While the latest Covid-19 statistics suggest that just under 650,000 South Africans have tested positive, Discovery Health CEO Dr Ryan Noach and his team of experts think otherwise. “Working backwards from the deaths” – as Dr Noach describes it – they have estimated that a whopping 13-million South Africans have in fact caught the virus. Here, BizNews founder Alec Hogg finds out exactly how that number was reached and along the way, and discusses the positive and negative impacts the Covid-19 lockdown had on both the population and the economy. – Jarryd Neves
Dr Ryan Noach is with us, the chief executive of Discovery Health. Today you put your team together and gave a media update on the pandemic. There was a lot of meat in there, Ryan. Starting off with the conclusion that you came to. The official data tells us that 650,000 South Africans have had Covid-19. Your numbers say 13-million have been infected. That’s a very large difference. Take us through it.
I think this isn’t an unusual situation. We’ve seen in many countries around the world, the very high asymptomatic rate. The fact that Covid-19 manifests as a mild disease in the majority of people, means that the confirmed recorded figures (where there’s been a positive test) are way below the actual infected numbers. So the big question is, how do we get to this 13-million?
The best way to get it – in our view – is to work backwards from the deaths. The Medical Research Council of South Africa has published a report updated yesterday, demonstrating 42,000 excess natural deaths during the period. Now, these are non-trauma related deaths and there’s a very high probability – in our view, a 90% probability – that these deaths are related to Covid-19. They’re completely out of the usual trend of deaths by natural causes. When you look at the graph, you see the spike of natural deaths at the time that the Covid epidemic peaks.
So 90% is a fair assumption that is related to Covid-19. That would mean around 37,000 total Covid deaths, assuming then an infection fatality rate of between point three and point four. That means – based on the work that was done by the Imperial College and also a group of epidemiologists who published in the Lancet journal – the likely mortality rate, the real mortality rate from this disease is in the space of point three to point four.
Counting the costs of Covid-19
That correlates with what we’ve seen. So if that’s true, if they are 37,000 deaths in South Africa – based on this MRC report – and the infection/fatality rate is in the range of point three to point four, you can work backwards and extrapolate the number of infected individuals and it works out to about 13-million adult South Africans. Now, why that number makes sense is because it correlates quite closely with the data that emerged from UCT (University of Cape Town) and the Cape Town Metro study that was published last week. The Cape Metro published a study from their antenatal clinics – which are obviously young and healthy pregnant women – and the HIV clinics where they did antibody testing for the Covid-19 antibody.
They found a 37% CERA prevalence rate. Their data leads us to believe that 37% of the adult population at those clinics was exposed to Covid-19. Our number of 13-million represents just over a quarter of the South African adult population. So, these two numbers do correlate. We think that’s a reliable extrapolation.
We are learning so much about this as we go along. The data that gets put into the public domain can’t be entirely accurate because of the huge number of asymptomatic people, as you’ve just explained and as we well know. So that’s a good number. But does it mean that we have herd immunity? And what is herd immunity? What does it mean?
The epidemiologists tell us that to achieve genuine herd immunity, you need about a 60% exposure or immunity level in a population. I think what’s interesting is that the 13-million infections that we speak about are probably concentrated more than likely in metropolitan areas. So actually, as a percentage of the adult population in those areas, we may be much closer to 50% of the populations infected in those areas.
In the Cape Metro study, they did have regional demographics and they demonstrated that. In Khayelitsha, there were up to 50% positive antibodies in the people at their clinic. We may be getting close to herd immunity which the epidemiologists claim is at 60%. I worry about that message because I think that it comes with a complacency or a risk of complacency.
We should be quite the opposite. We should remain very alert and aware of the non-pharmaceutical interventions and our behaviour and make sure that we take the necessary precautions. Considering the massive economic impact of a lockdown, we really do want to open the economy safely. We want to protect people’s lives, but at the same time get things productive and make sure we don’t have a second wave.
That’s a big story. We saw that the GDP in South Africa halved in the second quarter. South Africa’s GDP is about R1,5-trillion per quarter. So that means we lost R750-billion. That’s the cost of Covid-19 so far. On the other hand, how many lives did we save? I suppose it’s very difficult to say any life is worth X, but you need to start somewhere. In your presentation today, you did come up with a figure that about 10,000 lives have been saved by lockdown and that could go to 16,000. How does that work through?
We foresee that the mortality linked to these MRC excess death reports will probably end up at about 50,000 excess deaths or Covid-19 related deaths by the end of the year. We think that would have been – by the end of the year – about 16,000 deaths worse. That’s about 30% more people who would have died in the absence of our lockdown, in addition to all the other precautions that we’ve taken. So one has to look through different lenses.
