‘I Think of It in Terms of Years’: The Future of the COVID-19 Pandemic in South Africa

By Chloe Reichel

“No One Is Safe Until Everyone Is Safe” goes the rallying cry for global vaccine equity.

We would think that the COVID-19 pandemic already has made this point clear enough.

And yet, pundits are heralding the “end” of the pandemic in the U.S., all while viral variants that may be capable of evading the protection of vaccines continue to crop up both domestically and internationally.

In this Q&A, South African journalist and human rights activist Mark Heywood offers a look at the national COVID-19 epidemic in South Africa. The sobering reality there, in terms of morbidity and mortality, and in terms of expectations for the future, underscores the urgency for globally coordinated leadership and action to address the pandemic.

Our conversation from late March 2021, which has been edited and condensed, follows.

Chloe Reichel: The pandemic has been devastating in South Africa. Elsewhere you’ve mentioned that the official COVID statistics versus excess mortality tell very different stories. So could you give me a sense, to the best of your ability, of a truer picture of things, in terms of infections and mortality?

Mark Heywood: In terms of infections, the official record of infections obviously has been based upon positive COVID-19 tests. You have to take into account that, as with many countries, there is limited access to COVID-19 testing (for example, people who live in rural areas, or who don’t access health care services because they are “illegal” immigrants), and there is a limited capacity to test.

To date in South Africa, just over ten million tests have been conducted.

So, official statistics of the number of COVID-19 infections are now over 1.5 million. But unofficially, an academic at Wits University, professor Alex van den Heever, suggests that there could have been as many as 20 million infections; he bases his calculations not upon national prevalence surveys, but on the Medical Research Council’s excess deaths record and several district-based seroprevalence surveys.

20 million is probably an exaggeration, but there’s agreement among most leading infectious disease scientists in South Africa that the figures are probably five to ten times the official numbers, and that obviously also plays out in deaths.

The official number of COVID-19 deaths is just over 53,000, but our Medical Research Council, which collates all certificates on death in the country, has measured “excess mortality,” i.e., all deaths above the average before COVID-19, and it has shown the excess mortality, since May 2020, has just passed 150,000 excess deaths.

Most of those deaths will be COVID deaths. The deaths that are not COVID deaths are COVID-related, insofar as the lockdown caused a fracturing of health care systems, and therefore, there has been an increase in tuberculosis-related mortality, HIV-related mortality, I would imagine an increase in infant mortality, malnutrition, and so on. So it is very, very serious.

Maverick Citizen has just done an investigation of the impact of COVID-19 in one of our nine provinces, the Eastern Cape, which has been the worst-affected province. In some parts of the Eastern Cape, the case fatality rate has been 12%, which means that if the Eastern Cape was a country, it would be the worst affected country in the world. And the Eastern Cape has a population of about seven million people.

Apart from the numbers, it’s also important to understand that most of the people who have died, as in the United States, are people who are poor. Many people have died preventable deaths, because they were admitted into hospitals that did not have ventilators or oxygen, and therefore died within a hospital setting. They would not have died if they had been able to access quality and appropriate care.

And many of the deaths are of essential workers. I’ve seen one figure that 2,000 teachers have died. Many health care workers have died, including many very experienced healthcare workers who were based in teaching hospitals and universities. So, the ramifications of this very high mortality rate, and its implications for human rights and health care services going forward, are also very high.

CR: Do you have a sense of how things got to the point where they are?

MH: One, is that the lockdown, I believe, was profoundly mistaken in the way it was executed.

We should have learned lessons much earlier that the lockdown was not succeeding in preventing infections. What it was succeeding in doing was disrupting society and making it even more difficult to prevent infections. So if people were not getting food, and suddenly were dependent on grants, then they would be queuing for food parcels, queuing for the grants when they came out.

I think historically, when the world looks back, we’ll realize that one of the problems was that coercive measures were adopted, rather than reaching contracts with people and communities, where people were helped to understand, and to change behaviors that created a risk of COVID transmission.

Less coercion doesn’t mean that there would have been no restrictions or criminal penalties. But I believe you could have reached contracts with people. It would have cost a lot of money. But it would have cost a lot less money than has been lost due to the economic devastation, to invest in communities, to invest in effective communication. I think that is one of the factors.

And then the second thing is just the socio-economic circumstances. People living in overcrowded informal settlements, people living in overcrowded flats and buildings, have very little possibility of practicing social distancing and protecting themselves and protecting others.

