HIV/AIDS VULNERABILITY AMONG MIGRANT FARM WORKERS

ON THE SOUTH AFRICAN – MOZAMBICAN BORDER

Researched for

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)

By

INTERNATIONAL ORGANIZATION FOR MIGRATION (IOM) REGIONAL OFFICE FOR SOUTHERN AFRICA

Pretoria, South Africa February 2004

For a better tomorrow for al l . Japan International Cooperation Agency

Japan International Cooperation Agency (JICA) PO Box 14068 Hatfield 0028 Pretoria, Republic of South Africa Telephone: +27 12 346 4493 Fax: +27 12 346 4966 e-mail: jicasa@mweb.co.zaWeb site: http://www.jica.go.jp This Study was commissioned to: International Organization for Migration (IOM) Regional Office for Southern Africa PO Box 55391 Arcadia 0007 Pretoria, Republic of SouthAfrica Telephone: +27 12 342 2789 Fax:+27 12 342 0932 e-mail: mrfpretoria@iom.intWeb site: http://www.iom.int ©Japan International Cooperation Agency (JICA)

HIV/AIDS VULNERABILITY AMONG MIGRANT FARM WORKERS

ON THE SOUTH AFRICAN – MOZAMBICAN BORDER

Researched for

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)

BY

INTERNATIONAL ORGANIZATION FOR MIGRATION (IOM) REGIONAL OFFICE FOR SOUTHERN AFRICA

Pretoria, South Africa February 2004

For a better tomorrow for al l . Japan International Cooperation Agency

TABLE OF CONTENTS FOREWORD..........................................................................................................................ii LIST OF ACRONYMS.......................................................................................................... iv ACKNOWLEDGEMENTS.................................................................................................... v EXECUTIVE SUMMARY ..................................................................................................... 1

Key Findings................................................................................................................................................1 Recommendations ......................................................................................................................................4

1. INTRODUCTION .............................................................................................................5

Stages of the Migration Process................................................................................................................5 Farm Workers as a Mobile Population....................................................................................................6 Existing Research on Farm Workers and their Vulnerability to HIV/AIDS....................................7 HIV/AIDS in Southern Africa.................................................................................................................8

2. METHODOLOGY.............................................................................................................9

KAP Survey .................................................................................................................................................9 Mapping Exercise .................................................................................................................................... 11 Qualitative Interviews ............................................................................................................................. 12 Gap Analysis............................................................................................................................................. 12

3. RESULTS OF QUANTITATIVE SURVEY ................................................................... 12

Survey Data............................................................................................................................................... 12 Discussion of Survey Data ..................................................................................................................... 26

4. RESULTS OF QUALITATIVE INVESTIGATION ...................................................... 30

Living Conditions .................................................................................................................................... 30 Working Conditions ................................................................................................................................ 33 Migration................................................................................................................................................... 34

5. GAP ANALYSIS................................................................................................................ 40

Provincial Government........................................................................................................................... 40 Farm Owners............................................................................................................................................ 41 Primary Health Care (PHC) Clinics ...................................................................................................... 42 Private Clinics........................................................................................................................................... 43 Mobile Clinics........................................................................................................................................... 43 Non-Governmental Organizations ....................................................................................................... 43

6. CONCLUSIONS AND RECOMMENDATIONS......................................................... 44 ANNEX ................................................................................................................................ 46

Health services at Hoedspruit and Burgersfort primary health care clinics .................................... 47 Non-Governmental Organizations working with farm workers ...................................................... 57 Non-Governmental Organizations working with HIV/AIDS issues ............................................. 59 Maps .......................................................................................................................................................... 63 Public transportation routes around Hoedspruit ................................................................................ 67 References................................................................................................................................................. 69

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FOREWORD Japan International Cooperation Agency (JICA) stands at an epochal time of large reforms in its almost 30-years history and has become an Independent Administrative Institution of the government of Japan. The field of health remains one of the core Themes in JICA’s Development Assistance. As UNAIDS has found, nearly 5 million people all over the world become infected with HIV every year. 70% percent of those are estimated to be in the African Region. Various initiatives and efforts have been taken by many stakeholders, including governments, UN agencies, and Development partners. However there are many issues still to be targeted and there are great needs still to be addressed. HIV/AIDS do not merely pose a single health problem that threatens the lives of individuals in developing countries. Rather, the issue looms large as a serious detrimental factor for the socio-economic development of developing countries, through a vicious cycle where worsening health conditions breed and exacerbate poverty. As a result, the problem of infectious disease is one of the principal issues in developing countries. JICA South Africa Office commissioned the International Organisation for Migration (IOM) to conduct a baseline survey to identify vulnerability of farm workers and gaps along the South Africa-Mozambique Border. The report “HIV/AIDS Vulnerability among Migrant Farm Workers on the South African-Mozambican Border” identified many issues that stakeholders can address. However, identifying the relationship between the mobility of farm workers and HIV/AIDS vulnerability needs further study. These kinds of studies targeting farm workers are scarce. As we know, a large portion of Sub-Saharan African populations is farmers. HIV/AIDS Vulnerability among Migrant Farm Workers on the South African-Mozambican Border identified the needs of its target group and hopefully partners will utilize this report to develop interventions. JICA would like to thank IOM for their committed and competent work in the report. We also wish to thank people who took time to share their ideas and respond to the interviews.

Hiroshi Murakami

Resident Representative JICA South Africa Office

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FOREWORD At the beginning of the 21st century, one of every 35 persons worldwide is in some kind of migrant status. In 2001, the world saw 80 million people migrate in relation to employment. Though the reasons for people’s mobility may differ, the risks and vulnerability that they may encounter to their sexual health are similar, as are the approaches to deal with them. In Southern Africa, the system of migrant labour is extensive and continues to gather together men and women at work sites while leaving their partners and families behind. At the same time, the HIV and AIDS epidemic is devastating large parts of the region, with separate countries facing the highest adult HIV prevalence rates in the world. In South Africa alone, it is estimated that 4.5 million people are living with HIV and AIDS is today the single biggest cause of death, accounting for 25% of all deaths in the country in 2000. While the linkages between mobile populations and the HIV epidemic are receiving increased attention in Southern Africa, - and IOM has released two publications on this subject in 2003 - very few intervention programmes addressing migrants and their partners have been implemented and the need for responses that address the particular vulnerability of mobile populations to HIV infection is urgent. Farming areas are no exception. This research study, which was undertaken by IOM over a 3-month period, was initiated to shed light on one of the many migrant groups in Southern Africa, namely, migrant farm workers employed on commercial farms, - a group which has received little attention so far. In South Africa, international migrants have been employed on farms for many years, however little is known about how the migration patterns and the unique circumstances of life and work on farms affect the vulnerability of farm workers to HIV. The survey also sets out to gain a better understanding of the availability and access to health services by migrant farm workers in the receiving areas. We hope that this report, which covers only a relatively small area and a limited time frame will nonetheless address the existing information gap and sufficiently highlight the vulnerability of foreign (as well as South African) farm workers to HIV and AIDS, as well as the need for urgent and effective responses. In commending this report to a wider readership, I would like to express, on behalf of IOM, our gratitude to everyone who facilitated the farm survey in Mpumalanga and Limpopo provinces – and to The Japan International Cooperation Agency (JICA) for the generous collaboration and financial support which made the survey possible. Hans-Petter Boe Regional Representative for Southern Africa International Organization for Migration

Pretoria

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LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ARV Anti-retro viral

ATICS AIDS Training and Information Centers

BCC Behaviour Change Communication

CBDM Cross Border District Municipality

CBO Community Based Organizations

CHOICE Comprehensive Health Care

DC District Council

DOH Department of Health

FRRP Farm Workers Research and Resource Project

HIV Human Immunodeficiency Virus

HSRC Human Sciences Research Council

IOM International Organization for Migration

JICA Japan International Cooperation Agency

KAP Knowledge, Attitudes and Practices

LC Local Council

MC Mobile Clinic

NGO Non-Governmental Organization

PHC Primary Health Care Clinic

PMTCT Prevention of Mother to Child Transmission

SA South Africa

SAHRC South African Human Rights Committee

SAMP Southern African Migration Project

STI Sexually Transmitted Infection

TB Tuberculosis

UIF Unemployment Insurance Fond

UNAIDS Joint United Nations Programme on HIV/AIDS

UNESCO United Nations Educational, Scientific and Cultural Organization

VCT Voluntary Counselling and Testing

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ACKNOWLEDGEMENTS This report was researched and written by IOM Research Consultant, Maciej Pieczkowski, and IOM Programme Officer, Liselott Jönsson, from August through November 2003. Research assistants in the field were Dudu Dlamini, Regina Mathumbu, Stanley Lekoba, Elly Mokoena, Rhyne Phala and Tshalala Nkuna. They were ably assisted by Margaret Ubisi and Joyce Khoza, and by Abien Kgole, nurses from the Hoedspruit and Burgersfort Primary Health Care clinics, respectively. We would also like to thank Professor Eric Buch, School of Health Systems and Public Health, Pretoria University, for invaluable discussions and guidance on the research methodology. Thanks are also due to Mr Zeleke Worku at the Council for Scientific and Industrial Research (CSIR). IOM also owes appreciation to the Hoedspruit and Burgersfort Farmers’ Associations for facilitating this research, and to individual farm owners in the two districts for giving IOM access to their farms and staff. We would like to thank all farm workers who participated in this study, for sharing their time, thoughts and experiences with us. Without them this study would not have materialized. Finally, on behalf of IOM, we would like to extend its gratitude to the Japan International Cooperation Agency for its support and collaboration through this project.

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EXECUTIVE SUMMARY A few years into the new millennium, migration, mobility and HIV/AIDS have become significant global phenomena. Today there is increasing recognition that migrants and mobile populations are more vulnerable to HIV/AIDS than populations that do not move. Often overlooked are migrant farm workers in Southern Africa. Little is known about how migratory patterns and the unique circumstances of life and work on farms affect the vulnerability of farm workers to HIV. Between August and October 2003, the International Organization for Migration (IOM), in collaboration with the Japan International Cooperation Agency (JICA), conducted a behavioural surveillance survey among farm workers living and working in the South African border region with Mozambique. 183 South African and foreign workers were surveyed on 12 farms in two farming districts in the Limpopo and Mpumalanga provinces to find out more about their knowledge, attitudes and behavioural practices relating to HIV/AIDS. A mapping and a gap analysis exercise were also carried out to assess health - including HIV/AIDS - services available to farm workers in the surveyed areas. Key Findings Lack of Access to Information and Misconceptions about HIV/AIDS The two farming districts are characterized by a striking lack of both governmental and non-governmental HIV/AIDS interventions directed specifically at farm workers and migrants. This gap has contributed to poor knowledge of HIV/AIDS among workers and allowed many myths about the disease to go unchallenged. In addition to misconceptions about the disease, there is a widespread belief among workers that there is a cure for HIV/AIDS and, among some, that HIV/AIDS is not deadly. In both cases, these beliefs could be leading many into a false sense of security concerning the dangers of the disease. HIV/AIDS is rarely openly spoken about on the farms (there is little encouragement to make disclosure and great reluctance to be tested) and few workers recognize AIDS as a potential cause of death on the farms. Taken together, these attitudes to HIV/AIDS and a lack of basic knowledge create little incentive for adopting precautionary measures in sexual relationships. The high illiteracy levels among farm workers suggest that few workers are able to benefit from printed HIV/AIDS educational materials. Prevalence of High-Risk Sexual Behaviour High-risk sexual behaviour is common between men and women on farm compounds, both in sexual relations with steady and casual partners, and in cases of transactional sex. A significant number of workers reported having two or more concurrent sexual partners, and there are indications that during the harvesting season transactional sex flourishes at the compounds. Use of condoms is extremely poor: they are rarely accessible on farms, and a significant proportion of workers believe that they are seldom or never effective. There are also many myths surrounding their use, most commonly that condoms carry HIV/AIDS and are responsible for the spread of the

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virus. Mozambican farm workers, the single largest group of non-South Africans on farms in the region, use condoms less frequently than SouthAfrican workers, and generally display higher levels of unsafe sexual practices. Though VCT is accessible at nearby clinics, Primary Health Care (PHC) nurses in both farming districts reported low levels of HIV/AIDS testing among farm workers and high prevalence of STIs. Impact of Migration Different categories of migrants are each vulnerable to HIV infection in a unique way. Internal migrants to the farms, both SouthAfricans and foreigners (mostly Mozambicans) from the villages of the ‘trust’ areas may be exposed to HIV/AIDS infection because of the effect of ‘split households’. When men or women in stable relationships migrate alone to seek work in another region or district, some appear to cultivate new, often concurrent, sexual relationships at farm compounds which are unsafe. Secondly, internal migration between farms, season after season, by young SouthAfrican and foreign women, (as seen by high rates of turnover reported by farm owners) in search of temporary employment also has negative consequences. It discourages the formation of stable relationships because of continually changing employment opportunities and forces many women to engage in transactional sex out of necessity, very often with men on many different farms. Cross-border migrants are particularly vulnerable to HIV infection. Because of their high mobility and short stays on the farms, they are rarely able to access health services or be reached by the infrequent HIV/AIDS information campaigns targeted at farm workers. Their insecure legal status is a barrier to access to public services for fear of being deported. In addition, cross-border migrants have to cope with separation from their family units, feelings of anonymity and loneliness, mental stress associated with the dangers and uncertainty of migration, and a basic need for acceptance and recreation which may lead them to engage in unsafe sexual experimentation. Low standards of living on farms Farm workers’ vulnerability to HIV should be seen as inextricably linked to the socio-economic context of the farms. A picture of the workers’ vulnerability emerges when one considers the combined impact of the entire gamut of negative social, economic and labour conditions which exist on farms. Each worker confronts difficult basic conditions: not only poor pay together with often exploitative working conditions, but also overcrowded accommodation, poor sanitation, long absences from home, boredom, limited recreation opportunities, and a meagre hand-to mouth existence with little hope for the future. When one’s daily life is a struggle in so many respects, HIV/AIDS appears as a distant threat, only one of many faced daily by workers. Interviews with workers give a sense that many feel disempowered, leading them to believe that they have few choices and little possibility to improve, or alter the course, of their lives. They lament that there is little hope for the future, which suggests that workers may have little incentive to act in a manner which will safeguard their health in the long term, or seek help when their health and well being is threatened.

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Women’s Vulnerability This survey found that in several respects, female workers living in the two districts are especially vulnerable to HIV/AIDS. Firstly, women have poorer knowledge of HIV/AIDS. For example, they are often confused or ill-informed about the means of transmission of the disease, especially Mozambican women. Secondly, women often display attitudes towards HIV/AIDS which may make them more vulnerable – many more female than male workers, for instance, believe there is nothing they can do to protect themselves from HIV/AIDS. Thirdly, female workers report higher levels of unsafe sexual practices.

