist with the decision to certify people as having first or second degree impairment. Without access to this test, people with ARDs can go undiagnosed until severe disease develops.

Suspicion of Health System
"We would appreciate it if all the people affected by asbestos, black and white, go to the same hospital. If there is one thing to be done, though, we need a clinic where both white and black attend. This would satisfy us that we are being treated equally. As it is now we see no whites at the clinic. Does this mean that whites are not affected?" - Ga-Mopedi resident

Many people are distrustful of doctors in both the public and private sectors. The distrust we encountered extends beyond physicians, as we found people were often suspicious of the entire medical system. Indeed, some doctors were prohibited from diagnosing workers with ARDs. Their allegiance was clearly to the mining companies(78). Because of the legacy of oppression and, in particular, the experience of many people with mine doctors, people in the villages around Kuruman expressed suspicion about the loyalties of all physicians. Many had doubts about the ability to receive an honest diagnosis from any doctor in South Africa. Although clearly few physicians are tied to industry and the vast majority are honest and committed to their patients, all doctors have been equated with industry in the minds of many people with whom we spoke.

Leaders at Ga-Mopedi also expressed doubt about the equality of services offered to whites and blacks, suggesting that whites received more ready diagnosis of ARDs, while blacks were told to go to inferior doctors or hospitals and were often misdiagnosed or given substandard treatment. These fears and suspicions make some blacks less likely to seek medical care or diagnosis and present a serious deterrent to utilisation of health services. Convinced that the care is better at Kuruman Hospital than at Batlharos, there was a definite preference for the predominately white hospital in town over the hospital closer to the villages, whose clientele is mostly black. Many people feel that their records have been lost at Batlharos, have been told they are not sick when they were, or have been diagnosed with TB or asthma when they believe they are sick from asbestos.

As a consequence of their fear that some doctors collaborate with mining companies, people at Ga-Mopedi suggested that foreign-and therefore considered unbiased-doctors should visit the villages. Another suggestion was that a team of government doctors should visit the villages, together with a representative from Gefco to diagnose cases.

Lack of Co-ordination Between the Health Care and Compensation Systems
Although they should be interwoven, medical services and compensation are distinctly fragmented in both the minds of those involved and the structures in place for each system, especially in the state health system. Thus, according to one practitioner at Batlharos Hospital, a patient seeking compensation will receive a BME, complete with chest X-rays and a physical exam, but due to a lack of resources, the X-rays will not be reviewed by a doctor before the films and forms are sent to the MBOD for diagnosis. Because of this, patients experience delays in diagnosis and treatment of ARDs. In addition, the discontinuity of services results in many patients falling through the cracks in the system and never receiving medical care. More often than not, patients do not return to the doctor after filing for compensation.

7.1.2.5 Training of Health Service Providers

Training Programmes of Doctors and Nurses in Practice
Prior to 1994, there was no formal training of occupational health nurses or doctors within the public sector. As we learned from a researcher at the NCOH, a 1991 investigation of rural South African hospitals looking at TB and occupational disease (including ARDs) found significant deficiencies in provider knowledge about occupational health, compensation, and effective TB strategies and controls. The DoH has recognised this need and initiated a number of initiatives to train health practitioners in occupational medicine. Both the MBOD and NCOH have training programmes for those doctors and clinics they approve to do BMEs.

The DoH has initiated programmes to train nurse practitioners in the Public Health sector in occupational health. The three centres of training are Nelson Mandela Medical School at the University of Natal, the Peninsula Technikon in Cape Town, and the University of Bloemfontein. The training programmes are beginning to make a difference in the Northern Cape and the North-West provinces but have not yet reached their full potential. Training programmes in the Northern Province have been in place for longer and the placement and training of occupational health nurses in hospitals serving the former Pietersburg asbestos fields have greatly increased the provision of occupational health services, including BMEs and follow-up on compensation claims. Based on these and other experiences at the district level, the DoH is writing a training manual focusing on local and regional capacity building.

However, because DoH programmes are still in the early implementation stages, their effects have not been fully felt in the Kuruman area. There is one occupational health nurse at Batlharos Hospital and at the end of the year there will be one such nurse for the Kgalagadi District based at Kuruman Hospital. Other nurses we spoke to had learned about ARDs from information disseminated by the DoH. We could not locate any doctors, however, who have been formally trained in occupational health. Despite this lack of formal training, the doctors practising in the province have a wealth of experience in dealing with asbestos. Many of them were involved with the mines or have worked in mining areas for many years and are quite knowledgeable about the diagnosis and treatment of ARDs because of the large number of people affected.

On the other hand, few doctors with whom we spoke had a strong knowledge about the compensation system. Some were reluctant to spend much time and energy learning about ARDs when TB and HIV/AIDS were viewed as more pressing problems. All doctors are required to earn a certain number of points each year through Continuous Professional Development (CPD). To meet the requirement, doctors can choose to attend workshops or read journal articles and answer questions. If an individual chooses, he may pursue CPD in occupational health, but it is not required. With few formal training programmes in place, knowledge amongst health service providers depends in large part on their individual interest and personal clinical experience. This is especially true in rural hospitals where providers see high levels of general sickness and injury, and are less likely to be attuned to specific diagnosis of occupationally induced disease or environmental disease from industrial sources.

The South African Society for Occupational Medicine (SASOM) and the South African Society of Occupational Health Nurses (SASOHN) are professional organisations for doctors and nurses, respectively, who are interested in occupational health. SASOM has run workshops, seminars, and training sessions on issues, such as compensation, related to occupational health. The IHRG has developed a manual for training courses of health service providers at the primary care level for ARDs. This training programme was conducted from 1997 to 1999 and involved doctors, nurses, and environmental health officers in five provinces, including the Northern Cape.

