Humanitarian crisis close to home

Life for migrants, both South African and foreign, in inner-city Johannesburg is precarious: potentially hundreds of buildings in the city, mostly inhabited by migrants, are below international health standards for refugee camps.

For foreign migrants, many of whom are undocumented or awaiting asylum claims, dire living conditions may be exacerbated by anxiety over their futures in South Africa.

The involvement of home affairs immigration officials in the recent police crackdown called Operation Duty Calls and the lifting of the moratorium on the deportations of Zimbabweans at the end of December, is heightening the anxieties of certain health workers that improvements in foreign migrant access to health care over recent years may be undone.

Médecins sans Frontières (MSF), which runs a clinic in the inner city and conducts health promotion in inner-city slum buildings, has raised the alarm about both the conditions of the buildings and the potentially adverse consequences of the recent turn in migration policy.

Refugees live in appalling conditions
A recent MSF survey of around 500 respondents in 30 buildings gives some indication of the extent of the health crisis in inner-city Johannesburg. The survey showed standards well below international refugee guidelines created by the United Nations.

The survey indicated that 38% of respondents were below water access standards by sharing a tap with more than 200 people and 49% shared a toilet with more than 100 people, which is below the level of an acute emergency, and 84.5% are living below minimum standards of overcrowding.

MSF has identified 82 buildings in the inner city where an estimated 50 000 to 60 000 people, mostly foreign migrants, live in substandard conditions. The MSF clinic in the inner city has reported high rates of respiratory and dermatological illnesses, specifically related to poor living conditions.

“Many of the people living in these buildings have been displaced by political violence, instability and economic crisis in their own countries — they have been forced to migrate to South Africa to survive, similar to people seeking refuge in formal refugee camps around the world,” said Lynne Wilkinson, MSF deputy head of mission.

“We need to start recognising that the majority of the building inhabitants have nowhere else to go and are forced by circumstance to live in these appalling conditions.”

According to the city of Johannesburg’s development planning and urban management department, there are 1 305 “bad buildings” identified in the inner city, including those abandoned by landlords or illegally occupied, though there is no official population estimate.

The department attributes the poor health conditions primarily to the infrastructural collapse as a result of service payment arrears. Ten of these buildings have been targeted in Operation Duty Calls so far. Undocumented migrants have been arrested, though the department claims that crime, and not illegal migrants, is the primary target.

A life lived in darkness
In one building near Jeppe visited by the Mail & Guardian, the dark was perpetual and claustrophobic. Without electricity and few windows, passages were lit by candles, casting flickering silhouettes. The air was dense with paraffin fumes, and burns and graffiti stained the walls. Lift shafts were filled with garbage. Large rats prowled the waste and mosquitoes rose from pools of stagnant water. A few hundred inhabitants — both foreign and South African — dwell here, but only one of several floors had running water.

The experiences of a young Zimbabwean woman, Akudzwe (not her real name), living in this building exemplify the hazards of life for foreign migrants here. She claims to have left Harare fearing Zanu-PF political intimidation.

Arriving in South Africa with no family, she was homeless at first before moving into the building in 2008. Residents were evicted for three days in early 2010 and she lost her asylum-seeking papers, and remains without documents. Though there is some support and community in the building, her situation remains harrowing.

“Sometimes you can have bad dreams, because some [people] are dying inside, they’re not going to hospital,” explained Akudzwe. “Sometimes they go to hospital, but they can be discharged while they are still sick, and they come back two days later and die. Some are afraid.

“Sometimes when you are going to hospital, they don’t treat us well as foreigners, but if you come [to the MSF clinic] you get treatment, but if you go straight to Johannesburg, sometimes you can sleep on the bench and they don’t attend to you. They have that attitude of saying you are foreigners.”

Akudzwe fell pregnant in South Africa and was turned away from prenatal care at a state hospital, and ended up giving birth in a stairwell of the building.

Migrants struggle to overcome stigma
Although even undocumented migrants in South Africa are entitled to primary health care as well as HIV/Aids and TB treatment, many have struggled to overcome language barriers as well as stigmatisation by government health services.

According to MSF and the Forced Migration Studies Programme (FMSP), however, the situation has been improving over the past two years but challenges in negotiating health access remain. They both warn that the present turn in migration policy may be a significant setback to the health gains of the past years.

“Operation Duty Calls and its associated raids in the inner city are likely negatively affecting the health of migrant communities,” said Jo Vearey of the FMSP. “Beyond affecting healthcare access, I think there are issues of trauma and social disruption similar to the impact of deportations.”

Health promoters and foreign migrants alike fear that the intensification of surveillance of foreign migrants and the lifting of the moratorium on deporting Zimbabweans at the end of December may deter migrants from seeking healthcare, exacerbating public health concerns.

In addition, deportations can disrupt both HIV/Aids and TB treatments, leading to treatment failure and potentially the development of drug resistance that can be spread.

Problems with regularisation
Dr Refik Bismilla, the executive director of health for the City of Johannesburg, does not share these fears. According to Bismilla, the regularisation of foreign migrants will help with health planning and resource allocation.

“As long as people don’t register you don’t know the numbers you are dealing with,” said Bismilla, “By people registering you can begin to move in the direction of planning your health services and getting the requisite resources.”

Bismilla also believes the operation will help to crack down on criminal activities such as illegal abortions that create health problems. According to Bismilla, migrant access to health services has been improving and the city is undertaking projects such as the introduction of translators into health clinics to improve access and overcome language barriers.

MSF and other groups are concerned that the present regularisation will only cover a fraction of Zimbabweans living in the country, and that many will not receive asylum in the coming year. In spite of differing perspectives, MSF and the City’s health department are working together to develop a memorandum of understanding on migrant health in the city centre.

Large-scale migration to inner-city Johannesburg has become entangled with the perennial problems of urbanisation, housing, unemployment and service delivery. Health challenges in the so-called “bad buildings” of the inner city are potentially on the scale of a humanitarian crisis, and yet remain hidden in their darkened corridors.

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