When the coughing started, Noxolo* thought it was just a stubborn flu. But weeks later, the night sweats, exhaustion and weakness forced the seasonal farm worker from Khayelitsha to seek help — a visit to the clinic that would change her life and cost her a season of work on a Cape wine farm.
Noxolo says she initially ignored the symptoms.
“When I started coughing, I didn’t think much of it. I thought it was just normal flu, and it would pass. But I had night sweats and struggled to go to work because I felt weak. My husband suggested that I should go to the clinic,” she said.
She eventually visited Kuyasa Clinic in Khayelitsha, where tests confirmed she had tuberculosis (TB). The diagnosis meant she had to begin months-long treatment and miss out on seasonal work she depends on to support her family.
Her story is far from unique.
South Africa is among 30 countries globally with the highest TB burden. In 2023 alone, more than 270,000 people were diagnosed with the disease, and about 56,000 died.
Health experts say agricultural workers are particularly vulnerable.
Research by the University of Pretoria found that workers in the agricultural sector face an increased risk of TB due to several interacting factors, including exposure to silica dust, infection from co-workers and the socio-economic conditions many workers live in.
The study conducted in agricultural communities in Limpopo, published in 2023, recorded extremely high TB incidence among farm workers — 1,685 cases per 10,000 agricultural workers — highlighting how exposed the workforce can be.
Because TB treatment lasts several months and patients are often already ill by the time they are diagnosed, the disease can remove workers from farms for long periods.
Living and working conditions fuel risk
Neeltjie Le Roux, programme manager at the Aurum Institute, a leading healthcare organisation dealing with HIV and TB in South Africa, says the conditions in which many farm workers live and work contribute to the spread of TB.
“Many workers live in crowded accommodation on farms, which increases the risk of TB spreading,” she said.
“Farms are also often far from clinics or hospitals. Most workers don’t have their own transport and rely on taxis or lifts, which can be expensive. Going to the clinic often means losing a full day of work and pay.”
Sometimes people relocate practically overnight when work on one farm ends, and they move to another farm where work is available. This movement makes it difficult to maintain continuity of care for TB, which requires several months of treatment.
— Neeltjie Le Roux, programme manager at the Aurum Institute
Because many workers support extended families, they frequently prioritise earning money over seeking medical care, even when they have symptoms.
Seasonal labour patterns also complicate treatment.
“Farm workers often move between farms depending on where work is available,” Le Roux said.
“Sometimes people relocate practically overnight when work on one farm ends, and they move to another farm where work is available. This movement makes it difficult to maintain continuity of care for TB, which requires several months of treatment.”
As a result, workers often face a difficult choice between protecting their health and maintaining their income.
The danger of delayed diagnosis
Early detection of TB is critical, both for patients and for communities where they live and work.
“When someone with TB starts treatment, their infectiousness usually drops quite quickly,” said Le Roux.
“But if people delay getting tested or interrupt treatment, TB can continue to spread, especially in crowded living environments on farms.”
Screening programmes can help identify cases early, but reaching farm workers is not always easy.
“Farm workers are often considered a hard-to-reach population because of where farms are located and because the workforce is highly mobile,” she said.
Given that the sector relies predominantly on unskilled labour and employs a significant number of seasonal workers annually, it can be challenging to quantify the precise impact that the ill-health of one or two workers may have on overall sector sustainability.
— MEC Ivan Meyer
According to Le Roux, screening initiatives are far more effective when farmers and agricultural organisations cooperate.
“When farms allow access, it becomes possible to organise mass screening activities directly on farms, which helps identify cases earlier.”
However, the department of health often lacks the resources to conduct routine outreach to farms, meaning many screening programmes depend on NGOs and donor-supported initiatives.
Some farms have tried to support treatment adherence by training administrative staff to assist with Directly Observed Treatment (DOT), allowing workers to take their medication on the farm instead of travelling daily to clinics.
Workers diagnosed with TB are usually booked off work for the first two weeks of treatment when they are most infectious, after which many can return to work while continuing treatment.
Impact on farms and food production
The Western Cape department of agriculture says the health of farm workers is essential for the sustainability of the sector.
MEC Ivan Meyer said agricultural workers form the backbone of the industry.
“Given that the sector relies predominantly on unskilled labour and employs a significant number of seasonal workers annually, it can be challenging to quantify the precise impact that the ill-health of one or two workers may have on overall sector sustainability,” he said.
“But the cumulative effect of health risks within the workforce remains an important consideration for long-term productivity and stability.”
Le Roux notes that agriculture is particularly labour-intensive, especially in fruit, wine, horticulture and dairy farming.
“When workers become ill with TB, it can affect productivity in several ways. Workers may be absent from work for periods of time, or they may not be able to perform physically demanding tasks while they are ill,” she said.
During harvesting periods, even a small reduction in the workforce can slow down the picking and processing of crops.
In dairy farming, the impact can be immediate because daily operations such as milking must happen at fixed times.
“If a worker is diagnosed with infectious TB, farms may need to temporarily remove them from certain duties until treatment starts and they are no longer infectious,” she said.
The challenge of hidden illness
Meyer said employers are often unaware when workers fall ill.
“The health status of individuals remains confidential, and agricultural workers are under no obligation to disclose their medical conditions,” he said.
Untreated illnesses can affect productivity across any sector, he added.
Though seasonal labour can sometimes replace workers who fall ill, the broader impact of disease within the workforce should not be underestimated.
“Untreated diseases within the workforce can influence overall productivity, labour stability and the long-term resilience of the agricultural sector,” Meyer said.
Efforts to improve healthcare access
Over the past five years, the Western Cape department of agriculture has introduced healthcare worker training for farm workers in partnership with the Western Cape department of health and wellness.
The programme trains agricultural workers to serve as on-farm healthcare workers who can assist colleagues and liaise with local clinics.
The initiative has primarily been implemented in the Cape Winelands, where large numbers of farm workers live and work, and will expand to the Overberg District this year.
Nearly 80 workers have completed the training so far.
These trained workers collaborate with clinic staff, help distribute chronic medication and perform basic health assessments using first-aid kits supplied through the programme.
Health authorities also conduct screening and awareness campaigns during community outreach events, agricultural shows and public awareness initiatives.
For workers like Noxolo, however, the immediate reality remains the long road to recovery, and the loss of income that comes with it.
For now, she says her focus is on finishing her treatment and regaining her strength.
“I just want to get better so that I can go back to work again,” she said.
* Name changed to protect identity
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