The IHRG has over the past two years, with the support of the Chief Directorate Non-personal Health, the Mpumalanga Health Department and the MBOD, run workshops for nurses and doctors in Mpumalaga Province. Training sessions took place in villages closest to the Msauli chrysotile asbestos mine, relied on local experience and knowledge, and specifically plan to build capacity at Primary Health Care and District Health levels. A central component of this training is the parallel workshops involving the experiences of ex-miners, local residents, and the Ekulindeni Asbestos Committee. These community-based groups and members of civil society actively collaborate with local clinics and Embhuleni Hospital for BME's and compensation processing. The training programme also involves trade unions, the DoL, DME, and DEAT. It is foreseen that these activities will help towards sustainable development programmes, particularly in relation to environmental contamination.

Training of Medical and Nursing Students in ARDs and Occupational Health
Medical professionals we spoke to both in Cape Town and the Northern Cape agreed that students learn very little about ARDs in medical school. This cursory exposure to the diseases does not provide sufficient background in diagnosis and treatment for doctors working in areas with high prevalence. According to doctors and researchers to whom we spoke in the Northern Cape, medical school does not prepare doctors for the large number of patients with ARDs they encounter in mining regions such as Kuruman. Furthermore, although occupational health is included in nurses' basic training curriculum, the providers we interviewed felt the curriculum does not focus sufficiently on ARDs and is not adequate for nurses stationed in asbestos regions.

7.1.2.6 Disease Surveillance
To date, data on the prevalence of ARDs have not been systematically collected in the Kuruman region. The available evidence - both documented(79) and anecdotal, as we learned from doctors in the Kuruman area - suggests that occupational disease, including ARDs, remains vastly underreported in the Northern Cape and the North-West Province. According to the MBOD Annual Report, 45 retired mineworkers in the Northern Cape and 23 in the North-West Province were certified for non-TB occupational diseases between 1 April 1999 and 31 March 2000(80). This is most likely an underestimation, considering that at Batlharos Hospital, the Occupational Health Office usually sees between 30 and 40 patients for BMEs every month and the private doctor we spoke with in Kuruman performs up to 100 BMEs per month.

These figures provide a contrast with the Northern Province and Mpumalanga, both also predominately rural areas with a similar history of asbestos mining and milling. Through intensive, co-operative campaigns at area hospitals and the formation of community-based committees, health researchers and providers have enabled many individuals to receive both health care and compensation(81, 82). Work in Mpumalanga has focused on creating closer links between district hospitals and local people, including local announcements directing ex-workers to local clinics for examinations. In the Northern Province, the secondary result has been the reporting of more than 500 cases of non-TB occupational disease in the same one-year period, the great majority of them asbestos-related.

The IHRG has worked with local unions in the Northern Cape to improve medical surveillance, X-ray quality, and training of lung function technicians at former crocidolite mines and mining areas, primarily through negotiated settlements with mine management. These efforts complemented the IHRG medical surveillance audits at five mines in the Northern Cape.

Because the compensation system represents one of the few mechanisms for surveillance of ARDs and other occupational disease, providers' knowledge about the reporting system is key. Providers are required by law to report all compensable disease to the MBOD and BMEs. These reports combined with outreach are a potentially effective tool for disease surveillance.

SORDSA is a voluntary reporting system, whereby doctors notify the NCOH of occupational respiratory diseases, including ARDs. SORDSA Alert, an informational newsletter, is put out every month by the NCOH. Two issues, August 1999 and August 2000, described the diagnosis and management of ARDs. However, the newsletter is not distributed to all providers. Doctors must sign up to receive the newsletter and register to be part of SORDSA. Furthermore, because reporting is entirely voluntary, SORDSA faces the same problems that inhibit mandatory reporting of occupational diseases to the MBOD. For example, from October 1996 to October 1998 only three cases of occupational disease were reported from the Northern Cape. The North-West Province reported a total of 13 occupational cases. In contrast, the Western Cape reported 410 cases in the same period and Gauteng Province reported 2425(83).

There are few surveillance mechanisms for systematic reporting of asbestosis and other pleural or parenchymal changes due to industrial environmental asbestos exposure. In the case of cancers (including mesothelioma), providers are required by law to report cases to the National Cancer Registry. However, overburdened providers in rural areas where ARDs are prevalent do not regularly report cancers to the Registry. Providers also may not link cancers of the lung to asbestos exposure and may instead attribute them to smoking, or may simply not search for a causative agent. Mesothelioma, although generally known by providers to be linked to asbestos exposure, requires specialised facilities to diagnose and may require a post-mortem removal of the heart and lungs. Since non-occupationally exposed individuals are not eligible for compensation, there is little incentive for families to seek full diagnosis of mesothelioma. A national mesothelioma registry modelled after Australian efforts was in effect in the 1960s and 1970s, but presumably served only whites.

7.1.3 Conclusion
Despite many improvements and the national commitment to comprehensive health services on a district level, medical care remains inadequate in the Kuruman area. On every level, patients with ARDs encounter serious obstacles which prevent them from accessing the necessary health care services. In addition, these services are not sufficient even when they can be accessed. Barriers to high quality diagnosis and treatment of ARDs include transportation, lack of information on the diseases, lack of equipment, price of medical care, and lack of trust in doctors. Few resources are available for outreach programmes to disseminate information about the available health services and to build trust between doctors and patients, or to provide better equipment in clinics.