From a clinical and an epidemiological lens, that’s a very good story. We have saved lives. We’ve protected people and I think we can be very proud as a country, of our response from a clinical and epidemiological perspective. We cannot turn a blind eye to the economic impact. My own views, this economic impact is going to be far reaching and long lasting. It’s not necessarily only the fault of a stringent lockdown. The virus has caused this economic recession in almost every market that we’ve seen across the world. We’re seeing these poor GDP reports and contracting economies all over the world.
It is a huge price to pay and only history will tell us what could have been done differently, in order to still achieve great clinical outcomes and potentially, protect the economy. I must say that it’s getting easier to make judgments as time goes by. But at the time, it was impossible to have the foresight to look forward and tell.
If only we had the app that Discovery developed for the Department of Health. It could have been so different if that had been around six months ago. Surely it would have informed much of the policy decisions on lockdown and so on.
We’re very excited about the app, but it is only one component of a multifaceted response. Contact tracing is critical. The quicker we can trace the contacts of somebody exposed to a positive case – and be diligent about their isolation and quarantine if necessary – the more quickly we’ll flatten the spread. I think that the evidence for that is predominantly available out of Hubei province, where they took such stringent action around contact tracing that they managed to squash the curve almost immediately.
In retrospect, having now seen other countries around the world fight this epidemic, one has to marvel at how China managed the contact tracing and the isolation associated with it. We’re very excited about the app. We built it at no cost to the Department of Health and have given it to them. It’s their app. They have contributed cost towards it too. The Presidency has been involved in supporting the Department of Health on it. It uses the Apple/Google API, which Apple and Google created for the whole world’s benefit.
We would encourage as many people as possible to download the Covid SA app. Once you’ve downloaded it and switched it on, there’s nothing more to do. It works in the background of your phone and as long as your Bluetooth is on, it will warn you if you’ve come into contact with somebody who is Covid-19 positive.
I had a good chat recently with one of our leading lawyers, Emma Sadleir, who explained in great detail why she has downloaded the app and why the privacy issues are not there. As you said before on the Google and Apple development, it was specifically to take that into account. She did say to me that you had a senior counsel from your side who made sure that all the privacy regulations were followed. Why go to such extremes?
In 2020, privacy has to be first and foremost in our minds and everything that we do. Certainly as a financial services company – dealing with confidential financial and medical information – we don’t do anything without first ensuring that it’s safe, secure and that privacy is protected. So, that’s a routine part of our governance. Of course, the Department of Health – who owns the app – have done all sorts of due diligence and privacy checks on it, too. You can be assured that your identity is not disclosed.
The technology is so clever. It stores a token on your local device for the phones that you’ve come into contact with. If one of those phones recognises the Covid-19 positive patient, the tokens talk to each other and the token shows up on your phone. After 14 days of no exposure, those tokens are completely destroyed and disappear from your device. There’s actually no identity attached to the tokens at all. It’s a very secure environment.
Hopefully it will be of use when one goes into the future. If they were to be a second wave – I watched the webinar and you did make mention of that – even though infections have fallen dramatically in South Africa and are at a very low level now. Why are you worried that there could be a second wave?
I guess just watching the rest of the world’s patterns, particularly in Europe. We saw in Europe two to three months of low grumbling Covid infection rates and now a sudden resurgence. This is particularly in Spain and France. It looks a bit different to the first wave in those two countries. The population that’s infected now seems to be much younger. The mortality rate and the morbidity associated with it that we’re seeing seems to be much less severe. The morbidity and mortality reduction in severity could be because of the younger age. We don’t know yet.
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It could also be that there’s just a lag and that there hasn’t been enough time yet and we’re actually still going to see some severe morbidity and mortality. I really hope for those countries that that’s not the case at all. We are optimistic. We are seeing steadily declining infection rates and very low rates of infections at the moment. We really would urge everybody to take the right interventions. It is these precautions and our behaviour that’s going to determine whether we have a second wave or not. So, wear a mask – it’s critical.
You may be totally asymptomatic and infected. Be kind and respectful to those around you and don’t go out without a mask. Maintain social distance and be cautious about it. Download the app and allow others to benefit from contact tracing. I think if we do these things, I’m relatively optimistic that we’ve had enough of the exposure in South Africa that we can avoid a second wave.
Just to go back to the cost of all of this and the lives that were saved. Working through that GDP number that evaporated in the second quarter (because of lockdown), it cost us about R46-million per life, that will be saved as a result of that.
But part of the benefit of the lockdown that you were discussing today, is that we managed to postpone the pandemic for long enough to be able to actually know how to handle it better. Just unpack that a little bit for us, because if we hadn’t had a lockdown, presumably we would have been similar to those countries that were hit early on and very hard?
Just parking the economic aspects for a second and looking at it from a clinical and epidemiological perspective, there’s no doubt that the lockdown did two massive things. The one is that it delayed our peak and flattened our curve. It led in the shape of our outbreak in South Africa to controlled regional outbreaks, as opposed to if we had allowed for travel to continue and people to continue not to social distance. We probably would have had more of a simultaneous outbreak across the country.