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Recommendations Based on the findings of the study, the following interventions are recommended: 1. Increase HIV/AIDS awareness among farm workers, farm owners, traditional healers, and

indunas. Special attention should be paid to improving the HIV/AIDS knowledge of women and migrant farm workers;

2. Introduce prevention and care projects, especially HIV/AIDS peer education among farm

workers; 3. Improve and encourage access to VCT facilities by farm workers; 4. Improve care and support to workers living with HIV/AIDS on farms; 5. Improve working and living conditions on farms, especially by ensuring adequate provision of

basic amenities, recreation facilities and housing; 6. Encourage farmers’ associations and farm owners to develop and introduce HIV/AIDS policies

in the workplace; and 7. Conduct further research into (a) the impact of HIV/AIDS on farms, and (b) migration patterns

in the region and their connection to HIV/AIDS.

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1. INTRODUCTION People move for a variety of reasons – some voluntary – some not. During the past few decades, the African continent has seen dramatic political, economic, social and demographic changes. These have been accompanied by rapid urbanization, significant population displacement, and migration. Studies show that mobile populations are more vulnerable to HIV/AIDS than populations that do not move. In many countries, areas reporting higher seasonal and long-term mobility have accompanying higher rates of HIV infection. For example, an epidemiological survey carried out in the Konkola Copper mines (Zambia), showed that of 8 523 mine workers surveyed, 18% were infected with HIV/AIDS1. Rates of infection also tend to be higher along main transport routes and in border regions. A study by the Medical Research Council of South Africa (MRCSA) reports that at one stop, 95% of the drivers involved in the survey were infected with HIV. Of the 34% who indicated that they had stopped for sex while on their routes, there was a high percentage of condom non-users (29%)2. Such studies indicate that migration and mobility not only increase the vulnerability of migrants to HIV/AIDS, but also that of their partners at home. Stages of the Migration Process The vulnerability of mobile populations to HIV/AIDS is often related to a particular stage of the migration process. For this purpose IOM uses a process framework for HIV/AIDS based on four stages of migration:

• Origin: where people come from, why they leave, and the relationships they maintain at home while away;

• Transit: the places people pass through, how they travel and their behaviour while they travel;

• Destination: where people go, the attitudes they encounter and their new living and working conditions;

• Return: the changes that have occurred in people’s lives and the conditions they find upon their return.

Some migrants are most vulnerable at their destination: for example, men who work far from home, such as mine workers who live in male-only camps or barracks. For others, the greatest risk occurs in transit. This is the case for female informal traders who may have to trade sex in order to survive or complete their journeys. The increased vulnerability of mobile populations to HIV/AIDS is created by conditions inherent to the migration process. Some migrants live in a legal vacuum, with no residence or work permit in the host country, fearing deportation. Because of poverty, many migrants are forced to accept jobs

1 UN Regional Integrated Information Networks (2001), Miners HIV Survey, UN Irin, 31 March, http:allafrica.com/stories/200103310039.html 2 Medical Research Council of South Africa (MRCSA) (2000), The role of truck drivers in the spread of HIV/AIDS

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below their qualifications and under conditions that are in the grey area of illegality. Being powerless, they are frequently subject to various kinds of exploitation, including sexual exploitation. Social Exclusion and Xenophobia It has long been clear that the AIDS pandemic thrives in an environment of social exclusion. Most mobile populations work and live in such an environment. Separated from their familiar social structures and from shared norms, values, language and social support, they are more likely to engage in risky behaviour. The ‘otherness’ of migrant populations often creates a situation where xenophobic practices, isolation and hostility are rife in host communities. Consequently, their new environment often lacks strong community cohesiveness and has the effect of increasing risky sexual practices. Limited Access to Public Services Because of their insecure legal status, migrants often have only limited access to government public services, such as health facilities. In addition, the migrants’ mobility and irregular working hours prevent them from visiting health clinics and other public services during opening hours. Gender dynamics The social construction of gender and sexuality underlies the HIV vulnerability of mobile populations. Adverse and dangerous working environments contribute significantly to male gender construction and sexuality. Along with the boredom and loneliness of these jobs, the men frequently experience dangerous and unpleasant working conditions, poor accommodation and “anti-community” environments, to which they may respond with exaggerated “masculinity” and sexual bravado. Gender norms supporting several sexual partners are often found among migrant men, exacerbating HIV vulnerability. Farm Workers as a Mobile Population In 2002 IOM, together with Care International, conducted a study on the linkages between mobility, migration and HIV/AIDS in Southern Africa3. One of the mobile groups reviewed were commercial farm workers; it was found that they are vulnerable to HIV much in the same way as mobile workers in the mine industry and construction sector. Their living and working conditions place them at no uncertain risk, and, in addition, they are accorded very few rights and little labour protection. The findings indicate that:

• Farm workers often live in compound accommodation, tents or shacks that are unhygienic, overcrowded and lacking in privacy;

• Casual and commercial sex is common on or near commercial farms; • Commercial farms are characterized by a high incidence of STIs and other common

diseases;

3 IOM (2003), Mobility and HIV/AIDS in Southern Africa: A field study in South Africa, Zimbabwe and Mozambique

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• Most farms do not have HIV/AIDS programs or STI services; • Farm workers’ access to health care services is often limited; • The sector employs many undocumented migrant farm workers and cross-border migrants

who are reluctant to access health services for fear of revealing their lack of legal status to the authorities and risking deportation. As a result, diseases such as STIs remain untreated and those who are HIV positive may try to hide their status and only seek help during the final stages of the disease;

• Many farm workers have seasonal contracts which increase their mobility; • Recreational facilities are sorely lacking; and • Income-earning opportunities are strikingly unequal for men and women

Existing Research on Farm Workers and their Vulnerability to HIV/AIDS The IOM/Care research study undertaken in 2002 was a first step towards documenting and analyzing the experiences of farm workers and their vulnerability to HIV/AIDS in South Africa. However, a review of the existing literature, reveals that little other research has been conducted on commercial farm workers in South Africa in general, and on their vulnerability to HIV/AIDS in particular4. Little, if any, information is available concerning the knowledge, attitudes and behavioural practices of farm workers with regard to HIV/AIDS and the circumstances under which they live and work. On the other hand, subsistence farmers have been the subject of further attention and research; hence more is know about this group in terms of vulnerability to and the impact of HIV/AIDS on their lives. Among the limited research information available on commercial farm workers in South Africa is a survey conducted by the Farm Workers Research and Resource Project (FRRP) in 1996. This national survey was the first of its kind to attempt to document working conditions on South African farms5. More recently, the Southern African Migration Project (SAMP) 6 published its report Borderline Farming: Foreign Migrants in South African Commercial Agriculture. The report recognizes that a large number of South African commercial farms depend heavily on cross-border migrants to meet their seasonal and temporary labour needs. It confirms poor living and working conditions and systematic exploitation of undocumented labour on many farms in South Africa. However, while giving insight to the working and living conditions on the farms, neither of these two studies touches upon the issue of HIV/AIDS or the vulnerability of farm workers to HIV infection. Following several reports and complaints about farmers' brutality towards their workers, poor employment and living conditions on the farms, and cases of child labour, the South African Human Rights Commission (SAHRC) launched an inquiry into human rights conditions in farming

4 IOM and UNAIDS (2003), Mobile Populations and HIV/AIDS in the Southern African Region: Desk review and Bibliography on HIV/AIDS and Mobile Populations 5 Greenburg S, Hlongwane M, Shabangu D and Sigudla E (1996), State of South African Farm Workers 6 Crush J (ed.) (2000) Borderline Farming: Foreign: Migrants in South African Commercial Agriculture, Southern African Migration Project, Migration Policy Series, No 16

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communities in June 20017 and published its report in September 2003. The report mentions lack of access to farms, long distances that must be travelled to reach services, absence of awareness among workers of their rights and inadequate service provision by the state. Furthermore, the report cites a general and widespread lack of compliance with labour legislation, low salaries, and discrimination against women workers, seasonal workers and illegal foreign workers. Importantly, the inquiry also found that “the lack of information on HIV/AIDS is of great concern and indicates that the challenges the pandemic presents in farming communities are not being confronted.”8

Recognizing the lack of information and subsequent to the findings of its research study undertaken in 2002,9 IOM decided to conduct an in-depth survey among local and migrant farm workers in Limpopo and Mpumalanga provinces to gain a better understanding of risk behaviour and vulnerability to HIV/AIDS among this group. HIV/AIDS in Southern Africa Home to more than 29.4 million people living with HIV/AIDS, Southern Africa is the epicentre of the global HIV/AIDS pandemic. Whereas sub-Saharan Africa represents only 10% of the global population, it is estimated that this region accounts for 28.5 (70%) of the 40 million people worldwide living with HIV/AIDS at the end of 2001. In countries such as Botswana, Swaziland and Zimbabwe, more than one in three adults aged 15-49 is currently living with HIV/AIDS.10

South Africa In South Africa alone it is estimated that 4.5 million people are living with HIV/AIDS. Today AIDS is the single biggest cause of death, accounting for 25% of all deaths in the country in 2000.11 The 2002 national antenatal survey, undertaken by the national Department of Health, calculated prevalence among pregnant women to be at 26.5%12. The Nelson Mandela/Human Sciences Research Council (HSRC) Study of HIV/AIDS, Household Survey 2002 made a finding similar to that of DoH: a prevalence of 24% among pregnant women13 Both estimates reflect extremely high HIV prevalence among the South African population. Limpopo and Mpumalanga Provinces Most studies reflect geographical variations in the HIV/AIDS prevalence rates between provinces with KwaZulu-Natal continuously having the highest prevalence rate (36.5%) and Western Cape the 7 South African Human Rights Committee (SAHRC) (2003), Inquiry into Human Rights in Farming Communities, www.sahrc.org.za 8 Ibid 9 IOM (2003) 10 UNAIDS (2002), Report on the Global HIV/AIDS Epidemic 11 MRCSA (2001), The impact of HIV/AIDS on adult mortality in South Africa. South African Medical Research Council, Burden of Disease Research Group 12 Department of Health, South Africa (DoH SA) (2003), HIV and Syphilis Seroprevalence Survey of Women Attending Public Antenatal Clinics 13 Human Sciences Research Council (HSRC) (2002), Nelson Mandela/HSRC Study of HIV/AIDS, Household Survey 2002, p.53

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lowest (12.4%).14 Mpumalanga, has a prevalence rate of 28.6%, which makes it the third highest level in the country while Limpopo is estimated at 15.6%. Only Northern Cape and Eastern Cape provinces have lower infection rates. As for the general population, there were an estimated 440 000 people infected with HIV/AIDS in Mpumalanga by 2001, out of a total population of 3 122 991.15 This corresponds to approximately 14% of the province’s population. According to the Mpumalanga Provincial Health Department, “the rate of infection is particularly alarming in districts situated on the migrant and trucking routes throughout the province.”16 Surveillance data from TB hospitals reveals that there is a rapid evolution of the dual TB/HIV epidemic, which is similar for most rural South Africa.17 In Limpopo there were an estimated 517 000 people (9.8% of the provincial population) infected with HIV/AIDS. 2. METHODOLOGY The present study was designed as a rapid risk assessment and used a combination of quantitative and qualitative research techniques. The central data collection method was a KAP (Knowledge, Attitudes and Practices) behavioural surveillance questionnaire containing key indicators. The KAP survey was complemented by in-depth interviews with select male and female farm workers; as well as a mapping and site inventory exercise conducted around both survey sites, (including the 12 farms where questionnaires were administered), and at the district and provincial levels. Also included was an analysis of needs and gaps in existing organizational responses to HIV/AIDS in districts close to the survey sites. KAP Survey Two survey sites were chosen at the district council level: Bohlabela Cross Border District Municipality (CBDM) and Sekhukhune CBDM, both straddling the Limpopo-Mpumalanga provincial boundary west of the Kruger National Park18. These sites were selected according to two criteria: (1) evidence of concentrations of foreign farm labour and, (2) an intention to coordinate future HIV/AIDS care and prevention interventions emanating from this research in line with government’s developmental priorities in local districts19.

14 DoH SA (2003) The national survey is based on information taken from 396 sampling sites and samples from 16 587 women. It refers to the sexually active part of the population. 15 HSRC (2002) 16 Mpumalanga Provincial Health Department (2003), Strategic Plan, p.16 17 Ibid 18 See Annex, pp.65,67 19 Both CBDMs are special presidential development nodes

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Obtaining support from farm owners To secure access to farm workers, the Limpopo and Mpumalanga Agricultural Associations were approached, as well as the locally-based Hoedspruit and Burgersfort farmers’ associations, all of which responded positively to the proposed research. At each of the survey sites, representatives of farmers’ associations facilitated introductions to the farmers with whom arrangements were then made concerning the practicalities of the survey. Once the purpose of the study had been explained, farmers introduced researchers to the ‘induna’, or farm foreman, usually the most senior farm worker. The farmers’ permission to conduct interviews and the use of the ‘induna’ to communicate that permission to workers was critical in securing their participation in the survey and assuaging fears and suspicions. Farmers associations assisted in the choice of farms to be surveyed at each of the two sites. The study team tried to secure access to both small farms owned by individual farmers, as well as to a number of larger company-owned mango and citrus farms common around Hoedspruit. In total, seven farms around Hoedspruit and five farms around Burgersfort were surveyed, one of which served as a pilot site for the questionnaire.20

Difficulties Experienced in Accessing Farm Workers While the support and permission given by farm owners to enter farms was critical, a number of difficulties relating to accessibility of farm workers arose during initial visits to the farms. Firstly, it became clear that farm workers could only be approached for research purposes during weekends, due to their long working hours during the week and to the difficulties involved in accessing distant and rural parts of South Africa at night. As a result, the questionnaires could only be administered to farm workers during weekends. Secondly, a great many farm workers around Hoedspruit and Burgersfort, often Mozambican, are temporary/seasonal workers who are employed for only a limited period during the year, generally from December to March on mango farms and April to August/September on citrus farms. Many of these workers had left the farms by the time this survey began. Thirdly, many workers around both towns commute daily between their homes in the ‘trust’ villages and the farms, arriving by bus early in the morning and returning home after 5pm in the evening, thus spending all week nights and weekends at their homes away from the farms. This internal mobility made it impossible to administer questionnaires to this segment of workers whose social and sexual lives are more closely connected with their villages/communities than with the farm compounds where they work. These three considerations have led to the exclusion from the survey of certain categories of farm workers, in particular, a certain quantity of temporary and foreign labour that the study team had expected to sample in this survey. Staffing Four interviewers were hired, two men and two women, to administer questionnaires. All four had experience in quantitative survey methods and were Tsonga and Sotho speaking, the two main languages spoken by farm workers around Hoedspruit and Burgersfort.

20 The discrepancy in the number of farms surveyed at each site is owing to some of the accessibility issues discussed above, in particular the unavailability of workers at farm compounds on weekends following ‘pay day’.

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Two nurses from the Hoedspruit PHC clinic and one from the Burgersfort PHC were hired to act as intermediaries between researchers and farm workers. All three nurses regularly visit farms around both sites on mobile clinics and were well known to workers at each of the 12 farms visited. Their presence at the farm compounds during the interviews allayed suspicions about this survey’s intentions and helped to ensure a smooth modus operandi. After the interviews, the nurses distributed condoms and HIV/AIDS pamphlets to workers and were available to answer questions arising from the interviews.