7.1.4 Recommendations
Based on our research in the Kuruman area, we recommend that the following steps be taken to improve access to health services for ARDs:

7.2 The Compensation System

7.2.1 Background
A major priority of the new government since 1994 has been to address the rights of workers to compensation for occupationally related disease, and specifically to include black miners and ex-miners in the compensation system. The two laws that now cover compensation and medical coverage for occupational injuries and disease are the Compensation for Occupational Injuries and Diseases Act (COIDA) of 1993 and the Occupational Diseases in Mines and Works Act (ODMWA) of 1973, amended in 1993. COIDA is administered by the DoL, while ODMWA is administered by the DoH. COIDA provides for "mandatory reporting of all occupational injuries and diseases (excluding miners with occupational lung disease) to the Compensation Commissioner in the DoL." In addition to compensation for disease and disability, the act provides for medical expenses to treat the occupational disease or injury, and benefits to spouses and dependents of a deceased workers(84).

ODMWA governs the lifelong monitoring and surveillance of former mineworkers and the evaluation of both former and active miners for possible compensable occupational lung disease such as ARDs(85). The act pertains to all employees who are exposed to an occupational health "risk" and all asbestos mines are classified as "risk work"(86). The act, however, does not cover medical expenses to treat disease. Furthermore, although disease caused by domestic and industrial environmental exposure to asbestos is a problem, there is currently no legislative framework to provide health services or compensation for those who did not work in the mines. In addition, there is no mechanism to compensate the many women who worked on the mines, but who were never recorded as official mine employees(87). As stipulated by the 1996 Mine Health and Safety Act, the medical surveillance of an active miner is the responsibility of the employer. Once unemployed, workers are entitled to receive free BMEs every two years as provided through the MBOD(88).

The MBOD is a directorate within the National DoH. The Certification Committee, a tripartite committee including stakeholders from labour, the mining industry, and government, certifies miners with occupational lung diseases as defined by the ODMWA. Currently, there are three levels of compensable lung diseases: first degree, second degree, and TB current. Second degree disease is defined as greater impairment than first degree and results in a higher compensation award(89). The amount of compensation is based on the salary of the worker in accordance with a formula predetermined in ODMWA, and consists of a lump sum benefit or a pension.

In order to apply for worker compensation, mineworkers must first apply through the MBOD. The MBOD application requires the following:

Once the MBOD determines compensation eligibility, the Bureau notifies the claimant of its decision in writing. A copy of this letter is also sent to the health service provider. In the case of a compensable disease finding, the letter is also sent to the Compensation Commissioner. Before distributing compensation, the Compensation Commissioner requires the worker to provide the following additional documentation:

Both the MBOD and the Compensation Commissioner are centrally based in Gauteng. Monies distributed for compensation come from a Mines and Works Account, funded by employer levies, and a State Account, funded by taxpayer monies(91).

If initially rejected, workers can reapply for compensation and are also eligible to advance from first degree to second degree compensation status. In addition, a worker's dependents may apply for compensation if the worker is deceased(92). Only the deceased worker's spouse and children less than 18 years of age are considered compensable dependents, and the statute of limitations from the time of death to the compensation claim filing date is three years.

Until the ODMWA was amended in 1993, the method for compensation was racially discriminatory, with white workers receiving compensation up to 13-fold greater than black employees having equivalent disease(93). In addition, prior to 1994, white and coloured miners were required to receive a certification of fitness from the MBOD, while black miners received only a superficial examination at the mines(94). This led to incomplete medical surveillance, and thus low access to compensation for black mineworkers. Before 1994, white ex-miners were entitled to a free BME by the MBOD every six months. When the Amendment Act opened the system to ex-miners of all races, the statute extended the time period between BMEs to two years in order to deal with the increased demand, according to senior officials at the MBOD and CCOD. Thus, although the Amendment Act of 1994 brought about the deracialisation of ODMWA, the new salary-based compensation system remains discriminatory(95).

According to a former official in the MBOD, attempting to integrate the large number of miners and ex-miners who were previously excluded from the compensation system has necessitated reaching out to neglected communities to inform members of their rights. The Bureau has made significant progress on this monumental task. They currently maintain over 800,000 files and have been computerising their records(96).

The National Asbestos Summit highlighted a number of concerns about compensation and provision of health services for ARDs. A major result of the Asbestos Summit was the recommendation that a National Commission of Inquiry be established to review the compensation system. Parliament should drive this process, and a proposal for a new system should be produced(97). The Asbestos Summit identified the following problems with, and improvements needed to, the system of compensation:

As a result of some of the problems with the compensation system identified above, many eligible South Africans, especially those in poor, rural areas, do not receive compensation(99). To remedy this problem, the Asbestos Summit identified the following issues to be addressed as a matter of urgency during the creation of a new system:

Throughout the Asbestos Summit, presenters advocated for collective involvement. They stressed that the new compensation system should "build on the resources of local communities as well as those provided by the state and industrial developers"(102) Our study used the Asbestos Summit as a starting point to assess perceptions of the compensation system among officials and affected people. A summary of problems identified in our interviews with the current system is provided below.

7.2.2 Barriers to Compensation

7.2.2.1 Confusion and Lack of Information
"There is a lot of confusion among South Africans about compensation." - a Senior Official at the CCOD

One of our most consistent findings is that people generally knew very little about the compensation system. Few people knew how ex-miners or their families could apply for compensation and in each of our interviews, people said that no one had explained the system to them. We therefore decided to explain the application process in each village that we visited. It is interesting to note that before this explanation, people expressed few opinions about the compensation system, while afterwards, it was often difficult to end our meetings due to extensive discussion on the topic. People at Ncweng wondered why no one from Batlharos hospital had come to "highlight them" about the compensation system. They identified the DoH as the organisation that should take responsibility for this task.

