Thabo Mokoena spent 22 years underground in the gold mines around Carletonville, a town about 80 kilometres west of Johannesburg. He started as a loader, then worked as a winch operator, and by the time he retired in 2018, his lungs had accumulated enough silica dust to cause progressive massive fibrosis. A clinic run by the Aurum Institute confirmed the diagnosis in 2020. Three years later, Mokoena is still waiting for his compensation claim to be processed. He is not alone.

Across South Africa's gold-mining regions, a crisis is growing. Clinics are diagnosing silicosis — a preventable, incurable occupational lung disease — in thousands of former miners. But the compensation system, designed to provide financial relief for those whose health has been destroyed by decades of dust exposure, has ground to a near halt. The tension between medical care and administrative paralysis has created a limbo where men receive a diagnosis but no resolution.

At the Carletonville silicosis clinic, a steady stream of former miners arrives each week. Many are in their 60s and 70s, some younger, all carrying the same story: years of breathing dust-laden air in tunnels where ventilation was often inadequate. The clinic offers chest X-rays, lung function tests, and clinical examinations. When silicosis is confirmed, doctors explain the diagnosis and refer the patient to the Medical Bureau for Occupational Diseases (MBOD) for compensation assessment. That is where the process stalls. The MBOD, a government body under the Department of Health, is supposed to evaluate claims and certify eligibility for payouts from the Compensation Fund for Occupational Diseases. But the bureau has been overwhelmed for years. As of late 2024, some estimates put the backlog at roughly 10,000 to 15,000 claims pending at any given time, with an average wait exceeding 18 months. Many miners die before receiving a cent.

Mokoena, now 63, describes his frustration. “They took my X-rays, they told me I have silicosis, they said I must apply for compensation. I went to the union office, they helped me fill forms. That was 2021. Nothing has happened. Every time I call, they say it is still being processed.” He pauses. “I am not the only one. Many of my former colleagues are in the same situation.”

The clinic staff are caught in the middle. They can diagnose, treat symptoms like breathlessness and cough, and refer patients for oxygen therapy or tuberculosis screening. But they cannot speed up the compensation machinery. “We see men who are clearly disabled by this disease,” says Teboho Mosala, a nurse at the clinic. “We tell them their lungs are damaged, but we cannot tell them when they will get help. That part is not in our hands.”

How South Africa’s Silicosis Compensation System Fell Behind

The legal framework for compensating miners with occupational lung disease dates back to the Occupational Diseases in Mines and Works Act of 1973. That law created a system where the MBOD certifies disease and the Compensation Fund, financed by levies on mining companies, pays out lump sums and monthly pensions. The system was designed for a different era — when the gold-mining workforce was smaller and the disease burden less understood.

By the 2000s, the backlog had become chronic. A 2016 report by the Bench Marks Foundation estimated that fewer than 10 percent of eligible miners ever applied for compensation, partly because of complex paperwork and partly because many former miners had moved away from mining towns or died before completing the process. A landmark class-action settlement in 2018, in which mining companies agreed to pay out an estimated 5 billion rand to compensate miners for silicosis and tuberculosis, was supposed to streamline claims. But the settlement created its own bureaucracy.

“The class-action settlement did not fix the underlying system,” says Mpho Letlape, a public-health researcher at the University of the Witwatersrand who has studied the compensation process. “It created a separate claims process for a subset of miners, but the main MBOD system remained broken. The settlement also required miners to prove they worked at specific mines during specific periods, which is difficult when records are incomplete.”

The result is a two-tier system: one track for those covered by the class action, and a slower, more uncertain track for everyone else. Even miners who qualify under the settlement often wait months or years for their cases to be reviewed. The mining industry, through the Minerals Council South Africa, has argued that many claims are incomplete or lack sufficient medical evidence. Unions counter that the industry is deliberately slow-walking claims to minimise payouts.

Clinics Fill a Void That Government Cannot or Will Not

Given the state of the compensation system, clinics have become the de facto frontline for miners seeking help. The Aurum Institute, a non-profit that works closely with the mining industry and government, runs mobile screening units that travel to rural areas in the Free State, North West, and Gauteng provinces. These units offer chest X-rays and spirometry, and refer positive cases to fixed clinics for confirmatory diagnosis.

“Our role is to find the disease,” says Mosala. “We diagnose, but healing is incomplete if there is no financial support. A man who cannot work because his lungs are scarred needs more than an inhaler. He needs to feed his family.” The clinics also partner with the National Union of Mineworkers (NUM) to help miners gather the documents needed for claims — employment history, medical records, proof of identity. But the union’s capacity is limited.

The clinics treat the medical consequences of silicosis — chronic cough, chest pain, recurrent tuberculosis — but they cannot address the economic consequences. Many miners have no other source of income. Some rely on disability grants from the state, which are smaller than compensation payouts and require separate applications. Others fall into debt or depend on family members.

