with HIV in 2020. HIV prevalence is estimated 13% of total population, and 19% in age range . [1] Tuberculosis is the leading overall cause of death, followed by diabetes mellitus (leading for females) [6] .
Although it is a higher-middle income country, South African society stands out as one of the most unequal in the world [7] . In 2017 it was estimated that around 30.5 million people (55% of the population) lived below the Upper Bound Poverty Line [8] . The economy contracted two consecutive quarters in the last half of 2019 [9] and unemployment in the last quarter of 2019 was 29% (26% among males, 31% among females) [10] . The informal sector accounts for slightly over one third of the workforce [10] . The country is food secure at a national level but not at the household level, with individual and household food security relying predominately upon income [11] .
Prior to COVID-19, South Africa had 7200 critical care beds, 3500 intensive care beds, and 2700 high care beds, out of a total of 100,000 hospital beds overall, with 75% occupancy [12] . However, provincial differences exist [13] . South Africa has a public healthcare system aiming at universal coverage but in practice there are significant challenges meeting demand and individuals who can afford private health insurance commonly do, with larger employers (such as the authors") commonly making this mandatory. million people (roughly 30% of the population) rely on social grants [17] and thus need to travel and queue to receive these grants, and non-grant relief measures (e.g.
food parcels) also commonly involve queuing.
These factors may explain the apparent unresponsiveness of the epidemic to the lockdown regulations. Contrary to widespread political and popular views, no changes in the shape of the curve can be attributed to the introduction or easing of any regulation at this stage.
The first change in trajectory (viewed on a logarithmic scale) was a sharp easing off that took place at the time lockdown was introduced, and cannot therefore be attributed to lockdown, although it could potentially be attributed to the initial measures introduced on 15 March (we do not say that it is attributable, only that this is a theoretical possibility).
The second change is a gradual easing in the later part of July, well into Alert It was and remains far from clear what difference the lockdown made to the preparedness of the healthcare system: as noted above, data is simply not available.
The hospitals were in fact overwhelmed [19] , but then the tide turned anyway. It is simply impossible to tell at present what difference if any was made either by the regulations that were put in place or by diversions of resources within or to the healthcare system. Testing is perhaps the strongest point of the healthcare response, but even here, over half of the four million tests conducted have been private [14] .
The substantial stimulus package has also fallen short in its initial implementation, with food parcels being diverted by corrupt local government officials [20] , and system failures making the collection of grants difficult even months after their introduction [21] . There was also some backpedaling in respect of certain grants, notably the top-up to the Child Support Grant being adjusted to apply per caregiver and not per child. These failings have obvious potential for health impact.
The indirect health impact of COVID-19 is so far hard to assess. Despite efforts, we have been unsuccessful in obtaining causes of death data from the South African authorities. There are anecdotes from frontline medical workers of an increase in malnutrition cases but without the cooperation of the state, analysis is difficult; and senior scientists have been attacked by politicians for expressing views about indirect