In our interviews, it was clear that the second phase of the process - after the MBOD has certified disease - is particularly confusing. A senior official at the MBOD told us that once clients receive the letter from the MBOD, they believe that the compensation money will arrive shortly. Many people do not know that they must send further documentation to the CCOD. Our findings confirmed the assessment of the MBOD. For instance, a man from Sedibeng showed us a letter that he had received from the MBOD in 1998, certifying him with compensable disease and requesting further documentation. He had done nothing with the letter and did not know how to proceed. As discussed earlier, even physicians in the area lack information about the compensation process.

7.2.2.2 Access to Health Services and Diagnosis
Since the compensation process begins with a BME, barriers to diagnosis, treatment, and access to health services for ARDs also impact one's ability to be compensated for ARDs (See Section 7.1.2.4). Many people who believe they suffer from ARDs complained that doctors at local clinics and hospitals routinely send them home with a clean bill of health. Ex-miners in both Sedibeng and Seven Miles spoke of discrepancies between local doctors' diagnoses and the MBOD's findings. A person at Seven Miles said, "We are not satisfied, because when doctors check our lungs here, they find a problem, but when we send the results to the MBOD, the letter they send to us says that we are just fine." Officials have also criticised the accuracy of the certification process. While an ex-miner has the right to appeal the MBOD's decision, the appeals process is slow and carries a statute of limitations of only 18 months. Since ex-mineworkers generally lack an understanding of the process, appeals to the MBOD require considerable initiative by committed health service providers.

It is important to note that many of the people to whom we spoke are in desperate need of the income that compensation could provide. We found that many people were actually upset when given a clean bill of health. Thus, frustration around diagnosis may be as much a result of the general poverty of the region as an indication of actual under-diagnosis of sick ex-mineworkers.

When an ex-miner dies, there are additional barriers to the diagnosis necessary to compensate dependents. If the worker has died recently, the heart and lungs must be sent to the NCOH. However, we encountered a strong reluctance to comply with this stipulation based on an unwillingness to desecrate the deceased. Even if a family would agree to a post mortem, doctors are often unaware of a deceased individual's mining history and thus fail to indicate ARDs as the cause of death. Family members are often unaware of their rights, and neither argue for a more accurate diagnosis nor request an autopsy. When family members fail to apply for compensation immediately, many have trouble recovering the necessary X-rays, hospital records, and labour documentation to apply later. This confusion coupled with a short statute of limitation makes acquiring benefits extremely difficult.

7.2.2.3 Corruption
The compensation system is beset with fraud. Literate and knowledgeable individuals often take advantage of ex-mineworker's lack of information about the application process, offering false or actual assistance in exchange for an initial fee or a percentage of an ex-mineworker's compensation award. Such corruption is a well-documented problem in both the Northern Province and Mpumalanga(103). Fraud exists in the Kuruman area as well. People in Ga-Mopedi, Sedibeng, and Seven Miles paid someone in Kuruman to speed the process of compensation. In Sedibeng and Seven Miles, we heard rumours about a large sum of money "from overseas" waiting in Kuruman to compensate people. This story led to false hope. The people of Ga-Mopedi, already aware that they had been deceived, called for an extensive police investigation. (See Section 8.1.2.2 for a more detailed explanation of the compensation fraud that occurred in the Kuruman area)

Aside from violating the law, compensation fraud adds to people's confusion. Once they pay a corrupt agency, people wait a long time for money that will never arrive. During this time, they do not follow any legitimate compensation procedures. Since the first part of the compensation application must be filed through a practitioner approved by the MBOD, more people are vulnerable to assistance scams during the second phase of the process. A senior official at the CCOD described fraud prevention as the main motivation behind the request for further documentation. It is ironic that the round of compensation designed to allay corruption actually creates enough confusion to facilitate deception.

7.2.2.4 Labour History
Difficulty in obtaining an adequate labour history is a major barrier to receiving compensation. Under apartheid, many workers were not properly registered at the mines. This is an especially severe problem for many women who worked at mines informally(104). In addition, many health service providers are not trained in occupational health, and do not ask about labour history. As a result, people often fail to obtain the paper documentation of risk work that is necessary for compensation. Even when occupational health nurses at public health clinics, such as the clinic at Batlharos Hospital, are trained to assist in taking labour histories, people have trouble remembering their exact work histories. In addition, the proper evidence often does not exist in the mining records or the cost of obtaining evidence is prohibitive. For example, Gefco, the main asbestos mining company in the Kuruman area, charges ex-mineworkers R25 to process their proof of labour. The people with whom we spoke uniformly object to this charge, stressing that most people cannot afford this expense, and asserting their opinion that Gefco is unjustly charging people for what is rightfully theirs. Furthermore, Gefco will soon close its Kuruman office. Records will be deposited at a central warehouse in Kuruman, but it is unclear whether former workers will have easy access to their records.

Participants at the Asbestos Summit supported creating a system to accept oral evidence of labour history(105). This recommendation was supported by a senior official at the NCOH who suggested that applicants could speak face-to-face with a group of assessors. While it may seem that this strategy would invite more fraud, it would prevent many eligible ex-mineworkers from being denied compensation simply on the basis of illiteracy and faulty record-keeping by industry. As for the concern that such a system would be more administratively difficult and expensive, we observed that the requirement of paper documentation renders the current process unnecessarily long and wasteful, and prevents many workers from receiving compensation.

