TABLE C4
C2.3 Level of urbanisation
This region's population is almost totally urbanised. According to the Development Bank of Southern Africa 93 % of the population of Region H was "functionally urbanised" {i.e.
living- in urban, peri-urban and semi-urban areas)5 in 1989 (OSSA, 1991 :40). The greatest non-urban component is found in KwaNdebele, where only 66 % of the population is functionally urbanised (p. 40). In terms of the official (census) classification, however, only 82 % of the region's population was urbanised in 1989, with only 10 % of the Kwa- Ndebele population living in urban areas (OSSA, 1991 :39).
C2.4 Migration
Very little information is available on recent inter-regiof\al and intra-metropolitan migration trends. Certain general observations can however be gleaned from the literature:
C In Table C5 Simkins' net migration estimates for Region H are given (cf. Urban Foundation, 1990). These implicit migration assumptions indicate an expected annual increase in the number of people moving into the study area at least until the end of this century.
c Oscillatory labour migration remains a feature of the PWV. According to information obtained from the CSIR's Division for Building Technology,. it is estimated that there were 304779 hostel beds in the PWV in 1992 (Peter Gill, personal communication, 1993). Following the violent conflict around hostels in the Witwatersrand I Vaal areas, and the initiatives to upgrade certain state-owned hostels, particularly with a view to providing family accommodation, changes tn the patterns of migratory labour may be expected in the future. Estimates derived from surveys in a hostel complex in Soshanguve in the Pretoria region (DEMACON, 1993) indicate that many hostel residents see the hostels in which they are living as permanent residences, and that at least half of all residents would like to bring their families to live with them in the propo.::ied upgraded
I
converted hostels.Although the findings for the Pretoria region cannot be directly applied elsewhere in the PWV, current trends and policy debates suggest that migratory labour may be subject to change and even decline over the long term. Unfortunately, this will, if anything, exacerbate the existing physical accommodation crisis in the PWV.
5 The so-called 'official' urbanisation rate pertains to persons living in a town with a municipality or some form of local government supplying services to the inhabitants of the town. This is an undercount, as a significant number of people cluster around towns or form 'towns' without official recognition (peri-urbanI. In addition, people living in the vicinity of an urban area who are dependent on the urban area for their source of income, are also functionally urbanised (semi-urban). All of these people are included in the definition of the functionally urbanised population.
60
D The Urban Foundation
(1991: 21)
COl, lment on the phenomenon of circulatory migration, and conclude that many sucb in-migrants may be using the! cheap, low- investment accommodation offered by informal settlements as a way of establish- ing a foothold in the urban economy. This is another migration issue which urban planners will have to deal with in the PWV for years to come.TABLE C5
ESTIMATED NET MIGRATION NUMBERS AND RATES FOR REGION H
(1980-1985,1985-1990,1990-1995
AND1995-2000)
AFRICANS + 195 +10 +933 +38 +787 +26 +986
ASIANS +10 +18 +2 +3 +2 +3 +1
"COLOUREDS" +24 +22 +7 +5 +7 +5 +8
WHITES +48 +8 +35 +6 +33 +5 +29
TOTAL +277 +10 +976 +30 +829 +21 +1 024
'These figures are expressed in thousands.
2Expressed in terms of the
1980
population base concerned.3Base:
1985.
4Base:
1990.
5Base:
1995.
SOURCE: Urban Foundation
(1990: 17,27, 37
&50).
C2.5 Demographic dependency ratio
+13 +1 +3 +1 +10
All the population groups had a lower demographic dependency ratio in
1987
than the corresponding figures for South Africa (Dept of National Health and Population Development,1987).
This is confirmed by the data provided by the Development Bank for the total population of Region H in1985
and1989
(DBSA,1991 :45).
These findings are probably another confirmation that migration to the PWV may be dominated by job- seekers in the age group16 - 65,
and that many of them may tend to leave older people and young children in the areas of origin. The data provided by the Development Bank of Southern Africa (OSSA,1991 :38)
show that67
% of the1989
population of Region H was in the age category15 - 64
years (with29
% younger than15
years, and less than4
% older than64
years).61
C2.6 Total fertility rate
The "total fertility rate" (TFR) refers to the average number of children born alive to a woman in her reproductive years
(15-49)
assuming that prevailing fertility rates remain unchanged. In TableC6
the TFRs for the PWV area (Region42)
and South Africa in1987
are given.TABLE C6
TOTAL FERTILITY RATES FOR THE PWV AREA
(1987)
PWVarea
2,80 1,54 2,73 1,74
Republic of SA
5,20 2,80 3,40 2,10
SOURCE: Department of National Health and Population Development.