Sampling Method and Size A convenience/quota sampling method was employed in selecting respondents due to the difficulty in accessing workers, as explained above. Researchers made an effort to sample equal numbers of temporary and permanent workers, men and women, and South African and foreign labour. 16 respondents, 8 men and 8 women, were asked to participate at each farm and two farms were surveyed per day. 183 respondents were surveyed in total. Mapping Exercise Concurrently to the KAP survey, a mapping and site inventory exercise was carried out at three different levels: on farms, in Local and District Councils, and at the provincial level. On each of the 12 farms surveyed, the researchers recorded basic information about farm compounds, including the type and quality of housing, living arrangements, the availability of basic services (electricity, water, and sanitation) and the existence of recreation facilities. In addition, a record was kept of the availability of condoms at farm compounds, and of the existence /presence and visibility of posters or billboards containing HIV/AIDS information. At Local Council level, mapping included: • the general and specific HIV/AIDS services offered at Hoedspruit and Burgersfort PHC clinics,

including the availability of essential medicines and equipment; • farming districts covered by mobile clinic services; • clinics and hospitals located around both survey sites; • information about NGOs working in the fields of HIV/AIDS, farm worker advocacy and

refugees, including their mandates and activities; and • important public transport routes. Finally, at the provincial level, information was collected on HIV/AIDS and TB infection rates, VCT sites, and clinics and hospitals across both Limpopo and Mpumalanga provinces. Data from Statistics South Africa was collected to give indications of population size, as well as of the scale of employment in the agricultural industry at local, council, district council and provincial levels.

11

Qualitative Interviews In-depth, qualitative interviews with farm workers were carried out at both survey sites to supplement information gathered through the KAP survey. Semi-structured conversations were undertaken with farm workers on issues of migration, sexuality and marriage, social life on farms, and HIV/AIDS. Most workers agreed to the recording of the conversations on micro cassette and were open to discussing the issues. Gap Analysis A gap analysis of existing organizational responses to HIV/AIDS in the region was carried out. NGOs working in the field of farm worker advocacy, HIV/AIDS and refugee legal advice around the survey sites were assessed on the content of their HIV/AIDS programmes and the extent to which they target farm workers, migrants and other populations. As indicated, HIV/AIDS related services at two PHC clinics close to the survey sites were assessed, including services offered by mobile clinics. 3. RESULTS OF QUANTITATIVE SURVEY The following section of the report will reflect the key findings of the quantitative survey displayed in graphs. For practical reasons and to limit the length of the report, not all findings were translated into graphs. Survey Data The survey included an almost equal number of men (89) and women (94). Efforts were made during the administration of questionnaires to survey workers between the ages of 18 and 45, based on the assumption that this would correspond to the sexually active part of the farm worker population – 90 % of all women and 96% of all men sampled fell into this age category. In terms of social status, over 80% of workers surveyed claimed to be involved in a relationship, either through marriage or with a steady partner. Of 183 surveyed farm workers, 55 men and 48 women were permanent workers while 33 men and 43 women were temporary workers (4 are unclassified). Labour statistics from the 12 farms indicate that temporary female workers outnumber male temporary workers, sometimes by as much as 3 to 1.21 Consequently, the more or less equal number of male and female temporary workers included in the survey means that women are slightly under-represented in this study. 21 Data obtained from farm owners

12

Among the 183 respondents, 94 were South African and 75 were workers from three other Southern African countries – Mozambique, Swaziland and Malawi. Of these three, Mozambicans were by far the largest group, (72 respondents, 41 male and 31 female), followed by Malawians (2 respondents, 1 male and 1 female) and one Swazi (male). 14 respondents did not wish to reveal their nationality. Description of Farm Labour Categories Understanding the character of farm worker populations on the Limpopo-Mpumalanga provincial boundary where the KAP survey was implemented requires a grasp of the complex and multiple categories of farm labour common in the region. There are three broad sets of categories of farm workers which are based on employment status, patterns of migration and residence, and nationality. 1. By employment status, farm labour in the Mpumalanga-Limpopo region can be divided into those workers who are permanent, seasonal and temporary: (1) usually, permanent workers have been employed on a farm for more than three months and occupy skilled or low managerial positions; (2) seasonal workers are employed for harvesting citrus, mangos and vegetables and usually are employed for the duration of the ‘picking’ and ‘packing’ season; and (3) temporary workers are the ‘general labour’ on many farms and are both the lowest skilled and lowest paid workers, normally employed for specific short-term tasks requiring few skills. Both farmers and workers refer mostly to only two categories of workers, ‘permanent’ and ‘temporary’, calling seasonal workers in the sense described above ‘temporary’ workers. 2. A second set of categories of farm workers in the Mpumalanga-Limpopo region relates to common patterns of residence and migration in the area: (1) ‘Resident’ farm workers work and live permanently on farms where they have security of tenure; (2) ‘Tenant’ workers also work and live permanently on farms but have no security of tenure. They live in farm compounds owned by the farmer, migrating home mostly once a month to their homes in the villages situated in traditional ‘trust’ areas; (3) ‘Commuter’ farm workers are those who commute daily by public transport between their homes in the villages and the farms on which they are employed; and (4) ‘Foreign migrant’ workers are persons who regularly cross international borders to search for work in South Africa and have strong ties to their home countries. 3. Lastly, a differentiation should be made between local (i.e. South African) and foreign labour. Within the category of foreign labour are migrants who are recent arrivals to South Africa and those who are well-established in South Africa, having lived in the country for a number of years. Although there are clear ties among Mozambican farm workers in Mpumalanga province to their home country, “it is a fallacy to assume that all non-South Africans are recent migrants.”22 The FRRP survey found that over 50% of “immigrant farm workers” had been on South African farms for more than five years and as many as 16% had been on one for 11-20 years.23

22 Crush, (2000) p.5 23 Ibid.

13

Farm Workers’ Health and Access to Health Facilities

Access to PHC clinics

86.6

13.4

0 10 20 30 40 50 60 70 80 90 100

Yes

No

Percentage workers

Farm workers from the two survey sites access health care almost exclusively at the Primary Health Care (PHC) clinics in Burgersfort and Hoedspruit. For the few respondents who experience difficulties in accessing a PHC clinic, the most commonly cited obstacle was the lack of money not for actual health services, as all health services at the Burgersfort and Hoedspruit PHC are free of charge, but for transportation to the clinic (41%). Some farm workers access health care at one of the five private clinics run on large, company-owned farms in the Hoedspruit district. Such clinics are often situated conveniently close to the workers’ compounds, and are therefore within easy physical access. However, since workers are charged per consultation, for basic services and for medication this may constitute an obstacle to access which is not experienced by those workers using the government-run PHC clinics. Limited statistics from Hoedspruit and Burgersfort PHC clinics indicate that the most common medical conditions and/or illnesses among patients - of whom a significant proportion are farm workers - are hypertension, diabetes, upper respiratory tract infections, skin problems/infections, muscle pain, tuberculosis (TB), diarrhoea, STIs, urinary tract infections and HIV/AIDS (the available statistics do not reflect differences between men and women). General services offered at the above two PHC clinics are supplemented by mobile clinic services, operating around and beyond the survey sites. Each mobile clinic service has two vehicles staffed by two professional or staff nurses who visit selected farms and other ‘calling points’ on a monthly basis (a few farms are visited once every three months). Ten out of twelve of the surveyed farms are covered by the mobile clinic services24. Limited statistics from these two mobile clinics indicate that the most common medical conditions and/or illnesses among patients, - again, of whom a significant proportion are farm workers - are very similar to those recorded at the PHC clinics: hypertension, diabetes, upper respiratory tract infections, skin problems, muscle pains, tuberculosis (TB), diarrhoea, STIs, urinary tract infections and infections related to HIV/AIDS. When asked about the service provided by both PHC and mobile clinics, on the whole workers were satisfied. 24 See Annex pp.49-59

14

Apart from accessing primary health care at clinics close to the farms, farm workers turn to five other significant sources of medical assistance. These include the farm owner (14.8%), the farm supervisor (13.1%), private doctors (13.7%), hospitals (19.1%) in the region, and traditional healers (14.8%). Farm Workers’ HIV/AIDS Knowledge and Attitudes With very few exceptions, all farm workers had heard of HIV/AIDS (96%). There were no significant differences in the replies given by different nationalities or between female and male farm workers.

HIV/AIDS transmission, workers' beliefs

0 10 20 30 40

Sharing tools at work

Touching someonewho is sweating badly

Hugging anotherperson

Coughing

Sharing cups andplates

Percentage workers

Yes, HIV can be transmitted in this way Don't know if HIV can be transmitted in this way

When asked about how HIV/AIDS is transmitted, the survey reveals that misconceptions are common among farm workers. While 89% of the sample stated that sex without a condom is a means of transmission, as many as 42% believed or reported not knowing whether coughing or sharing cups and plates spreads HIV. Respondents expressed the following views during group interviews:

I heard people talking about HIV/AIDS but I don’t know how it gets into a person. They say it starts as something like a small disease and ends up being AIDS. There is a need to find ‘muti’ [traditional medicine] to cure AIDS.25

25 Group interview with farm workers, Hoedspruit area, 26-27 September 2003

15

HIV/AIDS gets into people in different ways… One example is that when we sit together talking, you may find that my saliva gets through your mouth and you get AIDS. You can also get AIDS by sharing a cup of water with someone else, especially if it is used without being washed. You can also get AIDS through sexual intercourse. The way I heard is that you can get AIDS through unprotected sex, like having sex without a condom and your blood contact can give you AIDS. If people use one toothbrush they can get AIDS.26

Importantly, a break down of the above data by sex further indicates that women have less knowledge than men about the means of transmission.27

HIV/AIDS transmission, female and male workers' beliefs

0 10 20 30 40 50 60 70

Sharing tools at work

Touching someone who issweating badly

Hugging another person

Coughing

Sharing cups and plates

Percent workers "Yes and "Don’t know answers combined

Female workers Male workers

26 Group interview with farm workers, Hoedspruit area, 26-27 September 2003 27 The difference in knowledge concerning means of transmission between female and male workers is statistically significant at the 1% level of significance according to Fisher’s exact chi-square test

16

Can HIV be transmitted in this way? South African and Mozambican workers' beliefs

0 10 20 30 40 50 60

Sharing tools at work

Touching someone whois sweating badly

Hugging another person

Coughing

Sharing cups and plates

Percentage workers ("Yes" and "Don't know" answers combined)

SouthAfrican Mozambican

There are differences between South African and Mozambican workers as to the knowledge of the means of transmission, which indicate that the latter are generally less informed.

Is there anything you can do to avoid getting HIV/AIDS? Male workers' beliefs

96%

2% 2%

Yes, there isNo, there isn'tDon't know

Is there anything you can do to avoid getting HIV/AIDS? Female workers' beliefs

68%

11%

21%

Yes, there is

No, there isn'tDon't know

When asked if there is a way of protecting yourself against HIV/AIDS infection, again there is an important difference between the answers of male and female farm workers. 32 % of all women surveyed answered that they ‘do not know’ or ‘do not believe’ that there is anything they can do to

17

avoid infection.28 A breakdown by nationality confirms that among Mozambican female workers the figure is even higher, at 50%. By comparison, only 4% of male farm workers, both South African and Mozambican, ‘do not know’ or ‘do not believe’ that there is anything they can do to avoid HIV infection. When asked how they can protect themselves, the majority of workers mention condom use as the main method. Other means cited include abstinence and faithfulness.

We can only protect ourselves by using condoms and apart from that there is nothing we can do. It is not possible to abstain from sex, we are trying but it is difficult. If you abstain your man will have another woman and chase you away.29

How much male workers worry about having HIV/AIDS

80%

5%

15%

A lotA littleNot at all

How much female workers worry about having HIV/AIDS

21%

34%

45%

A lotA littleNot at all

As many as 80% of male farm workers report worrying a lot about being infected by HIV. Among female farm workers 45% ‘worry a lot’ about having HIV/AIDS and 34% do not ‘worry at all’. This big difference in the results between male and female workers needs to be considered in the light of the finding that women have less knowledge than men about means of transmission and prevention of HIV/AIDS infection.

Percentage of workers who knew someone who had died of AIDS

42%

57%

1%

Knew someone who died of AIDSDid not know anyone who died of AIDSDon't know if anyone they knew died of AIDS

Can you die from HIV/AIDS? Workers' beliefs

90%

3% 7%

Yes No I don't know

28A statistically significant association between sex and knowledge about how to avoid HIV/AIDS is confirmed at the 1% level of significance according to Fisher’s exact chi-square test 29 Group interview with farm workers, Hoedspruit area, 20-21 September 2003

18

42 % of the surveyed farm workers know of someone who has died of AIDS, which suggests that many have already encountered the disease:

I remember my friend whose health declined drastically and remember asking him if he was okay. He did not last even three days and he was dead, I believe dead of AIDS. His partner also died of AIDS, shortly after we buried my friend.30

Several respondents were also able to recognize the symptoms of HIV/AIDS infection such as body decline, sores and coughing but more than half, 57%, report not knowing of someone who has died of AIDS:

I do not believe that there is HIV/AIDS. I have not seen anyone with AIDS. They say a person with AIDS has dry skin.31

As reflected in the graph above, 90% of all farm workers believe that HIV/AIDS kills. 10% of the workers say that they ‘do not know’ whether HIV/AIDS is deadly or say that the disease ‘does not kill’. Taking into consideration the fact that the farm worker population in the two provinces is in the thousands, 10% represents a significant proportion of farm workers. A comparison between the sexes indicates that more female than male farm workers believe that AIDS is not fatal or report not knowing if AIDS can kill. Respondents who do not believe that HIV/AIDS kills commonly refer to the powers of traditional healers and to those of the church:

There is no ‘muti’ [traditional medicine] for AIDS. All that people can do is accept Jesus Christ and live by the word of God and pray. There is an example of one person who contracted HIV and was a member of a certain congregation and converted to another and the priest and the congregation prayed with her. She is now cured. Traditional healers are said to be able to cure AIDS but I don’t trust that. My cousin’s sister died of AIDS, but was taken to the same healer called Hlathikulu. He gave her all the herbs but she still died.32

30 Group interview with farm workers, Burgersfort area, 20-21 September 2003 31 Group interview with farm workers, Hoedspruit area, 20-21 September 2003 32 Group interview with farm workers, Hoedspruit area, 20-21 September 2003

19

Workers' assessment of the cause of death on farms

0 5 10 15 20 25 30 35

TB

AIDS

Old Age

Exhaustion

Natural causes

Murder

Occupational Injury

Accidents

Witchcraft

Hunger

Dihorrea

Kwashiorkor

Don't know

Cau

se o

f dea

th

Percentage workers

In comparison to other illnesses and medical conditions, HIV/AIDS is regarded by farm workers as an insignificant cause of death on farms. Interestingly, no women reported HIV/AIDS as a cause of death on their farms, which is in line with the finding that fewer women worry about being infected and generally have poorer knowledge about HIV/AIDS. The most commonly cited cause of death on the farms was ‘natural causes’. Witchcraft is regarded as the second biggest ‘killer’ on farms. When asked directly about witchcraft as a cause of death, almost 50% of all workers felt it was an important one. Some farm owners, on the other hand, report having noticed a difference and experienced more deaths, if not on their farms, at least among their staff:

