Struggling to find the right response in a time of uncertainty
Could a ‘one size fits all’ lockdown response end up harming more people than the virus itself in least developed countries, such as Malawi? Are the ‘right’ measures being put in place and are they working? These are the questions pondered by German Development Cooperation and other partners working with the Government of Malawi in the COVID-19 crisis.
After a slow start, many health experts fear that without urgent action a COVID-19 tidal wave may be about to hit Africa and that weak and under-resourced health systems are likely to be overwhelmed by a significant surge in cases. The World Health Organization recently warned that, if left unchecked, COVID-19 could claim 10 million African lives within six months: ‘We are at the beginning in Africa,’ Dr Mike Ryan, Executive Director of the WHO’s Health Emergencies Programme, said in mid-April.
No one yet knows how the pandemic will play out in Africa
Despite such apocalyptic warnings, and a steady spread in cases, the reality is that no one yet knows how the pandemic will play out in Africa. Malawi was one of many African countries to move early and hard – and perhaps more coherently than some European countries – to prevent and limit the spread of COVID-19. On 20th March President Peter Mutharika announced a travel ban on foreign nationals entering the country. A 150 billion Kwacha (around 180 million Euros) multi-sectoral National COVID-19 Preparedness and Response Plan was launched on April 8th, the same week that Malawi recorded its first positive case. However, at the time of writing, there have been just 41 confirmed cases and three deaths.
Intense debate about the ‘right’ response
The apparently low numbers of cases in some of the world’s poorest countries are encouraging but also difficult to interpret. Since the first African coronavirus case was confirmed in Egypt on February 14th, the virus has spread to virtually all corners of the continent. Given limited testing capacity, recorded cases are likely to underestimate the true burden, but compared to the USA and parts of Europe, the figures in countries such as Malawi still appear to be low.
Africa’s youthful population (the average age is 19.4 years) may help to explain the number of confirmed cases so far as the majority of the population might remain asymptomatic. The effect of ultraviolet light or a climate where people spend more time outside may be other factors. There has been some conjecture about whether people with underlying conditions such as tuberculosis might respond differently to COVID-19, conceivably making patients more resistant, because of a previously triggered immune response, rather than more vulnerable as is usually surmised – but, as yet, there is no evidence for any of these hypotheses.
Some health professionals believe that the continent may in fact be better placed to deal with the pandemic than Europe or North America because of its long history of dealing with infectious diseases. Others caution against a ‘one size fits all’ response of lockdown and containment for poor countries such as Malawi, predicting the loss of fragile informal incomes and increased poverty, malnutrition and famines ‘of biblical proportions’ (according to the World Food Programme). Against this background, what assistance can and should German Development Cooperation and other development partners offer to Malawi and other African partners in the current unchartered circumstances?
Supporting COVID-19-related capacity development and procurement
Alongside other development partners, the Malawi German Health Programme, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the Federal Ministry for Economic Cooperation and Development, has adjusted its focus to work with the national Ministry of Health and Population and local governments of the four partner districts Dedza, Lilongwe, Mchinji and Ntcheu on COVID-19-related capacity development, training and procurement.
According to Dr Paul Dielemans, GIZ, ‘We have been working hard to get treatment centres up and running across the country.’ However, it has been extremely challenging to decide on the best course of action in a country where the health sector is weak and under-resourced. There has, for example, been a debate whether treatment and isolation centres should be kept separate, and whether home isolation should be allowed for those with mild symptoms and how this could be managed.
The current strategy is to isolate mild and asymptomatic cases at home or in an isolation centre depending on the local situation. While all districts have identified isolation centres, treatment centres have only been set up in districts with major ports of entry. Patients requiring intensive care and possibly ventilation will be referred to one of the Central Hospitals. Kamuzu Central Hospital (KCH) has been designated as one of the main COVID-19 treatment centres in the country. Its new 18-bed COVID isolation unit admitted its first patient two weeks ago.
Closing the borders disrupts vital supply chains
Although it is perhaps a natural instinct for any country to pull up the draw bridge in a pandemic crisis, closing borders can quickly lead to hunger and life-threatening poverty for a resource-poor and landlocked country like Malawi. Relatively few people enter the country by air – the rest came by road across Malawi’s long and highly porous borders, which are impossible to control effectively. The closure of the airports and airspace has led to problems with procurement of essential supplies and personal protective equipment (PPE), a problem compounded by export restrictions placed on medical items by more than 70 countries.
On the ground in Ntcheu District
The challenges facing many of the districts are immense. Ntcheu is a big district of around 681,000 people which borders Mozambique. Although an isolation tent has been set up near the district hospital, it currently stands on bare earth and still needs a concrete base and mattresses. The district has no rapid diagnostic testing kits and patients requiring ventilation have to be referred to central hospitals. According to Isaac Mbingwani, the District Director of Health and Social Services, however, much more basic issues need to be tackled:
Seven of the district’s 39 health facilities do not have running water and depend on water from bore holes. Supplies of PPE are inadequate, the training of health workers on COVID-19 is not yet complete, hospital and health clinic spaces are overcrowded and there are severe shortages of trained medical staff. Isaac is concerned that growing numbers of returning migrant workers, who may be infected and need to be quarantined, could overwhelm the district’s limited contact tracing ability. Paul Dielemans agrees with him: ‘The first identified patient had 80 contacts – so you can imagine that one District Health Officer and one vehicle cannot cope easily.’