1987.
Sosio- ekonomiese streekprofiel: beplanningstreek 42. [Socio-economic regional profile:,
Planning Region 421. Pretoria, p.
28.
For KwaNdebele the TFR was estimated to be about
5,5
in1988
{Department of Health and Welfare,1989: 15),
while the general TFR for Bophuthatswana - not broken down for individual districts - seemed to vary between4,8
and5,2
in1988
(Mostert,1989:30).
More recent data on fertility is, however, not available.C2.7 Contraceptive use
The percentage of women who have ever used contraception in the PWV area for the period
1987-89
is given in TableC7.
It is clear that the vast majority of women who are exposed to the possibility of conception in this region have made use of contraception, and more than70
% have used the generally more reliable modern methods. In fact, only20 %
of fecund African women indicated that they were not using contraceptives, while the corresponding proportions for Asian, "coloured" and white women were16 %, 12
% and9
% respectively (Mostert & Du Plessis,1990:14-15).
62
TABLE C7
PERCENTAGE OF WOMEN IN THE PWV WHO HAVE EVER USED CONTRACEPTION (1987-9)
Breast-feeding/ abstinence Any method (excl. breast- feeding)
Efficient ("modern") method:
Condom Pill IUD Injection
Female sterilisation
59
75
73 3 30 21 43
3
17 34
8
81 82 92
73 79 90
8 3 16
43 30 67
28 21 32
10 43 8
14 3 18
SOURCE: Mostert, W.P. & Du Plessis, G.E. 1990. Indices of fertility and family planning according to development region: 1987 - 1989. Unpublished memorandum to the Director General of the Department of National Health and Population Development.
Pretoria: HSRC.
C3 MORTALITY AND MORBIDITY
This section concentrates on general mortality and child morbidity. Very little information is available on a regional basis, and therefore a case-study approach will have to suffice.
The situation in Alexandra will be reported in some detail, and a brief look at the situation in an informal settlement may also be appropriate.
C3. 1 Mortality rates
The detailed 1990 mortality data for the PWV area, as obtained from Death Register forms filed at the Department of Home Affairs and reported by the Central Statistical Services (see CSS, 1992a for Asians, "coloureds" and whites; 1992b for Africans), allowed us to construct Table C8. This table provides an overview of the 1990 age-specific mortality rates (per 1 000 of the population in the age group concerned) for the PWV area. The population figures on which these data are based, were obtained from Simkins (Urban Foundation, 1990: 22, 32, 42
&
55). Since these figures and rates are based on registered deaths, they almost inevitably represent undercounts, and because there may63
of the population in the age group concerned) for the PWV area. The population figures on be a serious bias in the racial distribution of the undercount, we are of the opinion that the figures presented here should be treated with the utmost caution.
TABLE C8
ESTIMATED AGE-SPECIFIC MORTALITY RATES FOR THE PWV AREA, 1990
0-4 6,7 8,2 2,7 5,5 2,7
5-9 0,4 0,4 0,2 0,5 0,3
10-14 0,5 0,5 0,2 0,5 0,4
15-19 1,1 1,1 0,5 1,7 1,0
20-24 1,8 1,9 1,7 3,2 1,5
25-34 2,4 2,6 1,9 3,5 1,6
35-44 4,0 4,7 2,2 5,9 2,4
45-54 7,4 8,7
6,711,8 4,9
55-64 16,0 16,9 20,2 26,8 13,6
65-74 37,8 44,4 36,8 51,0 30,5
75 + 90,3 93,1 78,5 92,4 88,7
TOTAL 4,7 4,9 3,8 5,5 4,1
C3.2 Life expectancy
The definition of life expectancy at birth is the number of years a newborn child can be expected to live, assuming that prevailing mortality conditions remain unchanged. The life expectancy for the population of Region H is about 65 years (DBSA, 1991). The life expectancy for KwaNdebele is, according to Department of Health and Welfare (1989) for males about 61 years and about 64 years for females.
