1 3Mark Daku , Andrew Gibbs Jody Heymann2 , 1 2 McGill University, Political Science, Montreal, Canada; Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa

3 McGill University, Institute for Health and Social Policy, Montreal, Canada

For further information contact: Mark Daku, mark.daku@mail.mcgill.ca or Andrew Gibbs, gibbs@ukzn.ac.za

Representations of

XDR-TBin South African Newspapers

MethodsUsing the Factiva online newspaper archive, we collected articles which mention XDR-TB (and

variants of this keyword) from 18 South African newspapers between February 2004 to July 2009 [4].

This gave us a sample of 310 articles on XDR-TB. We categorised articles into themes, sub-themes,

and thematic networks according to Attride-Stirling's framework for thematic network analysis using

QDA Miner v3.2.1 [5, 6]. The networks were constructed, explored, and patterns were identified and

interpreted.

ResultsThe thematic network analysis identified two main dimensions:

causes of XDR-TB and treatment approaches/solutions.

Table 1Dominant media-identified causes of XDR-TB

Quote 1:

Sadly, resistance to cheap

and fast-acting “first-line”

treatments has emerged.

Because patients have all too

often failed to complete their

treatments, “multidrug-

resistant” (MDR) tuberculosis

has spread. Business Day,

10 March 2008”

Table 2Dominant media-identified treatment approaches/solutions

Ensuring treatment of patients: XDR-TB needed to be 'solved' by the effective treatment of patients who were living with the illness, by providing them with effective medication.

Adherence to first line medication: Paralleling the focus on patients' failures to adhere to first-line TB medication as a cause of XDR-TB, was the focus on the need to improve adherence to TB medication among patients.

Patient targeted approaches: This sub-theme focused on strategies directed at people living with XDR-TB to improve the chances of their treatment and reduce the likelihood of them infecting others. This however, typically revolved around limiting their human rights, through holding patients in hospitals against their wishes and so forth. (Quote 2)

Improved surveillance for XDR-TB: It was recognised that XDR-TB could only be solved if health practitioners could identify it quickly. The media also stressed the need for practitioners to understand the scale of the disease if it was to be managed effectively. (Quote 3)

This work is made possible by HEARD’s Joint Funding Arrangement (JFA) supported by:

Content and findings of this work do not necessarily reflect the views of the JFA partners.

BackgroundThe design and implementation of health policies are shaped by research,

funding, networks and popular understandings of health issues. In South Africa,

the media is a key source of information for those who develop and implement

these policies [1]. While the media can contribute to elite agenda setting, more

important for our purposes is the impact that the media can have by 'framing'

issues in specific ways. The media does so by selecting “some aspects of a

perceived reality and [making] them more salient in a communicating text, in

such a way as to promote a particular problem definition, causal interpretation,

moral evaluation and/or treatment recommendation” [2]. If elites are influenced

by the media, and the media consistently frames an issue in a particular way, this

is worthy of attention.

In this study, we are interested in understanding how the media frames health

issues by examining the case of Extensively Drug Resistant Tuberculosis (XDR-

TB) in South Africa. Current research emphasises XDR-TB's close relationship

with HIV/AIDS as an opportunistic infection [3]. Given that South Africa has one

of the highest levels of HIV-prevalence globally and has the largest reported

cluster of XDR-TB infections in the world, the effective management of XDR-TB

is a crucial issue for health policy makers in South Africa.

Individual Institutional

Largest sub-theme, focused on how patients with XDR-TB were likely to have acquired it due to poor adherence to TB medication (Quote 1)

Relatively small sub-theme, emphasised nosocomial transmission of XDR-TB in hospital settings

Costs of testing are high, resulting in people being diagnosed late

Quote 2:

To contain the further spread of drug-resistant TB, the

department decided to isolate patients infected with the XDR

strain. [Health Minister] Tshabalala-Msimang said this had not

been an easy decision, but had been taken with the interests of

the public in mind. Mail & Guardian, 28 March 2008

Quote 3:

The World Health Organisation (WHO) yesterday announced

plans to provide a new rapid test for multidrug resistant

tuberculosis (MDR-TB) to developing countries, the first

significant technological advance in fighting TB in more than

50 years. The test can give results within two days, a

dramatic improvement on today's tests, which take up to

three months in some parts of the world. Faster diagnosis

should lead to more effective treatment of patients with

MDR-TB, and help curb the spread of the disease, said

Martie van der Walt, scientist with the Medical Research

Council, which worked with the National Health Laboratory

Services to gather evidence that the test is reliable in routine

clinic conditions. Business Day, 1 July 2008

Individual Institutional Systemic

ConclusionOur analysis identifies a trend in South African media to identify a broad range of causes of XDR-TB,

while emphasising that treatment approaches should be directed at the individual.

It is within this frame that those in charge of designing and implementing XDR-TB programmes come

to understand the issue. Such an emphasis is problematic for two reasons. First, framing patients as

problematic leads to controlling, rather than empowering, approaches to treatment and prevention.

Second, it ignores an increasing body of evidence demonstrating the role of hospital and community

routes of XDR-TB infection and treatment [7-10]. The effect of the media, and its particular framing of

XDR-TB, may lead South African policy makers to make poor choices in regards to the most effective

way to treat and prevent XDR-TB.

Works Cited1. Jacobs, S. and K. Johnson, Media, Social Movements and the State: Competing Images of HIV/AIDS in South Africa. African Studies Quarterly, 2007.

9(4).2. McCombs, M., The Agenda-Setting Function of the Press, in The Press, G. Overholser and K.H. Jamieson, Editors. 2005, Oxford University Press: New

York.3. Gandhi, N., et al., Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South

Africa. The Lancet, 2006. 369(9547): p. 1575-1580.4. Dow Jones. Factiva. 2009; Available from: http://factiva.com/.5. Péladeau, N., QDA Miner version 3.2.1. 2009, Provalis Research: Montreal.6. Attride-Stirling, J., Thematic networks: an analytic tool for qualitative research. Qualitative Research, 2001. 1(3).7. Mitnick, C., et al., Community-Based Therapy for Multidrug-Resistant Tuberculosis in Lima, Peru. N Engl J Med, 2003. 348(2): p. 119-128.8. Basu, S., et al., Prevention of nosocomial transmission of extensively drug-resistant tuberculosis in rural South African district hospitals: an

epidemiological modelling study. The Lancet, 2007. 370(9597): p. 1500-1507.9. Bekker, L. and R. Wood, Community-based management of multidrug-resistant tuberculosis in South Africa [Editorial]. The International Journal of

Tuberculosis and Lung Disease, 2010. 14(4): p. 379-379.10. Heller, T., et al., Community-based treatment for multidrug-resistant tuberculosis in rural KwaZulu-Natal, South Africa. The International Journal of

Tuberculosis and Lung Disease, 2010. 14: p. 420-426.