PRETORIA, South Africa — Steep racial, social and economic inequalities further complicate South Africa’s fight against COVID-19. With high rates of HIV/AIDS and tuberculosis (TB), the country’s efforts to quell the spread of COVID-19 through lockdowns and the diversion of medical resources are ever so important. However, in many ways, COVID-19 is acting as a catalyst for better public health. Initiatives are already underway to revitalize public health in South Africa while addressing multiple problems at once, such as combining TB and COVID-19 testing sites, as well as streamlining medication delivery.
Public Health in South Africa
South Africa is a country of 57 million people with a per capita income of $13,090. Life expectancy at birth is 67 years for women and 61 years for men. Additionally, the infant mortality rate is 36 per 1,000 live births. South Africa is home to the world’s largest HIV/AIDS outbreak. Roughly 12% of the South African population is HIV-positive, and over 2 million HIV-positive people are not on antiretrovirals. TB and HIV/AIDS are both among the top 10 most common causes of death in South Africa.
South Africa learned crucial lessons about public health from the early stages of its HIV/AIDS response. Twenty years ago, South African leaders barred the public access to antiretrovirals, because they believed such medications were poisonous. Instead, they advised people to treat AIDS with beetroot or garlic. Studies show that the misinformation regarding HIV/AIDS from that administration cost 300,000 lives. After a change in leadership and a series of lawsuits, the government spent millions on antiretrovirals and launched a community health campaign to stem the spread of misinformation. They also received help from the United States of America’s PEPFAR (the President’s Emergency Plan for AIDS Relief).
COVID-19 in South Africa
South Africa’s experience with HIV/AIDS control allowed it to execute an early and strong response to COVID-19. A strict lockdown was implemented before a single COVID-19 death occurred. Included in their response was the institution of a curfew from 11:00 pm to 4:00 am and a mandate requiring South Africans to wear masks. The government also banned alcohol sales to ease the burden on the national healthcare system. This decision was based on the reasoning that alcohol leads to fights, domestic violence and binge drinking.
Despite these efforts, South Africa remains the hardest-hit country in Africa. Over 250,000 people have been infected with COVID-19 and more than 4,000 people have died from the virus. In response to the rapidly increasing caseload, which is doubling every two weeks, the country has extended its state of emergency. Although large public spaces, such as basketball arenas and convention centers, have been converted into field hospitals, there is a shortage of healthcare workers. Contact tracing has also been very difficult, due to a backlog in testing causing a two-week waiting period before patients receive their results.
Fortunately, there is still hope within key branches of South Africa’s pandemic response. The first COVID-19 vaccine trial in the continent began in South Africa. Additionally, PEPFAR community health workers have redirected their efforts from HIV/AIDS to COVID-19. So far, they have screened nearly 6 million people, and have provided information about prevention and testing to the public.
HIV/AIDS, TB, and COVID-19: A New Syndemic
A syndemic involves “two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population.” For example, HIV/AIDS and TB are syndemic because if one’s immune system is slowly being destroyed by HIV, one is much more likely to contract other infections, including TB.
In South Africa, a new syndemic has emerged, involving HIV/AIDS, TB and COVID-19. Studies show that the three diseases collectively worsen one another. HIV increases a COVID-19 patient’s risk of death by a factor of 2.75, while also increasing a patient’s risk of having active TB by a factor of 2.58. Because HIV affects the immune system and TB damages the lungs, both are likely to increase the severity of COVID-19.
The effects of syndemics can be social as well. Crucial resources for HIV and TB are being diverted to the COVID-19 response. The number of TB tests conducted dropped by half because patients could not visit clinics during the lockdown. The lockdown also prevented patients from accessing their TB and HIV medications.
However, the pandemic offers an opportunity to reform public health in South Africa by addressing the HIV-TB-COVID-19 syndemic. Doctors Without Borders is combining TB, HIV and COVID-19 screenings at some South African locations. The COVID-19 response has also led to streamlining the delivery of medicine. Medication can be delivered to a patient’s home or even collected from a vending machine. These initiatives signal hope that COVID-19 will be a catalyst for addressing a variety of public health issues in South Africa through the integration of public health programs.
The Path Forward
Global and public health experts note that the COVID-19 pandemic both exposes and provides an opportunity to address the very social inequities that have exacerbated it. Dr. David Barnes, a professor of the History and Sociology of Science at the University of Pennsylvania, described the pandemic as an “ultraviolet light” or “social x-ray” that reveals the preexisting vulnerabilities in a population, such as poverty, inequality, and racism.
These vulnerabilities are present in South Africa and around the world, and they are instrumental in worsening the effects of pathogens. Dr. Michael Joiner, a professor of Medical Anthropology and Global Health at the University of Pennsylvania, similarly notes that socially and economically disenfranchised populations feel the negative effects of the pandemic more strongly. He stresses that access to information about the virus and preventive measures, which are easier to obtain at the higher socioeconomic levels of the social totem pole, will be crucial in containing the spread of COVID-19 in South Africa and around the globe.
– Isabelle Breier