South Africa mustn’t forget the public—and that includes migrants and refugees—in its public health response to COVID-19.
There’s never a good time for xenophobia. But this is an especially bad time. We shouldn’t be wasting energy reminding the South African government and all who live in South Africa of this; we really do have more pressing issues. We should be focusing on delivering an inclusive public health response to COVID-19, one that ensures we don’t leave behind any members of oft-marginalized groups, including the LGBTQI+ community, people who sell sex, residents of over-crowded and under-served informal settlements, people with disabilities, and those who are citizens of other countries. We have no time to waste; as soon as we forget the “public” in public health, and fail to remedy South Africa’s chronic xenophobia, our attempts to flatten the curve will fail.
To successfully address COVID-19, our public health programming must engage with everyone in South Africa, including refugees, asylum seekers, and migrants from elsewhere on the continent and beyond. We must use inclusive language in our messaging, and avoid the tendency of the state to refer to South African “citizens”—rather than to “all in South Africa”—in their COVID-19 communication. We must work collectively and without discrimination if we are to have any chance of slowing down the virus’s spread. This isn’t negotiable: it is a must in the context of COVID-19 if we are to support, as best we can, our already struggling public healthcare system (which, by the way, is not struggling due to the presence of foreign migrants in the country, in spite of popular opinion to the contrary).
On March 23, 2020, President Cyril Ramaphosa announced a 21 day lockdown to slow down the spread of COVID-19, starting at midnight on March 26. This example of decisive political leadership, although entwined with a plethora of difficult—if not impossible—decisions to be made about how to effectively lock-down a country associated with such high levels of entrenched inequity, is welcomed (and demonstrates the kind of political action needed to address COVID-19, something that countries such as the US and the UK could learn from). The President is fully aware of the challenges South Africa faces, acknowledging that “ (w)ithout decisive action, the number of people infected will rapidly increase from a few hundred to tens of thousands, and within a few weeks to hundreds of thousands. This is extremely dangerous for a population like ours, with a large number of people with suppressed immunity because of HIV and TB, and high levels of poverty and malnutrition.”
The day following the President’s announcement, South Africa’s number of confirmed cases of COVID-19 had increased to 554. Less than a week later, this had risen to 1187.
Although evidence suggests that people living with HIV, who are on treatment, and who are virally suppressed, are likely to face no more risk than people without HIV should they acquire COVID-19, the impacts on those who are not on treatment is unknown. But it’s expected to result in worsened outcomes. We know that only around 60 percent of people living with HIV in South Africa are on treatment, and just over 50 percent are virally suppressed. We also know that current or previous tuberculosis results in poor lung health.
We must urgently encourage all people in South Africa who do not currently know their status to test for HIV and TB and start on treatment if needed. We need to also urge all who may have stopped their treatment in the past to come back into the system. This requires the involvement of everyone: access to testing and treatment for HIV and TB must be made easily and safely available not only to South African citizens but also to all foreign migrant groups, as outlined in existing legislation. This includes refugees, asylum seekers, visitors and undocumented migrants. The National Department of Health (NDoH) needs to work closely with the Department of Home Affairs (DHA) to ensure that everyone can access the necessary healthcare services. Foreign migrants experience multiple challenges in accessing public healthcare, and often fear accessing services if they hold irregular documentation status.
We must ensure that all in South Africa know that they can safely, and without any fear of negative consequences, access testing and treatment for HIV, TB, COVID-19 and other chronic conditions as needed (we know, for example, that high blood pressure and diabetes are risk factors for poorer health outcomes associated with a COVID-19 infection). Exclusion of some members of the public from a nationwide public health response will stall attempts to slow down the spread of COVID-19. The DHA should implement a moratorium on the arrest, detention, and deportation of undocumented migrants, and a blanket extension of six months or more on all asylum seeker permits. Whilst DHA has closed Refugee Reception Offices (RROs), and they have assured asylum seekers that there will be no penalty for the expiration of their permits during the 21 day lockdown, there is no clarity no what will happen after these 21 days. Several banks have announced that they will not close the bank accounts of asylum seekers whose permits expire—a welcomed and necessary intervention. But more is needed. Strong intervention and accountability measures need to be enforced by the NDoH to hold all healthcare providers to account in their responsibility to include everyone in South Africa in our response to COVID-19. This is essential for any attempt to increase testing and contact tracing for COVID-19: foreign migrants have a long history of experiencing challenges in trying to access healthcare in South Africa, including experiencing xenophobic attitudes from frontline staff, and this must be addressed immediately.
But it’s not only about access to healthcare.
Following the announcement of a national lockdown, the Minister of Small Business Development, Khumbudzo Ntshavheni, outlined a range of economic initiatives aimed at supporting small, medium, and micro-enterprises (SSMEs) who will be negatively impacted by the lockdown. While confusion exists about the final regulations, initial criteria for SSMEs to qualify for this support included whether a business is owned by a South African citizen. But that isn’t the immediate concern for public health.
As part of her address, Minister Ntshavheni spoke of the important role that spaza shops—small independent shops selling basic goods in areas where access to food is limited—play in supporting food security in South Africa. As a result, they have been declared as an essential service that will remain open during the 21 day lockdown. Many spaza shops are owned and run by foreign nationals, some of whom employ South African citizens and large numbers of people rely on these foreign-owned spaza shops to access food. In spite of this, Minister Ntshavheni indicated that, “those spaza shops that will be opened are strictly spaza shops that are owned by South Africans managed and run by South Africans. We want to make sure that quality of food and assure quality of products is there.” Closing foreign-owned spaza shops and scaremongering about food safety standards will negatively affect South African citizens and foreign migrants alike. This is yet another example of the hypocrisy we are witnessing in the time of COVID-19; in spite of confusion and requests for clarity about the justification for this regulation, the first day of lockdown saw the use of force by the police to shut down foreign-owned spaza shops.
A week ago, the President emphasized that, “I want to make it clear that we expect all South Africans to act in the interest of the South African nation and not in their own selfish interests.” Such a call to action applies to all government ministers, to all public health interventions, and to all associated economic mitigation strategies. We have no time for xenophobia and certainly no time for discriminatory policy that threatens the effectiveness of the national response to COVID-19. Through political leadership and evidence-informed public health programming, this can be overcome. Whether Minister Ntshavheni retracts her proposed closure of foreign-owned spaza shops or not is almost irrelevant: the damage is already done. A government representative, in this moment of crisis, has suggested—with no evidence—that spaza shops run by foreign nationals are dangerous to our health. She has effectively played into the prevalent anti-foreigner and xenophobic sentiments that plague South Africa, at a moment when tensions are high and community frustrations can easily manifest as targeted violence toward foreign nationals. Her plan to close foreign-owned spaza shops will negatively affect the health of South African citizens and of everyone in South Africa. It’s not foreign-owned spaza shops that are a risk to our health; it’s xenophobia.