We had these regional outbreaks that were relatively controlled and later than expected. So, the healthcare system could improve its infrastructure. The two big areas where that happened was clearly in the case of PPE. There was just insufficient PPE in the country – in every country in the world – to deal with this pandemic.
What South Africa could do was bring in PPE. The Solidarity Fund, Business SA and the Department of Health worked together brilliantly to supply enough PPE to the healthcare professionals. Then in addition to that, add other infrastructure. Field hospitals, to get standard operating procedures and protocols and to sort out logistics and ergonomics in the medical facilities to ensure that the healthcare system was ready. This stood us in very good stead.
The other thing that we did by buying this time – and I think it was an unintended consequence, but in the end it was deeply fortuitous and undoubtedly saved lives – is that because we were later than the rest of the world and we bought this extra time, we were able to learn lessons from the evidence emerging from all over the world, around how best to treat the disease. Things that we could do that no other country – certainly New York and Italy didn’t have the luxury – was able to do.
Early oxygen saturation monitoring, early detection of this phenomenon of silent hypoxia or the low oxygen levels in the blood, the use of corticosteroids, cortisone and corticosteroids in the treatment of the severe illness – which dramatically changes mortality. There were 30-40% reductions in death as a result of the introduction of cortisone. The change in thresholds for ventilation. Ventilating Covid pneumonia much lighter than we would ventilate a typical pneumonia.
Using high flow nasal oxygen or positioning – putting people on the stomach to recruit new parts of their lungs – long before we start the ventilation. We didn’t know about these modalities when New York and Italy had the outbreaks. They were seeing mortality rates at 70 and 80% in the ICUs. We had much better ICU outcomes here in South Africa. Kudos to our clinicians – both in the public and private sector in South Africa – who have demonstrated that they are of the best in the world. They delivered outstanding care and we had excellent outcomes from the Covid-19 experience here.
They were also very much in touch with others around the world – other clinicians in Italy and New York and so on. You’ve spoken about globular numbers. Discovery Health is by far the dominant player in the South African market. How do your figures – within Discovery Health – compare with the national figures? In other words, I’m trying to find out if you can use your real life experience, as sometimes people are a little cautious about believing the statistics that are given out nationally.
We saw that the importance of these kinds of outbreaks is what the shape of the outbreak curve looks like. The shape of the Discovery Health member outbreak curve – if you superimpose it on the national curve – looks almost identical.
We think we had a very good microcosm in our environment of what the national experience was – notwithstanding that the socioeconomic status of the members of Discovery Health is different to that of the country and in general is higher than that of the country. It’s offset by the fact that the Discovery Health membership has a slightly higher age group and a slightly higher prevalence of people living with chronic diseases. So there are these differences, which our actuaries and clinicians are able to adjust for.
The Discovery Health membership represents about 6,5% of all South Africans. So it’s quite interesting to be able to track the outbreak. We did about 500,000 tests for our members. 14% of all Discovery Health members had a test at some point, which is quite interesting. Of those, 2,3% of Discovery Health members tested positive. That represents about 10% of the total number of positive cases in the country. So although we represent 6,5% percent of the country’s lives, we represented 10% of the positive reported cases.
This is a story about access to testing. Because of the higher socioeconomic status of our membership, it’s very likely that better access to testing. So we had more reliable test results and more people that were tested per capita. So about 18% of all of the positive cases inside the Discovery Health member base required admission to hospital. That correlates very closely with the data that you see out of other parts of the world. In Italy, they reported about 22% admission rates. In New York City it was about 255. If you adjust for age, this correlates entirely.
So that made a lot of sense. I think the big difference is in our fatality rate. The Discovery Health membership experienced a 1,9% case fatality rate. So that’s the number of deaths divided by the total number of confirmed infections. That’s 1,9% dramatically better. That is three to six times better than what we see in the other countries who had the top ten outbreaks in the world. That is, I think, because of our country’s approach to Covid-19, which was a lockdown. This gave the clinicians lots of time and gave the healthcare system time to prepare.
We see much better outcomes suddenly from July onwards, in our healthcare system. Once corticosteroids were available, once Remdesivir was being given, once we’d learned how to treat it. So, we have benefited from being later in the cycle. Of course, the economic consequences are dire. We’re all concerned about this. We’re all watching this very closely. I think they are long-term ramifications of these economic consequences.
It’s difficult to say what’s right and wrong, and I’m certainly not the right person to venture a guess on that. But we do need to be deeply empathic to the economic situation of the country. We all need to come together and stimulate this economy. Use local products, use our local hospitality services – restaurants, game lodges and hotels – and really try and get our economy kick started, while at the same time taking the necessary social distancing precautions.