Responding to HIV/AIDS and chronic vulnerability in an urban context: lessons learned from informal street traders in Durban, South Africa

My niece was sick and died last year. I looked after her because nobody else was interested… She didn’t say that she had AIDS, but I knew and she knew … My main worry is that I won’t be able to work, and then what will happen?… I tell my kids that one day we will have a problem: I will die and they need jobs. But they have stopped looking…

54-year-old Zulu seamstress from Warwick Junction’s, Berea Railway Station, Durban, South Africa

For those of us who live, spend time or work with vulnerable groups in southern Africa, it is becoming increasingly clear that we do not need to head for remote rural areas to reach these communities. On the pavements of central Durban, for instance, we can see the chronic, underlying and differentiated vulnerabilities of informal traders. There are an estimated half a million street traders in South Africa alone, and numbers are growing there and throughout the region. Like the seamstress quoted above, who supports 18 people on her trading income, the majority of street traders are women, and most have begun trading out of necessity – for their own survival and the survival of their families. Yet such urban vulnerabilities are often overlooked. The humanitarian sector has historically focused on rural areas; it is only slowly coming to recognise that urbanisation is compounding the humanitarian issues faced by many in this region.

In South Africa, the end of apartheid in 1994 led to increased population mobility and an accelerated process of urbanisation. At the same time, HIV entered the country, and quickly grew into the largest HIV/AIDS epidemic in the world. Responding to this epidemic requires careful consideration of changing population demographics, and a detailed understanding of where vulnerable populations are likely to live and work in the decades to come. HIV infection levels are still rising, and the longer-term effects of AIDS remain unclear. The substantial time lag between the spread of HIV infection and the impact of rising levels of adult morbidity and mortality suggests that the social effects of AIDS will be felt for generations. Yet these impacts are not predetermined: action can be taken to mitigate the epidemic’s negative outcomes. This requires a better understanding of what makes people vulnerable to HIV infection and to the broader effects of AIDS.

This article presents the lessons learned from participatory research with street traders carried out from 2004 to 2006; it highlights potential areas for humanitarian intervention among this vulnerable and growing urban population. The study investigated what makes street traders vulnerable to HIV and AIDS, how traders are currently affected by the epidemic, and why. The research involved interviews and focus groups with approximately 60 participants, including street traders, health care providers, municipal employees and traditional healers. The research was conducted in Warwick Junction, the largest trading and transport hub in Durban, with 8,000 kerbside traders selling goods and services to 500,000 commuters who pass through the area each day.

Chronic and underlying vulnerabilities to HIV and AIDS

In South Africa, HIV prevalence among women attending antenatal clinics has risen from 0.8% in 1990 to 29.5% in 2004; in KwaZulu-Natal, the province with the highest prevalence, it is now 40.7%. Although the AIDS epidemic is new to South Africa, vulnerability is not. AIDS is revealing and exacerbating pre-existing conditions of vulnerability, insecurity and inequality. Four overlapping issues emerged in this study.

Poverty and livelihood insecurity 

Street traders’ vulnerabilities are linked to the lack of affordable housing in the city, impoverished and insecure working environments, lack of access to water, poor sanitation, unstable incomes and a lack of social security. Together, these conditions make it difficult for traders to take time away from work, care for sick family members and absorb the costs of funerals, orphans and sick adult family members. Risky sexual activity is also associated with intense poverty.

Mobility and dislocation from families 

Most traders in Warwick Junction come from surrounding rural areas and maintain close ties to their homes, sending money back and visiting regularly. As the case of the Zulu seamstress indicates, incomes often support large numbers, with households spread over three or more locations. Being displaced from their families creates tremendous stress and, in the context of the epidemic, traders’ oscillating mobility makes it difficult to care for sick family members. In addition, many traders worry about not having adequate social support were they to fall ill.

Lack of access to information, services and resources

South Africa is one of the few countries in the region with well-established public health care, and is working towards providing social security. However, this research has indicated that traders are not accessing public clinics; they feel that they cannot take the time away from their trading sites, and many report being turned away from clinics because they do not have addresses in the city of Durban. They also find it difficult to access anti-retroviral therapy (ARV) Furthermore, they face a severe lack of access to information both on HIV/AIDS and on how to apply for social transfers, loans and municipal housing. This lack of access to services and information is a key issue for displaced and migrant urban communities.

Stigma, mixed messages and intergenerational silence 

In South Africa, voluntary testing and counselling centres are readily accessible in most urban areas. As in many parts of the region, however, traders report that the stigma attached to AIDS makes them reluctant to get tested or to access support. Many older traders feel unable to talk about the epidemic with their children, and younger traders do not want to talk about it with their parents; this silence is a source of immense stress to many. Among informal traders, there is also scepticism about the existence, causes and prevention of AIDS.

