Growing consensus indicates that progress in tuberculosis control in the low- and middle-income world will require not only investment in strengthening tuberculosis control programs, diagnostics, and treatment but also action on the social determinants of tuberculosis. However, practical ideas for action are scarcer than is notional support for this idea. We developed a framework based on the recent World Health Organization Commission on Social Determinants of Health and on current understanding of the social determinants of tuberculosis. Interventions from outside the health sector-specifically, in social protection and urban planning-have the potential to strengthen tuberculosis control.

Recent theoretical work hypothesises that a polarised society like South Africa will suffer a legacy of ineffective social capital and blocked pathways of upward mobility that leaves large numbers of people trapped in poverty. To explore these ideas, this paper employs a mix of quantitative and qualitative methods. Novel econometric analysis of asset dynamics over the 1993-98 period identifies a dynamic asset poverty threshold that signals that large numbers of South Africans are indeed trapped without a pathway out of poverty. Qualitative analysis of this period and the period 1998-2001 more deeply examines patterns of mobility, and confirms the continuation of this pattern of limited upward mobility and a low-level poverty trap. In addition, the qualitative data permit a closer look at the specific role played by social relationships. While finding ample evidence of active social capital and networks, these are more helpful for non-poor households. For the poor, social capital at best helps stabilise livelihoods at low levels and does little to promote upward mobility. While there is thus some economic sense to sociability in South Africa, elimination of the polarised economic legacy of apartheid will ultimately require more proactive efforts to assure that households have access to a minimum bundle of assets and to the markets needed to effectively build on those assets over time.

Investing in social protection in sub-Saharan Africa has taken on a new urgency as HIVand AIDS interact with other drivers of poverty to simultaneously destabilise livelihoods systems and family and community safety nets. Cash transfer programmes already reach millions of people in South Africa, and in other countries in southern and East Africa plans are underway to reach tens and eventually hundreds of thousands more. Cash transfers worldwide have demonstrated large impacts on the education, health and nutrition of children. While the strongest evidence is from conditional cash transfer evaluations in Latin America and Asia, important results are emerging in the newer African programmes. Cash transfers can be implemented in conjunction with other services involving education, health, nutrition, social welfare and others, including those related to HIV and AIDS. HIV/ AIDS-affected families are diverse with respect to household structure, ability to work and access to assets, arguing for a mix of approaches, including food assistance and income-generation programmes. However, cash transfers appear to offer the best strategy for scaling up to a national system of social protection, by reaching families who are the most capacity constrained, in large numbers, relatively quickly. These are important considerations for communities hard-hit by HIV and AIDS, given the extent and nature of deprivation, the long-term risk to human capital and the current political willingness to act.

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