You find more people attending clinics and taking sick leave than in the past but I wouldn’t say alarmingly so. What we do find, though, is people really becoming really ill and dying. Confirmed HIV deaths, 3 in the last three years. Suspicions…a lot more. You will find that people come and resign…We ask them, why do you want to resign? They say, ‘Look, I’m tired, I want to go and rest.’ But this is not new. I grew up on a farm and that is they way it is. People, especially women, will work for 10 years and then they come and say to you, ‘I now want to go home’. This is not necessarily an AIDS thing but you find this happening more and more. And then you hear 3, 4, 5 months later, you hear that they died’ […] We sometimes find that a lot of these people, they haven’t had themselves tested but they have got a very good idea, so they resign, they take their pension money, they go home and they die. Where you find the most deaths is your men aged 35 and up. That’s where we tend to get most of our deaths.33

33 Interview with farm manager, Hoedspruit, 30 September 2003

20

Perceptions among farm workers of the size of the HIV/AIDS problem on their farm

72.1

19.4

19.8

71

8.1 9.7

0%

20%

40%

60%

80%

100%

Men Women

Sex

Per

cent

age

wor

kers

Don't knowNot a big problemA big problem

When asked directly about the HIV/AIDS problem on their farms, however, 72% of male workers experienced it as ‘a big problem’ while the corresponding figure for female workers is only 20%.34 71% of women reported that HIV/AIDS is ‘not a big problem’ on their farm. More South African than Mozambican male workers see HIV/AIDS as a big problem on their farm and an almost equal number of men and women report not knowing how big the problem might be. When farm owners were asked to comment on HIV/AIDS as a problem on their farms, some reported having felt the direct impact of HIV/AIDS:

I don’t want to guess what percentage of people are infected with AIDS but I’m sure that if I take a guess of more than 40% I will not be too far off. Not necessarily all of them are affected work-, performance-wise, but a percentage of them are. […] What we see is that this performance is going down, down, down, on average. If you ask them [workers], to a lot of them it is because the people are sick. And I ask them, ‘What do you mean sick?’ Now you have some people, mostly your more educated ones as far as AIDS is concerned, they talk about a ‘slow puncture’. They call somebody with AIDS a slow puncture... But they will tell you its things like TB, or he’s got a skin problem, he’s got a problem with his…they sometimes call it ‘his blood is dirty’ or he’s got an internal problem [all referring to HIV/AIDS]35.

34 A statistically significant association between sex and the perception of the HIV/AIDS problem on the farm is confirmed at the 1% level of significance according to Fisher’s exact chi-square test. 35 Interview with farm manager, Hoedspruit, 30 September 2003

21

Some farmers have also noticed a higher level of absenteeism among their workforce, but not necessarily an increased number of deaths:

I think it [absenteeism] has picked up a little bit. I cannot say the percentage, a slight increase. […] All I can say is that, what I’ve noticed, people are not as strong as they used to be…[funerals] have increased a lot... Usually family members…they come and ask for help… [that has increased] in the last 3-4 years.36

Farm Workers’ Sexual Practices

Number of concurrent sex partners among workers with a spouse or steady partner

7.41.2 0.6 0.6

26.4

63.9

0

10

20

30

40

50

60

70

1 Partner 2 Partners 3 Partners 4 Partners 5 Partners 6 Partners

Per

cent

age

wor

kers

An important finding is the high frequency of concurrent sexual relationships among the workers. Among married workers or those involved in a steady relationship, 36% admit to having two or more concurrent sexual partners. Compared by sex, more male than female workers have concurrent sexual relationships. A breakdown by nationality reveals that more Mozambican workers report having concurrent sexual relationships than South African workers (28% among South Africans against 43% among Mozambicans). The number of respondents who are neither married nor involved in a serious relationship is too small to interpret into a reliable observation about concurrent sexual relations. Nevertheless, among this small sample, 44% report having two or more sexual partners:

Some [workers], both permanent and temporary, have their own wives at the villages. They all have boyfriends and girlfriends - it is something common. Some men have 3-4 girlfriends, the same with women.37

36 Interview with farm owner, Hoedspruit, 1 October 2003 37 Group interview with farm workers, Burgersfort area, 20-21 September 2003

22

Transactional Sex Responses from male and female farm workers indicate that transactional sex is taking place on the farms, involving the exchange of money, clothing, gifts or food. 52% of female workers surveyed report exchanging goods for sex while involved in a steady relationship with a boyfriend. No significant difference was detected between permanent or temporary female workers in this regard. Interestingly, only 13% of male workers report having offered gifts in exchange for sex with women. Abuse and rape were not reported to be a big problem on farms. Nevertheless, what clearly transpires from the in-depth interviews is that female workers often do not feel that they have a choice about whether or not to engage in sex:

Respondent: No, people do not rape on this farm or on surrounding farms. It is safe here. If somebody proposes you, you just agree. It is much better.

IOM Interviewer: How many times do you agree to everybody’s proposals? Respondent I do not count, but I can not stay alone. When my boyfriend does not like me

anymore I move on. As to how many times, it does not matter. This is not at choice any more, it is poverty that push us. You will not know if the next man is better or not but it is worth a try.38

Condom Availability and Use Although farm site mapping confirms that condoms are rarely available at workers’ compounds, the overwhelming majority of workers, 93%, know where to find condoms and how to gain access to them, almost exclusively at public hospitals and PHC clinics. However, this knowledge is poorly reflected in rates of condom use, especially among women.

Do you believe condoms prevent HIV/AIDS?

7.8

6.7

7.8

14.5

63.1

0 20 40 60 8

Always

Most of the time

Seldom

Never

I don’t know

Percentage workers0

While 63% of all workers believe that condoms “always” prevent HIV/AIDS, male workers place significantly greater faith in the efficacy of condoms as a means of preventing HIV transmission

38 Interview with female farm worker, Hoedspruit area, 20-21 September 2003

23

than female workers. 84% of male workers believe that condoms “always” prevent the transmission of HIV compared to 44% of female workers. Almost four times as many female workers as male workers believe that condoms “never” prevent the transmission of HIV/AIDS while roughly an equal number of female and male workers say that condoms “seldom” work. A high percentage of women - one quarter - report not knowing whether condoms prevent the disease compared to only 2% of male workers who report not knowing. A frequent misconception among respondents seems to be that condoms themselves are carriers of HIV infection and therefore should not be used:

Condoms are important but we don’t trust them... These condoms are perceived to be AIDS carriers. I have never used a condom in my life, I only see them. The main problem with condoms is the oil and the worms on it. […] I can’t agree to sleep with a man who would want to sleep with me using a condom. I will just tell him I don’t use that thing.39

Male workers' condom use with wife or girlfriend

41%

0%45%

10% 4%

Never Once only SometimesMost of the time Always

Female workers' condoms use with husband or boyfriend

75%

1%

13%

7% 4%

Never Once only Sometimes

Most of the time Always

Differences are evident between male and female workers when it comes to condom use in marriage and in steady relationships. 75% of female workers report “never” using a condom with their primary partner, approximately twice as many as male workers. There are no differences between permanent and temporary female workers who report “never” using a condom. 55% of men, as compared to 20% of women, report using a condom “sometimes” or “most of the time” with their primary partners. Only 4% of men and women report “always” using a condom. When the data is analyzed along lines of nationality, Mozambican women, in particular, report very low rates of condom use: 89% report “never” using a condom with a husband or boyfriend, compared with a rate of 66% for South African women. Approximately one third of South African men and half of Mozambican men report “never” using a condom.

39 Interview with female farm worker, Hoedspruit area, 20-21 September 2003

24

Male workers' condom use outside marriage or steady relationship

32%

0%

32%

14%

22%

Never Once only SometimesMost of the time Always

Female workers' condom use outside marriage or steady relationship

63%

0%

20%

3%

14%

Never Once only SometimesMost of the time Always

36% of male workers report using a condom “always” or “most of the time” with a casual sex partner, as opposed to 14% with a wife or a girlfriend. Condom use among female workers also increases when having sex outside marriage or a steady relationship, although the increase is not as significant as among male workers. Condom use “always” or “most of the time” increases from 10% to 17% of women with casual sex partners. Most strikingly, almost twice as many female workers as male workers report “never” using a condom in a casual sexual relationship. This is a significant indicator of their potential risk to HIV infection.40 When the data is analyzed along lines of nationality, a greater proportion of Mozambican workers than South African workers claim to ‘never’ use condoms both in their primary relationship and in casual sexual relationships. In conclusion, whether having sex within a steady relationship or marriage, or in a casual sexual relationship, male workers’ generally practice safer sex than female workers. With regard to farm workers who are neither married nor involved in steady relationships, it is difficult to make any reliable observations about the frequency of their condom use as the sample of these workers is fairly small, amounting to a mere 16 workers. Nonetheless the figure for this small sample size is very high, at 75%. Again, frequency of condom use within this group appears to be lower among women than men.

40 A statistically significant association between sex and the practice of having unsafe sex with casual partners is confirmed at the 1% level of significance according to Fisher’s exact chi-square test

25

Reasons for not using condoms

1.2%

10.4%

6.7%

1.8%

23.3%

10.4%

15.3%

9.2%

49.1%

0.0%

0% 10% 20% 30% 40% 50% 60%

Condoms are too expensive

Limited Access to condoms

Condoms reduce pleasure

Condoms break

Feel embarrassed to ask partner

My partner dislikes them

I don't like them

I don't feel I need one

I trust my partner

I haven't thought of using one

Percent workers

Looking at the statistics for male and female workers combined, the reason most often cited for not using a condom with a spouse or steady partner, is the belief that they can trust their sexual partner. However, disaggregated by sex, it is clear that this reason is overwhelmingly given by male workers: as many as 74% compared to 24% of female workers. Among female workers, the main reason given is that their husband or boyfriend does not like condoms and/or that they “haven’t thought of using a condom”. More than twice as many female workers as male workers feel that they do not need a condom. Discussion of Survey Data Knowledge To summarize the results, it appears that many of the farm workers surveyed possess very basic knowledge about HIV/AIDS. They seem to pick up information through various sources, including clinic nurses, radio, TV and through printed materials. However, their knowledge seems somewhat superficial and it is likely that many have picked up fragments of information but have never been given a complete picture of the disease. The fact that only 75 out of 183 farm workers report having received any HIV/AIDS information strengthens this hypothesis. In sum, an image emerges of these communities as one where basic knowledge about HIV/AIDS is lacking and where myths about the disease and beliefs in traditional healing methods are rife. It is also evident that many of the workers who have received information about HIV/AIDS have not fully internalized the message; as a result HIV/AIDS remains a distant problem for them.

26

The high illiteracy rate – approximately 50% among both men and women workers – is undoubtedly part of the reason behind the low knowledge level. In addition, there is minimal coverage of farms by various HIV/AIDS service providers and a lack of care and prevention activities. During the mapping exercise, no HIV/AIDS posters, information or condom distribution points were observed on any of the farms surveyed. Importantly, it was found that female workers have poorer general knowledge and are to a far greater extent uninformed about HIV/AIDS than male workers - this difference is consistent throughout the knowledge section of the survey results. Literacy and educational levels among female and male workers give no leads as to this difference; they are more or less the same for all workers surveyed. To put the results into perspective, a comparison was made with HSRC’s findings for the general SA population.41 This 2002 study found that male and female South Africans generally do not differ significantly in respect to HIV/AIDS knowledge. Hence, it is possible that this survey has captured something unique to the farm setting which would deserve further attention and research. A similar difference, between Mozambican and South African workers, although not statistically significant, is equally difficult to explain. That Mozambican workers have less HIV/AIDS knowledge could be related to language issues and possibly be explained by the fact that, at least for ‘new comers’, it is difficult to access information. Sexual Behaviour The survey results reveal a mismatch in terms of knowledge and behaviour among farm workers, especially men: among those workers who possess basic HIV/AIDS knowledge, sexual behaviour nevertheless is often unsafe. This trend is important but not unique to farm workers surveyed in this study - it has been a common finding in the Southern African region and one of the riddles facing HIV/AIDS experts. The incidence of concurrent sexual relationships reported by farm workers was unexpectedly high. Again, this finding does not correspond to national findings as reported by HSRC.42 The seasonal character of farm work largely explains this pattern. At harvest season and with the arrival of temporary workers, sexual networking among farm workers increases, in particular between permanently employed men and young, female temporary workers:

Most men have many girlfriends, from 4-5. The number increases during the temporary employment - it is the time that men change girlfriends and leave the older ones and go to the new one. They accumulate as many as 30. They leave some of us [women]. They no longer even look or talk to us. […] they only come back when the temporary [season] is over … There is no faithfulness in both men and women.43

41 HSRC (2002) 42 Ibid 43 Group interview with farm workers, Hoedspruit area, 20-21 September 2003

27

The nature of the relationships that develop between the permanent male workers and the temporary female workers is usually one of transactional sex. As the temporary women begin to arrive at the start of the picking season, “there is overcrowding in the rooms…and the permanent men come scouting, choosing the beautiful ones. [They] take them and stay with them in their own houses. Some may take two or three.” The young women are not passive in this process. They specifically target men who have well paying jobs on the farm and in exchange for sex and becoming their girlfriends they are guaranteed food, money and “nice things.” Young temporary female workers on company farms who would normally be forced to commute daily to a farm at their own expense use these relationships to gain access to living quarters at the compounds usually reserved for permanent workers and their spouses/partners. Others appear to enter into these relationships because of instability in their lives. Having been abandoned by their husbands or boyfriends, they are left to take care of small children and look for new relationships with men as a means of providing for their children:

We need porridge, that is what brought us to these men. I came to the farm with babies. I earn R200. I have three children…My man is a Shangaan. He ran away after giving me children…That is why I want another man, to help maintain my babies.44

For many of these women, it is a vicious circle. They look to men to support the children they already have but “[…] the men do not care. They just give these women babies, many babies. They enjoy it. They give babies to different women,” said one farm worker. The women end up bearing more children – “everybody here has babies, at least two or three. Especially the temporaries are having babies with the permanent men on the farm.” It appears that female temporary workers rarely develop lasting relationships with permanent men. At the end of the season, they eventually leave the farms with little of the family stability they were hoping to find. Wives of permanent workers who find themselves abandoned by their husbands, in turn, seek out different sexual partners during the temporary season. An annual season of sexual networking between young temporary female workers and older permanent workers appears to be part of the culture of all farms where temporary workers are employed in significant numbers. Some men are reported to take on two or three girlfriends during each season. Others take as many as four of five and “when they are together, they boast that they slept with more women…They want to exchange [women] and prove to their friends that they can sleep with them all. They do not tell you that they love you. They just want to test and move on.” Men who make the most money and have important status on a farm appear to develop more extensive sexual networks, none more so than the farm supervisors or ‘indunas’. At the beginning of each season, the indunas are responsible for alerting communities about the availability of work and on many farms are closely involved in the hiring process. As a result, they are often able to secure work for family or friends but also for women who they see as potential girlfriends. Refusal to grant sexual favours to indunas could mean losing one’s job on the farm.

