Existing socioeconomic inequalities shape COVID-19 impacts, with a disproportionate effect on black Africans and marginalised and low socioeconomic groups, found a study in the SA Medical Journal. COVID-19 in-hospital mortality was highest in black Africans, followed by coloureds, Indians and whites.
More black women were hospitalised from COVID than any other race, and most of those who died from the pandemic also tended to be younger than those from other racial groups.
The authors write:
These conditions have consistently led to higher mortality among black Africans (68.5%) compared with whites (9.5%), coloureds (7.7%) and Indians (1.8%). The high mortality of black Africans due to other pandemics in SA, such as TB and HIV, is well known.
Similar observations were made in the USA, where African Americans had disproportionately high infection and mortality rates due to COVID-19. COVID-19 deaths were also higher among the elderly, as expected. In 2009, 151 700 – 575 400 deaths among H1N1 admissions were of older patients (≥50 years). The results of the present study show higher mortality among males than females.
Similarly, men (6.3%) had a higher case fatality rate (CFR) than women (5.5%). Men may delay visiting health facilities because they generally have poor health-seeking behaviour, which may increase disease severity. They may also have underlying health conditions of which they are not aware. Men are also known to have more risky health behaviours, such as tobacco and alcohol use, than women. These risky behaviours are associated with an increased risk of cardiovascular disease (CVD), and CVD is reported to be higher in men than women.
Several factors may explain the lower mortality in women. Generally, women are known to have better health-seeking behaviours than men, which could increase their opportunity to be screened for COVID-19 and diagnosed early and not become severely ill. Specifically, women are traditionally responsible for the family’s health and are likely to be knowledgeable about pathological symptoms. As such, they have been reported to be more likely to use healthcare services than men.
It is important to note that although the mortality rate was higher for men than women, females’ cumulative incidence risk has consistently remained high since the beginning of the pandemic. This risk may be attributed to gender inequalities such as women being in service occupations and vulnerabilities in domestic and local chores; many women are compelled to be part of super-spreader events as they need to cook and serve food at such events for financial security.
These findings provide insight into gender-related differences in healthcare or disease risk. Analysis and documentation of these differences are essential for improving service delivery and assessing the dual goals of improving health status and reducing health inequalities. It should be noted that the in-hospital mortality rate does not represent total COVID-19 mortality, as many deaths occur outside healthcare facilities. For example, in EC, >40% of persons who died outside healthcare facilities tested positive for SARS-CoV-2.
Lead researcher Refilwe Phaswana-Mafuya, a professor of epidemiology and public health at the University of Johannesburg, told the Sunday Times: “This research “is not meant to divide us but it gives guidance on interventions going forward”, she said. “Everyone keeps saying the pandemic exposes inequality but if you don’t get down to the nuances of that, it’s like saying nothing at all.”
“Black Africans [across both genders] were hospitalised at younger ages than other race groups, with a median age of 52 years. Whites were hospitalised at older ages than other races, with a median age of 63 years,” said Phaswana-Mafuya. Whites were also “significantly more likely to die at older ages compared with black Africans, coloureds and Indians, who died at younger ages”.
She said the ratio of deaths to hospitalisations by race and gender increased with increasing age in all groups, but “this ratio was highest among black Africans and lowest among whites”. The median age of black African females dying from COVID was 63 whereas for their white counterparts it was 73.
Wits University infectious disease specialist professor Francois Venter, head of health organisation Ezintsha, said that with vaccine rates higher among the well-heeled, protection against hospitalisation and death from COVID is higher too. “If you’re rich you’re more likely to get vaccinated. The government has done a shocking job with the uninsured,” he told the Sunday Times, saying that demand creation and access were badly done, and vaccine incentives came too late.
But even before the virus strikes, environmental factors are at play. “Poor people just do worse with any illness because of stresses related to nutrition [due to lack of access to healthy food] and immunity, to name but two,” Venter said. “So every single metric around poverty puts you in a vulnerable position. And then when you do get sick, you get screwed over by the health system.”
Study details
Understanding the differential impacts of COVID-19 among hospitalised patients in South Africa for equitable response
N Phaswana-Mafuya, O Shisana, W Jassat, S D Baral, Keletso Makofane, E Phalane, Khangelani Zuma, N Zungu, Martha Chadyiwa
Published in The South African Medical Journal on 5 November 2021
Abstract
Background
There are limited in-depth analyses of COVID-19 differential impacts, especially in resource-limited settings such as South Africa (SA).
Objectives
To explore context-specific sociodemographic heterogeneities in order to understand the differential impacts of COVID-19.
Methods
Descriptive epidemiological COVID-19 hospitalisation and mortality data were drawn from daily hospital surveillance data, National Institute for Communicable Diseases (NICD) update reports (6 March 2020 – 24 January 2021) and the Eastern Cape Daily Epidemiological Report (as of 24 March 2021). We examined hospitalisations and mortality by sociodemographics (age using 10-year age bands, sex and race) using absolute numbers, proportions and ratios. The data are presented using tables received from the NICD, and charts were created to show trends and patterns. Mortality rates (per 100 000 population) were calculated using population estimates as a denominator for standardisation. Associations were determined through relative risks (RRs), 95% confidence intervals (CIs) and p-values <0.001.
Results
Black African females had a significantly higher rate of hospitalisation (8.7% (95% CI 8.5 – 8.9)) compared with coloureds, Indians and whites (6.7% (95% CI 6.0 – 7.4), 6.3% (95% CI 5.5 – 7.2) and 4% (95% CI 3.5 – 4.5), respectively). Similarly, black African females had the highest hospitalisation rates at a younger age category of 30 – 39 years (16.1%) compared with other race groups. Whites were hospitalised at older ages than other races, with a median age of 63 years. Black Africans were hospitalised at younger ages than other race groups, with a median age of 52 years. Whites were significantly more likely to die at older ages compared with black Africans (RR 1.07; 95% CI 1.06 – 1.08) or coloureds (RR 1.44; 95% CI 1.33 – 1.54); a similar pattern was found between Indians and whites (RR 1.59; 95% CI 1.47 – 1.73). Women died at older ages than men, although they were admitted to hospital at younger ages. Among black Africans and coloureds, females (50.9 deaths per 100 000 and 37 per 100 000, respectively) had a higher COVID-19 death rate than males (41.2 per 100 000 and 41.5 per 100 000, respectively). However, among Indians and whites, males had higher rates of deaths than females. The ratio of deaths to hospitalisations by race and gender increased with increasing age. In each age group, this ratio was highest among black Africans and lowest among whites.
Conclusions
The study revealed the heterogeneous nature of COVID-19 impacts in SA. Existing socioeconomic inequalities appear to shape COVID-19 impacts, with a disproportionate effect on black Africans and marginalised and low socioeconomic groups. These differential impacts call for considered attention to mitigating the health disparities among black Africans.
Sunday Times Pressreader article – Covid’s racial realities exposed in new research (Open access)
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