“Farm Girl”. This is my new nickname from the team in KwaZulu Natal, South Africa. It does, unfortunately, have several negative connotations. ‘Farm Girl’ is a brand of baked beans: so not that bad, I guess. Its other local meaning is, politely, ‘a woman with many boyfriends’. Let’s go for the former: I definitely don’t fit into the latter at the moment! This is my new nickname because of all the time I now spend on (or looking for) sugar-cane farms.
The hills of Eshowe and Mbongolwane are green with sugar cane for most of the year: the region is known for its sugar production and the area is dominated by farms, mills and green fields. Sugar cane is cut manually, using a machete. It is hard, manual labour: people work long hours, rising well before dawn to walk to the fields before the sun rises high in the sky and it become too hot to work. Cane-cutters are usually paid per metre of cane that they cut, and much of the money they earn is sent home to support their families across South Africa, Mozambique and Swaziland.
Working such long hours – and only being paid for the cane that you cut – means that many farm workers are unable to get to their local clinics during opening hours. People understandably don’t want to miss work to go to a clinic, as it means they will miss out on being paid. Some farm-workers live in remote ‘compounds’ (a word I don’t particularly like, but the one used locally to describe their accommodation) which are several hours walk from their nearest clinic. They don’t have easy access to transport, and if there is transport available they don’t necessarily have the money to pay for it. This means that they can’t access HIV testing services easily, and, if they are HIV positive, are not always able to go to the clinic to collect their treatment. Not taking ARV treatment as prescribed puts the patient at risk of developing opportunistic infections as well as resistance to their prescribed drugs.
One of my first jobs when I joined the project in KwaZulu Natal was to drive around (OK, be driven around by someone who knows the roads inside out and can get us across rivers and out of muddy ditches when required) and map all of the farms in the area. This meant driving up to some extremely intimidating gates with even more intimidating dogs to meet the farm owners and ask for access to their farms and arrange to meet the people working on them. Many of them were very welcoming and acknowledged that HIV was a problem on their farms during these initial discussions, but not all of them realised the extent of the problem. The HIV positivity rate varied per farm, but in some cases, we found that more than half of the workers were HIV positive.
Once we had permission to work on farm property, we visited farm workers in their (often remote) compounds. The mobile HIV testing team is made up of HIV counsellors, nurses and also community mobilisers who explain to people what MSF does in their area and what HIV testing involves. The service is free and immediate – if someone decides to test for HIV, they receive their results within 20 minutes.
Unfortunately, simply providing a service does not mean that it will be instantly popular. Stigma and discrimination is high amongst sugar-cane workers: many fear losing their job if the farm owner learns that they are HIV positive, even though this should not happen. Others do not want to disclose their HIV status to those around them out of fear of being discriminated against. Many share very small rooms with other cane-cutters – it is hard to keep anything secret in an over-crowded dorm and there are few private places to store medication.
Even offering counselling to someone in their own home is not always welcomed. After a long day in the field, when their faces are dry and cracking with the mud they use to protect themselves from the sun, people want to wash, cook dinner, look after their children, not invite a counsellor into their home. The last thing they want is talk about HIV.
MSF’s HIV testing services are free and confidential but most of all they are voluntary. MSF cannot force someone to ‘know their status’ and every individual must be ready to test for HIV in their own time. All we can do is go back to the farms regularly, continue to provide education and information, distribute condoms and allow people to come to us when they are ready. The key is providing options: if you don’t want to test today, we can come back another time. If you don’t want to test at home, here are the details of our other services in town. If you already know that you are HIV positive, let us help you to get your treatment if you need it.
Some days I came home from the muddy cane fields and felt so disheartened. I felt guilty because I had arranged for a whole team of people to spend their entire afternoon on a farm, sitting huddled together against the cold and the rain, waiting patiently for clients to arrive….and they didn’t. I’d ask the project “is this a waste of time and resources?” and they’d tell me “no, be patient. People need to test in their own time, and by visiting them again and again we are giving them that opportunity.” MSF has tested huge numbers of people since introducing community testing, so it is a strategy that works…even if it does require patience sometimes.
Even now as I sit in Brussels waiting for a flight to my next mission in Liberia, two years after earning my “Farm Girl” nickname, I can still map the farms in my head, recite the names of the farm-owners and their sugar estates. I can explain to someone exactly which bumpy dirt road to take, which field to turn down, who to talk to when they get there. My time spent in the bitter-sweet world of sugar-cane farming was an incredibly eye-opening one for me, and one which was not always easy to swallow.
The project in KZN has spent the last two years working with local farm owners, the Department of Health and farm workers to find solutions for HIV testing and provision of treatment that work for everyone. It has been a constantly shifting process, the team making changes to the services that they offer based on the feedback they receive. The team has very recently been able to begin distributing ARVs on farms, making it even easier for people to get their HIV treatment. More on this another time…