44 Group Interview with farm workers, Hoedspruit area, 20-21 September 2003

28

Women are most disadvantaged because their success on the job depends on whether they agree to the love proposals he makes to them. Many women who refused lost their jobs. The women you see here, he slept with them. He has a lot of women. That one in that house there has three wives and girlfriends and the one staying in this house has five different wives and countless girlfriends. He got them all in here when they came looking for work. He chooses the beautiful ones.45

On all farms, indunas are the de facto leaders and representatives of farm workers. Although they are supposed to be aware of important community issues, such as HIV/AIDS, the abuse of power and practices of favouritism by male workers in positions of authority place many young women, as well as their own wives, in danger of HIV infection. Condom use in stable relationships or between mutually monogamous partners is normally seen as less important than that with casual sex partners. However, in light of the picture described above, where many married workers often engage in casual sex, the issue of condom use in stable relationships becomes increasingly important. Many of the married workers or workers in steady relationships who report not using condoms with their primary partner are very likely engaging in high risk sexual behaviour because of the high rates of concurrent, casual sex partners and the alarmingly low figures of condom use with these casual sex partners, as reported by both male and female workers. What is striking is the big difference in condom use among male and female workers. Often uninformed and unaware of the risk and dangers related to HIV/AIDS, female workers are less likely to change their behaviour and take preventive measures. The mismatch between knowledge and behaviour among male workers is more difficult to explain. Why do so many of them engage in casual and unsafe sex despite signs of good knowledge about means of protection and transmission? In line with what has been mentioned earlier, this could be related to the fact that the HIV/AIDS ‘message’ has not been fully internalized and that, due to scanty information, HIV/AIDS remains a distant problem. Workers could also be more prone to risk behaviour due to the general situation on the farms, including poor living and working conditions, as well as to the insecurity and instability of their lives, such as the lack of job security and legal status. In terms of health seeking behaviour among the farm workers, it was found that many of the respondents were strongly reluctant to get tested for HIV and it is likely that very few are aware of their status.46 A very common feeling expressed was ‘what you don’t know won’t harm you’:

45 Group Interview with farm workers, Hoedspruit area, 5 October 2003 46 Findings relating to workers’ reluctance to be tested for HIV are in line with the HSRC’s findings for the general South African population (HSRC (2002) Nelson Mandela Study of AIDS).

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We are afraid because we can be told that we are HIV/AIDS positive. Once you discover you are HIV positive you will think a lot and will have a difficult life. You will think of death in 4-5 years time or maybe 10 years and feel haunted by the disease.47

Attitudes Male and female perception of the HIV/AIDS problem on the farms is again different. Tracing this difference back to the lower levels of knowledge and awareness recorded among female workers, we find a logical pattern - female workers do not perceive HIV/ AIDS as a big problem on their farms and consequently worry less than men about being infected. That a majority of male workers worry about being infected could be interpreted as a sign that they, more often than women, engage in casual, unsafe sex and are aware of the risks that such behaviour creates. An ‘I’ll believe it when I see it’ attitude was commonly recorded. Respondents who had not themselves witnessed somebody affected by HIV/AIDS were not convinced of the seriousness of the disease, and this may well be an underlying factor in the high risk behaviour reflected above. The low level of recognition of AIDS related deaths by farm workers seems to be linked more closely to the stigma attached to HIV/AIDS, and the fact that people avoid speaking openly about the disease, than to the fact that HIV/AIDS related deaths do not occur.

Most of us who are HIV/AIDS infected do not disclose it for fear of being shunned by other people and families. People will no longer love you like before.48

It also seems to be common practice that workers who fall ill leave the farm to die in their homes and are buried in their villages, hence many deaths actually occur outside the farms.

I can’t really tell the truth about danger of HIV/AIDS on this farm, since we never heard anyone telling us about someone who died or is infected with HIV/AIDS on the farm. […] People are buried at the villages and most of them die of unknown illnesses.49

4. RESULTS OF QUALITATIVE INVESTIGATION Living Conditions Accomodation Farm compounds are separate areas on a farm property where workers live, sleep, cook and eat, entertain themselves and spend free time. The compounds are their ‘homes away from home’ during the month-long periods they normally spend away from their villages in the ‘trust’ areas.

47 Group interview with farm workers, Hoedspruit area, 26-27 September 2003 48 Group interview with farm workers, Hoedspruit area, 26-27 September 2003 49 Group interview with farm workers, Hoedspruit area, 26-27 September 2003

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Compounds are often socially diverse sites, home to a mix of decade-long South African and foreign employees, recent cross-border migrants, job seekers from other districts, and a seasonal deluge of young female temporary workers arriving at harvest time. The farmer provides the compound accommodation for which workers usually pay a nominal rental, about R60 per month. Detailed mapping of the compounds of each of the 12 farms was conducted, in order to determine the type and condition of workers’ accommodation, living arrangements, sanitation facilities and opportunities for recreation. Accommodation types differ but most compounds typically have a combination of small houses, each divided into 2-4 rooms, and bigger dormitories, some with as many as 16 rooms (both the houses and dormitories are usually built from bricks and have tin roofs).50 Permanent and temporary workers usually share the same houses and dormitories though on one Burgersfort farm there was a sharp division – some 45 permanent workers were found each to have their own room in a brick dormitory while 80-90 temporary workers were sharing two 16-room dormitories in a warehouse that had been converted from a pig-sty. At most compounds, each small room is either shared by a family (man, wife/partner and children) or between 2-3 single workers, creating cramped, though not inhumane, living arrangements. The arrival of temporary workers during harvesting season, however, has a significant impact upon the availability of living space in the houses and dormitories at farm compounds. Permanent workers are often forced to share their houses and rooms with temporary workers, creating serious overcrowding. Farm owners try to maximise the use of limited available space and often prevent permanent workers from living in the compounds with their spouses or partners (unless they are also employed on the farm). Temporary workers are worse off in this regard, rarely being allowed to share their compound accommodation with a spouse, partner or child(ren).51

Basic Amenities Basic amenities available to workers are often lacking at farm compounds. All 12 compounds which were visited had clean running water but sanitation facilities were found to be especially deficient. Ablution blocks consist entirely of pit latrines and are often too few to hygienically service the number of workers using them (in one case, 80 workers were having to share 3 pit latrines). Hot water is rarely available and as much as one third of the compounds visited were found to be without electricity. Recreational Facilities There are very few sources of entertainment or recreation available to workers during their free time. Virtually none of the compounds visited had a community hall available to workers or any other type of recreational facility - two farm compounds had a television available to workers. The only

50 Other types of compound accommodation mapped by IOM, though less common, included brick and thatch rondavels, tin shacks, tents, and dormitories built from prefab plaster. 51 Some farmers attempt to minimize the creation of ‘split households’ through their hiring practices. Two farmers from the Hoedspruit area and one from Burgersfort said that they tried to hire both a man and his wife so that they can both live at the compound. Others, especially the large company farms around Hoedspruit, rely on temporary workers who are daily commuters and thus live with their families in the villages of the ‘trust’ area

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recreational amenity visible on almost all the farms was a soccer field and workers spend a great deal of time each weekend taking part in matches or watching the games. But “apart from soccer, there is nothing available for the people to entertain themselves with…we are suffering,” said one worker.52 It is not surprising, therefore, that “alcohol is [often] the only form of entertainment,” according to another worker.53 Improvements in Living Conditions It was found that Mozambican workers generally live peacefully alongside South African farm workers and that the two nationalities are never segregated into separate compounds, nor that one group enjoys markedly better living conditions than the other. However, there appears to be some grounds to believe that these unacceptable living standards remain unchallenged in the Hoedspruit farming district partly because of the nature of the balance of foreign and local workers on farms. South African workers report that Mozambicans, often in the majority on a farm, have frustrated local workers’ attempts to improve living conditions and wages. They argue that:

[Mozambicans] are exploited and readily available for any overtime work. It makes it difficult for us [South African workers] to launch any complaint…[about] toilets, electricity and houses in general. As they are in the majority…in the farm compound, they are submissive to the farmer. They do not care as long as they get little money to buy food. The Mozambicans side with the farmer and they say that those toilets are okay.54

Further, despite the establishment of a minimum wage in agriculture, South African workers feel that Mozambicans often undermine their efforts in this regard.

They [Mozambicans] don’t have problems with the money they are paid…They do not even complain about it…Because they are suffering, they just accept whatever they are given and show dedication to their work…They arrive in numbers and find jobs. The farmer cuts our wages to accommodate them…When we embark on a strike about the wages…they don’t support us as they think R400 is enough for them.55

It is not clear from the limited accounts how widespread this effect is across the Hoedspruit area or whether impoverished Mozambicans allegedly retarding change on farms are recent cross-border migrants or permanently-settled Mozambicans from the ‘trust’ area. At the same time it is important to keep in mind that in some instances efforts are made to improve the quality of life on the farm compounds. For example, many progressive farmers in the area, have improved and extended housing, provided acceptable levels of sanitation, and built crèches and schools on their farms. Nevertheless, the grievances of South African workers cannot be ignored and do not bode well for change in many of the farm compounds where human living conditions remain sub-standard.

52 Group interview with farm workers, Burgersfort area, 20-21 September 2003 53 Group interview with farm workers, Burgersfort area, 20-21 September 2003 54 Group interview with farm workers, Hoedspruit area, 20-21 September, 2003 55 Group interview with farm workers, Hoedspruit area, 27-28 September 2003

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Working Conditions The study was not specifically tasked with investigating employment conditions on farms as part of the KAP survey and the small number of farms visited also makes it difficult to be accurate and conclusive. However, the recent report published by the SAHRC, which summarizes public hearings into “Human Rights Violations in Farming Communities”, finds employment conditions in the South African agricultural industry to be poor and generally not compliant with government legislation. The Commission reported that:56

• There is general and widespread lack of compliance with labour legislation; • Conditions on farms are not conducive to the organisation of labour due to a lack of access

to union organisers and an environment of intolerance and hostility; • Wages are generally low; and • Female workers, seasonal workers and illegal foreign workers are most vulnerable to poor

working conditions and are discriminated against in farming workplaces. In Limpopo, specifically, the SAHRC observed “a general lack of knowledge by farm workers and farmers of labour legislation”, non-compliance with labour laws (including arbitrary dismissals), long working hours, the existence of child labour, assaults occurring within the workplace57, working without pay, and non-registration of workers for UIF (Unemployment Insurance Fund). Women were found to be generally paid less for the same work.58 In Mpumalanga, a similar picture is reported by the Commission. The most frequently reported matters to the Commission relate to non-compliance with labour laws, excessive working hours, wages (non-payment for Sunday work, non-payment for sick days, and unexplained deductions by employers), and absence of leave, especially complaints that farm employers do not grant maternity leave.59 Farm workers’ future and prospects Few farm workers feel optimistic about their future partly because of poor living standards and employment conditions. Many expressed their urgent need for improved housing and better wages as a means of addressing their prospects on the farms, in addition to the need for general improvements to their quality of life and living conditions. When asked about her future on a farm, one worker simply said that she wanted to feel “well cared for.”60 Until these basic needs are met and people, especially the youth, living on farms are given hope, “South Africa will not have farm workers with a love and knowledge of their work and a willingness to labour,” in the words of Ruth First. For the present, the reflection of one farm worker in the Burgersfort area appears to remain true: “the future is bleak for many farm workers.”61 56 SAHRC (2003) 57 As an example, in February 2004, a farm worker was allegedly beaten and fed to hungry lions by a Hoedspruit farm owner and three accomplices. Reported in This Day, 12 February 2004, p. 10. 58 SAHRC (2003) 59 SAHRC (2003) 60 Group interview with farm workers, Burgersfort area, 20-21 September 2003 61 Group interview with farm workers, Burgersfort area, 20-21 September 2003

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Migration Foreign farm labour surveyed in the Mpumalanga-Limpopo border region is overwhelmingly Mozambican and falls into two categories: (1) Mozambican ex-refugees who have been living in South Africa since the late 1980s and early 1990s and whose migration is mostly internal, and (2) recent Mozambican migrants whose movement is cross-border and for whom the farms of the border region are often temporary stops on their way to South Africa’s urban centres. Farm employment in the border region is a magnet for migrants in Southern Africa and those known to work there, other than the Mozambicans who are the biggest group, are migrants from Malawi, Swaziland and Zimbabwe. The following section on farm labour migration focuses on migration specifically from Mozambique. Migration Patterns among Farm Workers living around Hoedspruit The employment and migration patterns of Mozambican farm labour in South Africa are a ‘borderline’ phenomenon, for two reasons. In the first place, a significant number of Mozambicans have made the border region,62 immediately to the west of the Kruger National Park, their permanent home. Many are former refugees who came to the area during the Mozambican war in the 1980s and settled in the former homeland areas of KaNgwane, Gazankulu and Lebowa. After the war they chose to stay in South Africa and today between 10 000 and 80 00063 are believed to be living in Limpopo province. Having settled alongside South Africans in the villages of the densely-populated Bushbuckridge and Maruleng LCs, a large number have lost their ties to villages and families in Mozambique, and have no interest in returning there.64 Most of the foreign respondents who took part in the KAP survey belong to this group of permanently settled Mozambicans (75% claimed to have lived in South Africa for 10 years or more - see graph below65).

62 ‘Border region’ or ‘region’ in this document refers to the area straddling the Limpopo-Mpumalanga provincial boundary, immediately to the west of the Kruger National Park and falling into Bushbuckridge and Maruleng LCs. 63 IOM (2003),p.59 64 Crush, J (ed), p.19 65 The graph, though labelled “foreign workers”, represents length of residence cited overwhelmingly by Mozambican workers (the data includes only 3 other nationals – 2 Malawians and 1 Swazi).

