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A gravedigger works in the COVID-19 section of the Maitland Cemetary in Cape Town, South Africa on July 15, 2020 as a burial takes place in the background.The Canadian Press

As the COVID-19 pandemic sweeps across South Africa at a frightening rate, authorities have been preparing an array of responses: field hospitals, oxygen supplies, triage centres and expanded morgues and cemeteries.

But while many hospitals are crowded with patients, and while the country suffers the world’s fourth-highest number of new daily cases, the mortuaries and grave sites appear to be much slower to fill. It’s one of the enduring mysteries here: why do South Africa, and most other African countries, seem to have a relatively low death rate from the virus? And can this low rate be sustained?

In the early stages of the pandemic, many experts were worried that Africa’s mortality rate would be catastrophically high. They fretted about fragile health systems, impoverished governments and severe shortages of health workers and crucial equipment such as ventilators.

Instead, the African continent today has a case fatality rate of just 2.2 per cent – far less than the global rate of 4.4 per cent. This compares to a case fatality rate of 8 per cent in Canada and 15 per cent in Britain.

The hardest-hit country on the continent, South Africa, has a case fatality rate of just 1.4 per cent – and the rate has been steadily declining for weeks.

Early models had projected that South Africa would have 50,000 deaths from the virus by the end of this year. But by Friday, it had recorded just 4,804 deaths – even though it has the world’s sixth-largest number of confirmed infections.

South Africa now has more confirmed coronavirus cases than Britain or Italy. Yet, it has barely one-tenth as many deaths as Britain, and only one-seventh as many deaths as Italy.

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“The most important measure of success is the number of lives we save,” President Cyril Ramaphosa said in a televised speech to the nation this week.

“We owe the relatively low number of deaths in our country to the experience and dedication of our health professionals and the urgent measures we have taken to build the capacity of our health system,” he said.

South Africa’s doctors and nurses, while toiling courageously at the front lines, have also benefited from global advances in treatment methods.

Because of an early lockdown in South Africa, coupled with the global travel patterns that limited the number of early imported cases, the worst surge of COVID-19 cases was delayed until June and July in major cities such as Johannesburg. This meant that hospitals had time to learn of new treatment methods: high-flow nasal oxygen, instead of mechanical ventilators, for example, and the steroid dexamethasone for severely ill patients.

Those methods had been tried successfully in European and U.S. hospitals and in Cape Town, the first epicentre of the virus in South Africa. “There’s an advantage to going second, not first,” said Jeremy Nel, head of infectious diseases at Helen Joseph Hospital, a large hospital in Johannesburg.

Analysts suggest, however, that other factors are also contributing to the low fatality rate in South Africa, and in most other African countries. And the death rate may actually be higher than the officially recorded number.

One of the biggest factors is Africa’s youthful population – the youngest in the world. The median age in South Africa is 27, and the median age in the entire African continent is less than 20. Since older people have a much higher risk of dying from the virus than younger people, the demographics have helped African countries to keep their death rates low.

In addition, because of its youthful population, Africa has a relatively small number of long-term care homes, a big source of infections and deaths in countries such as Canada.

One possible factor in most African countries could be the relatively low rate of obesity and diabetes – two of the biggest risk factors for the virus. (South Africa, however, has one of the highest rates of obesity and diabetes in the African continent, so this doesn’t explain the low mortality rate in this country.)

While the low fatality rate in Africa is impressive, scientists are cautioning that the rate might be undercounted – and could still increase significantly.

This is partly because the pandemic was slow to arrive in Africa, but also because of the low levels of virus testing and death reporting in most African countries.

“Are we counting everybody?” asked John Nkengasong, director of the Africa Centres for Disease Control and Prevention, at a briefing this week. “Because of fragile and weak mortality surveillance systems, is it possible that we’re not counting all of the deaths in the community properly?”

Since a rise in deaths will usually lag a week or two behind a rise in confirmed cases, the death rate could soon increase significantly in countries such as South Africa, where the case numbers have been soaring in recent weeks.

South Africa has better systems for recording deaths than many other African countries – but even here the death rate for COVID-19 might be significantly undercounted.

Analysts at the South African Medical Research Council have estimated that the country had nearly 11,000 excess deaths in the period from May 6 to July 7, based on a comparison between all natural deaths and the expected mortality rate during the national lockdown. Officially there were 3,349 deaths from COVID-19 during that period, suggesting that the real number of coronavirus-related deaths is much higher than the official number.

An example might be Zindzi Mandela, youngest daughter of Nelson Mandela, the anti-apartheid hero who became South Africa’s first democratically elected president.

She died this week in a Johannesburg hospital at the age of 59, and her death is not officially included in South Africa’s coronavirus statistics. But her family disclosed on Wednesday that Ms. Mandela had tested positive for the virus on the day of her death.

Her family will not know the exact cause of her death until it has received the results of an autopsy. For most who die without a diagnosis during the pandemic, however, autopsies are not performed, and their death might never be officially recorded as a COVID-19 death.

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