7.2.2.5 Inefficiency
"Many even amongst the dead have had the doctor tell them that they are sick, but they have not got compensation." -Resident of Ga-Mopedi

"The amount of compensation should be increased, and it should not be such a long, long process."-Resident of Sedibeng

According to the experiences of the IHRG, "it may take, on average, between 6-8 months for claims to be certified by the MBOD and settled by the CCOD"(106). According to the NCOH, the average lag time for a claim under ODMWA is 3 years. In every village we visited, people uniformly calling for a faster compensation process. We heard complaints that people who had X-rays sent to the MBOD have yet to receive any results. Many were concerned that ex-mineworkers die while waiting for their results. A man at Ga-Mopedi said, "Many even amongst the dead have had the doctor tell them that they are sick, but they have not got compensation." Furthermore, although many of the people we spoke with told us that they have applied for compensation, few told us that they had received benefits. Confusion about the application process and unwillingness to discuss personal finances may partially explain these findings, it is nonetheless evident that the compensation system remains sluggish.

7.2.3 The Legal Framework
As identified in the Asbestos Summit, there are deficiencies in the current compensation legislation. In our interviews, we encountered criticism of the compensation laws, as well as suggestions for improvement.

7.2.3.1 Exposure to Industrial Contamination of the Environment
"I went to the doctor and he diagnosed me with asbestos disease, but I never worked in the mines. How can I get compensation?" - Resident of Ga-Mopedi

We encountered a great deal of concern about people that had never worked in the mines falling ill with ARDs. A private medical practitioner in Kuruman sees as many as two patients with mesothelioma each week, many of whom never worked in the mines or in the processing or transport of asbestos. In addition, recognising the substantial contamination of their villages by asbestos, people were deeply concerned about future illness for themselves and their children. A man from Kuruman remarked, "The fibres travel very far and into town. What about my children living in town?" A man from Seven Miles said, "Asbestos affects all breathers, but the law only compensates ex-miners." As a result, the people we spoke with insisted that those suffering from ARDs contracted though environmental exposure be compensated. A man from Ncweng said, "Why does it happen that if you are driving a car, and you get in an accident with a third party, and the car collapses killing a baby, the insurance must pay for the baby, even though it was not driving? We don't accept compensation only for mineworkers."

Government officials and NGOs also support compensating non-ex-mineworkers suffering from environmental exposure to industrial contamination. Many hoped that the Cape Plc. case would set a precedent to allow additional claims against multinational companies. While this prospect may provide relief in the future, the issue of compensation for environmental exposure also needs to be dealt with independently of litigation. Officials and residents of affected villages were well aware that the outcome of litigation is uncertain and that the multinational companies may go bankrupt to avoid responsibility. A senior official at the CCOD suggests that the government could create an entirely separate legal framework to deal with compensation for the environmentally exposed. Others argue that further fragmentation of the compensation system should be avoided. According to a senior official at the NCOH, an interim measure might be to compensate all sufferers from mesothelioma, since mesothelioma is specific to asbestos and the rates are relatively low. Other strategies must be developed to compensate people suffering from asbestosis and asbestos-induced lung cancer, who never worked on the mines.

7.2.3.2 Fragmentation of Responsibility for ARDs
"Responsibility for compensation is divided between two government departments with different administrative criteria for assessing claims and making awards, resulting in an inequitable [and inefficient] system"(107).

The division between COIDA and ODMWA causes confusion about and inconsistencies in occupational health service provision and compensation. ODMWA only covers lung disease, while COIDA covers all diseases and injuries. Only ODMWA provides the free benefit examinations necessary to diagnose ARDs in unemployed workers, while only COIDA provides for the medical care and treatment of workers(108). Thus, an ex-mineworker with an occupational ailment other than lung disease may find it difficult to access diagnostic services. At the same time, an ex-mineworker with lung disease may not be able to obtain medical care. In a few of our interviews, ex-mineworkers complained of non-respiratory ARDs involving the eyes or the skin, but did not know where to seek assistance. We also found substantial frustration around the difficulty of obtaining medical care for ARDs. As the Asbestos Summit recommends, South Africa needs a single body legislated to deal with compensation for all occupational illnesses(109). Whatever legal framework is adopted should ensure that all people suffering from any ARDs have adequate access to diagnostic services, compensation, and medical care.

7.2.3.3 Post-Mortem Requirement
One stipulation within ODMWA, the required post mortem upon an ex-mineworker's death, conflicts with commonly held values in the Kuruman area. People are reluctant to subject the deceased to a post mortem. In Sedibeng, a young woman asked, "If you remove the heart and lungs, will you not delay the process of a funeral?" The Constitution of South Africa states that the government "may not unfairly discriminate directly or indirectly against anyone on one or more grounds . . . "(110) Many people feel that the post mortem requirement discriminates against their religious beliefs and cultural norms. ODMWA was created under the apartheid government in 1973, and amended in 1994.

7.2.3.4 Age Limits on Inheritance
Our informants expressed dissatisfaction with the fact that only spouses and children under the age of 18 may receive compensation for a deceased mineworker. A man at Ncweng said, "This law is discriminating. I think that even if I am 50 years old, anything that belonged to my parents is my inheritance. The people who make this law have no right to change our customs." Of course, democratically made laws may contradict some people's customs. However, rather than broadly applying existing legislation, laws should reflect a consensus among government officials and citizens. It is necessary to listen to all voices before crafting legislation as sensitive as compensation law.