The situation parallels other gaps in South Africa’s health system. For example, in public TB clinics, treatment is available but contact tracing software goes unused, leaving chains of transmission unbroken. Similarly, silicosis clinics can treat the individual but cannot fix the system that fails to compensate them.

What the Data Reveals About Delayed Payouts

The scale of the backlog is difficult to pin down precisely because the MBOD does not publish real-time data. But several sources provide a rough picture. A 2022 report by the South African Human Rights Commission noted that the MBOD had a backlog of roughly 12,000 claims, with some cases dating back to 2015. The commission found that the bureau lacked sufficient staff and that its paper-based filing system was prone to errors and delays.

Another study, published in the South African Medical Journal in 2023, estimated that only about 30 percent of miners diagnosed with silicosis ever received compensation. The study followed a cohort of 500 miners diagnosed in 2018–2019; after four years, only 150 had been paid. The rest were either still waiting, had died, or had given up on the process.

The human cost is stark. Men who spent decades underground often die before their claims are resolved. Silicosis is a progressive disease; even after diagnosis, lung function continues to decline. Many miners also develop tuberculosis, which accelerates the damage. “We see men who come in for a check-up, we diagnose silicosis, and six months later they are dead from TB or respiratory failure,” says Mosala. “Their families never see the compensation.”

The delays also have a racial dimension. The majority of affected miners are Black South Africans or migrant workers from Lesotho, Mozambique, and other neighbouring countries. Migrant workers face additional barriers: they often lack South African identity documents, their employment records may be held by labour brokers, and they may return home before their claims are processed. Some die in their home villages without ever knowing the outcome.

Disagreement Among Experts on Responsibility

Who is to blame for the compensation gap? The answer depends on whom you ask. The National Union of Mineworkers points to the mining companies. “The industry has known for decades that silica dust causes disease,” says Thabo Mokoena (no relation to the former miner), a NUM health and safety official. “They fought against compensation for years. Even now, they challenge claims in court, they demand more evidence, they delay. It is a form of attrition.”

The Minerals Council South Africa, which represents the mining industry, offers a different view. In a 2024 statement, the council said that many claims are incomplete or lack the required medical documentation. “The industry has paid out billions in compensation,” the statement said. “But we cannot process claims without proper records. It is a shared responsibility between government, unions, and employers to ensure that records are accurate and accessible.”

Public-health researchers like Letlape argue that the system itself is the problem. “Blaming one actor is too simple,” she says. “The system was designed for a smaller, more stable workforce. It has not adapted to the reality of migrant labour, high turnover, and fragmented employment records. Digitising records and creating a single window for diagnosis and claims would help, but that requires political will and investment.”

The disagreement is not merely academic. It shapes how resources are allocated. If the problem is seen as employer tardiness, the solution is legal pressure and penalties. If it is seen as incomplete records, the solution is better data collection. If it is seen as systemic design failure, the solution is reform. Each diagnosis leads to a different prescription, and the lack of consensus means that none is pursued vigorously.

Narrowing the Gap: Practical Steps That Could Work

Despite the gridlock, there are examples of progress. A pilot programme in the Free State province, run by the Aurum Institute in partnership with the Department of Health and the NUM, has tested a streamlined approach. Under the pilot, miners are screened at mobile units, their records are digitised on the spot, and the same team that makes the diagnosis also submits the claim electronically to the MBOD. The pilot, which began in 2022, has reduced the time from diagnosis to claim submission from an average of six months to about two weeks.

“The key is integration,” says Mosala, who works in the pilot area. “When the same person who takes the X-ray also helps with the paperwork, the claim moves faster. But this requires training and dedicated staff. It is not a magic bullet.” The pilot covers only a few hundred miners per year, a fraction of the estimated 30,000 to 50,000 former miners who may have silicosis.

Other proposals include setting binding time limits on MBOD decisions — for example, requiring the bureau to rule on a claim within 90 days or automatically approve it. Legislation to that effect has been discussed in Parliament but has not been enacted. Another idea is to create a central digital registry of employment history for mineworkers, so that proving where and when a person worked does not depend on crumbling paper records held by defunct mining companies.

None of these steps are easy. Digitising decades of employment records across hundreds of mines is a massive undertaking. Setting binding time limits would require the MBOD to hire and train more staff. And any reform would need the cooperation of mining companies, unions, and government — three parties that have often been at odds. The pilot in the Free State shows that progress is possible, but it is slow and small-scale.

The gap between diagnosis and compensation is not unique to silicosis. In Kenyan HIV clinics, viral load is tracked but same-day antiretroviral therapy initiation lags behind guidelines. In US postnatal clinics, baby weight is monitored while postpartum blood pressure checks go unbooked. The pattern is the same: one part of the system works, another part does not, and patients fall through the gap.

For Thabo Mokoena, the wait continues. He still visits the clinic for check-ups. His lung function is declining slowly. He has stopped hoping for a quick payout. “I know the system is slow,” he says. “I just hope it comes before I die. If not, maybe my children will get it. But they are not the ones who worked in the mines.”