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Number of years lived in South Africa (foreign workers)

4

1

32

3

5

21

4

9

4

13

76

5

23

2 21 1 1

1 2 3 4 5 6 8 10 11 12 13 14 15 16 17 18 19 20 22 25 30 42

Years

Num

ber o

f wor

kers

From their homes in the border region, this large resident population of former refugees is a ready source of labour for the farms lying south and west of Hoedspruit. Since they are permanently settled in South Africa and have few ties to Mozambique, their movement is limited to short-distance internal migration between their homes in the villages and the farms which lie between 20 and 60 kilometres away. Using public transportation (bus or minivan taxi), Mozambicans living in the settlements of western Maruleng LC migrate along an east-west axis linking their villages to farms surrounding Hoedspruit (see maps). Those living in Bushbuckridge LC migrate similarly along a north-south axis linking major settlements such as Acornhoek (and others to the south and east) to the same Hoedspruit farms. It is important to note that South African farm workers living in the ‘trust’ areas also migrate between their homes and the farms. They work alongside permanently settled Mozambicans on the same farms around Hoedspruit and in this sense, their migration in the border region is identical – it is internal and covers relatively short distances between their villages and the farms. In other words, as one source remarked, “everybody is a migrant.”66

In addition to those Mozambicans who have settled permanently in Maruleng and Bushbuckridge LCs, the employment of more recent, cross-border migrants in the region, often on the same farms as the permanently-settled Mozambicans, strengthens the ‘borderline’ character of foreign farm labour in south-eastern Limpopo. However, recent migrants differ from the permanently-settled Mozambicans in several important ways: (1) they appear to have closer and more recent ties to family and places of origin in Mozambique; (2) their migration to South Africa is motivated not by war but by the inter-related push factors of poverty, drought and famine in Mozambique; (3) their

66 Interview with Paul Pronyk, Rural AIDS and Development Action Research programme, HSDU, Acornhoek, 19th August 2003

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movement is both cross-border and internal; and (4) for some, at least, the border region appears to be merely a transit point on their way to urban destinations in South Africa. The more recent migrants are, again, mostly from Mozambique and travel frequently backwards and forwards across the international border. They are “well-versed in the legal and clandestine ways of border crossing…they know the district well, which farms to avoid and where to seek work,” reports SAMP.67 The evidence is strong from in-depth interviews with farm workers that most recent migrants to the border region enter it, undocumented, through the Kruger National Park. This suggests that their cross-border journeys originate somewhere along the sparsely populated borders that eastern Maputo and eastern Gaza provinces in Mozambique share with South Africa (and the Kruger National Park). Places of origin in Mozambique cited by recent migrants, Massingir, Chokwe and Xai-Xai in Gaza province, give some indication that they live close to the South African-Mozambican borderland across which they migrate.68 Routes through the Kruger National Park Migrants travel through the Kruger National Park on foot and face multiple dangers during their sometimes month-long journeys: fatigue, starvation and thirst, wild animals and the possibility of losing their way:

The route through the Kruger Park, at Skukuza Camp…it has so many animals. Some, you do not know them, you’ve never seen them before…how dangerous they are. But we just carry on and ignore them. Mozambicans are strong medicine people. When animals see us, they run…We drink water with animals. In extreme cases, people drink their own urine. The Phalaborwa route has water, especially if you are from Chokwe [Mozambican town in Gaza province]. It is also a short route.69

Migrants referred to a number of different routes through the Kruger National Park. The northernmost entry point through the Park is said to be around Pafuri where the borders of Zimbabwe, Mozambique and South Africa meet. Further south is the “Phalaborwa route” [referring to the South African town of Phalaborwa on the western border of the Park] which is allegedly the “simplest”.70 The route through the Park terminating in Phalaborwa appears to be an important one – a number of Mozambican farm workers referred to the town as the location of their homes; one farmer, employing some 90 Mozambican farm workers on a farm outside Hoedspruit, draws heavily on the town of Lulekani, immediately to the north of Phalaborwa, for temporary Mozambican labor. Other villages surrounding Phalaborwa were also reported by farm workers to be home to Mozambicans, including Mashishimale, Penter and Mapietskraal.71

In central Kruger National Park, there are two major routes connecting Mozambique with the ‘trust’ areas where many migrants have families, friends and connections - the “Manyaleti Route” (also

67 Crush, J (2000), p.6 68 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 69 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 70 Group interview with farm workers, Hoedspruit area, 20-21 September 2003 71 Group interview with farm workers, Hoedspruit area, 27-28 September 2003

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reported to be ‘easy’) and the route which passes through Timbavati National Reserve.72 Other migrants use routes even further south and among these, the Skukuza route [referring to a town by that name in the Park] appears the most common. Workers also mentioned a nearby route passing through Lower Sabie in the Park. White River, a town close to Nelspruit and not far from Lower Sabie, appears to be a major destination and area of concentration of Mozambican farm workers. Routes South of the Kruger National Park Apart from crossing through the Park on foot, migrants also reported crossing by car through the Lebombo border post (at Komatipoort) by bribing officials. SAMP, in its research in the Mpumalanga Lowveld, reported that migrants sometimes make use of the services of ‘Mareyane’, illicit border guides, who are common in the Komatipoort border region south of the Kruger National Park. Once in South Africa, recent Mozambican migrants seek work in the very same farming districts of the border region where more permanently settled Mozambicans have been working for many years. Though their exact numbers are not known, farm workers interviewed claimed that cross-border migrants “are coming in large numbers…they come everyday”73 and that “they continue to come…we see new Mozambican faces almost every year”74. There is little, if any, organized recruitment of such migrants - “they just come on the farm looking for jobs,” said one worker.75 Some are fortunate to have family, friends or connections among the permanently settled Mozambicans living in the ‘trust’ area who offer them housing and assistance in finding work.

We see a lot of them. Once they arrive here, they know where they are going to stay…They have families [in South Africa] that will accommodate them and show them where to get jobs.76

Indications are that ‘recent migrants’ should not be mistaken for people who have no previous experience of migrating to, and looking for work, in South Africa. A good deal of them appear to cross the international boundary frequently, maintaining their ties to family and places of origin in Mozambique but also knowing exactly when to cross over to South Africa to take advantage of hiring around harvest time, usually between December and February, and April and September. “They know the different seasons and the kinds of production coming in that season,” reported one worker.77 “If we see no chance of getting new jobs, most of us go back home and wait for citrus production season…But it is difficult staying in Mozambique,” said another.78 Others remain behind in South Africa after the harvesting season and migrate internally in search of more work.

We communicate as workers. We go as far as Phalaborwa and other areas like Hazyview, Tzaneen and Bushbuckridge to look for jobs…As colleagues, we share information about who [hires] and

72 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 73 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 74 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 75 Group interview with farm workers, Hoedspruit area, 20-21 September 2003 76 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 77 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 78 Group interview with farm workers, Hoedspruit area, 27-28 September 2003

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where. We go approaching different farm owners for short-term contracts… We use the little money we have to go all over the place in search of new jobs.79

One farm worker recounted some of the hardships migrants endure between harvesting seasons.

They [Mozambicans who stay behind after the season is over] suffer. They have no plans. The problem is, when you are unemployed, you cannot sleep on any of the farms – the farmers do not allow you…And you end up roaming the streets, playing into the hands of the police. They arrest you and deport you back to Mozambique.80

Migrants’ Transit Points and Destinations An interesting question that arises from these accounts and migration patterns is the extent to which the border region is a final destination for workers or merely a transit point for internal migration to other regions and cities in South Africa. SAMP has observed that farms of the border region straddle major migration and transportation routes to the south and west, and that “many migrants simply use [them]…as a ‘refuelling station’ before moving onto their primary urban destination.” Farm worker interviews confirm this – they contain references to farm workers searching for jobs in other parts of Limpopo and Mpumalanga, in Pretoria and Johannesburg, and in “companies and factories.”81 The fact that farmers in the border region report high turnover rates among temporary workers adds credibility to the ‘refuelling station’ scenario. However, exact numbers of workers, their destinations, and length of stay are not known. Migration Patterns among Farm Workers living around Burgersfort A similar spatial relationship to the situation in Hoedspruit exists between workers and farms in the Burgersfort area where a sprawling former homeland, Lebowa in this case, exists in close proximity to white-owned commercial farms, a major source of employment in the region. The farms are located south of the small town while most workers live in densely populated rural villages of the huge former homeland to the north, about 75kms due west of the border region. The movement patterns of farm workers between these villages and the farms to the south are again a case of internal, short-distance migration along a north-south axis and by means of public transportation (minivan taxi)82. Many farm workers migrating to farms south of Burgersfort are reported to live in the villages of Driekop, River Cross and Bothashoek. Others mentioned as being homes to farm workers are Mafarafara, Mabotsa, Ga Malekana, Mashamthane, Ga-Madiseng, Ma-London, Sitsheng, Ga-Matodi, Penge, and Alberton. Although permanently settled Mozambicans do live in these villages, there appear to be far fewer of them here than in the ‘trust’ area of Bushbuckridge LC. However, there is the possibility that Mozambicans from the border region migrate to, and find work on, the farms south of Burgersfort. It was not possible, through this study, to establish whether this was in fact the case, nor the extent 79 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 80 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 81 Group interview with farm workers, Hoedspruit area, 27-28 September 2003 82 See Annex, p.69

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to which more recent migrants find work there. Finally, some Swazis were also reported to be working on Burgersfort farms. Migration between Households Another element of migration, inquired about in the questionnaires, relates to the phenomenon of ‘split households’ among workers where either a man or a woman working on a farm lives apart from his/her spouse during employment. Survey results indicate that a relatively high percentage of workers live together with their spouse or steady partner on the farms. However, this is true mostly for permanent workers – many more temporary than permanent workers report having a spouse or steady partner who lives in a village or town a considerable distance from the farm where they are employed. Gender and Migration from Mozambique Mozambican women work on farms but generally they are not cross-border migrants. Instead, they belong to the group of permanently-settled Mozambican ex-refugees living in settlements near farming districts of the border region.83 Most are young and employed overwhelmingly as temporary workers whose popularity with farmers in the region has meant that on many farms they outnumber temporary male workers, sometimes by as much as a ratio of 3-to-1. Farm worker interviews and SAMP’s research suggest that most recent cross-border migrants are young and male. Legal Status of Foreign Labour Respondents were not asked about legal documentation in the KAP survey to avoid giving the impression that the research team wanted to single out Mozambicans for deportation, a common fear among those encountering strangers on farms. What is known is that the legal status of both the permanently settled and recent Mozambican migrants vary. During its 1998 research, SAMP investigated farm workers’ legal status and reported that among Mozambican farm workers are:84

1. Mozambicans who are South African citizens; 2. Legal and undocumented ex-refugees (some with South African IDs acquired in South Africa’s

1995 amnesty with Mozambique and some without); 3. Mozambican “legal illegals” (migrants with forged or counterfeit South African documentation);

and 4. Mozambican undocumented migrants (some with Mozambican IDs, many without). In addition, there are legal Mozambican temporary workers in parts of Mpumalanga who include some of those recruited by ALGOS (a recruiter of Mozambican labour for South Africa) in Mozambique under a long-standing bilateral treaty between Mozambique and South Africa, as well as some with legal contracts acquired for them by the farmer after they were hired illegally, and some

83 Crush, J (2000), p.9 84 Crush, J (2000), p.7

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with so-called “farm IDs” (name tags issued by farmers to protect their workers from arrest, under an informal understanding with the local police.)85 Interviews with farm workers did not delve too deeply with regard to legal status, again, to avoid intimidating migrants. Nonetheless, some Mozambican migrants did volunteer information, recounting especially their difficulties in applying for permanent residence due to reported corruption at certain offices of the Department of Home Affairs in the Bushbuckridge LC. Some referred to the availability of false South African documentation which, however, was often too expensive to acquire.86 Finally, many permanently-settled Mozambicans and more recent migrants of differing legal status are often picked up during raids conducted around Hoedspruit by the South African Police Service, leading to their deportation. 5. GAP ANALYSIS Provincial Government In both Mpumalanga and Limpopo provinces, HIV/AIDS is reflected as a priority in the provincial health strategies,87 and HIV/AIDS prevention and care activities form an integral part of the primary health care system in both provinces. HIV/AIDS/STI/TB programmes are delivered through the primary health districts and services include home-based care, VCT facilities, prevention of mother-to-child transmission (PMTCT), awareness, education and information activities, condom distribution, syndromic management of sexually transmitted infections, and TB treatment. Anti-retroviral (ARV) treatment is not yet a part of the programmes provided through the provincial health systems, and is only provided in rape cases or to pregnant mothers who have tested HIV positive. In Mpumalanga province the HIV/AIDS/STI/TB programme includes the following objectives and performance indicators for the period 2002-2006:

• Establishment of new VCT sites; • Strengthening of NGO/CBOs providing home based care services; • Establishment of community based condom distribution sites; • Establishment of peer education programmes; • Ensure effective application of Syndromic Management of STI in public health facilities; • Awareness, Education and Information activities; • Human resource development and staffing; • Social mobilization; and • Establishment of step-down facilities.

85 Ibid 86 Group interview with farm workers, Hoedspruit area, September 27-28 2003 87 Limpopo province, Department of Health and Welfare (2003), Strategic Plan 2003/2004 and Mpumalanga Provincial Health Department (2003), Strategic Plan for 2003/4 2005/6

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The Department of Health in Mpumalanga has no specific programme(s) covering farm workers, apart from mobile clinic services. One of the main challenges facing the province in the implementation of its HIV/AIDS programme is a severe shortage of staff. Currently, the allocated HIV/AIDS budget is not being spent due to human resource shortages. Another constraint is the rural character of the province (60.9% of the population live in rural areas) which affects service delivery.88

In Limpopo, similar objectives and performance indicators have been identified for the HIV/AIDS/STI/TB programme for the period 2001-200689:

• Increase in number of facilities providing VCT; • Establishment of home based care sites; • Increase in number of individuals accessing VCT; • Increase in number of individuals accessing PMTCT sites; • Strengthen capacities of CBOs/NGOs to deliver services; • Expand condom distribution; and • Improved prevention of TB.

