Returning home to die: circular labour migration and mortality in South Africa

Abstract

Aim: To examine the hypothesis that circular labour migrants who become seriously ill while living away from home return to their rural homes to convalesce and possibly to die.

Methods: Drawing on longitudinal data collected by the Agincourt health and demographic surveillance system in rural northeastern South Africa between 1995 and 2004, discrete time event history analysis is used to estimate the likelihood of dying for residents, short-term returning migrants, and long-term returning migrants controlling for sex, age, and historical period.

Results: The annual odds of dying for short-term returning migrants are generally 1.1 to 1.9 times (depending on period, sex, and age) higher than those of residents and long-term returning migrants, and these differences are generally highly statistically significant. Further supporting the hypothesis is the fact that the proportion of HIV/TB deaths among short-term returning migrants increases dramatically as time progresses, and short-term returning migrants account for an increasing proportion of all HIV/TB deaths.

Conclusions: This evidence strongly suggests that increasing numbers of circular labour migrants of prime working age are becoming ill in the urban areas where they work and coming home to be cared for and eventually to die in the rural areas where their families live. This shifts the burden of caring for them in their terminal illness to their families and the rural healthcare system with significant consequences for the distribution and allocation of health care resources.

Figure 1

Life table probability of dying by sex, period, migrant status and age. The life table probability of dying (_nq_x) is greater for short-term (recently) returned migrants in all sex–period–age categories. There are large increases in the risk of dying with age and in the second period for both sexes.

Figure 2

Difference between life table probabilities of dying by sex, period and age: Short-term returning migrants / residents and long-term returning migrants. The absolute difference between the life table probabilities of dying of short-term returning migrants and all other people is large and positive in all sex–age categories except for males 60–79 years. The largest differences are for females 20-59 in the second period 1998–2004.

Figure 3

Percentage of HIV/TB deaths by sex, period, migrant status and age (sums to 100% across resident statuses within each period). The distribution of HIV/TB deaths among migrant status categories within each sex–period category is displayed. Comparing the second to the first period clearly reveals a shift in the distribution of HIV/TB deaths across migrant status categories with a much larger fraction of HIV/TB deaths among short-term returning migrants in the second period 1998–2004 for both sexes and all ages, but most notably for ages 40–59.

Figure 4

HIV/TB deaths as a percentage of total deaths in each migrant status category by sex, period, and age. Within each sex–period–migrant status category the percentage of all deaths that are HIV related is displayed. This percentage increases between the first and second periods for all sex–migrant status categories. By far the largest increases are for young (20–59) short-term returning migrants, and especially for females.