7.2.3.5 Using Workers' Wages to Calculate Compensation
"Using wages for compensation is almost identical to using race." -Senior Official at the CCOD

Apartheid law stipulated higher compensation for whites than for other racial groups, but the current law bases compensation on the wage formerly earned. Historically, wages for blacks were substantially and consistently below those for whites. The amount of compensation for black workers is extremely low -- less than 4 months' wages(111). One woman in Sedibeng described the compensation that she received after her husband's death in a mining accident. The total amount of compensation was extremely low, only R3 980, and was allocated as a monthly pension of only R15. At the time, she was raising five children, and she maintained that compensation did not even begin to alleviate her difficult circumstances. Thus, although the 1994 Amendment Law was designed to deracialise ODMWA, a senior official at the CCOD asserts that "using wages for compensation is almost identical to using race." This indirectly discriminates against black mineworkers and creates a large discrepancy in compensation benefits between blacks and whites. Although there have been attempts to decrease this gap, the difference still remains large(112). We should note, however, that white ex-miners in Kuruman, who have received far greater compensation sums than the majority of blacks would receive, told us that their benefits also fall far short of the amount necessary to cover basic medical expenses. A senior official at the CCOD said that they have proposed an amendment to the law to deal with this issue.

7.2.3.6 Individual versus Collective Compensation
With limited resources to amply compensate people, the government may seek to supplement the impact of individual compensation claims by collectively compensating communities affected by ARDs. Villages with high rates of retrenchment and illness resulting from the legacy of asbestos mining could put collective compensation monies towards development efforts aimed to expand access to education, proper housing and sanitation, and health services. The people of Seven Miles promoted this idea: "We want compensation for the whole village to help ourselves. We have no hope, and are condemned by asbestos." This potential solution could be administrated through a structure such as the Presidential Trust Fund described in the Asbestos Summit. In order to consolidate resources and cut down on repetition and fragmentation, any efforts of collective compensation should occur via collaboration between the Departments of Labour, Health, and Welfare. In addition, the government should seek ways to hold multinational asbestos companies accountable as a means of partially recovering costs for these efforts(113).

7.2.4 Conclusion
There are numerous barriers to accessing compensation. In addition, payments are low, and the industrial environmentally exposed are overlooked. Too often compensation has little impact on the quality of life in areas affected by asbestos. A new legal framework for compensation should be developed as part of an integrated strategy to relieve and develop areas devastated by the legacy of asbestos mining. In the meantime, existing community structures should be engaged to optimise benefits under the current system. The government has already made significant efforts in this respect. In interviews with us, many officials made proposals to improve compensation legislation. At present, the recently constituted Committee of Inquiry into Comprehensive Social Security will be important.

7.2.5 Recommendations

7.3 Health Education and Promotion

7.3.1 Background
Previous sections of this report have emphasised that people exposed to asbestos want information about how to navigate the health care and compensation systems. In addition, people who live in areas contaminated by asbestos also need knowledge about prevention of exposure and rehabilitation of their land. Educational programmes have the potential to integrate knowledge of the dangers of asbestos with the development and transfer of skills so necessary to lay the foundation for a new economic base in impoverished areas. Most of the people we spoke with, whether government officials or residents of affected villages, recognise that the most effective educational programmes are participatory. Participatory educational programmes, which involve all stakeholders, can also be linked to research that helps people to identify and to prioritise their needs, as well as to develop organisational structures to disseminate information about why their villages are polluted, how to protect themselves from further exposure to asbestos, and how to access health services and compensation. In this section, we discuss educational and research initiatives of governmental departments, community organisations, trade unions, and researchers that have the potential to address the problem of asbestos exposure in highly effective ways.

7.3.2 Findings

7.3.2.1 Role of Local Activists
"When my children come in from playing in the garden, I have to pick blue fibres out of their hair. My husband died of asbestos. What is going to happen to my children now?" - Woman from Ga-Mopedi.

People we interviewed in the Kuruman district are deeply concerned about the contamination of their villages by asbestos. They see the deadly blue fibres in the streets, in the bricks of their houses, in their schools, and in the unrehabilitated dumps and mines on a daily basis. For them, the health effects of asbestos exposure are inescapable.

In the Northern Cape, CPAA in Prieska has been active in raising awareness of the tragedy of ARDs. They are well organised, informed, and trusted due to their honest and committed leadership. CPAA holds frequent public meetings in Prieska, which are very well attended. Over the years, they have established good working relationships with many local and provincial government officials. They help residents apply for compensation by disseminating information about the compensation process, sending sick people to the hospital for examinations, sending forms to the MBOD for people, and following up on compensation claims. They have accomplished much with a minimal budget but they have no office, phone, fax machine, or computer to facilitate their work.

Using their knowledge about asbestos and ARDs, CPAA has been able to lobby the government to remove all asbestos-containing roofs in the area, while ensuring the protection of the people who did the work. Major priorities of CPAA include plastering the walls of houses containing asbestos fibre bricks and demolishing and rebuilding the local school. (The school was built with asbestos-containing materials and currently has a long-jump pit softened by the blue fibres.) CPAA also wants to ensure that rehabilitation is conducted in a safe and sustainable way. This group, in particular, is in a position to help groups in other affected towns and villages organise themselves.