The challenges facing the province in implementing its HIV/AIDS programme are very similar to those facing Mpumalanga province. The province has a large rural population (89%) and access to services by the whole population is often difficult. Certain areas, such as Bohlabela and Sekhukhune for instance, have large unserved populations.90 Lack of qualified personnel is another factor cited by the Department of Health as an impediment to the implementation of its HIV/AIDS programme. Farm Owners With only one exception, none of the farm owners interviewed report having a workplace HIV/AIDS policy in place. Neither do any of the farm owners report having any ongoing HIV/AIDS programmes or activities on their farms. In the very few cases where activities have taken place on the farms it has been through sporadic external initiatives, by churches or by primary health care clinics. Such activities have included training in general health issues, HIV/AIDS awareness raising, and, currently in one case, PHC clinic nurses are training a farm worker in home based care. According to farmers, HIV/AIDS is not yet an issue that has the attention of the farmers’ association and hence is not really a topic for discussions at the regular meetings among farm owners: 88 Strategic Plan for 2003/4 2005/6, Mpumalanga, p.25 89 Strategic Plan 2003/2004, Limpopo, p.53 90 Ibid, p.41

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If we’ve got meetings, we don’t really discuss HIV. It is about farming or packing or something. If we have a meeting it is about that. We don’t really discuss this [HIV/AIDS]on a formal basis.91

A majority of farm owners are worried about the effect of HIV/AIDS on the farms but at the same time see the epidemic as a distant problem and have taken little, if any, action to prevent infection among workers or put in place any support mechanism (s) for affected workers. One explanation behind the lack of initiatives on the farms seems to be that farm owners lack knowledge of appropriate interventions. Also, it has to be said that in general the survey records both a poor attitude among farm owners towards the HIV/AIDS problem, and very little interest in the issue:

If somebody [a farm worker] falls away, he is easily replaceable. It is not a good statement to make but that’s life, that’s the fact. AIDS has had little effect on us due to the fact that it is not a specialized work, easily replaceable, people are easily trained in what they need to do. It does have an effect on people, sure, but on the business, very little.92

The site mapping undertaken on the 12 farms confirms that no farms display any HIV/AIDS information posters nor do they provide any information material. Only on one farm has a condom dispenser been installed in order for workers to access condoms easily. Primary Health Care (PHC) Clinics An assessment of Hoedspruit and Burgersfort PHC Clinics, the two main clinics accessed by farm workers in the surveyed districts, indicates that they provide a fairly full range of services including HIV/AIDS services, such as VCT, condom distribution, and STI syndromic management. Anti-retroviral therapy, however, is not provided by the clinics, with the exception of rape cases93. In terms of access and opening hours, the Burgersfort clinics remain open from Monday through Saturday, while the Hoedspruit clinic is open only Monday through Friday. To reach the clinics the farm workers need to travel on average 20 to 80 kms. HIV/AIDS/STI training and information campaigns provided by the clinics are limited or non-existent according to the clinic staff and even available printed material on STIs and HIV/AIDS is inadequate. In terms of staffing, both clinics report staff shortage of 2 to 3 nurses, due to ongoing training but also due to unfilled positions. A shortage of certain medical equipment is also reported and at least one of the clinics faces a constant lack of essential drugs, such as STI drugs, HIV rapid testing kits and family planning drugs. During the interviews the staff identified a need for additional physical space. The clinics are often very small and this creates privacy 91 Interview with farm owner, Burgersfort 3 October 2003 92 Interview with farm owner, Hoedspruit 3 October 2003 93 See Annex, pp.49-59

42

problems for the patients. Of late, with increasing frequency, the clinics face a situation where people in the terminal stages of HIV/AIDS access the clinics and many of them end up dying there. Private Clinics Some farms in the Hoedspruit area have private clinics which the farm workers can access. In these clinics workers are charged R40 for a general consultation, of which they normally contribute R6 to R20 while farm owners pay the rest. However, STD treatment and specialized medication is not covered by the farm owner but has to be paid by the farm workers themselves. Mobile Clinics Each PHC runs two mobile clinics (MC) in their districts. In Hoedspruit the MCs visit 88 farms on their rounds, and the Burgersfort MCs 36 farms. In the Hoedspruit area, the nurses estimate that they cover approximately 50% of the needs on the farms and that the number of service points could be easily doubled. They also see a need to expand their services in the trust areas, where many farm workers live. The frequency of visits to farms is limited to once a month or every three months94. Much like the clinics, the MCs provide HIV/AIDS/ STI related services, such as condom distribution, STI drugs and TB treatment and prevention. In the Hoedspruit district MCs also provide VCT services - this is not available through MCs in the Burgersfort district. Importantly, staff reports low levels of VCT sessions, indicating that the service is somewhat under-used. Of a total 6533 people served by the MCs in the two districts, the average number of VCT sessions administered per month amounts to 10 in Hoedspruit and 36 in Burgersfort. Non-Governmental Organizations A review of non-governmental organizations active in the Hoedspruit and Burgersfort districts indicates that while there are organizations focusing on HIV/AIDS issues, none of them target farm workers specifically.95 In the Burgersfort area in particular, the study team found many home-based care and educational initiatives, none of which, however, provide for farm workers. The AIDS Training and Information Centres (ATICS), offering counselling, condom distribution, testing and support groups, is one type of organization found both in Limpopo (where there is one) and Mpumalanga (where there are two ATICs) provinces. However, none of these three ATICs are located in the districts surveyed and hence are not easily accessible for farm workers in these two areas. 94 See Annex, pp.66, 68 95 See Annex, pp.60-65

43

No support groups reaching out to farm workers, neither in the Hoedspruit nor in the Burgersfort district, were identified. However, in a neighbouring district one support group aimed at farm workers is being run from Acornhoek and is known as the Farm Workers’ Support Group. This group visits farms in the Acornhoek area, currently on a monthly basis. Two to three peer educators accompany qualified nurses in order to facilitate HIV/AIDS educational and awareness programmes and condom distribution during visits to farms. Comprehensive Health Care (CHOICE), located in Tzaneen, Limpopo, provides HIV/AIDS home-based care through community volunteers but, like many others, this programme covers rural villages and does not reach out to farm workers. A few NGOs were identified that do focus on farm workers. However, these organizations focus mainly on workers’ rights and provide legal assistance. 6. CONCLUSIONS AND RECOMMENDATIONS The system of migrant labour in Southern Africa, which gathers together men and women at work sites while leaving their partners and families behind in typically impoverished areas, is a key factor in the pattern of the region’s HIV epidemic, with the cyclical nature of labour migration facilitating the spread of HIV infection. However, while migration most likely fuelled the HIV epidemic in Southern Africa at its early stages, this effect has diminished at a time when the epidemic is reaching its peak and infection is widespread. While awareness about HIV/AIDS and basic prevention knowledge is quite widespread among the populations of Southern Africa, this study has confirmed that there are still pockets of sub-populations, such as farm workers on commercial farms, which are lacking access to information and among whom misconceptions about HIV/AIDS are still very much alive. The prevalence of high-risk sexual behaviour recorded in the study must partly be ascribed to the apparent lack of information available to farm workers. However, it is also clear from the results that knowledge about HIV/AIDS does not necessarily translate into safe sexual practices. In this sense, the results support that of many other research studies and confirm, that to bring about behaviour change is without doubt one of the biggest challenges in the fight against HIV/AIDS on the continent. Another likely contributing factor to the high-risk behaviour among migrant workers, and farm workers in particular, is the observed poor living conditions on the farms, including poor sanitation, overcrowded accommodation and often exploitative working conditions, pointing to the inextricable link between the socio-economic context and HIV/AIDS vulnerability. Migration and high mobility is significant for the lives of many farm workers and impacts on their vulnerability to HIV infection in many different ways. The seasonal character of their work and continually changing employment opportunities discourages the formation of stable relationships, causes disruption of families, and creates feelings of anonymity and loneliness. The insecure legal

44

status of many foreign migrant workers appears to cause mental stress and also functions as a barrier for them to access public services. The strikingly high vulnerability to HIV infection among female workers is related to aspects of both knowledge, attitudes and behaviour. Very low levels of knowledge about HIV/AIDS explain part of their specific vulnerability. The transactional nature of the sexual relationships that often seem to develop in the farm setting, signals high dependency among female workers on male workers for their subsistence and that of their children, a structural powerlessness which makes female workers more vulnerable to HIV infection. A pattern of uneven sexual power also emerges from the study, according to which male farm workers decide whether or not to engage in safe sexual practices. Based on these findings, it is recommended that future initiatives to reduce the vulnerability of farm workers, including migrants, to HIV/AIDS should comprise the implementation of a Behaviour Change Communication (BCC) strategy, the development of care and support programmes on farms, the development of advocacy and technical assistance programmes targeted at commercial farm owners, and the promotion and implementation of HIV/AIDS workplace policies on commercial farms. It is also recommended that future activities include an extended research component, to verify and compare the significant findings of this assessment and to obtain further information on the specific vulnerabilities of farm workers in general and migrant workers specifically. Efforts should also be made to expand existing local initiatives to specifically target commercial farm workers, including migrant workers. Close cooperation between stakeholders, including relevant Government departments, local NGOs and farmers’ associations, should form the basis of these HIV/AIDS interventions directed at farm workers, to their ensure long-term sustainability.

45

ANNEX

46

HEALTH SERVICES AT HOEDSPRUIT AND BURGERSFORT PRIMARY HEALTH CARE CLINICS

BURGERSFORT PRIMARY HEALTH CARE CLINIC

STAFFING 0 Doctors 11 Professional Nurses 1* Staff Nurses (*currently on training) 6 Nursing Assistant 0 SASO (Specialised Auxiliary Services Officer) 3 Post(s) vacant

0 Professional nurses 0 Staff nurses

3 Nursing assistants 4 Mobile staff

Professional nurses 2 Staff Nurses 0 Nursing assistants 2 Post(s) vacant

2 Nursing Assistants

Minor ailments Yes Epilepsy Yes Ante-natal care Yes Hypertension Yes Immunisations Yes Asthma Yes Post-natal care Yes Bronchitis Yes Reproductive services Yes Arthritis Yes TB treatment Yes Other chronic Limited

Chronic care Yes Mental health - chronic Yes Eye care Yes Mental health - crisis Yes Cervical CA screening Yes Substance abuse Yes TOP counselling Yes Trauma - emergency Yes Termination of pregnancy No Rape & abuse No ARI/Pneumonia Yes Tubal Ligation & vasectomy No Diarrhoea child <5 Yes Delivery No Yes Malnutrition child <5 Yes Victims of violence (assault) No Other child illnesses Yes Community visits Yes Other adult curative Yes Home-based care No Diabetes Yes Oral health Disability Yes

47

SUPPLY OF ESSENTIAL DRUGS Adequate/Inadequate Adequate. Drugs/medicines in short supply Vitamin B Co tablets in short supply SUPPLY OF NECESSARY MEDICAL EQUIPMENT Adequate/Inadequate Inadequate Medical equipment in short supply Glucometers, HB meters, Doptones, ENT sets, BP

machines, wheel chairs, baby scales, oxygen cylinders

HIV/AIDS/STI SERVICES OFFERED VCT Yes Family Planning Yes Access to contraception Yes Condom distribution Yes Ante-natal care (nevirapine) No - Refer to Lydenburg Hospital Availability of printer materials of HIV/AIDS/STIs Limited HIV/AIDS/STI training and information campaigns No Outreach and peer education No Home-based care for PLWHA Yes Support groups for PLWHA 1 group based at the clinic Provision and management of anti-retroviral therapy No. For rape cases only. AZT. STI syndromic management Yes Treatment & prevention of TB Yes Availability of STI drugs Yes Prevention and management of OI and HIV/AIDS diseases Yes Services and care for orphans No

48

IDENTIFIED GAPS IN HIV/AIDS/STI SERVICES OFFERED AT THIS CLINIC Employment and skills projects for PLWHA, nevirapine provision

MOBILE CLINICS 2 Number of vehicles? Yes Farm visits? 36 Number of farms visited Monthly Regularity of visits to farms No Fees charged for mobile clinic services

Since 1988 only family planning. PHC on mobile since 1992

Length of mobile clinic service in this area

4 Mobile clinic staffing No Mobile clinic staffing shortfall Adequate Supplies of essential drugs and medical supplies As Above HIV/AIDS/STI services offered by mobile clinics Does the service need to be extended? Yes Service is adequate to farms on the schedule at the moment.

But 20 more farms could be covered. Need to extend service to the trust areas. At the moment 9 calling points in the trust areas.

Could anything be done to improve the service offered by the mobile clinics

Yes At the moment, cannot offer vaginal examinations as part of syndromic management, Haemoglobin (HB) tests. Could offer these. There is a need for more fixed clinics in the trust areas currently serviced by mobiles.

HIV/AIDS/STI SERVICES OFFERED BY MOBILE CLINICS VCT No Family Planning Yes Access to contraception Yes Condom distribution Yes Ante-natal care (Nevirapine) No Availability of printer materials of HIV/AIDS/STIs Limited HIV/AIDS/STI training and information campaigns No Outreach and peer education No Home-based care for PLWHA No Support groups for PLWHA No Provision and management of anti-retroviral therapy No STI syndromic management Yes Treatment & prevention of TB Yes Availability of STI drugs Yes

49

Prevention and management of OI and HIV/AIDS diseases Yes Services and care for orphans No

REFERRALS Hospitals to which patients are referred from PHC Clinic Lydenburg Hospital

Mandashoek Hospital Jane Furse Hospital Glencowey Hospital

Private doctors to which patients are referred from PHC Clinic None

COSTS Costs for general services offered None Costs for HIV/AIDS/STI services offered None (minimal charge for eye clinic)

PATIENTS 4355 Average total number of patients per month Unknown Average number of male patients per month Unknown Average number of female patients per month 54 (May 2003) Average STI cases per month 16 (May 2003) Average TB cases per month 31 Average VCT sessions administered per month Unknown Average number of non-South African patients per month Unknown Male Unknown Female Somalis, Mozambicans, Zimbabweans

Nationalities of non-South Africans attending this PHC Clinic

50

ACCESSIBILITY Consultation times 07h30 - 16h00, Monday - Saturday (overtime often worked) Nearest PHC clinics and distance in kilometres from this clinic Practiseer PHC 15 kms,

Dilokong 24 hour PHC clinic 31 kms, Bordershoek PHC Clinic 7 kms, Eertse Geluk PHC clinic 37kms, Boschkloof PHC clinic 42 kms

Nearest Hospitals and distance in kilometres from this clinic Lydenburg 67kms,

Mandashoek, Jane Furse, Glencowey Hospitals

FARM WORKERS HEALTH Most common health complaints of farm workers Hypertension Diabetes Upper respiratory tract infections Skin problems Muscle pains TB diarrhoea STI’s Urinary tract infections HIV/AIDS infections

51

HOEDSPRUIT PRIMARY HEALTH CARE CLINIC

STAFFING

0 Doctors 3 Professional Nurses 1 Staff Nurses (currently on training) 0 Nursing Assistant 1 SASO (Specialised Auxiliary Services Officer – NUTRITION) 3 Post(s) vacant 0 Professional nurses 0 Staff nurses 3 Nursing assistants

6 Mobile staff 3 Professional nurses 0 Staff Nurses 3 Nursing assistants 2 Post(s) vacant 2 Professional nurses (receiving training at the

moment. Due back in November 2003 and February 2004)

GENERAL SERVICES OFFERED Minor ailments Yes Epilepsy Yes Ante-natal care Yes Hypertension Yes Immunisations Yes Asthma Yes Post-natal care Yes Bronchitis Yes Reproductive services Yes Arthritis Yes TB treatment Yes Other chronic Limited Chronic care Yes Mental health - chronic Yes Eye care Yes Mental health - crisis Yes Cervical CA screening Yes Substance abuse No TOP counselling No Trauma - emergency Yes Termination of pregnancy No Rape & abuse Yes ARI/Pneumonia Yes Tubal Ligation & vasectomy No Diarrhoea child <5 Yes Delivery No Malnutrition child <5 Yes Victims of violence (assault) Yes Other child illnesses Yes Community visits Limited Other adult curative Limited Home-based care No

52

Diabetes Yes Oral health Limited Disability No

SUPPLY OF ESSENTIAL DRUGS Adequate/Inadequate

Inadequate. Supply of essential drugs is inadequate. Running out of medicines "all the time"

Drugs/medicines in short supply Family planning drugs, STI drugs, deworming drugs for children, antibiotics, aspirin, HIV rapid testing kits

SUPPLY OF NECESSARY MEDICAL EQUIPMENT Adequate/Inadequate Inadequate Medical equipment in short supply Delivery packs, stethoscopes, baumanometers, ENT sets, doptones,

glucometer strips, baby and adult scales, examination beds, vagina speculum, oxygen bottles,

HIV/AIDS/STI SERVICES OFFERED Yes VCT Yes Family Planning Yes Access to contraception Yes Condom distribution No Ante-natal care (nevirapine) Limited Availability of printer materials of HIV/AIDS/STIs Limited HIV/AIDS/STI training and information campaigns No Outreach and peer education No Home-based care for PLWHA No Support groups for PLWHA No Provision and management of anti-retroviral therapy Yes STI syndromic management Yes Treatment & prevention of TB Yes Availability of STI drugs Limited – Refer to Hospitals

Prevention and management of OI and HIV/AIDS diseases

No Services and care for orphans

IDENTIFIED GAPS IN HIV/AIDS/STI SERVICES OFFERED AT THIS CLINIC Run out of STI medicines

53

MOBILE CLINICS 2 Number of vehicles? Yes Farm visits? 88 Number of farms visited Monthly/3-monthly Regularity of visits to farms No Fees charged for mobile clinic services

Since 1992, on and off Length of mobile clinic service in this area 2 nurses per vehicle Mobile clinic staffing No Mobile clinic staffing shortfall As above Supplies of essential drugs and medical supplies Does the service need to be extended? Yes Exact areas of need to be determined Could anything be done to improve the service offered by the mobile clinics?