64
,-.'.
C3.3 Child /l,1orbidity
In the South African Demographic and Health Survey carried out from June 1987 to April 1988 by the HSRC,6 some information for African children for the PWV area is presented:
the percentages of the last two children under five years of age with the following specified illnesses in the two weeks prior to the survey were as follows: 15 % had respiratory illness, 17 % had fever, and 16 % had diarrhoea, 12 % of whom had diarrhoea 24 hours before the survey.
A health survey (with a sample size of almost 400) was undertaken by the HSRC in Khutsong during 1992 to look into health-related issues in an informal settlement area, and to determine community needs in terms of these parameters and primary health services (cf. Rossouw, Du Plessis & Smit 1992). The prevalence of common illnesses among children under three years of age, was 30 % diarrhoea 2 weeks preceding the survey, 32 % respiratory illnesses 4 weeks preceding the survey and 9 % measles 3 months preceding the survey.
C3.4 Immunisation
From information provided by the Department of National Health and Population Development (1987), 97-98 % of Asian, "coloured" and white children in Region 42 (i.e. the PWV area excluding KwaNdebele) have been immunised, compared to the 90 % of African children.7
C3.5 Alexandra Township case study
Alexandra, which is situated to the northeast of Johannesburg, provides a good setting for a case study on environmental and health status. According to Ferrinho et aT. (1991) approx- imately 19 % of the township's population of about 200 000 live in informal dwellings, and another 15
%
are accommodated in newly upgraded residences. The remaining two-thirds live in old brick houses in the area which is referred to as "Old Alex", 15 000 (8 %) of whom live in three large single-sex hostels. According to the 1985 census, 29 % of the population were under the age of 15 years, while 9 % were older than 50 years. The population pyramid shows an age structure typical of developing communities with a broad base and narrow apex, but with a bulge in the age category 20 - 29 years which is particularly visible among the6 The data were gathered from approximately 22 000 mothers of all population groups and 55 000 children born during the five years preceding the survey.
7 It is not stated in the Department's report what the age limitation for the analysis or the nature of the immunisation was.
65
resiclents of informal dwellings (probably indicating the presence of a large proportion of recent in-migrants).
Data obtained from the Alexandra Health Centre and University Clinic (AHC), which is a privately funded primary health-care facility, indicate that the minimum perinatal mortality rate in the maternity services at AHC was about 25 per 1 000 births in 198~ (Ferrinho et al.
1991). Young children under the age of 1 year account for over 60 % of the deaths in the ARC records, and the most common cause of death in children is gastro-enteritis. Since the 1950s violence has been part of the lives of Alexandra residents, and therefore it should not be surprising that adult men die mostly from acts of violence and trauma (mostly stab wounds). Adult women's deaths can, however, be ascribed to respiratory tract infections, cardiovascular diseases, abortions and trauma (often from gunshot wounds).
The level of immunisation coverage in Alexandra was analysed in a survey by Rees et al.
(1991), who found that, despite the relative availability and accessibility of immunisation services, only half the children were fully immunised when reaching age 1 year. (This proportion falls to only one-third in the case of the on-time immunisation rate, a tendency which is not uncommon even with a high level of immunisation coverage.) Poor people often find it difficult to visit the clinic, as was proved by the finding that those living furthest from the clinic had a significantly lower on-time immunisation rate; in fact, 39 % of mothers interviewed complained that the AHC was too far away.
Sexually transmitted diseases (STDs) form a major component of primary health care in the context of a weakening family life and a notable migrant-labour life style, such as in Alexandra. There is a high prevalence of STDs in the community. Indications are that high- risk sexual behaviour (multiple sexual partners) and ulcerative disease are fairly common, which point to the fact that there is a severe danger of HIV infection. According to Frame, Ferrinho and Phakathi (1991) about 20 % of the Alexandra population over the age of 15 years are treated at least once a year for STD, the vast majority of whom are treated by the 17 general practitioners in Alexandra who provided curative care during 1991 (Ferrinho et al.
1991:376).
