Context: introducing South Africa’s response to COVID-19

3 months into the SARS-CoV-2 outbreak and a week before the WHO declared a global pandemic, South Africa confirmed its first COVID-19 case on 5 March 2020. The time lag between the identification of SARS-CoV-2 and its confirmed arrival in South Africa gave the national Department of Health (DoH) and the National Institute for Communicable Diseases time to garner insight, advice and expertise based on other countries’ responses and experiences.

Following guidance from the WHO and the local scientific and healthcare community, the government pursued an interventionist rapid response to facilitate ‘flattening the curve’ through PHSM directives (Arndt et al 2020; Stevenson et al 2020; Stiegler and Bouchard 2020; World Health Organization (WHO) 2020b). Through an extended 5-week national lockdown, introduced on 27 March 2020, these (PHSMs) aimed to minimise transmission while providing the health system time to bolster services and prepare for the surge of cases expected later in the year/s (Gilbert et al 2020). South Africa’s PHSM strategy included: international travel controls, restrictions on internal movement and the closure of public transportation; the cancelling of public events and restrictions on gatherings, workplace and school closures; and stay-at-home/shelter-in-place restrictions (Salyer et al 2021). These accompanied typical behavioural adaptations such as physical distancing, mask-wearing, regular handwashing, self-quarantine and isolation when needed. A wide range of policy was also introduced to mitigate the lockdown’s economic and social impact (Arndt et al 2020).

The COVID-19 Risk Adjusted Strategy guided the national response from lockdown to the lifting of restrictions, throughout 2020 and 2021.(South African Government 2020) By mid-2022, South Africa had experienced four successive COVID-19 waves (Jassat et al 2022).4 For most, the impact of the pandemic became synonymous with increased socioeconomic hardship and struggle. With pre-existing extreme income inequality and high rates of both youth and generalised unemployment and poverty, the COVID-19 interventions revealed a significant underestimation of the scale and scope of need as well as the consequences of the cumulative pandemic/lockdown effects (United Nations Development Programme (UNDP) 2020).

In retrospect, the State-directed PHSMs used universal COVID-19 prescriptions without significantly drawing on contextual considerations including the vast local expertise garnered through decades of responding to the HIV and tuberculosis epidemics (van Heusden et al 2024). This contextual misalignment reinforces Wilkinson et al’s (2020) general criticism of the applicability and efficacy of COVID-19 PHSMs in resource-constrained communities, such as periurban informal settlements (ie, townships and slums) where the most vulnerable and marginalised live. Wilkinson’s analysis shows how vulnerability to COVID-19 is structurally interwoven into poor and marginalised communities’ experiences due to their intersectional positionality. In this context, PHSMs are unlikely to be universally protective and, in fact, are more likely to impact cumulatively and negatively the poor and marginalised (see, eg, Carlitz and Makhura (2021), Francis et al (2020), De Groot and Lemanski (2021) and Team and Manderson (2020)).

COVID-19, such as other pandemics before it, exploited and exacerbated existing structural inequities. Those already at risk of adverse health outcomes because of their social and structural vulnerability experienced themselves at greater risk of COVID-19 (Bambra et al 2020; van Heusden et al 2024; Team and Manderson 2020).

One of the manifestations of how COVID-19 amplified structural vulnerability in South Africa is excess deaths. The South African Medical Research Council initially estimated the official COVID-19 deaths at only one-third of the total number of deaths during the period 2020–2021 (Bradshaw et al 2022, 4). Subsequent research has since concluded that ‘85–95% of the excess natural deaths are attributable to COVID-19’ (Moultrie et al 2021).5 The largest number of deaths occurred during the second and third waves of the pandemic (Bradshaw et al 2022, 3), during which “constraints on the healthcare system … may also have resulted in a greater number of collateral deaths” (Dorrington et al 2021, 12).

