An in-depth analysis has proved what everyone feared: the impact of Covid-19 on South Africans was underpinned by every aspect of inequality that still haunts life nearly three decades into democracy.
The lead author of a paper published in the South African Journal of Science, Dr Waasila Jassat, told the Sunday Times last week: “Black people had a higher risk of dying of Covid and had poorer access to life-saving interventions such as intensive care and ventilation.”
The analysis, by the National Institute for Communicable Diseases where Jassat manages the hospital surveillance system for Covid-19, DATCOV, reveals the hard statistical evidence.
Jassat said the most telling statistics are these:
- black, Indian and coloured people had a higher risk of dying than white people;
- Covid-19 patients’ chances of dying were higher in public hospitals than private hospitals;
- in the public sector, black people had lower odds of being treated in intensive care and of being ventilated; and
- among all Covid-19 patients who died in hospital, only 10% in the public sector were treated in intensive care compared with 60% in the private sector.
The study explores why being black put people at risk of poorer outcomes during the first two years of the pandemic.
Said Jassat: “There is currently no conclusive evidence on biological or genetic reasons to explain this. Black people do have higher rates of co-morbidities like hypertension, obesity, diabetes, HIV, TB and chronic kidney disease that put them at risk for poorer Covid-19 outcomes.”
Also, “black individuals are employed in essential services, less able to work from home, live in larger, multigenerational households that don’t allow for social distancing, and have to use public transport, while other race groups were better able to shield and adopt measures for prevention and isolation”.
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Isobel Frye, executive director of the Social Policy Initiative, said: “Levels of co-morbidity are much higher among those with poor dietary options and malnutrition, respiratory disease related to living conditions, exposure to effluence like mining, and many other factors.
“A very different life cycle for the poor exists compared to the middle class and Covid highlighted the outcomes of that.”
The pandemic showed that socioeconomic status, still mainly defined by race, determined how you would fare if you fell ill.
Those treated in the public sector “had higher risk of dying compared to those treated in the private sector. A higher proportion of people with Covid admitted in private hospitals got treated in ICU, ventilated and received oxygen, compared to public hospitals,” said the study.
Jassat said average spending on medical scheme members is six times higher than on uninsured people who rely on public health care.
If Covid has exposed the underbelly of inequality in SA, are we prepared to do anything about it or are we going to let it continue to define who we are because doing something about it is going to require effort?
— Isobel Frye of the Social Policy Network
“Higher spending buys more medical expertise, specialised hospitals, sophisticated technology and equipment, and advanced and expensive medication,” she said.
Even in the private sector, “if you were not white you had higher odds of being treated in ICU or ventilated because you had a higher risk of dying”.
In the public sector, despite having a higher risk of dying, black Africans had lower odds of being treated in intensive care or ventilated compared with whites.
“The inequality could be due to black patients in the public sector more likely accessing care in rural district hospitals that had limited ICU or ventilators available,” said Jassat.
She and Frye emphasised the wake-up call Covid-19 provided, even though it only underlined long-standing problems.
“We argue that higher rates of chronic medical conditions, the risk of dying from Covid and lack of access to health services are related to structural inequalities, including unemployment, poor housing, low household income, food insecurity and environmental hazards, as well as social factors such as racism and oppression,” said Jassat.
Frye added: “The take-home, really, is that we saw the unravelling of the societal knit that had existed in a very precarious way even before the pandemic. During the lockdown we had to stop and breathe, and that gave us a chance to look around and realise the real impact of inequality and poverty.
“It’s trite to say we’re the most unequal society without looking at the implications of that on all fronts, from spatial inequality, to skills, to gender [and] the digital divide.”
Education was a good example, she said. While many middle-class children were able to study from home and spend quality time with parents, “the majority of kids in state schools lost 1½ years of tuition and we haven’t got our heads around the greater scarring and polarity of that”.
On the global stage, too, Covid-19 highlighted — and exacerbated — dire inequality.
“Other studies [from around the world] have also reported that people from vulnerable racial and ethnic groups were disproportionately affected by Covid-19, experiencing higher rates of infection, hospitalisation and death,” said Jassat.
A study in Brazil showed that whites were more likely to be admitted to ICU than people of colour, while a study in Chile found “a strong association between socioeconomic status and mortality” in favour of those with money.
A study in the US found Covid-19 “laid bare the social fault lines of society and that race, gender, age and education all affected vulnerability to infection”.
Where to from here?
“Transformation of the health-care system is long overdue, including narrowing the gap in resources between the private and public sectors,” said Jassat.
The government must provide efficient and inclusive nondiscriminatory health services and urgently improve access to ICU, ventilation and oxygen in the public sector, particularly in rural areas.
“The proposed National Health Insurance may be a vehicle for achieving this, but only if it considers redistribution of resources and access to health care at the heart of its planning.”
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