A child abuse register was opened at the Alexandra Clinic (AHC) in July 1988, and based on the cases treated during the 21-month period from July 1988 to March 1990 a disturbing picture emerges: during that time 140 abused children were treated, of whom 90 % were girls (Howard, Marumo & Coetzee 1991). Most common was sexual abuse (82 %), followed by physical abuse (9 %), neglect (7 %) and combined abuse (2 %). Sexually abused children treated at the clinic were almost exclusively girls (96 %), and more than a third (35
%)
of the sexually abused children were under the age of 5 years. The incidence of STD in sexually abused children was comparatively very high, namely 53 %. The cases of physical abuse,66
predominantly children between 6 and 8 years old, included injuries caused by beatings (fist or open hand), whipping (by a sjambok or electric flex), kicks, cigarette burns and attempted throttling. In half of the 10 cases of neglect the children (two of whom were physically handicapped) were abandoned.
C3.6 Air pollution
A longitudinal study by Terblanche
et al. (1992), known as the Vaal Triangle Air Pollution Health Study, of children aged 8 - 12 years evaluates exposure to and the effects of outdoorand indoor air pollution levels on the health of more than 10 000 white and African children living in Vanderbijlpark, Sasolburg, Vereeniging, Meyerton, Randvaal, and the Sebokeng/Sharpeville areas (Lekoa). This article is only the first in a series and discusses only the effect on white children in the area.
Ahealth questionnaire filled in by the parents of 10 187 children indicated that during the previous year 66 % had suffered from upper respiratory tract illnesses (URI) such as sinusitis, rhinitis and hay fever and 29 % from lower respiratory tract illnesses (LRI) such as bronchitis, chronic cough and chronic chest illnesses.
Extensive data on outdoor and indoor levels of air pollution as well as personal exposures to total suspended particular matter were collected. Preliminary results indicated that the level of particulate matter exceeds the USA health standards.
C4 NUTRITION C4.1 Introduction
According to Cameron (1992), South Africa's child mortality is at a very high level: "Indeed South Africa shares the ominous distinction of being one of only 8 countries that have under- 5 mortality rates in the UNICEF classification of very high to high ... " (p. 224). Human growth and nutritional status are viewed internationally as the most sensitive indicators of general health and well being among children (Cameron 1992), but since these have not been reported on a general and useful scale in this country, it is necessary to make use of case studies. One such case study deals with observations at Baragwanath Hospital. Another set of case studies deals with the differences between rural and urban children and between the children of urban well-off and less well-off parents.
C4.2 Child growth
A comparative study of the growth patterns of two groups of
rural (African) children, againstthose of two groups of urban children, the one group "well-off' and other "average", was undertaken by Cameron (1992). These four different studies were compared in terms· of the
67
growth correlates of different socio-economic environments of children. The two urban samples were taken from Soweto in the PWV area. The so-called privileged group consisted of 307 African children (of between 5 and 19 years old) whose parents could afford to have·.
them attending high-quality private schools in the Johannesburg area, while the "average"
group- comprised 867 African children (aged between 5 and 14 years) whose parents had no alternative but to send them to the ill-equipped and overcrowded public schools in Soweto.
One of the two rural African groups consisted of 392 children (between the ages of 6 and 19 years) of farm labourers from the Vaalwater area in the northwestern Transvaal, and the other examined 420 children (also between 6 and 19 years old) from a "tribal" rural part of Ubombo in northern KwaZulu with a subsistence economy.
The study showed that, in general, the well-off urban children were consistently larger than all other groups, but these differences were not statistically significant. the "average" urban group were consistently (and at times significantly) smaller than their well-off counterparts.
Furthermore, rural children were consistently larger than 'average' urban children but smaller than the well-off urban group. The Vaalwater rural boys were significantly smaller than the well-off urban boys, but the differences between the girls were not significant, although the well-off urban girls showed faster sexual development than their Ubombo rural counterparts.
Cameron
et al.(1992) conclude from these findings that the "average" African urban environment in this country is not conducive to physical growth among children, but that adequate attention to socio-economic conditions can, as demonstrated by the well-off children, ensure that even an urban environment as notoriously bad as Soweto can be beneficial relative to a rural environment.
C4.3 Nutrition status