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It’s 5.30am on a cold Tuesday morning in a small Eastern Cape town. It could just as well be any town, in any part of South Africa, since a line has already started forming outside the locked gates of the public clinic. The queue spills over to the opposite side of the road, where people huddle outside a closed hair salon. The clinic gates will not open for another two hours.
I’m standing alongside a mother and her child. Both are on HIV-medication and have come for a routine pill collection. The child wears school uniform, hoping to head to class after his appointment. Others in the queue are missing work, or worrying about the children they’ve left at home. Like most of those gathered here, the mother, Andisiwe, has stood in this line countless times. She knows its rules and rhythms. Some of the people around us are ‘place holders,’ sent to queue on someone else’s behalf. Andisiwe herself has sometimes asked a friend, who lives much closer to the clinic, to reserve her position in the line. The friend charges a fee of R15 for her services.
Most of those waiting here would queue again later that month for their social grant payouts. On ‘grant day’, even the clinics are emptied, as families spill into the town centre and join the long lines for the cash machines, and then for the grocery stores.
Waiting is an indelible feature of life here, and part of what it takes to survive. This is especially true for those like Andisiwe and her son, Luyanda, who will be collecting medication routinely for the rest of their lives.
When the first case of Covid-19 hit South Africa, the question on everyone’s lips was what impact the virus would have in a country with such high HIV and TB prevalence? What would happen to people like Andisiwe and Luyanda, who were wrapped up in the country’s long pre-existing history with infectious epidemics?
Based on data from the Western Cape Department of Health, we now have some answers: people with HIV are more than twice as likely to die of Covid-19 if they contract it, while the risk of death for those with active TB increases three-fold. But the more worrying finding came from a slice of the data where fewer people were looking: the effect of non-communicable diseases. At the time the study was undertaken, half of the Covid-19 deaths in the Western Cape were associated with diabetes; 20% with hypertension; and only 12% with HIV or active TB. A person’s chances of dying from Covid-19 increased fourtimes if they had diabetes, and thirteen times if their diabetes was uncontrolled.
There is a lesson in these findings – a lesson that can also be read from the country’s queues.
Queues have been central to the experience of Covid-19 lockdown as people line up for grocery stores or to receive food parcels.  But for many South Africans, queueing is nothing new. Most of South Africa’s elderly and chronically-ill will spend weeks of their year waiting in line, whether for clinics and hospitals, government grants, or month-end shopping. In a harsh irony: those most likely to die of Covid-19 are also more likely to be exposed to it while waiting in line. Here, in the country’s queues, is where social and biological vulnerabilities collide — and collude.
It now seems that fears surrounding Covid-19 are keeping some people away from clinic queues.[1] During a time in which testing and treating long-term illness is all-the-more important, routine and preventative care is being interrupted.
We simply can no longer delude ourselves by treating one ‘disease’ in isolation from another; or centring infectious illnesses over non-communicable ones.
While the Western Cape study was able to isolate the independent effect of HIV on risk of death from Covid-19; it is important to acknowledge that all the HIV-positive patients who died of Covid-19 in the Western Cape also had other underlying conditions. With the help of HIV-treatment, they had lived long enough to develop other chronic conditions, like diabetes or high blood pressure. Some research suggests that people with HIV are at greater risk of diabetes and hypertension than those without – partly because of the virus itself, and partly because of its treatment.[2] TB, too, heightens a person’s chances of developing diabetes.[3]
Vulnerabilities compound: both in our bodies and in our social environment. Already, in the Western Cape, Covid-19 hotspots are retracing lines of inequality,[4] mapping onto the neighbourhoods that are most food and income insecure, have the fewest education opportunities and are most lacking in basic services. These are the places where queues are longest.
Khayelitsha, now a Covid-19 hotspot, also has higher rates of mortality from HIV, hypertensive disease, diabetes and stroke than the rest of Cape Town.[5]
Covid-19 does not arrive to a blank canvas. Instead, it snakes through pre-existing queues, igniting sites of vulnerability. As it does, it teaches us that we cannot have a narrow, disease-specific approach to health. Sickness is systemic. And health is about the whole person, not just a single infection. In fact, the WHO definition of health points to its multi-dimensional nature, asserting that health is not just the absence of disease but a complete state of physical mental and social wellbeing.[6] While we are all looking forward to a breakthrough Covid-19 vaccine and the development of new treatments, this need not be yet another time of waiting. Instead, we can double-down our response to the country’s pre-existing disease burden, strengthening the resilience of our people, neighbourhoods and health systems and in doing so start addressing the root causes of ill health.
[1] Dr Francois Venter, as quoted by Alcorn, K. June 2020. ‘People with HIV at greater risk of Covid-19 death in South African study,’ AIDSMAP. Available at https://www.aidsmap.com/news/jun-2020/people-hiv-greater-risk-covid-19-death-south-african-study
[2] Maseko TSB, Masuku SKS (2017) The Effect of HIV and Art on the Development of Hypertension and Type 2 Diabetes Mellitus. J Diabetes Metab 8: 732. doi:10.4172/2155-6156.1000732
[3] WHO. 2016. Tuberculosis and Diabetes. Available at:Â https://www.who.int/tb/publications/diabetes_tb.pdf
[4] IOL. May 2020. ‘A look at the Western Cape Covid-19 hotspots and the province’s plan to curb infections.’ Available at: https://www.iol.co.za/news/south-africa/western-cape/a-look-at-the-western-cape-covid-19-hotspots-and-the-provinces-plan-to-curb-infections-48398963
[5] Smit et al. 2016. ‘Making unhealthy places: the build environment and non-communicable diseases in Khayelitsha, Cape Town,’ in Health & Place 39, 196-203.