Differentiated vulnerabilities: age and gender 

Not all traders experience the same set of vulnerabilities. In order to devise effective strategies to mitigate future AIDS impacts, it is important to understand this differentiation. Two findings from this case study are key.

First, the research in Warwick Junction showed that older women – the grandmothers – are suffering the greatest social, emotional and economic impacts from the AIDS epidemic because they are the main caretakers and breadwinners in their families. Many are caring for several children and family members who are falling ill, and the epidemic is having a significant financial impact on them as they struggle to cover the costs of funerals, orphans, treatment and care. Many suffer from their own chronic health problems and, like the Zulu seamstress, they are afraid of what will happen if they can no longer work.

Second, there is a profound sense of anxiety, inevitability and fear of infection among young traders due to the stigma of AIDS and an overall lack of social support. Many young traders feel hopeless about the future: young women are worried about leaving children and feel powerless to negotiate sexual practices; young men are deeply fearful of the stigma around AIDS, and many worry about not having family or social support were they to become sick. This is compounded by a perception that they have no chance at a ‘better’ or more secure life (including no opportunities for formal employment or education), and some report compensating for this by drinking and taking part in risky activities.

Implications for mitigating the impact of AIDS in an urban context 

In South Africa, there have as yet been no comprehensive efforts to mitigate the future impacts of AIDS. HIV/AIDS continues to be framed as a medical issue, and despite the multidimensional and widespread consequences of the epidemic, responsibility for AIDS continues to fall to provincial and national health departments. AIDS poses both an immediate humanitarian crisis and a longer-term development challenge.

This case study has indicated that vulnerabilities are driven by pre-existing conditions of impoverishment, livelihood insecurity, uneven family responsibility and gender inequalities. It has also shown that these conditions are changing with, and in some cases being exacerbated by, rapid social shifts. The majority of informal traders are facing the epidemic amidst the stresses of urban migration, dislocation from their families and sub-standard living and working conditions. Moreover, as unemployment rises and urbanisation continues, this vulnerable population is likely to grow. These issues need to be addressed in order to mitigate the future impacts of AIDS.

There are opportunities for development organisations and humanitarian agencies to assist in addressing vulnerabilities to HIV and AIDS – not only in difficult-to-reach rural areas, but also within growing and highly-accessible urban centres. Agencies could seek to work with governments to adopt integrative approaches that address underlying vulnerabilities, such as increasing the availability of social welfare grants and social protection, providing basic services to urban areas and creating more secure livelihood opportunities. Humanitarian assistance can also aid in impact mitigation directly, for example by providing information, water and shelter.

Potential entry points for intervention derived directly from the research in Warwick Junction include:

• There is a need for information outreach in trading hubs such as Warwick Junction; traders require information at their trading sites on social transfers, housing, legal services, health services and HIV/AIDS. This could involve dispatching community outreach workers.
• Traders need access to water, toilets, sanitation and shelter within trading hubs. This is especially important as the HIV/AIDS epidemic progresses. Given that AIDS results in intestinal infections and skin lesions, having access to water and toilets could make living with HIV much less degrading and debilitating. In addition, HIV suppresses the immune system, and people living with HIV are therefore more susceptible to environmental health stresses. Humanitarian agencies could distribute water, shelter, soap and other basic materials.
• Traders need access to public health clinics, including access to city addresses in Durban. Humanitarians could work with municipalities to assist informal traders to access health care facilities and secure city addresses.
• Traders require affordable and safe accommodation near their trading areas. Many are sleeping on the streets or living in impoverished conditions. Secure, accessible and clean housing would reduce the impacts of HIV/AIDS on traders, especially on older women. They would be able to care for sick family members nearby without having to give up their livelihoods. Efforts should go towards building shelters, assisting traders to access public housing and working with municipalities to increase security and improve conditions in urban settlements.

There is both a need and an opportunity for humanitarian actors to expand their programming in urban contexts, and to become involved in efforts to reduce vulnerabilities among urban migrant groups. In southern Africa, such efforts are crucial not only to securing the immediate well-being of millions of people, but also to responding to the growing consequences of HIV/AIDS.

May Chazan is a doctoral candidate in the Department of Geography and Environmental Studies, Carleton University, Ottawa, Canada. Her email address is: mchazan@connect.carleton.ca. The research on which this article is based was hosted by the Health Economic and HIV/AIDS Research Division (HEARD – website: www.heard.org.za) at the University of KwaZulu-Natal. It was funded by Canada’s International Development Research Centre Ecohealth Programme Initiative. The author would like to thank Sbo Radebe, Nthombi Thula, Sihle Sithole and Phumzile Cele for their assistance with fieldwork, as well as all the street traders and other participants in Warwick Junction and Durban who made this study possible.