In Episode 57 of Inside Covid-19, South Africa’s healthcare system is holding up despite a surge in hospitalisations; the court rules against Guardrisk, with costs, after it is sued by a Cape Town restaurant demanding settlement on a Business Interruption insurance claim – but Santam still refuses to budge; and some in-depth perspectives on the Covid-19 experience in South Africa and elsewhere from UK-based Professor Alan Whiteside. – Alec Hogg
In today’s Covid-19 headlines:
- South Africa’s confirmed coronavirus cases broke above 200,000 yesterday, the 15th highest of any country. The country is in fourth place on new daily cases and is 9th on daily deaths. Although the impact of the virus continues to rise, there are now clear signs that the Western Cape has peaked, with Gauteng now the national hotspot. Thus far health workers, with the support of field hospitals, have coped with the influx of Covid-19 patients. Context coming up with Discovery’s head of clinical excellence, Dr Noluthando Nematswerani.
- Brazilian president Jair Bolsonaro has become the second sceptical high profile political leader to contract the coronavirus. After spending time in intensive care when hospitalised in April, UK prime minister Boris Johnson thanked the medical staff for saving his life. 65 year old Bolsonaro is an outlier among world leaders, denouncing the virus as “a little cold” and last week did not wear a mask when attending a 4th of July party at the US Embassy in Brasilia, despite having been ordered to do so last month by a Brazilian court. Brazil has 1.6m confirmed cases of Covid-19 and over 66,00 mortalities, highest of any country except the United States, which yesterday went past 3m infections and 133,000 mortalities.
- The impact of Covid-19 on South African consumer confidence has been dramatic, with the FNB/BER index dropping to the level last seen after the destructive aftermaths of the Rubicon Speech in 1985. Second quarter responses caused the index to drop from an already weak -9 to what the compilers describe as “a shocking -33”. It is only three index points below the all time low recorded 35 years ago. The survey was conducted in the first half of last month following the switch to the less restrictive lockdown Level 3 on June 1.
- South Africa’s largest short-term insurance company Santam says it is sticking to its policy of not paying claims from clients with Business Interruption policies despite Mr Justice Andre le Grange’s strong ruling today that these claims are valid. The judge ruled against insurer Guardrisk on all counts and said it had to not only meet the claim of Cape Town restaurant Café Chameleon, but to also pay the costs of its lawyers.
Doctor Noluthando Nematswerani is with us as one of our regular visitors here on the Inside Covid-19 podcast. Nolu, we’re now seeing the infections in South Africa escalating, and with it comes more hospital admissions. So, are they managing to cope?
Sadly, we are at that stage now where – in certain provinces – we’re seeing an increased number of cases. And with that, obviously, we are going to start seeing certain people getting admitted. I think maybe just to put it in context: we know that (with every – if we’re looking at people who are infected) 80 percent will safely be managed in the out of hospital environment, whereas 20 percent will require hospitalisation.
But obviously, as the volumes increase, the 20 percent becomes quite a significant number. We started seeing this in the Western Cape where they had their first surge before other provinces like the Eastern Cape and Gauteng which followed. And I think we are also hearing that in KZN there is a demand for hospitalisation as well. So, I think what it really boils down to is that once we see these increasing numbers of infections, there will be a requirement for a hospital bed capacity.
Eastern Cape is currently, I think, struggling, and I think it also talks to what was in place prior to Covid-19. We know that the Eastern Cape obviously already had some challenges from a health-care/bed supply point of view. Gauteng – maybe not as much, but we are seeing how Gauteng is catching up in terms of numbers to the Western Cape. But we have not really had any indication that they are reaching full capacity. But there is definitely a strain in their hospital environment – some facilities more than others.
But I think right now: we are at that point that, obviously, if you look at why we had the lockdown it was really to delay the increasing number of cases – to prepare the system. But there is no system that can be fully prepared for the significant number of cases that may require hospital care.
In the Western Cape they seemed to handle it okay (also with additional facilities: tent beds and stuff like that). Is it also the situation in Gauteng – that we have the facilities in our province to handle it?
Yes. So actually, the Gauteng Department of Health has informed us that they have repurposed quite a few beds in their existing facilities. You will be aware of the field hospital in Nasrec, and I think they are looking at various other facilities that they can convert into field hospitals.
