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How race, money and where you live affect who survives COVID

When COVID-19 hit South Africa, it was clear it was a disease that showed no prejudice in who was targeted for infection, with the profile of victims cutting across class and race. But a completely different picture emerges in an analysis of how the disease affected different groups, notes MedicalBrief.

Researchers, who wanted to answer the question: “Why are black Africans, coloured and Indian people, seemingly being disproportionately affected by COVID-19?”, analysed the data of more than 400,000 people infected with COVID. Writing in Bhekisisa, they say the data were collected between March 2020 and January 2022 from DATCOV, a system that was created during the pandemic, and which allowed for public and private COVID-19 hospital admissions to be recorded in the same database.

They found that the country’s history of racial inequalities, even after almost 30 years of democracy, still affects who lives or dies, who gets an intensive care (ICU) bed, or who has access to lifesaving oxygen or ventilation when they end up in hospital.

The key findings of the analysis by Waasila Jassat, who leads DATCOV, Cheryl Cohen, associate professor in epidemiology at the University of the Witwatersrand and co-head of the Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, and Nicholas Crisp, deputy director-general in the National Health Department responsible for implementing the country’s National Health Insurance (NHI) scheme, were:

  • People of colour (black Africans, Indian and coloured people) had a higher risk of dying of COVID-19 than whites;
  • People admitted to public hospitals were more likely to die of COVID-19 than those with beds in private hospitals; and
  • Black Africans admitted to public hospitals had a lower chance than white people of getting an ICU bed or being ventilated – despite having a higher risk of dying.

The researchers looked at demographic information such as age, sex and race; risk factors for falling seriously ill with COVID, such as age, obesity, diabetes and hypertension, and compared the data to the type of treatment someone received and the outcome thereof.

They argue that a legacy of long-standing inequalities has resulted in structural discrimination and exclusion to healthcare based on race.

“There is little conclusive evidence that genetic or biological reasons alone can explain the racial and ethnic differences in people’s likelihood to get infected with SARS-CoV-2 (the virus that causes COVID-19) or die of it. In fact, attributing poor clinical outcomes in vulnerable race groups solely to genetics and biological differences has historically been responsible for marginalising their health needs.

“Rather, we need to look at the impact of structural inequalities such as unemployment, poor housing, low household income, food insecurity and environmental hazards, as well as social factors such as racism and oppression, to find the answers.

“Our study showed that people of colour and people with lower incomes (we used the type of health facility used as a proxy for someone’s income) had a higher risk of dying of COVID-19 and a lower chance of being treated in an ICU or being intubated.

“Our data show that most COVID-19 hospital admissions were among black African, coloured and Indian people of working age.”

The data add weight to the argument for universal healthcare, highlighting the disparity in who had access to medical care. South Africa has a two-tiered health system where in 2019, 40% of all spending on healthcare in the country was in the private healthcare system, which serves only 27% of the population. Higher spending buys more medical expertise, specialised hospitals, sophisticated technology and equipment and advanced and expensive medication.

Only one out of 10 black Africans belongs to a medical aid and only just over 15% of the population can afford medical insurance; the rest have to rely on under-resourced state hospitals and clinics or pay for private healthcare in cash. "Our study showed black Africans were less likely to be admitted to private hospitals — and that Indian and white people had a higher chance of accessing a private hospital bed. They therefore also had a higher chance of survival, as our results reveal that public patients were more at risk of dying from COVID-19 than private patients."

The survey also highlighted the difference in quality of care across the provinces. A Spotlight report says it showed the risk of a hospitalised person dying from COVID-19 in the Eastern Cape was almost double (1.9 times) the risk of someone dying of the disease in the Western Cape. In the largely rural provinces of Limpopo and KwaZulu-Natal, the risk of hospital patients dying from COVID-19 was respectively 1.7 and 1.5 times that in the Western Cape.

Principal author Jassat says there is a “huge” difference in risk of COVID-19 mortality between provinces even after accounting for age, sex, comorbidities, and admission to either private or public hospitals.

“We know that Eastern Cape, Limpopo, and KwaZulu-Natal have many rural communities with big health access challenges. However, the data also reflect the difference in quality of care in the different provinces,” she says.

Jassat says the study confirms others conducted in the United Kingdom, United States, and Brazil and various systematic reviews that found black and minority ethnic groups had a higher risk of mortality and severe disease due to poor access to healthcare services.

The authors say the findings show the need for collecting data on socio-economic status and race with age and sex to identify populations most vulnerable to COVID-19.

The study authors urge national government to provide efficient and inclusive non-discriminatory health services and urgently improve access to ICU, ventilation, and oxygen in the public sector.

Jassat says the data shows a lower proportion of patients in the public sector were in ICU, ventilated, or treated with supplemental oxygen, which highlights the inequity of resources between the public and private sectors, including hospital beds, healthcare workers, and equipment such as ventilators and oxygen.

According to the study, patients were more likely to get supplemental oxygen in the private sector (46.3%) compared to the public sector (37.4%) overall across all age groups older than 20 years. In the public sector, black African patients received the lowest percentage of supplemental oxygen (46.4%) with the highest being received by those of Indian descent (57.9%) and for whites at (55.3%). In the private sector, the lowest percentage of patients to receive oxygen was black African patients (43.6%) and the highest percentage was for white patients at 63.3%.

There were also differences in treatment in ICU and ventilation by race and health sector. There was less inequality in the private sector, where black groups with the highest risk of mortality were most likely to be treated in ICU or ventilated. Jassat says in the public sector, black African patients were less likely to have been admitted to ICU and ventilated than white patients even though they have a higher risk of mortality. “This could be due to black patients being more likely to access care in rural district hospitals that had no ventilators or ICU available.”

Jassat says the high prevalence of comorbid diseases may play a role in the increased severity of COVID-19 in people in South Africa. Referring to the study, she says 40.4% of black African patients reported having comorbidities compared wiith white patients (45.6%). However, 31.6% of comorbidities were unknown for black people while the unknown for whites was a lot less at 14%.

While it is well known that HIV and tuberculosis prevalence is highest among black Africans, Jassat says the South African Demographic and Health Survey (2021) has suggested a very high rate of hypertension, diabetes, obesity, and undiagnosed and poorly controlled disease for black African people, putting them at higher risk of mortality.

“But it’s not just a white or black issue. It’s a class issue. People with higher socioeconomic status were probably better able to prevent infection and get vaccinated,” she says.


Bhekisisa article – Inequality kills: How race, money and power affect who survives COVID (Open access)


SA Journal of Science Survey – The intersection of age, sex, race and socio-economic status in COVID-19 hospital admissions and deaths in South Africa (Open access)


Spotlight article – COVID-19: Death risk in SA differed depending on where people were hospitalised (Republished under Creative Commons Licence)


See more from MedicalBrief archives:


The demographic face of COVID-19 in South Africa — Johannesburg University


South Africa’s 8 coronavirus lessons for the rest of Africa


How COVID gave African countries the opportunity to improve public health


Higher COVID-19 mortality in young Africans than European and US counterparts


The challenges to collecting accurate COVID-death statistics in SA





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