Death rates double in poor areas

Covid-19 is killing twice as many people in poor communities than elsewhere.

Statistics from Cape Town showing mortality rates of more than 5% in the poorest areas are likely to be replicated nationwide, public health experts said this week.

They said poorer people are at heightened risk of dying from Covid-19 due to their relatively high burden of disease, socioeconomic status and limited access to critical care.

Their comments came after the Christmas and New Year weeks produced successive all-time records for deaths in SA as the second wave - driven by a highly contagious new Covid variant - surges through the country. Deaths officially attributed to the virus have continued to accelerate rapidly since the new records were set.

Health minister Zweli Mkhize told the Sunday Times this week that when Covid-19 arrived, a "huge concern" was how it would affect communities with a high burden of disease and poor access to health services. 

"Where you have poor nutrition, unemployment, congestion, the conditions for spread of the virus are much faster and the resistance of individuals due to poor immunity is much worse. Therefore that combination becomes a toxic concoction," he said.

University of Cape Town public health specialist professor Leslie London said higher mortality in poorer areas could be linked to testing constraints that delayed diagnosis and treatment.

"There is also less access to critical care and ICU beds in the public sector as these are extremely scarce resources," he said.

Epidemiologist professor Taryn Young, head of global health at Stellenbosch University, said comorbidities were to blame for high mortality linked to disadvantaged communities.

However, wider access to Covid-19 testing in the private sector could give a flawed impression that mortality in richer communities was low. "Better access to private testing in more affluent areas will result in more cases being detected in those areas and this will also drive down the mortality rate in those areas," she said.

Detailed daily statistical updates from the Western Cape government mean it is easy to assess differences in mortality and infection rates in Cape Town's eight health sub-districts.

Klipfontein, which includes densely populated townships such as Gugulethu, Nyanga and Delft, has a mortality rate of 5.55%, and Khayelitsha's rate is 5.05%.

By contrast, the northern sub-district, which includes Durbanville, Brackenfell and Kraaifontein, has a mortality rate of 2.37%. The national mortality rate is 2.78%.

Western Cape health spokesperson Mark van der Heever said the high burden of disease in poorer areas contributed to the severity of illness. "Areas which have a higher number of people with comorbidities will in turn have higher numbers of deaths should these vulnerable persons become infected," he said.

London said that in poorer areas, "even if the prevalence of diabetes is similar to richer areas, it is more likely that people have had long-standing and poorly controlled diabetes, placing them at increased risk of poor Covid-19 outcomes. HIV and tuberculosis also increase the risk of Covid-19 death, although modestly, and these are more prevalent in poorer areas."

Poorer areas' lower infection rates but higher mortality could be because people in wealthier suburbs had relatively easy access to Covid-19 testing in the private sector, he added.

Young said Covid-19 has exposed disparities in society, particularly in people's ability to protect themselves from the spread of the disease. Authorities should use the pandemic to address the social determinants of health by adjusting guidelines and policies.

Damaris Kiewiets, chair of the Cape Metropolitan Health Forum, said the diversion of resources to fight Covid-19 has left other health services in limbo. "The suspension of routine checkups and screening means that many who are at high risk of Covid-19 complications can't have their health condition in check," she said.

"As a result, many patients have uncontrolled chronic illnesses, including diabetes, hypertension and cardiovascular diseases.

"All the department of health has been doing is to simply refill their chronic meds. There are no doctors to do screening and routine checkups. My own mother, who is a heart patient and is 90 years old, hasn't had an ECG screening that she gets every six months for almost a year now."

"When such patients get Covid-19 they often don't know their health status and if their disease is uncontrolled they are likely to die as their prognosis will be poor and won't be prioritised to get an ICU bed."

Kiewiets said the pressure on hospitals and clinics meant some patients were told to go home and take flu medication. "I've had frantic calls from people who said they had Covid-19 symptoms and were simply brushed off at clinics, only to test positive later. By that time they have infected everyone in their families."

Western Cape head of health Dr Keith Cloete said screening surveys on pregnant women and HIV patients had shown that people in different parts of the metro had different rates of exposure. This was evident in Khayelitsha, where the peak of the second wave was almost half of the first wave, and in Klipfontein, where the peak has just surpassed that of the first wave.

"In the second wave we are seeing a flatter peak in those two areas. We are making a hypothesis that there was some inherent herd immunity in those two areas because of high levels of infection from the first wave.

"Our scientists will look at this. We'll look at the data and then confirm that hypothesis if this is the case."

Dr Shakira Choonara, an independent public health practitioner in Johannesburg, said while comorbidities, age and the strain on health services were likely to be important in determining mortality rates, "researchers/scientists are still attempting to understand why some areas have higher infections and mortality compared to others".

She said so far there is "no clear-cut answer", although there is increasing debate around whether some areas are developing herd immunity, and other factors could include lower testing or poor recording of deaths.

Choonara said official mortality statistics were subject to numerous limitations, and the South African Medical Research Council's (SAMRC's) weekly reports on "excess deaths" during the pandemic had made clear that a significant proportion were likely to be attributable to Covid-19.

By January 5 - the latest date for which SAMRC data is available - there had been 83,918 excess deaths since May 6, when the phenomenon was first observed. By Friday, the official Covid-19 death toll was 36,467.

Choonara said: "Mortality is a highly complex phenomenon and Covid-19 trends will be impacted by factors such as age, comorbidities and access to health services."

Professor Mosa Moshabela, dean of the school of nursing and public health at the University of KwaZulu-Natal, said the crux of the issue was the global phenomenon of "inverse care law".

"This law means that the people who need health care the most are unlikely to access it, and the ones who need it less are likely to access it more," he said.

"So you may find that someone with milder symptoms in an affluent community is far more likely to get easier access to services than someone who is extremely sick in a poorer area.

"We need to make sure that when we do the evaluation of the impact of Covid-19 we are able to access it from a socioeconomic status. Socioeconomic status is more important for me than race because you can do something about socioeconomic status in the short term."

Covid-19 ministerial advisory committee co-chair professor Salim Abdool Karim said Covid-19 mortality rates are influenced by age more than race. There are fewer known cases in the poorer communities because infected individuals are asymptomatic more often due to the younger profile of the population.

Howard Phillips, an emeritus professor of history at UCT and an author of books about previous pandemics, said the poor are always more vulnerable to epidemics due to their socioeconomic circumstances and poor immune systems.

"On the face of it, pre-existing disparities in health, living conditions and access to health care would seem to lie at the root of the difference in mortality, which this pandemic, like others before it, has exacerbated and highlighted," he said.

"Germs driving epidemics search out weaknesses in the societies which they strike and exploit them to the full in their quest to reproduce themselves as quickly as possible.

"They thus affect the most susceptible in communities hardest, those whose constitutions have been compromised by poor health and nutrition, unsanitary and overcrowded living, and those lacking easy access to good medical care at home.

"In doing so they usually worsen these deficiencies, putting those whom they attack at increased risk of death. For these reasons the chief victims of epidemics are the poor."

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