The under-reporting of the cause of death relates to deaths that occurred outside of hospitals/health facilities. As official statistics “only reflect those known to have died with a prior positive test … or who tested positive post-mortem [the data]… is therefore heavily skewed to deaths occurring in healthcare facilities (both public and private)” (Dorrington et al 2021, 12). The DoH issued a directive, during the first COVID-19 wave, that “all deaths that occur outside of health facilities should have a post-mortem swab taken to establish whether the death could have resulted from COVID-19” (Dorrington et al 2021, 14). This proved difficult to implement, and the postmortem COVID-19 test was typically not administered in the case of home deaths. The lack of access to testing resources due to global and local supply and distribution issues, lack of available personnel and sociocultural sensitivities around administration itself contributed to this (Lewins et al 2022).

The data on excess deaths provides insight into the scale of death associated with the COVID-19 pandemic in South Africa, even if not all deaths were directly caused by SARS-CoV-2. Importantly, these data allow us to take stock of the massive experience of loss that families and communities have undergone. The data urge us to understand and support bereaved communities across the diverse cultural, religious and social landscape of the country. Therefore, the consideration of bereavement in these terms provides some suggestion of current and future psychosocial, emotional, mental and spiritual needs, as grief is just one of the lasting consequences of the COVID-19 pandemic.

Our intention was to understand the experiences of bereaved communities and their grief work from a sociocultural perspective, in the context of restriction, disruption and excess death. We found experiences of multiple losses in the context of ritual incompleteness associated with the COVID-19 restrictions which led to unaccomplished grief work. We turn our attention to these restrictions to provide critical context of the specific PHSMs that governed deaths, the handling of human remains and funeral and burial processes during the COVID-19 pandemic in South Africa.

COVID-19 restrictions on the handling of human remains, funeral and burial practices

Prior to SARS-CoV-2, the South African National Health Act6 made provisions for special funeral and burial measures to be introduced in the case of deaths due to infectious disease. Ringane et al (2019, 587) list the following circumstances where this may be applied:

[v]iruses and bacteria that can spread postmortem [as] methicillin-resistant Staphylococcus aureus, hepatitis B and C viruses, severe acute respiratory syndrome-related coronavirus, prions, HIV, Mycobacterium tuberculosis and Ebola virus.

The 2014/2015 Ebola epidemic in Sierra Leone and neighbouring countries in which “the corpses of Ebola victims [were deemed] highly contagious, [and] there was considerable risk of transmission during funerals, through ritual body washing and contact between mourners” (Lipton 2018, 802) shaped collective attitudes and informed infection prevention and control (IPC) best practice within healthcare and the funeral industry in the region. As astutely noted with Ebola (Lipton 2018, 802), it is unsurprising that with COVID-19, the handling of human remains, and the funeral and burial practices have been ‘the heaviest and highest-profile arena of regulation’. Prior to COVID-19, Ringane et al (2019) found the need for increased regulation and standardisation within the funeral service industry in South Africa, which partially explains the approach taken.

The array of Environmental Health Guidelines (EHG), issued on 27 March 2020, provided direction for how to manage deaths at home and within healthcare settings during the COVID-19 pandemic. For those who died at home, family members were instructed not to ‘handle the body’; only undertakers were permitted to remove the body; and instructions for disinfecting clothing, bedding and belongings were provided (Department of Health (DoH) 2020, s3(a), (b), (c)).

For those who died at a healthcare facility, explicit directions were given for preparing and transporting the body to the mortuary/undertakers and for preparation for burial/cremation. These initial guidelines included placing the body in a body bag, mandating personal protective equipment (PPE) for those handling the remains and disinfecting or disposing of all surfaces, equipment, bedding and/or body bags (Department of Health (DoH) 2020).

As such, several EHG clauses had the potential to clash with a variety of funeral traditions across the sociocultural spectrum. African Christianity and other forms of traditional rituals encompass practices that involve physical closeness such as washing, dressing, touching or kissing the deceased’s body. The EHGs stated that:

Washing of the human remains can only be performed at the mortuary/funeral undertaker’s premises, no washing is allowed out of the mortuary/funeral undertaker’s premises (Department of Health (DoH) 2020, s2(g))

If the family wishes to dress the human remains, they may do so at the funeral undertaker’s premises before the body [is] placed in the body bag (Department of Health (DoH) 2020, s2(h)).

