This case study is part of a Local Democracy Research Centre paper on global health inequalities. Read Still unequal: dealing with health inequalities through the pandemic and beyond
The International Journal for Equity in Health published a paper Income-related health inequalities associated with the coronavirus pandemic in South Africa: A decomposition analysis in January 2021. (Chijioke O. Nwosu Adeola Oyenubi)
The South African government imposed a very strict nationwide lockdown in March 2020 to control Covid-19. The authors highlight how this resulted in “vulnerable populations (low earners, those in informal and precarious employment) being more likely to be adversely affected through job losses and the resulting income loss”. Income loss is likely to result in reduced ability to access healthcare and a nutritious diet, with the subsequent impact on health. They conclude that the economic dislocation caused by the pandemic will disproportionately affect the health of the poor:
Being African (relative to white), per capita household income and household experience of hunger significantly predicted income-related health inequalities in the COVID-19 era (contributing 130%, 46% and 9% respectively to the inequalities), while being in paid employment had a nontrivial but statistically insignificant contribution (13%) to health inequality.
Those living under inhospitable housing conditions like shacks were more likely to find the lockdown more unbearable, raising the possibility of worsening (psychosocial) health outcomes. Given existing deep socioeconomic inequalities in South Africa mostly due to the legacies of apartheid, it is not surprising to imagine that the health outcomes of the poor are more likely to significantly worsen relative to the well-off during this crisis. As noted in popular media, COVID-19 has brought the steep economic inequalities in South Africa into sharp focus.
The report concluded that “given the significance and magnitude of race, hunger, income and employment in determining socioeconomic inequalities in poor health, addressing racial disparities and hunger, income inequality and unemployment will likely mitigate income-related health inequalities in South Africa during the COVID-19 pandemic”.
A survey of South Africans – the Covid-19 Democracy Survey (Bekker M, Roberts B, Alexander K, Bohler-Muller N. Hungry – we are starving at home 2020) indicated that 34 per cent of adult South Africans were going to bed hungry during the lockdown – substantially higher than 11.3 per cent of the population who were vulnerable to hunger in 2018.
An article in Borgen Magazine in July 2020 highlights the impact of Covid-19 in areas where race-biased spatial segregation has remained. It describes how Khayelitsha a township in Cape Town, with a population of over 400,000 saw a rapid rise of Covid-19 cases. By mid June 2020 South Africa as a whole had documented over 83,000 COVID-19 cases. Khayelitsha has reported a total of about 5,800 cases, with approximately 1,500 deaths. Additionally, Western Cape recorded 44,143, or 53 per cent of all claims in South Africa.
Areas adjacent to Khayelitsha, such as Muizenberg, Kalk Bay and Fish Hoek were able to maintain healthier conditions throughout the lockdown. Residents in these areas were able to practice social distancing and healthily quarantine in their households with access to basic needs such as food, water and shelter.
Western Cape was therefore the epicentre of the pandemic as at June 2020 and Khayelitsha accounted for over 11 per cent of infections despite making up only 6.7 per cent of the provincial population. In contrast, Stellenbosch (a more affluent and mostly white city) which constitutes about 2.7 per cent of the provincial population only accounted for 1.5 per cent of infections.