Why South Africa’s coronavirus outbreak could be a ‘catalyst for transformation’

CAPE TOWN, SOUTH AFRICAThe three-point line and bleachers are the first signs that Khayelitsha Field Hospital is atypical. Once a community sports hall, there are now roughly 60 hospital beds lining center court. Jerseys have been swapped for face masks, visors, and green scrubs, which the medical staff wear to tend to COVID-19 patients.

The hospital sits in a sprawling patchwork of shacks and low houses on the outskirts of South Africa’s second-largest city. Here, dense living conditions and poor sanitation make handwashing and social distancing difficult. Subsistence incomes mean the lockdown takes an immediate toll on livelihoods.

This is especially true in the community of Khayelitsha, a coronavirus hotspot that also has the highest prevalence of tuberculosis (TB) in the Cape Town metropolitan area; in 2015, one-third of its pregnant mothers were HIV positive.

“The people who were struggling before are now doubly at risk,” says Claire Keene, Khayelitsha medical coordinator for Doctors Without Borders (MSF), which runs the field hospital in partnership with local health authorities.

South Africa’s COVID-19 epidemic has bucked some of the trends seen in other nations. Locking down early, just three weeks after the first case was confirmed on March 5, seems to have spared the country the rapid exponential rise seen in Italy and Spain. But the country has been unable to stop the spread, as South Korea and New Zealand managed to. Disease models predict that COVID-19 will claim between 40,000 and 48,000 South African lives by the end of this year. (Here’s how to measure your nation’s response to coronavirus.)

Now, as the country eases restrictions, which will allow its cash-strapped citizens to earn a living, South Africa is bracing for a wave of infections. Health-care networks designed to fight the world’s most devastating co-epidemic—HIV and TB—are being subsumed into the COVID-19 response. The government has deployed more than 28,000 community health workers to screen for the coronavirus in poor areas, and teams once established to trace the contacts of TB patients have pivoted to handling this year’s pandemic.

Yet many fear that shifting these resources could undo some of the hard-won progress made against HIV and TB. National data show that during the lockdown, the number of TB tests conducted was cut in half, as people couldn’t visit clinics, or didn’t want to for fear they might catch the coronavirus. According to many health workers, the lockdown saw a drop in patients accessing their TB and HIV therapies, and a large nationwide survey conducted by the country’s Human Sciences Research Council found that 13 percent of patients have struggled to access regular medication during the COVID-19 lockdown.

“It’s going to take us years to recover what we’ve lost in the past few months,” says Gavin Churchyard, CEO of the Aurum Institute, a Johannesburg-based research and health nonprofit.

Intersecting epidemics

The Khayelitsha Field Hospital is one of several temporary facilities established to house COVID-19 patients in Cape Town, which—with two-thirds of the country’s more than 50,000 coronavirus cases—is the current epicenter of South Africa’s epidemic. The field hospitals in Cape Town collectively plan to add 1,400 beds by the end of this month—but projections show the city could still run out of beds when the peak hits in July.

Khayelitsha residents face myriad challenges, from food and job insecurity to gender-based violence and drug abuse. Whereas any of these challenges could tip somebody into poverty or cause them to drop out of long-term HIV or TB care, COVID-19 “will make all those things worse,” Keene says.

Another challenge is the stigma that comes with a COVID-19 diagnosis. When the first coronavirus patients were detected in South Africa in March, many of Khayelitsha’s half-million residents didn’t worry about a disease that in their view affected only rich travelers. When the virus arrived in the informal settlements, those testing positive were shunned, and now people are scared, says Nompumelelo Zokufa, a patient support manager with MSF. “They are afraid that they will test positive and that they will be stigmatized, or that they won’t get well,” she says.

Nobody knows how the new coronavirus will behave in places like Khayelitsha. For the most part, the patterns of who dies from COVID-19 in South Africa mirror those seen in other parts of the world: the elderly fare poorly, as do people with underlying conditions, like diabetes. But little is known about how HIV, TB, and COVID-19 will interact. This makes Khayelitsha, and other communities like it, important hubs for better understanding this trio of pandemics.

On June 9, Cape Town’s regional government published its first data on the underlying causes influencing coronavirus deaths. It showed that people living with HIV or active TB were more than twice as likely to die from COVID-19 than people living without those conditions. COVID-19 mortalities were more likely to have diabetes, high blood pressure, or kidney disease—trends similar to those seen in China and the United States. But many questions remain, including why patients taking HIV antiretrovirals were as likely to die as HIV-positive people who weren’t on such medications, an outcome that runs counter to what scientists expected.

MSF has started experimenting with combining TB and COVID-19 screening at some of its locations in South Africa. By offering HIV self-administered tests at COVID-19 screening sites, the organization hopes to reach people who would otherwise be missed by their standard HIV programs.

As the county’s coronavirus battle heats up, these well-intentioned plans could end up taking a back seat. South Africa’s COVID-19 response is already showing strain. The country’s public laboratories have struggled to keep up with testing demand, and as of early June there was a backlog of 100,000 tests nationwide. Patients were waiting up to two weeks for results, a delay that has severely constrained the country’s ability to stay ahead of the epidemic by tracing and testing contacts of known cases, which are doubling every 13 days.

“If you aren’t getting the tests back on the same day, nothing else that you do will matter much,” says Churchyard in Johannesburg. “We clearly dampened the increase, but we couldn’t reverse it.”

A silver lining?

The most vulnerable places may offer the best opportunities to study COVID-19 in South Africa and to find comprehensive solutions. For two decades, researchers from Durban have gathered health data from residents of the rural uMkhanyakude District, on South Africa’s East Coast. In the 18 months leading up to the COVID-19 outbreak, they went further, gathering an unprecedented range of health data, including chest x-rays and biological samples from more than 17,000 residents.

If COVID-19 reaches uMkhanyakude, this research project could be poised to tease out genetic drivers of illnesses and show how infectious diseases like TB and COVID-19 interact with non-communicable conditions such as diabetes, says Emily Wong from Africa Health Research Institute (AHRI), one the scientists who leads the effort. But she hopes this opportunity won’t be realized.

South Africa’s rural health-care capacity lags far behind that of its metropolitan areas, where most COVID-19 infections have thus far been recorded. A lack of hospital resources, combined with the fact that elderly people head many rural households, means “it’s going to be a true public health disaster if COVID-19 gets there,” Wong says.

But the coronavirus pandemic could bring a silver lining to TB and HIV patients. Before the outbreak, many would spend a day each month at the clinic in long lines to collect their medicines. But these bottlenecks are finally being addressed because COVID-19 transmission in hospitals is a growing concern.

Several months’ worth of drugs are now dispersed in single visits, and patients can opt for home delivery or to collect their medications from vending machines. In this way, the pandemic is driving a much-needed move toward patient-centered health care in South Africa’s public hospitals, says Regina Osih, an HIV and TB expert at the Aurum Institute in Johannesburg.

For years, South Africa’s public health-care sector has tried to integrate its relatively well-resourced but stand-alone HIV and TB programs with its under-resourced general health services. The coronavirus crisis could be a catalyst for this transformation, Wong says. “We see the COVID response as a chance to accelerate that.”