And the third thing I would say is, we pay the price of underinvestment in public health for a decade; because the health system just wasn’t able to cope when the first and the second wave of COVID-19 came.

CR: How has the vaccine rollout been so far?

MH: It’s been a big problem.

At this point, 290,000 health care workers have been vaccinated with the Johnson & Johnson vaccine, and that has now been halted because of concerns about blood clots and following the decision of the U.S. FDA. Scientists have criticized this decision, and our regulator, the South Africa Health Products Regulatory Authority (SAHPRA), has just recommended resuming vaccinations. But currently, no one is being vaccinated. Nobody in the population as a whole (i.e., other than health care workers) has been vaccinated. The date for the start of a vaccination program is now meant to be in May, although registration of people over the age of 60 commenced on April 16th.

There are two issues really implicated here.

One is government failure to plan early for vaccines, but the second is the issue of vaccine apartheid and vaccine nationalism, and the untrammeled power of a handful of pharmaceutical companies that have developed vaccines. They’re holding governments to ransom for their excessive pricing.

They are imposing rules on governments. In this country, Johnson & Johnson has made a condition instructing the government to legislate the creation of a no-fault vaccine injury compensation scheme, and to fund that. Now, this isn’t a decision that has come from the executive, or from the legislature. The decision has been imposed on the country, by a pharmaceutical company, basically saying, “If you don’t do this, we will not sign the contract to supply you with vaccines.” And that is a hindrance, and that is slowing things down. And leaving us very, very prone to this epidemic.

There will also be other issues, there’s a lot of vaccine hesitancy, there’s a serious problem of vaccine misinformation. And then there will be the challenges that we face implementing mass vaccination within a broken and unequal healthcare system. So vaccine roll-out will be the next major challenge.

CR: What timescale do you think about the pandemic in?

MH: I think of it in terms of years. South African scientists, epidemiologists are thinking of it in terms of years.

The vaccine rollout is not going to get to a point where there’s sufficient numbers to create population immunity for at least a year. So that’s why we have to think in terms of years.

The unknown is, we don’t know how many people have actually been infected, we don’t know to what extent there may be parts of our country where there’s been such a high level of infection already, that it will influence the shape of future waves of infection.

And I think what we’re going to face as an issue going forward is the way in which COVID becomes much more interwoven with concurrent epidemics that it has allowed to accelerate again — HIV, tuberculosis, diseases of malnutrition, and so on. I think they will all manifest themselves more strongly as we go forward, as it appears that we’re under control, as people become more complacent. The things that have been hidden will become more visible.

CR: What do you think we could reasonably expect as a course correction going forward in South Africa, knowing how the government has responded over the past year and having a sense of what they may, or may not, be capable of?

MH: Well, the first thing is, will there be a course correction? I am not optimistic. I think we are going to see further use of lockdowns.

As we deal with further waves of epidemic, we could reasonably expect a greatly accelerated vaccine rollout plan, and much more exercise of the power of government and the state to obtain vaccines and to use them. There are barriers that are all capable of being overcome with sufficient political will, resources and vaccines. If by June 2021, we had vaccinated 10 million people, instead of probably by June 2021 having vaccinated (if we’re lucky), one and a half million people, that would clearly begin to make a difference in a whole number of ways.

The other course correction would be to invest money in socio-economic rights that will reduce vulnerability to COVID-19 — health care, food, water, better education — accepting that there is a legal, constitutional obligation to do so. And seeding economic recovery through human rights investment, that would have the benefits of assisting COVID-19 prevention and care.

But South Africa is not going that way. We are very stupidly, still committed to fiscal consolidation and austerity. Health budgets are being cut in the middle of an epidemic, and all of that will just make things probably worse than they are at the moment.

I expect to see political instability, social instability. I expect to see that some of the things like levels of hunger and unemployment, which have been kept out of sight up to now, will become more visible. So, I’m not very optimistic at this moment in time, although civil society organizations like the Treatment Action Campaign (TAC), SECTION27 and the C-19 People’s Coalition are doing their best to get changes by insisting that a holistic approach to human rights should drive the way we respond.

For further reading, see “One Year Later: COVID-19, Human Rights, and the Rule of Law in South Africa,” an update on how human rights and the rule of law have been affected by the COVID-19 pandemic in South Africa. To follow the COVID-19 epidemic as it unfolds in South Africa, read regular reports in Maverick Citizen.


Chloe Reichel

Chloe Reichel is the Petrie-Flom Center’s Communications Manager. She serves as Editor-in-Chief of the Bill of Health blog and leads the Center's broader communications efforts.

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