Unprecedented fear amongst health workers
Nurses in Malawi were temporarily on strike amid fears they won’t be able to handle a spike in coronavirus cases without proper PPE and equipment and better allowances. ‘On Easter Monday there was literally nobody in the hospital,’ says Dr Andreas Schultz, a German health expert seconded by the German Centre for International Migration and Development (CIM) to the Paediatrics Department at KCH. ‘Some nurses are still on strike, others are too afraid to come to work, others are away because of essential training which leads to further staff shortages.’ An increase of risk allowances, delivery of some PPE, and the resolution of Government to hire an additional 2,000 health workers have resolved the strike, but the truce remains fragile.
Dr Schultz has extensive experience of working across Africa during both the HIV and Ebola epidemics, but says ‘I have never experienced such fear and panic amongst health workers.’ He thinks much of that fear is a result of fake information on social media.
‘It is a real problem: We have facilities but no staff,’ says an exhausted Dr Alinafe Mbewe, the District Director of Health and Social Services for Lilongwe – the area with most infections in Malawi. She says her job is currently ‘overwhelming’, adding that in some areas the Malawi Defence Forces have had to step in to deliver babies. ‘PPE is the priority here. Without that we won’t be able to reassure staff to come back to work. It is going to be a disaster.’
The Malawi-German Health Programme was one of the first partners to offer help, she says. However, she worries that with so many international development partners facing their own problems at home, ‘Malawi will be forgotten’.
Tackling misconceptions about COVID-19
One of the main lessons learned from the Ebola epidemic in West Africa was that without community mobilisation and clear communication, it is very difficult to halt the spread of infectious diseases. COVID-19 is particularly challenging because so many positive people are asymptomatic. Despite the fear and panic amongst many health workers, people in the villages and townships ‘don’t really believe in COVID-19,’ says Dr Mbewe. ‘It is very hard to convince people it is real. As they are used to people suffering from HIV or TB, they say “Don’t try to tell us they died from COVID-19!”’
To address these misconceptions, GIZ has been partnering with the Story Workshop Educational Trust (SWET) for a two-month community mobilisation campaign. Via social media, radio spots and traditional leaders, the campaign counters such misconceptions and explains how people can protect themselves against infection.
SWET’s Chifundo Zulu says he has noticed some cultural changes already: ‘There has been a significant change in terms of hand shaking – most people are no longer doing it.’ Social distancing is, however, much more challenging in cramped households, crowded markets and so on, and limiting the number of people attending funerals and traditional ceremonies is still a problem. ‘It is hard to break old habits,’ says Chifundo: ‘This is a threat to the nation.’
A political pandemic
Malawi’s responses to the pandemic are taking place against a politically-charged backdrop. In February the Constitutional Court annulled the 2019 presidential election results, citing evidence of irregularities, and ordered fresh elections to be held. Originally scheduled for 19th May, these have now been postponed until July. Critics of the government believe the COVID-19 crisis is being used as an excuse for postponement and this in turn is making it harder to persuade people that the threat is real.
Ntcheu DHSS Isaac Mbingwani is worried that this political crisis is in danger of undermining Malawi’s response to the pandemic. ‘We need to leave politics aside and not wait for people to die,’ he says: ’Without the political will, and a multi-sectoral approach we will be finished.’
Lockdown barred by Malawi High Court
WHO recommends that decisions on lockdowns be context specific and in accordance with the demographics and particular circumstances of a country. Earlier in April, President Mutharika had announced that a 21-day coronavirus lockdown was due to start on April 19th. Human rights groups opposed this measure on the grounds that, to take account of Malawi’s circumstances, a lockdown could not be imposed without measures to cushion the poor and vulnerable from its economic effects. On 29 April, Malawi’s High Court barred the government indefinitely from imposing a lockdown.
In his address to the nation the same day, and following the approval of a World Bank US$37 million funding package to help Malawi respond to the coronavirus, President Mutharika announced a monthly $40 mobile cash grant for six months targeting 172 000 households and businesses affected by the pandemic. It is unclear whether the government intends to continue with its lockdown plans, but these political uncertainties are impacting on all aspects of COVID planning and preparations.
Empty hospital wards
So far the wards at Kamuzu Central Hospital and other health facilities have remained relatively quiet. ‘I have never seen the hospital so empty,’ says Dr Schultz. Normally at this time of year he says there would be 400 to 500 children in KCH’s overcrowded Paediatrics Department and wards, but now there are only around 140 patients. Dr Schultz and his colleagues say that from their clinical observations, health facilities have neither been overwhelmed with COVID-19 patients or experiencing many deaths – but that’s partly explained by fewer patients.
There are huge traffic jams to enter the hospital as people wait to have their temperature taken at the gates, he says: ‘This is not effective. People need to be sensitised to the dangers of COVID-19, but don’t deprive people from going to the hospital and continuing to seek health care for other conditions such as diabetes, cardiovascular diseases and HIV. We need to confront fears and be sensible and sensitive and not forget our routine services.’
A country holding its breath
So far it has been difficult to fully grasp the extent of the spread of the disease because testing is so limited. ‘The numbers are still very small but we expect there to be many more cases,’ says Dr Alinafe Mbewe, Lilongwe’s District Director for Health and Social Services for Lilongwe. She believes the numbers would be much higher if more testing was possible: ‘It’s just starting.’
Although Malawi German Development Cooperation has for some time focused on improved health data management and digitalisation, and a lot of progress has been made in this area, the current nurses’ strike and overall shortage of medical staff means that less data is being recorded at a crucial time when it is most needed to inform decisions.
‘Only time will tell whether we can contain the outbreak,’ says GIZ’s Paul Dielemans. But it is too early to breathe even a cautious sigh of relief or to say that, this time, Malawi, or Africa as a whole has dodged the coronavirus bullet – it might simply be behind the curve, with the pandemic still to pick up speed. For now ‘it’s largely guesswork’, he says.
Ruth Evans, May 2020