Mark A Collinson (University of the Witwatersrand), Philippe Bocquier (Université Catholique de Louvain)Jo Vearey (University of the Witwatersrand), Scott Drimie (International Food Policy Research Institute),Wayne Twine (University of the Witwatersrand), Kathleen Kahn (University of the Witwatersrand), Samuel Clark (University of Washington).Steven Tollman (University of the Witwatersrand)

REACHING THE INVISIBLE: HIDDEN LINKS OF ILL HEALTH BETWEEN SOUTH AFRICA’S

CITIES AND RURAL AREAS

RENEWAL Regional Workshop: A decade of work on HIV, food and nutrition security 9-11 Nov 2010

The Protea Breakwater Lodge, Waterfront, Cape Town, South Africa

Structure of the presentation1. Internal migration in South Africa2. Methods – the Agincourt Health and Demographic Surveillance System3. Who migrates to where? 4. Death rates: A dramatic increase in crude death rates5. Migration and mortality findings:

a. Trends in mortality rates – with and without return migrants b. Mortality rates by duration of residence

6. Summary and conclusion

Internal migration in South Africa• Before democracy there were high levels of circular labour

migration, mostly of males.• Pass laws and labour recruitment to mines and factories;

visits home once or twice per year• Restrictions on population movement lifted in 1986;

migration patterns were expected to become less circular and more permanent.

• Instead circulation increased; female migration increased; • Links between the cities and rural areas strengthened

2. Agincourt Health and Demographic Surveillance System (AHDSS)

•Population: 72 000 people in 12 000 households; Baseline census: 1992 •Annual census and vital events update. •Household list updated: Key information on vital events: pregnancy outcome, deaths, in and out migration, Verbal autopsy on all deaths Internal migration reconciliation Repeated cross-sectional modules: SES, Labour, Food Security, ID documents

Destination/Origin Category

number of out-

migrations %

number of in-

migrations %

village to village moves 40457 72% 40290 79%

nearby towns 6067 11% 2686 5%

secondary urban 4670 8% 4012 8%

Primary metropolis 2298 4% 1550 3%

Other and unknown 2996 5% 2357 5%

Total 56488 100% 50895 100%

3 a. Who migrates?To where?

Permanent migrants

Temporary migration

destination N Percent

Village to village moves 212 2%

Nearby towns 1277 11%

Secondary urban 4936 41%

Primary metropolis 5588 46%

Other unknown 48 0%

Total 12061 100%

3 b. Who migrates?To where?

Temporary migrants

Dramatic increase in crude death rate (x 3) from 1998 to 2003

8

0.0

05.0

1.0

15.0

2

1-94 1-1995 1-96 1-97 1-98 1-99 1-2000 1-01 1-02 1-03 1-04 1-2005 1-06 1-07Calendar Time

Female Male

Annualised death rates, June 1993 - December 2006

Mortality Trends with and without HIV/TB affected migrantsM

orta

lity

rate

s

10

11

Summary of findingsTemporary circular migration is vital for rural

household livelihoods, but there are serious health risks that need to be offset.HIV/AIDS and TB are overwhelming causes of

death in rural populations. The deaths of recently returned migrants from HIV/TB made the sub-district death rates double in less than 10 years. Migrants ‘returning home to die’ need special attention as they put extra burden on families and rural health structures

ConclusionHow do we achieve growth and reduce poverty and inequality at the same time? Proper information on migration in sending and receiving communities is vital

(date of move, type of move, duration...). Available census and surveys data are insufficient and may even be misleading.

Facilitate migration through improving roads in the rural areas. Make transport cheaper and safer.

Health structures must account for circular migration by strengthening the rural health system and implementing a nationwide patient-retained chronic medication card.

Urban planning needs to provide hygienic, affordable, rental accommodation in poor areas with access to health systems and food markets.