Yes Unable to fill up with petrol in Hoedspruit - need to drive to Phalaborwa each time. Bureaucracy in getting vehicles serviced hampers service offered

HIV/AIDS/STI SERVICES OFFERED BY MOBILE CLINICS Yes VCT Yes Family Planning Yes Access to contraception Yes Condom distribution No Ante-natal care (nevirapine) Limited Availability of printer materials of HIV/AIDS/STIs Informal HIV/AIDS/STI training and information campaigns No Outreach and peer education No Home-based care for PLWHA No Support groups for PLWHA No Provision and management of anti-retroviral therapy Yes STI syndromic management Yes Treatment & prevention of TB Yes Availability of STI drugs Limited – depending on severity

Prevention and management of OI and HIV/AIDS diseases

No Services and care for orphans

54

REFERRALS Hospitals to which patients are referred from PHC Clinic Tintswalo Hospital

Sekororo Hospital Private doctors to which patients are referred from PHC Clinic None

COSTS Costs for general services offered None Costs for HIV/AIDS/STI services offered None

PATIENTS 2178 Average total number of patients per month Unknown Average number of male patients per month Unknown Average number of female patients per month 16 Average STI cases per month Unknown Average TB cases per month 10 (Aug/Sept) Average VCT sessions administered per month Unknown Average number of non-South African patients per month Unknown Male Unknown Female Mozambicans, Zimbabweans Nationalities of non-South Africans attending this PHC Clinic

ACCESSIBILITY Consultation times 07h00 - 16h00, Monday - Friday Nearest PHC clinics and distance in kilometres from this clinic Cottondale PHC Clinic

The Oaks PHC Clinic 40 kms (west of Hoedspruit) The Willows PHC Clinic 48 kms (west of Hoedspruit) Mabins PHC Clinic 60kms (west of Hoedspruit)

Nearest Hospitals and distance in kilometres from this clinic Sekororo Hospital 80kms (west of Hoedspruit)

Tintswalo Hospital 33kms (south of Hoedspruit)

55

FARM WORKERS HEALTH Most common health complaints of farm workers Female Physical strains Respiratory Tract Infections, hypertension, STIs Male Physical strains Respiratory Tract Infections, hypertension Children Immunisations, RTIs, Unable to say

56

NON-GOVERNMENTAL ORGANIZATIONS WORKING WITH FARM WORKERS

LEVEL DETAILS PROJECT INFORMATION AND ACTIVITIES

National

National Land Committee (NLC) The NLC is an NGO network of land and development affiliated organisations working for land and agrarian reform with rural communities across South Africa PO Box 30944 Braamfontein, 2017 Tel: 011 403 3803 Fax: 011 339 6315 Website: www.nlc.co.zaE-mail: enquiries@nlc.co.za

Projects include Land Rights and Access, Land Development, Farm Worker Program The Farm Worker Program’s main objective is to ensure farm dwellers are able to protect, access and secure their tenure rights, improve their livelihoods and experience human rights in action. Co-ordinator: Dan Mabokela

MPUMALANGA

TRAC Mpumalanga Province TRAC-MP supports landless rural women and men of Mpumalanga in securing their tenure rights, sustainable livelihoods and promoting human rights. PO Box 98 Nelspruit, 1200 Tel: 013 755 4324 Fax: 013 755 4359 E-mail: cjwilliams@trac.org.zaDirector: Chris Williams

Activities include: Lobbying and Advocacy, Participate planning, Research, Community mobilisation, Fund raising, Capacity building and monitoring, Gender empowerment, Environmental awareness, Legal and para-legal service.

MPUMALANGA

Rural Women’s Movement Groblersdal/Moutse/Denelton Mirina Magana 083 494 8613

‘Mohede’ – AIDS project, Food Parcels, Training and Empowering Women,Education, Counseling andPoverty Alleviation

57

LIMPOPO

Land Access Movement of SA (LAMOSA) The Land Access Movement of South Africa (LAMOSA) is a community based organization made up of rural people in the former Transvaal who were dispossessed of their land by Apartheid, and who are landless and do not have any land rights, i.e. farm workers, labour tenants etc. BUSHBUCKRIDGE PO Box 62535 Marshalltown, 2017 Tel: 011 833 1060 Fax: 011 834 8385 E-mail: connie_lamosa@yahoo.com Director: Connie Mogale

LAMOSA's primary objective is to assist people in their efforts to return to their land, and to access and secure land rights to those who were disadvantaged, through land reform process.

LIMPOPO

Nkuzi Development Association (NKUZI) Nkuzi is a non profit organisation providing a range of support services to historically-disadvantaged communities wishing to improve their rights and access to land. PO Box 5970 Polokwane, 0750 Elim Office: Tel: 015 556 3042 Fax: 015 556 4697 Gauteng Office: Tel: 012 323 6417 Director: Marc Wegerif

Nkuzi provides services include: Information dissemination, advice, community facilitation, research and legal services. The core purpose of the Nkuzi is to enable and support marginalised rural and peripheral urban communities in exercising their land and related rights.

MPUMALANGA (non-NLC affiliate)

Landless People’s Movement The LPM is a national movement of landless people in South Africa. It is supported by the National Land Committee - a national network of nine land rights non-governmental organisations - but it is a completely independent grassroots structure of landless people. It is not an affiliate of the NLC. Mangaliso 072 127 4055

58

NON-GOVERNMENTAL ORGANIZATIONS WORKING WITH HIV/AIDS ISSUES

LIMPOPO

AIDS Training and Information Center, Polokwane Contact: Mr. H E Smith Tel: 015-290 2363 Fax: 015-290 2364 14 Palm Centre, 23 Grobler St, Polokwane Postal address: P.O. Box 111, Pietersburg, 0700

Activities include:

- Councelling - Condom distribution - Youth activities - Support groups

MPUMALANGA

AIDS Training and Information Center, White River Contact: Mr.Elfas, Nkosi Tel: 013-751 1176 Cell: 083 4175152 Fax: 013-752 3770

Activities include:

- Councelling - HIV testing - Condom distribution - Home based care

MPUMALANGA

AIDS Training and Information Centre-Witbank Contact: Ms L. Tholo Tel: 013 690 6204 Fax: 013 690 6459 Cnr. Swartbos & Louise Str, Witbank Postal address: P.O. Box 3, Witbank 1035

Activities include:

- Information - Resource library - Workshops - Condom distribution - Training

MPUMALANGA

Hlatlolanang Health and Nutrition Education Centre, Jane Furse Hospital Sekhukhune District Mpumalanga Contact: Naaka Tel: (013) 265 1000 Cell: 083 507 4666 Postal address: Private Bag X429 Jane Furse 1085

HIV/AIDS programs include: - Household food security - Prevention techniques

against opportunistic diseases

- Health Nutrition - Health Education - Advocacy - Child-headed households

59

MPUMALANGA

Education and Training Unit Waterberg District Mpumalanga Postal address P.O. Box 261604 Excom 2023 www.etu.org.za

ETU works with community-based organizations in South Africa as a non-profit organization running training programs in a number of areas including paralegal matters and HIV/AIDS.

- ETU equips and trains peer-educators in issues of health and HIV/AIDS working closely with traditional leaders and the local municipalities

MPUMALANGA

Perinatal HIV Research Unit And Rural AIDS and Development Action Research Programme (RADAR) School of Public Health University of the Witwatersrand Postal address: P.O. Box 2, Acornhoek 1360 Contact: Dr. Adele Hiya Tel: 013 795 5076 Fax: 013 795 5082

RADAR are collaborating with the Perinatal HIV Research Unit run by the Chris Hani Baragwanath Hospital through the HIV Wellness Clinic, VCT and VCTplus services at Tintswalo Hospital. - Comprehensive health care

is provided for HIV+ people with psychological support and health, HIV/AIDS

MPUMALANGA

Perinatal HIV Research Unit Farm Workers Support Group, Acornhoek area Contact: Mr. Ronnie Mashala Tel: 013 795 5076 Fax: 013 795 5082

- HIV support group visits

farms in the Acornhoek area. Monthly visitations with the view to making it weekly.

- 2/3 peer educators (trained by RADAR) accompany the qualified nurse to facilitate HIV/AIDS educational and awareness programs and condom distribution.

60

MPUMALANGA

Rural AIDS and Development Action Research Programme (RADAR) and the Small Enterprise Foundation (SEF) School of Public Health University of the Witwatersrand PO Box 2 Acornhoek 1360 Contact: Mr. James Hargreaves Tel: 013 795 5076 Cell: 072 267 5482 Fax: 013 795 5082

- Program to reduce HIV

and gender-based violence - Intervention with Micro

finance for AIDS and Gender Equity (IMAGE) in a set of villages outside Burgersfort, Limpopo Province.

RADAR is affiliated with the London School of Hygiene and Tropical Medicine and with the University of the Witwatersrand.

MPUMALANGA

Refugee Research Programme (Affiliated to University of the Witwatersrand) (WITS RRP) University of the Witwatersrand Private Bag X420, Acornhoek, 1360 Contact: Ms. Valery Seoke Tel: 013 795 5441 Fax: 013 797 0024

Wits RRP works predominantly with documented and undocumented Mozambicans living in villages throughout Bushbuckridge LC. Services to this target population include:

- Assistance with documentation Issues (to assist with permanent residency permits)

- Assistance for acquiring Birth Certificates for children

- Assistance for obtaining Child Support Grants

- Naturalization advice MPUMALANGA

Bushbuckridge Health And Social Services Consortium Contact: Mr. Moses Siwelani Tel:(013) 795 5412 Cell: 082 935 6722

Activities include:

- HIV/AIDS Education & Awareness

- Orphan Support - Life Skills - Care Of Terminally Ill - Mentor To 8 Home Based

Care Sites The Consortium acts as an umbrella organisation for 9 homebased care sites in the Bushbuckridge area. It acts as a mentor for these sites by providing training and support.

61

LIMPOPO

Comprehensive Health Care (CHOICE) 14 Peace Street, Tazneen 0850 Contact: Mrs. Fiona Macdonald Tel/Fax: 015 307 6329

Activities include: • HIV/AIDS Home-based care

through community volunteers • Peer education projects • Orphans and vulnerable

children • Awareness creation • First Aid • Agri health and safety • Food security and vegetable

gardening • Mentorship programme, etc.

62

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BOERBOOMKRAAL

VRAAIUITZICHT

WILDEBEESKRAAL

WILDEBEESTHOEK

DIE GROOTEBOOM

WILDEBEESTKRAAL

OLIFANTSPOORTJE

AAPIESDOORNDRAAI

Soe

Marota

Naphuno

Badimong

Ohrigstad

Montrose MineSekhukhuneland

Babina Naare Ba Kgoete

Burgersfort

±0 94.5 km

Legendlocal municipality boundary

village settlement

clinic / hospitalG

main road

!. town

farm boundary

farm with mobile health coverage

Farms covered by Mobile Clinics arou d Burgersfort (Greater Tubatse LC)n

5

66

PUBLIC TRANSPORTATION ROUTES AROUND HOEDSPRUIT

67

ALL OTHER BUS STOPS

Tzaneen

Phalaborwa Fcocaco

Nkowakowa Letsitele

Trichardtsdal Gravelotte

Welverdiende Enable Mica

Madeira Makgaung Worcester

Ireagh Geldenhuis Sawmill

Klaserie Lillydale Somerset Belfast

Hazyview Mkhuhlu

Cork White River

Nelspruit

BUS STOPS USED BY FARM WORKERS

Marritja Mabeans

White City Botshabelo

Thulamahashe Finale Clare

Molalane The Oaks Islington

Hluvukani Sigagula

Timbavati Cottondale Buyelane Inarna

Maripe School Moreku

Rooiboklaagte Bushbuckridge

Bewline Buffelshoek

Source: Great North Transport – Hoedspruit - Sept 2003

VILLAGES IN BUSH-BUCKRIDGE LC WHERE MOZAMBICANS ARE KNOWN TO RESIDE

Hluvukani

Welverdiend Lillydale

Clare Allandale Islington

New Forest Arthurstone

Edinburgh ‘B’ Mabharhule

Dixie Ludlow

Acornhoek Edinburg ‘A’

Uttah Hlavekisa

Athol Mkhuhlu Kildare

Agincourt Croquetlawn

Ireagh ‘A’ & ‘B’ Cork

Somerset Newington Huntington

Landela Dumphries Biosonto

Mambhumbu Source: Refugee Research Programme (WITS) 2003

68

REFERENCES Crush, J (Ed.)

2000 Borderline farming: Foreign Migrants in South African Commercial Agriculture, Cape Town/Queens University Canada

Greenburg, S. et al.

1996 State of South African Farm workers 1996, (Farm workers Research and Resource Project 1997) South Africa

Department of Health South Africa 2001 HIV and Syphilis Seroprelvanece Survey of Women Attending Public Antenatal Clinics,

Pretoria, Department of Health

Human Sciences Research Council (HSRC), 2002 Nelson Mandela/HSRC Study of HIV/AIDS, Household Survey 2002, HSRC,Cape

Town

IOM 2003 Mobility and HIV/AIDS in Southern Africa: A field study in South Africa,

Zimbabwe and Mozambique, IOM, Pretoria IOM and UNAIDS

2003 Mobile Populations and HIV/AIDS in the Southern African Region: Deskreview and Bibliography on HIV/AIDS and Mobile Populations, IOM, Geneva

Limpopo Province Department of Health and Welfare 2003 Strategic Plan for 2003/4 2005/6, Limpopo, Provincial Government

Medical Research Council of South Africa

2000 The role of truck drivers in the spread of HIV/AIDS. Press release, South Africa, MRCSA, November 2000

MRCSA 2001 The impact of HIV/AIDS on adult mortality in South Africa. South African Medical

Research Council, Burden of Disease Research Group. http://www.mrc.ac.za/researchreports/reports.htm

Mumpumalanga Provincial Health Department 2003 Strategic Plan for 2003/2004, Mpumalanga, Provincial Health Department

South African Human Rights Committee 2003 Inquiry into Human Rights in Farming Communities, www.sahrc.org.za UN Regional Integrated Information Networks

2001 Miners HIV Survey, UN Irin, 31 March, http:allafrica.com/stories/200103310039.html.

2000

69

UNAIDS 2002 Report on the Global HIV/AIDS Epidemic, UNAIDS, Geneva

70