If the family wishes to view the body, they may do so without touching it, using standard precautions at all times including hand hygiene (Department of Health (DoH) 2020, s4(d)).

Family members should not touch or kiss the body and should wash their hands thoroughly with soap and water following the viewing; physical distancing measures should be strictly applied (at least 1 m between people) (Department of Health (DoH) 2020, s4(e)).

People who died of an infectious disease (largely assumed to be COVID-19) at this time could ‘not be conveyed in public’ unless specific conditions were met. These conditions provided medical teams and funeral businesses ultimate diagnostic and social power as they governed individual and collective burial conditions throughout the pandemic. In the context of Zimbabwean migrants in South Africa, Carrasco (2024) describes how the medicolegal response evoked homogeneity, dispossession and devaluing of the corpse which communities felt was reminiscent of coloniality.

In the early months of the pandemic, when there was concern that human remains could transmit SARS-CoV-2, a requirement for public burials was that:

such human remains [were] placed in a polythene bag, sealed in an airtight container, placed in a sturdy non-transparent sealed coffin, embalmed and/or the total surface of the body covered with a 5 cm layer of wood sawdust or other absorbent material that is treated with disinfectant (Department of Health (DoH) 2020, s(6)(a)(i)).

In addition, it was specified that no one should open the coffin, remove remains and./or come into contact with the remains without prior approval (Department of Health (DoH) 2020, s(6)(b)(iii)).

The regulations further specified the length of time bodies could be kept at facilities, the length of funeral services, who could attend funerals and how graves could be dug (Department of Health (DoH) 2020, s(7), (8), (9)) depending on the phase of the pandemic. Furthermore, additional protections7 for the elderly and those with respiratory conditions were specified.

Like much public health guidance, the South African guidelines were written in an authoritative, biomedical and legislative tone, with no acknowledgment or consideration of the varied sociocultural beliefs and practices that inform bereavement, funeral and burial processes of the diverse population. South Africa’s ‘state exceptionalism’ (Bank et al 2020) becomes evident when compared with the WHO’s guidance.

The WHO’s interim guidance, of March 2020, emphasised that ‘there is no evidence of persons having become infected from exposure to the bodies of persons who died from COVID-19’ (World Health Organization (WHO) 2020c, 1). The WHO cautioned against expediting disposal and very much emphasised the ‘dignity of the dead’ and respecting their family in mourning and, ‘their cultural and religious traditions’, while minimising chances of any potential exposure among mourners (World Health Organization (WHO) 2020d). 6 months later, further interim guidelines explicitly clarified when body bags were needed and provided more guidance regarding families’ involvement in religious and cultural funeral and burial processes (World Health Organization (WHO) 2020c).

Meanwhile, grey literature gave voice to how South Africa’s policy was being implemented. This described how bodies of people who died from COVID-19 “[were] placed in leak-proof triple body bag[s]” for burial (Smith 2021),8 biohazard stickers were stuck on coffins, funeral workers were dressed in hazmat suits, and police monitored funerals, chasing away additional mourners9 and destroying traditional alcohol (prohibited at the time) and food (Bank et al 2020). All of which were deeply disturbing to bereaved families and communities.

Bank and Madini (2021) stressed how in the Eastern Cape, the regulations on “bagging the body and delivering it directly to the grave site… created enormous spiritual anxiety and popular anger, which traditional leaders largely ignored during the first wave as they strongly supported the COVID-19 regulations”. To demonstrate the enormity of incomplete ritual and unaccomplished grief (Tafaj 2021),10 we refer to a news item of the time, of a family in the Eastern Cape who resorted to digging up the grave of their relative, who died of COVID-19, to remove the three layers of plastic from his body, after which the body was reburied. The deceased’s widow could not sleep as she was haunted by the call of her husband, suffocated by the plastic he was wrapped within (Ntlanganiso 2021).

