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South African National Defence Force military health practitioners stand on guard at Air Force Station Port Elizabeth on July 5, 2020.

MICHAEL SHEEHAN/AFP/Getty Images

When the coronavirus arrived in South Africa, it was an illness of the affluent. The first recorded COVID-19 case, the country’s patient zero, was a 38-year-old businessman from a wealthy rural town who had been on a skiing holiday in northern Italy. He quickly recovered.

All of South Africa’s earliest cases were travellers returning from Europe. Tourists in Johannesburg were heckled with “corona, corona” chants from angry locals who saw them as the source. Even today, people speak scathingly of the “Italy 10” – the skiing group that was blamed for importing the virus.

But four months after those early tourist cases, the virus has become a devastating disease of inequality and poverty. It has ripped through South Africa’s poorest and most vulnerable communities, killing thousands of people from the crowded streets and shacks where people cannot afford to distance.

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The destruction has been catastrophic. The virus is spreading so rapidly here that South Africa has become the world’s fourth-largest source of new daily cases, behind only Brazil, India and the United States, despite its far smaller population. With a total of nearly 200,000 confirmed cases, it has surpassed France for the 16th-most cases in the world.

A health worker enters an ambulance outside the COVID-19 field hospital created in the International Convention Centre in Cape Town, South Africa, Monday, June 29. South Africa's hospitals are bracing for an onslaught of patients, setting up temporary wards and hoping advances in treatment will help the country's health facilities from becoming overwhelmed.

Nardus Engelbrecht/The Associated Press

Hospitals in Cape Town and Johannesburg have been pushed to their limits, overwhelmed with COVID-19 cases. In the biggest cities, and even in the smaller towns of Eastern Cape, the health system is under such severe strain that patients are often diverted to temporary field hospitals in convention centres and factories, while military doctors have been called in to help. At one hospital, oxygen supplies ran so short that patients were reportedly fighting each other for oxygen.

The official death count has nearly reached 3,200. But a study of excess deaths has suggested that the real number in some regions of the country could be twice as high. In parts of Cape Town, death rates have reached wartime levels.

Studies worldwide have found that the virus is taking its heaviest toll among the poorest communities, including ethnic minorities, immigrants, marginalized groups and blue-collar workers. But South Africa might be the most extreme example of this phenomenon – especially in its first COVID-19 epicentre, the province of Western Cape, home to the tourist mecca of Cape Town, where income inequality is drastic and growing.

“It’s definitely following all the fault lines of inequality in the province,” said Helen Schneider, professor of public health at the University of the Western Cape.

“The spread of the virus is definitely tracking where social distancing is much more difficult,” she told The Globe and Mail. “Population density is the big factor. All the nodes of highest poverty are affected.”

A man walks beneath a COVID-19 sign advising precautions people should take to prevent the spread of coronavirus in Cape Town, South Africa, Monday, June 29. South Africa's hospitals are setting up temporary wards and hoping advances in treatment will help the country’s health facilities from becoming overwhelmed.

Nardus Engelbrecht/The Associated Press

South Africa, according to World Bank data, is the world’s most unequal country, still badly divided by the apartheid-era gap between rich and poor. The virus has exploited this inequality to tear through the townships and inner cities, where it is almost impossible for many people to distance themselves or self-isolate.

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In Cape Town, the virus was seeded early by tourists and travellers who had been in Europe in February and March when the disease was circulating largely undetected. But the virus spread rapidly when it reached the poorest suburbs, despite an early lockdown that helped suppress its trajectory.

“It has definitely gravitated towards the parts of the city that are more densely populated and more vulnerable,” Prof. Schneider said.

“This is a disease of inequality. When you’re living among gang warfare and you’re facing insecurity and poverty, you’re not necessarily going to put social distancing high on your list of priorities.”

Western Cape recorded its first case of the virus on March 11, in a traveller who returned from Europe. For the first two weeks, the virus was primarily in middle-class areas such as the Garden Route and the Cape Winelands. But on March 29, the first cases were reported in two of Cape Town’s low-income, high-density communities: Khayelitsha and Klipfontein. The virus began rapidly increasing there and in similar neighbourhoods.

An elderly woman reacts as a heath worker collects a sample to test for COVID-19 in Katlehong, Johannesburg. South Africa's reported coronavirus cases are surging.

Themba Hadebe/The Associated Press

Today, the province’s highest death rates from the virus are in are in those same two communities. The relief agency Médecins sans frontières (Doctors Without Borders) built a 60-bed field hospital for coronavirus patients in Khayelitsha to relieve the pressure on the health system, but almost all of the beds were rapidly filled within a few weeks of its opening.

Khayelitsha, with a population of about 500,000, suffers from high unemployment and poor housing, with more than half of its people living in shacks without running water. It also has among the highest rates of HIV, tuberculosis, hypertension and diabetes in Cape Town.

“Communities that are really disadvantaged for various reasons are the most heavily impacted by the epidemic,” said Andrew Boulle, an epidemiologist at the University of Cape Town.

“Poorer areas are more heavily hit – that’s definitely a tragedy of COVID-19 in lower- and middle-income countries.”

Western Cape is now seeing death rates that are normally seen only in epidemics or times of war, Prof. Boulle said. “The last time we saw this in South Africa was at the height of the AIDS epidemic, prior to widespread availability of treatment,” he told a provincial media briefing.

A man wearing a face mask to protect against coronavirus, walks past a hair product billboard on the street in Soweto, South Africa, Monday, June 29.

Themba Hadebe/The Associated Press

“If the Western Cape were a country, at this point of time globally, we might be one of the countries with the highest daily mortality rates in the world. We are currently at about 70 deaths a day, and that could double by early August.”

After two months in which Western Cape was the epicentre, the virus is now spreading quickly in Eastern Cape and Johannesburg, where again the poorest and highest-density neighbourhoods are the hardest-hit.

Those communities have a deadly combination of factors against them. They are overcrowded and badly lacking in access to health care, water and sanitation. They also tend to have high rates of diabetes, hypertension, HIV and tuberculosis – the comorbidities that tend to be associated with the virus. Often their people have poor access to the medicine that can control HIV or diabetes, leaving them more vulnerable. And when they test positive, it is difficult to self-isolate in crowded homes.

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Because of the lingering spatial geography of apartheid, most poor South Africans live in formerly segregated communities, far from their workplaces. Their daily transportation is on crowded minibuses, where the risk of catching the virus is high.

Most of the country’s worst COVID-19 outbreaks have been recorded among ordinary workers whose workplaces are frequently crowded: underground mineworkers, hospital nurses, school teachers, bus drivers, factory workers, call-centre staff, prison guards, supermarket clerks and police-station employees.

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