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HEALTH-SOUTH AFRICA: Returning Sick – HIV, Illness, Death and Migration

Siyabonga Kalipa and Brenda Nkuna

CAPE TOWN, Apr 7 2009 (IPS) - It’s a Wednesday afternoon at the Joe Gqabi bus terminus in Philippi, Cape Town, and ticket touts scramble to recruit passengers wanting to travel to the rural Eastern Cape, a 1,000 kilometre, 16-hour haul away.

One of three long-distance ranks in Cape Town, tens of thousands of people pass through every year in a journey that is a legacy of the apartheid migrant labour system, which drew people to cities in search of work.

In post-apartheid South Africa, this trend has continued. Most urban residents from the Eastern Cape – the poorest province in South Africa with unemployment estimated at 30 percent and an HIV rate of 26 percent, according to 2007 Department of Health figures – retain strong ties with their rural origins after moving to Cape Town and other South African cities.

And while visits to family and friends create the impression of a holiday mood, in a country with 5.7 million people living with HIV and 1,000 deaths from AIDS every day, bus driver Ryan Xazana sees the tragedy behind travel at the Joe Gqabi rank.

“I once had a sick person on my bus and it was just a matter of hours after we left Cape Town when we noticed that he was no longer breathing. When I stopped to check on him he was dead, so we called an undertaker to come and pick him up.”

With a strong tradition of urban residents being buried at their rural homesteads in the Eastern Cape, Xazana says terminally-ill patients are sent home because their relatives would rather pay the $40 bus fare than the $700 it could cost for an undertaker to transport the corpse to the Eastern Cape.

South Africa’s migration is often misunderstood as a rural to urban flow; but the journeys of ill or seriously ill patients back to their rural origins underlines that the traffic is still both ways.

Research highlighting the higher number of infections around transport corridors and gateway towns is well-documented, but the complexity of illness as a driver of return migration is less well understood, and has far-reaching consequences for sick patients, rural households and health systems.

Research conducted in 2008 by the Centre for Social Science Research at the University of Cape Town, found that a range of factors were driving rural return.

Researcher David Neves says his research shows a “multiplicity of factors” are driving rural return. These included a loss of urban residence, being fetched by rural kin, and a desire to free their urban family of the burden of their illness.

Neves says the research has implications for the management of stigma which needed to be tackled at rural level and the healthcare infrastructure in terms of supporting patients in rural areas.

But he says the research is also a “corrective” to a simplified understanding of migration. Risk and vulnerability exist in both rural and urban locations and the two are “intimately connected”.

A failure to understand the factors driving return migration has an impact not only on health policy, but also on housing and social protection. For example, when a social grant recipient moves from one province to another, they have to re-apply for a grant, which has time and cost implications and leaves them without support while they await the grant. This has implications for not only their own livelihood, but those of the carefully crafted social and family networks that they are part of.

Mvuselelo Chicco Tokwe is one of those thinking of making the journey to the Eastern Cape. He lives in a two-roomed shack in Du Noon, a crowded township on the northern edge of the Cape Town Metropole.

He says he came to Cape Town to look for work in 2000, at the age of 25. But when he fell sick in 2007, his wife also migrated from the Eastern Cape to Cape Town to look for work and support the family.

He is HIV-positive, but has to manage with no running water and electricity in his shack, where he lives with his wife and three-year-old son.

An opportunistic infection of tuberculosis has also affected his spine and he needs a wheelchair to get around, but has difficulty negotiating the narrow and uneven pathways between shacks.

He has to send a ‘please call me’ signal to his neighbours via his mobile phone to ask them to help him to the communal toilet some 20 metres from his shack. The family sleeps in a three-quarter bed in one room, which also houses their clothes, stored in suitcases and black plastic bags. The second room is sparsely furnished with a couch, table, wall unit and two-plate stove.

“Whenever I want to do something in the house I must crawl around because the house is very small and cramped for my wheelchair.”

Now, having been discharged in December 2008 after two years in hospital, he wants to return to the Eastern Cape, but his position gives an indication of the push and pull factors that ill patients must negotiate in taking the decision to return home.

Medical advice is that he remain in Cape Town and his brothers, who are also in the city, offer a source of support and do not want him to return to the Eastern Cape. Leaving would mean that his wife and son remain behind.

On the other hand, there is the pull factor of his parents’ care at the rural homestead and the promise of potentially less-crowded living conditions. Either decision holds potentially serious implications for his urban and rural family.

Patricia Fekema, a community worker in Du Noon, said there HAS been a “tremendous” increase in migration of sick people back to the Eastern Cape. She says many ill children and adults living in townships have been “pushed away” by their relatives because of the increased costs of illness.

She says, however, that due to a lack of knowledge about diseases and HIV/AIDS, once in the rural areas the terminally ill were treated badly by their families and often faced isolation.

In many cases, they did not get enough food and had to walk long distances to get transportation and medication at clinics.

International Organization for Migration (IOM) information officer Nosipho Teyise said when it came to health policy on HIV/AIDS, the focus tended to be on individuals, while the virus also affected the community the person lived in as well. She said rural communities needed to be taught about HIV/AIDS and communication improved between these communities and government.

She said in order to address the HIV vulnerability of labour migrants in southern Africa, IOM had developed the Partnership on HIV and Mobility in Southern Africa (PHAMSA).

This aimed to reduce the HIV incidence and impact of AIDS among migrant and mobile workers and their families. She said the programme involved HIV education which reached migrant workers and the communties they lived in.

So far the programme is being piloted in Limpopo and Mpumalanga provinces, with the possibility of being rolled out to other provinces.