Presentation given in Sixth RENEWAL Regional Workshop: A decade of work on HIV, food and nutrition security. By Mark Collinson

1. REACHING THE INVISIBLE: HIDDEN LINKS
OF ILL HEALTH BETWEEN SOUTH AFRICA’S
CITIES AND RURAL AREAS
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)
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

2. Structure of the presentation
1. Internal migration in South Africa
2. Methods – the Agincourt Health and Demographic Surveillance System
3. Who migrates to where?
4. Death rates: A dramatic increase in crude death rates
5. 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

3. 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

4. 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

6. 3 a. Who migrates?
To where?
Permanent migrants
number of number of
out- in-
Destination/Origin Category migrations % 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%

7. 3 b. Who migrates?
To where?
Temporary 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%

8. Dramatic increase in crude death rate (x 3) from 1998
to 2003
Annualised death rates, June 1993 - December 2006
.02
.015
.01
.005
0
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 1-07
Calendar Time
Female Male
8

9. Mortality Trends with and without HIV/TB
affected migrants
Mortality rates

10. 10

11. 11

12. Summary of findings
 Temporary 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

13. Conclusion
How 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.