And if you think about the Western Cape, they had their Cape Town ICC, which was catering for those cases that were not as sick and not requiring intensive care. So they could decant from their other facilities into this field hospital. So, I think field hospitals become a very good alternative to ordinary hospital bed capacity. So, they improve that and allow for that movement of patients specifically when they no longer require intensive care.
What about KZN? It is the most populous province in South Africa – though not with as many facilities as one finds in the Western Cape and in Gauteng. How are they holding up so far?
So, I think we are concerned about KZN. We’ve heard reports that the cases are starting to increase. Even though (if you look at their numbers, considering that the first reported case came from KZN) I think their numbers have not risen as quickly and as rapidly as we had expected. But I think all the various provinces will peak at different times. But we are seeing an increase. I mean, if you look at the current stats, they are sitting at 7.7% of the total caseload that we’re seeing in South Africa right now (with Gauteng and the Western Cape sharing the bulk of the load).
But I think with every province – preparedness is key, because I think in Gauteng: for a very long while, we were sitting with very low numbers, but when the peak started, I think we actually exceeded the numbers that we’re seeing in the Western Cape at the time when they were seeing a surge in cases. So, I think there is no room for any province to relax and say we will not be hit as heavily as other provinces have been.
It’s really about making sure that bed capacity is created and not only relying on the available bed capacity, but supplementing with some of these and other field hospitals even in the Durban environment and also surrounding KZN regions.
In the initial stages of the virus, the health-care workers were really hard hit: up to 20% of people working in ICU’s were actually dying. Well, we know, thankfully, that’s massively improved today. But are the health-care workers properly protected all around the country?
So, Alec, we only hope so. The reports are that PPE is being provided for. And I think for me, it’s also very important to understand the sources of infection, making sure that health-care workers are aware of potential behaviours within the hospital facilities that expose them to infections.
We had a very interesting webinar some time ago where they were unpacking some of the investigation that was done at St. Augustines to see some of those issues that may actually lead to some of these mini hospital outbreaks (maybe not mini, because some can actually be major, because in a hospital setting you’ve got sick patients, also the type of procedures and also the exposure is different than where you are seeing people in their normal community).
So I think from our side, it is about making sure that there is proper access to PPE, and we’ve been assured that there is a provision of such. And in making sure that that is available, the next important aspect is for the health-care workers to make sure that the PPE is used appropriately and that they don’t convene in tearooms and do certain things that may also expose them to infections amongst themselves and with patients as well.
Just to close off with: it got very personal for me this week when a friend was on a ventilator in a hospital. So he’s very ill with Covid-19. Have we got enough ventilators now so that the people who need them are going to be able to have access?
This is a very important question, Alec. We’re getting quite a lot of questions – even from some of our members – around ventilators. I think, at the start of the pandemic: we saw that there was a lot of focus on ventilators. And I think what we’ve also learned from other countries, which is maybe a blessing, in that we are only seeing a surge at a later stage, so it gives us that opportunity to actually learn from countries, like Italy (where actually the outcomes related to ventilation were not great – where they were actually very poor).
So, there are other interventions that are being deployed now like high flow nasal oxygen and nursing patients in the prone position (which is lying on their stomachs) that have been shown to actually improve outcomes better than being ventilated. So I think the focus is really not on ventilating every patient who comes in.
So a lot of (I think majority of) patients can still be managed in the general ward: getting oxygen and using those various positions that improve outcomes. Only the very sick patients who need ventilation and need to get ventilation, but with the understanding that mortality, once a person gets into the ICU setting and also gets ventilated, is also very high.
So I think for me, maybe the message here is to say: if you can prevent the infection, please prevent the infection. The non-pharmacological interventions work: wearing masks – we see people not adhering to the wearing of masks, people are not socially distancing, we’re seeing people getting tired and fatigued with some of these interventions. But we are saying: we are not out of this yet. We are actually reaching the peak and therefore people must not get tired.
And also, if you do get infected: please be aware that 80% of people can still be safely managed in the out of hospital environment. There are devices that the high risk people can use to monitor at home so that – only if you are seeing deterioration, can you be admitted in a hospital setting. And those who are admitted in hospital – not everyone is going to require a ventilator. There are other interventions that can be provided for and still contribute to good clinical outcomes.