We found the potential for similar community organisation in the Kuruman area. The Ncweng Asbestos Committee is part of the General Health Committee of the Local Development Forum. The Committee is well informed about the dangers of asbestos and has been in contact with a number of governmental departments. They told us that they have been unsuccessful thus far in establishing a meaningful relationship with the local hospital, but continue to pursue contact. The Ncweng Asbestos Committee has already gone door-to-door in an attempt to estimate the prevalence of ARDs in the village, and to help people interpret their diagnoses. They have even sent fifteen people to the MBOD in Johannesburg for BMEs. During our research, outreach by the Ncweng group inspired the formation of a similar asbestos committee at Sedibeng. Although groups like the CPAA and the Ncweng Asbestos Committee show great promise, they are in grave need of resources to develop their work.

Although community organisations are an under-utilised asset, complex local politics may make these organisations fragile. Self-interested individuals may attempt to control organisations for the small financial benefits they might offer. As a senior official at the CCOD explains, "Community involvement should not be left unmonitored, because you will find that some have their own agendas. . . . We want seasoned community leaders representing social causes-not ones that crop up simply because of the compensation issue."

7.3.2.2 Role of Non-Governmental Organisations
Nationally, some NGOs have been involved in participatory health education throughout South Africa. The IHRG, for example, has run focus groups in Mpumalanga to educate people about asbestos-related issues, such as health care and compensation and, as discussed earlier, the training of doctors and nurses in diagnosis and management of ARDs(114). The IHRG has also been involved in occupational health and safety training of workers asbestos user industries. Another organisation involved in health education is the PPHCN, a national organisation whose office in the Western Cape we visited during our research. This programme trains elected and employed local people in a number of health care concerns so that they act as a liaison between local residents and officials. These people also act after hours as health care advisors and counsellors. Such a programme has not been tested in rural areas like the Northern Cape and North-West provinces but there is much to learn from the experience of such groups in training local people and health care providers.

At the moment, there are no NGOs specifically focused on the asbestos problem in the Northern Cape or North-West provinces. Some local organisations, such as the Moffat Mission in Kuruman and the Tswelolepele Initiative in the Ga-Segonyana and Moshaweng districts are committed to expanding their mission to include ARDs. The Moffat Mission currently conducts continuing education programmes focused on skills development and job creation which, in collaboration with local activists and with additional funding, could be utilised to address education about asbestos contamination and disease.

7.3.2.3 Participatory Research on ARDs
For political and methodological reasons, including the disinterest or inexperience of researchers in working with remote rural populations, few formal epidemiologic studies on ARDs have been conducted in the Northern Cape and North-West Province, and around Kuruman in particular. Some researchers, however, have worked effectively in other rural areas suffering asbestos. Felix's work in Mafefe in the 1980s and 1990s was instrumental in the formation of active community groups to educate people on the dangers of asbestos, and to advocate for compensation and rehabilitation. Discussions with community organizations and researchers in the Northern Cape and the North-West suggest that potential exists for similar efforts there, especially in Prieska where asbestos health-related structures are fairly well developed. The Asbestos Summit similarly encouraged participatory research and decision making to find collective solutions.

7.3.2.4 Public Outreach on Rehabilitation (See section 6.2.5.7 Local Involvement)

7.3.2.5 The Role of Trade Unions in Linking ARD Education to Skills Development

Programmes at the Everite Asbestos Cement Factory
Trade unions are ideally positioned to educate workers and their families about the dangers of asbestos and to work to re-skill former asbestos workers when they are retrenched. CAWU (now the NUM) conducted an awareness campaign in collaboration with the IHRG. More recently, the NUM has been instrumental in negotiating for an agreement with the company to sell the land where the workers have lived in hostels since the company opened in 1946. The housing units were built with asbestos-containing materials and are currently in disrepair. The development plan is funded by the South African government, personal savings of residents, and grants. It calls for the construction of new housing units to be built by former workers which will prepare the retrenched workers for jobs in the construction industry.

The NUM Skills Development Centre
The NUM is concerned about developing training programmes and sustainable development projects to assist retrenched and unemployed workers and their families, regardless of whether people are active members of the NUM. The NUM has an active centre in Batlharos that serves the Ga-Segonyana and Moshaweng municipalities. Many of the asbestos mines in the area were never unionised, but the skills development office is open to all people who are unemployed in the area. Most classes cost between R90 and R100, and the NUM pays about R900 for each student in the class. The classes are centred on developing agricultural and production as well as technical and business skills (e.g. chicken farming, brick making, fence making, and bread baking). They train between ten and twenty people per month and have about fifty inquiries per month.

7.3.2.6 The Role of Hospitals and Clinics in Education about ARDs
"Under the new district health care system, the Department of Health aims] to foster community participation across the health sector, to involve communities, in the planning, management, delivery, monitoring, and evaluation of health services to establish mechanisms to improve public accountability dialogue and feed back between the public and health providers and to encourage communities to take greater responsibility for there own health promotion and health care." -PPHCN document: "Community Involvement in Health."

Clinics and hospitals in the Northern Cape and North-West provinces are making serious efforts to educate people about health care and compensation. For example, Kimberley Hospital has just built an occupational healthcare unit that runs an extensive advertisement campaign about the availability of BMEs and compensation assistance. The occupational health care nurse in this unit said that much of their time was spent educating and helping people fill out compensation claims, and that 95% of the claims that they process are for ARDs.

The Batlharos clinic, located in the North-West Province, helps people complete compensation forms. They also have educational outreach programmes in the villages where we did interviews. Their goal is to hold a meeting every month; however, because of a lack of transportation, they are only able to visit about every three months. In addition to face-to-face meetings, the clinic also uses the radio to provide basic information about obtaining a BME and to advertise that their services are free. The people we spoke with in the villages, however, noted that these programmes were not reaching many people who they thought were entitled to compensation and medical care.

