The 1918 influenza killed an estimated 6% of South Africans. The impact varied substantially across the country. Mortality rates were pronounced in districts with a high share of black residents. We transcribe more than 50 000 death certificates to understand these unequal health outcomes. Using a novel indicators – whether a doctor’s name appears on the death certificate – we propose that the unequal health outcomes are a consequence of inequalities in access to healthcare services. Although these inequalities existed before October 1918, our results show that the pandemic exacerbated these differences. We explore the reasons that explain this widening gap in healthcare access.