By February 2021, the DoH relaxed its ‘evidence-based’ COVID-19 regulations to better align with the WHO’s guidelines (Ngobeni 2024) and to take cognisance of religious and cultural rights that provincial lobbyists, particularly from the Eastern and Western Cape and KwaZulu-Natal, had been actively advocating for, for some time (Ntlanganiso 2021). However, the new regulations still required that a ‘clear body bag must be used for transferring the body from the place of death to premises for further handling’ (Department of Health (DoH) 2021). Undertakers were now accorded key responsibilities to monitor and supervise families’ viewing and engagement with human remains. The amendments stated, “if the family wishes to wash and/or dress the body, they may only do so under the funeral undertaker’s supervision, before the body is placed in the body bag or shroud or blanket before placing it in a coffin” (Department of Health (DoH) 2021).

The use of PPE, although no longer hazmat suits, was still required for handling the body (Department of Health (DoH) 2021; World Health Organization (WHO) (2020a)). As above, a body bag, shroud or blanket could now be used to cover human remains for burial. Crucially, the amendments explicitly stated that “human remains and coffins may not be wrapped in plastic” (Department of Health (DoH) 2021). Additionally, biohazard stickers, as well as the sanitisation of the graves or clothes of the funeral congregation, were no longer required (Department of Health (DoH) 2021; Ngobeni 2024). While IPC concerns were still core, the funeral and bereavement began to be rehumanised.

Next, we document and discuss our participants’ experiences of familial loss and mourning. We discuss whether, to what extent, and how bereaved individuals, families and the resource-constrained communities in which they live were considered, engaged and/or cared for concerning death, funeral and burial processes and mourning experiences during the COVID-19 pandemic.

Methodology: researching COVID-19, death and mourning

The research aimed to provide an in-depth understanding of the impact of COVID-19 measures regarding the handling of human remains (including the management of deaths, funerals and burials) on bereaved communities between 2020 and 2021. We were interested in gauging the impact of the COVID-19 restrictions on the im/possibility of families and communities to accompany their loved ones by conducting funerals and burials in the way they ‘normally’ would have or would have wanted to. We explore the impact of these restrictions on bereaved families and communities, including on their mental health. We specifically focus on the lived experiences of urban black African communities that lost family member/s during the COVID-19 pandemic.

20 interviews were conducted with purposely selected participants residing in Gauteng and Free State provinces using the snowballing technique to identify those affected by loss. The sample enabled us to understand the experiences of death, funeral and burials among urban black African people, as the majority, yet a vulnerable sector of the population. The interviews took place in August and September 2021; 18 months after the first COVID-19 cases in the country. The sample consisted of adults from lower-income families who self-identified as black African and as Christian (of a range of denominations),11 and most resided in Soweto, Johannesburg.

Two research assistants conducted the interviews after receiving training in grief containment. This comprised a 1-day workshop where the issue of loss, mourning and grieving was discussed and responses to various scenarios in interviewing bereaved participants were discerned. In addition, debriefing practices were established, with the agreement that research assistants would debrief each other and the principal investigator (LNC) as needed. On a couple of occasions, the interviews could not continue as the interview was emotionally triggering for the participant. The research assistant/s contained or terminated these interviews and referred participants to additional psychosocial support.

Participants were not involved in the conceptualisation of this study as those who lost family members due to COVID-19 were deemed vulnerable at the project conceptualisation stage. However, an organisation that works with bereaved families and communities provided the training to the research team ahead of the fieldwork.

The interviews were conducted in IsiZulu, isiXhosa and English, as per the interviewees’ preference; were recorded with consent; and occurred in predetermined places near interviewees’ homes. None of the participants are identifiable, as all are reported here anonymously using pseudonyms, and the locations referred to are of sufficient scale to ensure protection of all participants.

It soon became clear that participants had experienced multiple deaths within their families and close social circles. At the time of the interviews, most participants reported they had lost three or four members of their families or close circles during the pandemic. One-third had experienced between 7 and 10 deaths, including participants who recalled losing ‘many people’ from among their families, work colleagues and friends. A smaller group reported just one loss within the year preceding the interview. The scale of loss was reflective of the inverse burden of care and grief with the ongoing and worsening strain on resources within a context of existing marginalisation and vulnerability, reflective of syndemic synergies.

