The rapid spread of covid-19 around the globe has brought the world to a stunning standstill. It has massively disrupted our lives in ways never experienced since the Spanish flu of 1918. Personal health and wellbeing have become a priority for most of us as we contemplate our mortality in the face of the global pandemic.
As a South African, I have been quietly watching my country’s pandemic response with pride and grave concern from my home in Johannesburg. I am proud at how proactive the government response has been so far. A multi-sectoral and multidisciplinary Inter-Ministerial Task Force was set up to support the response to covid-19. It’s public health policy, regulatory and pathology interventions are led by the scientific insights of infectious diseases experts from the National Institute for Communicable Diseases of South Africa (NICD-SA) and the National Health Laboratory Services (NHLS). I am proud because my country’s political leadership appear proactive, transparent, compassionate, and economically invested on a health issue that threatens its citizens. This is a marked and highly commendable departure from the AIDS denialist approach under President Thabo’s government. It is estimated that 350 000 of people died of AIDS in South Africa in 2007. 
There are regular public updates on national infection rates and mortalities. The National Health Department is continuously releasing easy to understand public education messages in the country’s 11 official languages on how to protect oneself and minimise personal risk of contracting covid-19. This is the first time that I have witnessed visible and concerted all of government collaboration on a public health issue since the dawn of democracy in April 1994.
The first case of covid-19 in South Africa was diagnosed on 5 March 2020. As of the 17 April, a total of 2,605 cases have been diagnosed with 48 deaths. Seven patients are listed as serious-critical and 903 patients have recovered. The number of tests conducted is 95, 060.  In recent days there has been a jump in mortalities. Initially we were seeing 1-2 deaths per 2-3 days. On one day last week 7 people died. We are now reporting 14 deaths in less than 72 hours.
South Africa currently has the highest number of covid-19 cases on the African continent. One cannot help but wonder if the current official numbers are a true reflection of the scale of the pandemic in South Africa. Health Minister Zwelini Mkhize is also concerned. He has ruefully warned that “[w]hat we may currently be experiencing is the calm before a heavy and devastating storm.”
The bulk of the first cases were people returning from international trips to Europe and the United States or their traceable contacts, with a few cases of local transmissions. However, the slow but growing numbers of local infections are of concern because the patients are from poorer and high density neighbourhoods. This new wave of infections will be aggravated by the existing high burden of communicable diseases like HIV/AIDS and tuberculosis, the rapidly growing burden burden of non-communicable diseases, a suboptimal public health system and gnawing in-country health and wealth disparities.
The country has the biggest HIV epidemic in the world. It is estimated that 7 700 000 were living with HIV in 2018.  HIV prevalence among 15-49 years was at 20,4% . The country also has a high burden of heart disease (second leading cause of death), diabetes (3,5 million living with and 5 million are pre-diabetic) and hypertension (23 million ). I am a patient living with the late effects of cancer treatments, heart failure and bipolar mood disorder and my diseases make me a member of the vulnerable people living with NCDs population. However, I am privileged to be able to pass the 21 day lockdown period in comfort—nourished and supported by family and friends and my medical team.
By contrast, I am concerned by the impacts of social determinants of health on my vulnerable compatriots with severe health conditions. More than 55 per cent of South Africans live below the upper-bound poverty line (less than R1, 227 per person, per month).  There are high levels of illiteracy resulting in high levels of health illiteracy. Studies have shown that low quality of education “acts as a poverty trap” and that people living in poverty have poorer health outcomes. [6,7] Millions of people live in informal corrugated shacks with poor sanitation and erratic running water supply. My concern for my country’s long term outcomes in this pandemic are informed by our knowledge of our strained public health system, the twinning of high burdens of communicable and non-communicable diseases, and a significant population of immune-suppressant people who are highly prone to contracting covid-19. The complex national disease patterns and social-economic factors are severe life-threatening challenges.
According to data published on 17 April 2020, 95,060 people have been tested.  The government announced last week that they will roll out community based symptom identification and on-site screening in pre-identified densely populated and underserved communities. They plan that soon 30,000 people will be screened every day. I wait with bated breath to see what the infection rates will look like. How the country ultimately copes with the pandemic will depend on urgent, bold, compassionate and non-siloed national health strategies based on equity and respect for all people, especially for the poor and other vulnerable populations.
Kwanele Asante is a health lawyer, bioethicist, and African health equity activist. She is living with 3 NCDs and a member of the WHO Civil Society Working Group on NCDs. She writes in her personal capacity.
Competing interests: None declared.
- HIV/Aids in South Africa, South African History Online
- COVID-19 Coronavirus Pandemic, Worldmeters.info website (accessed 07/04/2020)
- Heart diseases in South Africa, Heart and Stroke Foundation South Africa website
- Burden of NCDs in South Africa National Health Department (Personal correspondence)
- Statistics South Africa website
- Van der Berg et. al, Low Quality as Poverty Trap (2011), Stellenbosch Economic Working Papers No.25/2011
- Christopher Mansfield, Lloyd F Novick, Poverty and Health, NC Med J 73 (5), 366-373, 2012