The Ncweng Asbestos Committee would like to work more closely with the DoH. This group said that they were in a position to educate residents of their village about health and compensation, if they had funding from the DoH.

7.3.2.7 The Role of Public Schools
"Schools are central to the education for all. We need a programme of public education through the schools." - 1998 Asbestos Summit.

At the 1998 National Asbestos Summit, the Department of Education (DoE) was asked to join the alliance of government departments that were dealing with asbestos. The DoE has set up educational programmes in the villages that we visited in the North-West Province. The DEAT has petitioned the DoE to include environmental education into their new curriculum for 2005 to both educate students about the environment and to increase awareness of health and environmental career opportunities, such as in rehabilitation and pollution prevention. Such a programme may be helpful in addressing the long-term concerns of asbestos clean-up, as well as immediate health concerns of children in asbestos-contaminated areas.

7.3.3 Conclusion
Education about the many dimensions of the problem of asbestos is a pressing need in the Kuruman region. There are presently many structures in place that, with additional resources and support, could be utilised effectively to implement educational programmes linked to participatory research and skills development. On the basis of our discussions with many people in the Northern Cape and North-West provinces, we offer the following recommendations.

7.3.4 Recommendations

  1. South Africa, Department of Health, 1997. White Paper for the Transformation of the Health System in South Africa (South Africa: Department of Health, 1997).
  2. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001." The Industrial Health Research Group, University of Cape Town: 14.
  3. Strachan, Kathryn. "Growing pains in the district health system.": 1.
  4. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001." The Industrial Health Research Group, University of Cape Town: 16
  5. Morello, C. February 1999. "South Africa's blacks never knew that asbestos was killing them."
  6. Talent, J.M., W.O. Harrison, A. Solomon and I. Webster. 1980. "A survey of black mineworkers of the Cape crocidolite mines."
  7. MBOD, 2000. Annual Report of the Medical Bureau of Occupational Diseases. South Africa, Department of Health.
  8. Kisting, S., M. Jeebhay, and F. Abdullah. 1997. "Respiratory health surveillance programmes on asbestos mines in South Africa - Findings of medical audits over a five year period."
  9. Davies, J.C.A., B.G. Williams, M.A. Debeila, and D.A. Davies. 2001. "Asbestos-related lung disease among women in the Northern Province of South Africa."
  10. Many of the Gauteng case reports are in fact ARD cases from the Northern Province, but because the reporting physician was based in Gauteng Province they are compiled there. See SORDSA, January, 1999. Vol. 2 No. 4.
  11. Jeebhay, M. F. et al.. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001." The Industrial Health Research Group, University of Cape Town: 11.
  12. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.": 11.
  13. Mdluli, J. and Banyini, A. "The Guidelines of ODMWA." Informational pamphlet. Medical Bureau for Occupational Diseases.
  14. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  15. Mdluli, J. and Banyini, A. "The Guidelines of ODMWA." Informational pamphlet
  16. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.": 11.
  17. Mdluli, J. and Banyini, A. "The Guidelines of ODMWA." Informational pamphlet.
  18. Mdluli, J. and Banyini, A. "The Guidelines of ODMWA." Informational pamphlet.
  19. Mdluli, J. and Banyini, A. "The Guidelines of ODMWA." Informational pamphlet.
  20. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.": 20.
  21. Abdullah, F. et al. 1994. "Opinion: Occupational Diseases in Mines and Works Act, 1993." South African Journal of Medicine.
  22. Jeebhay, M. F. et al., "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.": 12.
  23. MBOD, 2000. Annual Report of the Medical Bureau of Occupational Diseases. South Africa, Department of Health.
  24. Jeebhay, M. F. et al., "Submission to the Committee of Inquiry into Comprehensive Social Security-2001."
  25. Jeebhay, M. F. et al., "Submission to the Committee of Inquiry into Comprehensive Social Security-2001."
  26. IHRG. February 2001. "Report on the IHRG Visit to Implement Stage 1 of the Mpumalanga Asbestos Project." The Industrial Health Research Group, University of Cape Town: 5-9.
  27. Jeebhay, M. F. et al., "Submission to the Committee of Inquiry into Comprehensive Social Security-2001."
  28. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  29. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  30. IHRG. February 2001. "Report on the IHRG Visit to Implement Stage 1 of the Mpumalanga Asbestos Project."
  31. McCulloch, Joch. "The History of Asbestos." Lecture. 21 June, 2001, District Six Museum, Cape Town.
  32. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  33. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.": 13.
  34. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.":21.
  35. Jeebhay, M. F. et al. 2001. "Submission to the Committee of Inquiry into Comprehensive Social Security-2001.":21.
  36. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  37. No. 108 of 1996: Constitution of the Republic of South Africa, 1996: 8
  38. Felix, M.. 1991. "Risking their lives in ignorance." In Going Green. ed. Cock, J. and Koch, E. Cape Town: Oxford University Press.
  39. Abdullah, F. et al. "Opinion: Occupational Diseases in Mines and Works Act, 1993."
  40. The National Parliamentary Portfolio Committee on Environment and Tourism. National Asbestos Summit Final Proceedings. November 1998: Esselen Park, Johannesburg.
  41. IHRG. February 2001. "Report on the IHRG Visit to Implement Stage 1 of the Mpumalanga Asbestos Project." The Industrial Health Research Group, University of Cape Town.