The focus of each participant interview was on one experience of a familial/friend’s death, as decided by interviewees. It was suggested that participants choose an experience where they were aware of the situation/events that surrounded that person’s death. The research assistants translated and transcribed the interviews. The interviews were coded using Atlas.ti, assistive software for qualitative analysis. Thematic analysis was then conducted by the primary author with a focus on understanding mourning experiences in the context of the COVID-19 restrictions on handling human remains. The emerging findings were triangulated with the existing literature and in conversation with the authors in an iterative process.

Findings: COVID-19 and the handling of human remains in cultural context

Death in Africa is always treated as an important matter. Funerals, in the various traditions that coexist in the culturally and racially diverse context of South Africa, are notable occasions where the community comes together. In urban areas, people are typically buried in cemeteries, while in rural areas, funeral rituals and burials typically take place at the home of the bereaved family. Despite variations within African communities, there is an important shared consideration about bringing the body and soul ‘home’ (Bank et al 2020).

As discussed, the elimination of regulations, in 2021, around ‘bagging the body’ became not simply about aligning with ‘best scientific practice’ but facilitated the identification of the corpse by families and provided families the possibility of performing religious or customary rituals. Hence, these also attended to the deep concerns and needs of bereaved communities.

In the following sections, we examine how funerals and burials were carried out by the urban black African Christian communities of our research participants, in township settings, under COVID-19 restrictions and how these families lived through and navigated these processes, and the massive loss brought about by the pandemic.

The intensity of participants’ loss was palpable. When asked about the number of deaths, one participant could not recount the exact number. She tells us,

…as far as people that I know, personally, I can't count. I mean, there’s a guy that I grew up with here in Mafikeng: He lost his mom, dad, sister, and brother in three weeks from COVID.

She continued recalling the losses around her, experienced within a few months.

When I think about it now, I'm getting goosebumps, because I think [of] people that I know personally. I have a … very close family friend … she’s closer to me than most of my biological aunts. She lost three siblings in less than three months… and her mom, dad, brother, sister. They were a family of five, now a family of one.

Within this landscape of loss, we gathered more detailed information on one of these deaths, as the closest person to each participant. Close members were mothers, fathers, grandparents, parents-in-law, sisters, aunts, uncles and cousins. One participant lost his fiancé. Several participants lost more than one member of their close circle in short periods when community transmission appeared rampant and thus illness, deaths and funerals overlapped in these families.

Boitumelo’s father-in-law died as the family was preparing to bury her mother-in-law.

… he was fine [her father-in-law]. He looked strong, but just because of his wife’s death, we thought ‘maybe he was stressed’, but he was talking, he was just fine… She was supposed to have been buried the next Wednesday, and then… They took him to hospital on Tuesday, in the afternoon. They took him to the hospital because now he was weak. He couldn't eat, he had sugar diabetes, and high blood [pressure], I think, and they took him to the hospital, and they thought, “okay, we'll just bury the mother-in-law without him around”. They'll just let him know how it went. Unfortunately, he died, I think, in the morning of the funeral. So, they had to stop everything and then, they were both buried on Friday.

Ritual incompleteness and unaccomplished grief work

As with Ebola, the COVID-19 restrictions limited the performance of customary rituals that would usually facilitate the deceased individual’s passage from life to death and assist bereaved communities in processing the death. The absence of such results in a state of ritual incompleteness, which can be understood, following (Van Gennep 1960) classic work on ritual, as a prolonged state of liminality; the phase between two conditions; life and death that funeral rituals aim to resolve. Associated with this is unaccomplished grief work, where the experience of mourning may not come to an end as funeral rituals are left incomplete. Waliggo (2006) and Dlamini-Myeni (2022) note the negative impact of the inability to practise traditional rituals on bereaved families in South Africa.

Since the onset of COVID-19, the connection between disrupted bereavement processes and distressing grief has been observed (Neimeyer and Lee 2021; Mitima-Verloop et al 2022). These point to alternative rituals and meaningful social support as ways to mitigate grief (Mayland et al 2020). While inconclusive, the rapid review by (Burrell and Selman 2022) of the impact of funeral practices on mental health, grief and bereavement states that ‘the ability of the bereaved to shape those rituals and say goodbye in a way which is meaningful for them’ was most crucial. They note the potential positive ramifications this could have during COVID-19.

Nwoye (2005) provides a useful perspective explicitly for understanding the link between rituals and grief in Africa. This framework focuses on ‘the spiritual/systemic/interactional nature of healing in grieving and the resources which the community makes available to bereaved persons’ (Nwoye 2005, 141). Accordingly, mourning is considered ‘a finite process with a definite beginning and ending’ (Nwoye 2005, 151), the way bereaved members are expected to live through this period is traditionally defined by communities in Africa, in ways that allow for grief work to unfold.

‘Grief work’ in this context is defined as ‘the patterned ways invented in traditional communities for the successful healing of the psychological wounds and pain of bereaved persons’ (Nwoye 2005, 151). Grief work is set ‘to prevent the bereaved person’s deep sorrow from degenerating into chronic negativity’ (Nwoye 2005, 151). The role of community and culture (through ritual and memory) are central to successfully dealing with grief and are thus intrinsic parts of grief work.

A culturally sanctioned death ritual is poignantly described by Ndeleni, a traditional healer and participant in this study. Ndeleni describes how healers, through ritual, handle this delicate matter facilitating a smooth transition from the realm of the living to that of the dead managing the passing of a soul. She recounts the burial of a fellow traditional healer who died in a hospital and whose passing was framed within the restrictions of the COVID-19 regulations.

In our traditional healing custom, when the deceased arrives, perhaps we meet them halfway, like [at] the nearest spot, at stop one, and then we come with her here [at the home]. When they [the hearse] arrive at the gate they drop her off and open the coffin by the gate and we phahla [speak to the ancestors] there, and pray to the ancestors, and inform them that “here, she is on her way”, [and ask] “may they welcome her spirit”. We pray and when done, we enter the house with her. When we are inside, once again we put her beads on her, because other healers when they pass away at the hospital; they [hospital staff] take off their beads. So, we do not send them off without their beads.12 We look for those we know [referring to beads] and put them on her, put on all her garb, and stuff as a traditional healer [needs] to leave with.

African bereavement rituals involve the bereaved stewarding the deceased’s soul to an ancestral-spiritual realm (Makhaba et al 2009; Ngubane 2004; Nwoye 2005). As Bank and Madini (2021) stress:

The key to a successful burial is “fetching the spirit” from the place of death and safely returning it home. This requires constant communication with the spirit of the deceased. This process needs to be continuous and ongoing until the body is put in the ground. There is great danger in death for the living which must be offset through communication with and care for the body.

The COVID-19 restrictions gave no consideration to the required care and space needed to ensure the communication to enable the shepherding of the deceased’s soul.

Ndeleni’s experience of burying another traditional healer shows how the responsibility placed on funeral directors, during COVID-19, did not ensure the required rituals could be performed. While the undertakers tried to allow some time for the necessary rituals to be performed, friends and family were highly constrained and unable to have physical contact with the deceased body, or to communicate with the deceased soul.

At the start of the pandemic, the undertakers brought the deceased home but in a sealed coffin:

So, we were not able to do that there [at the house of the deceased]. Yes, they [the undertakers] did bring her body early around 8 am so that we could perform our rituals but there was nothing we were able to do because the coffin was sealed shut. It was as though it was glued shut, such that it was impossible to open.

Then, all we could do was just rotate around it there [going around the coffin], rounding aimlessly.

The futility of this impromptu adaptation to the ritual is shown as Ndeleni emphasises how they were ‘rounding aimlessly’, rotating around the closed coffin. Therefore, the ineffectiveness of an obstructed ritual stays in the memory of the bereaved, and its incompleteness interferes with their grief work.

Attending to how funerals and burials are framed within Black African Christian traditions, the restrictions on contact with the deceased body and the gathering of mourners impacted urban families and communities in three broad areas, as follows.