We are living in one of those rare moments in which the rich and the poor of the global north and the global south are worried about exactly the same thing in the exact moment, and neither of them have a solution.
Therefore, both space and time are immaterial to our current lived experiences of our health and existence or mental wellbeing. Like the true pandemic that it is, Covid-19’s target is universal. It is silently finding anyone and everyone, and its victims literary range from Prince Charles and Boris Johnson of the UK to Noah Nobody of the South African slums of Alexandra.
It is thanks to this indiscriminate targeting, and the speed with which it is spreading, that Covid-19 has terrified and stunned the world perhaps far more than it ought to. To put this in perspective, a few borders away from Malawi, Ebola has just finished its latest killing spree in which it claimed 66 percent of the known victims, and in some of its past outbreaks, it killed nearly all of them (90 percent). In contrast, 80 percent of Covid-19 sufferers experience self-resolving mild symptoms, while the rest get better after hospital treatment and only a small proportion (1- 4 percent) die.
Yet if we remain unprepared, it really doesn’t matter whether Covid-19 is more dangerous than Ebola or not. For example, the Spanish Flu of 1918, had a similar case fatality rate to Covid-19, but by the time it was over, it had infected 500 million people and killed 50 million of them. Three hundred thousand of these deaths occurred in nearby South Africa. Therefore, even a mild disease can kill millions of people, if it is allowed to infect people unchecked.
One of the key interventions that brought Covid-19 infections down in China was the complete lock down of Wuhan, the source of the disease. Since then, we have seen western countries—the UK, France, German, Italy, and the US—implement their lock downs.
African governments, including Malawi have also recently announced their versions of lock downs, and for Malawi these include school closures, banning public gatherings of more than 100 people, public awareness, following up of at risk individuals, border controls, travel bans and testing those who meet the criteria.
However, the Malawian intervention package does not include many of the critical elements that support the successful implementation of effective lock downs. These include complete withdrawal of people from public spaces—working from home, closure of all shops, common markets—and provision of social-economic support packages to businesses and individuals.
The effective Chinese lock down was full and draconian in its totality, in that it completely grounded its population except in very few and limited circumstances —food and medicine shopping. Therefore, questions must be asked about whether the measures that Malawi has in place are protective enough to trigger the same response that the Chinese lock down did and if not, how can we plug up the gaps? Such a task must, as of necessity, take into account our context.
For illustrative purposes, let’s assume that the lock down was a prescription from ‘Doctor Government’, to ‘Patient Malawi’. Ideally, patient Malawi needs to behave like patient China, taking the full course of the lock down tablet until Dr. Government advises otherwise. However, we know that if the drugs are complicated or they have nasty side effects, patients take them erratically, or they abandon them. Thus in Malawi’s case, a Chinese style lock down is physically, socially, culturally and practically impossible and it has nasty side effects.
This is because the majority of Malawians live in crowded village huts, or crowded houses in crowded township slums, they shop in crowded markets, and they use congested modes of transportation.
In addition, they live on an “eat-as-you-work” basis with no buffer savings to support effective stay at homes so they have to buy their food every day. In any case, very few are in jobs that are amenable to home working, and their workplaces are overcrowded. Further, many of those who could isolate effectively, would remain linked to individuals who cannot isolate—domestic workers.
Finally, a draconian lock down in ultra-crowded slums with dubious air circulation, water supply and sanitation provision could trigger other kinds of outbreaks and health catastrophes such as TB, cholera, diarrhoea, measles, scabies and all kind of communicable diseases, plus parasites such as head lice and bed bugs. Ironically, this could bring disease and probable death to slum dwelling populations who may have had the least risk of exposure to international Covid -19 in the first instance.
The key point to note is that that effective lock downs are never implemented as stand-alone interventions. They are one part of a coherent set of cross-sector interventions, covering health, economics, law and social services. For example, the UK Covid-19 response includes working from home measures (totality of response) government grants to businesses which have been forced to close (economic intervention), targeted support for vulnerable groups—tailored advice for those with known chronic illnesses (health) support with shopping (social services), restrictions of movements and gatherings for everyone (totality of intervention) enforcement action for those ignoring measure (the law).
Obviously, Malawi does not have the financial muscle to compensate people in this way. So, it is perhaps pointless to compare Malawi with the UK. But for the same reason, it is also unwise to just copy those parts of a UK policy that we can implement such as random school closures where for example, our children may have been safer in boarding schools which have minimal exposure to travellers, while ignoring the actual parts of the UK intervention that work, such as banning gatherings of more than two rather than 100 people.
Therefore, two things are clear; the first is that Malawi can only achieve a very modest lock down, the second is that a draconian lock down is undesirable, impractical, and counterproductive, because it could breed other kinds of killer outbreaks in populations which were least exposed to Covid-19.
However, this does not mean that our modest lock down is unnecessary. One likely outcome is that it would partially reduce Covid-19 infection rates and any kind of reduction in infection rates is good news.
However, when we consider that; gatherings of 100 people are still allowed, Sadc travel is still ongoing, risky work spaces, including where international travellers congregate, for example banks, are still open; that we still circulate cash notes in large quantities; that open markets are still operating, and that self-isolating individuals may flout the rules, we can conclude that unless we creatively beef up this porous Covid-19 response, the risks of an escalating Covid-19 infections remain widely open. Thus our highly porous intervention may simply have given us a false sense of security without the benefits.
If that is the case, patient Malawi could fail to get better, but would still suffer all of the economic side effects of the drugs—the worst of both worlds! These could include an economic downturn precipitated by business closures, job losses, reduced income, food shortages, malnutrition, and all the associated vices such as crime rates soaring.
Thus, patient Malawi could become that typical patient who developed drug resistance due to a combination of partial drug administration and lack of patient care. Some of these difficulties are already being felt in the poor communities of India, following a lock down that did not take the context into account the India’s context.
However, all is not lost. We can develop a Malawian response that beefs up our inevitably porous lock down. For example, although we cannot work from home, with the cooperation of employers, we can identify and remove all risky individuals from all kinds of work places to their homes until they are safe. This will, of course, need us to increase our testing capabilities, and is not easy.
However, if we are to successfully fight off Covid-19, we will do well to take advantage of the current Covid-19-free status immediately. Things are developing fast, and already, the UK is talking of introducing Covid-19 antibody testing kits which may indicate if someone has Covid-19, or has had it in the past and is immune. It is hoped that this test could eventually be available for home testing.
If the public cooperates, such developments would help us remove as many people as we can from public spaces until they were safe, without relying on impractical lock downs that send everyone home or having porous ineffective lock downs. However, this is likely to take time before we are even able to access it.
Although we cannot enforce the Chinese style draconian lock down, we can enforce individualised or mini versions of it. For example, we could replace the current relaxed self-isolation advice, with more draconian or State-monitored isolation, albeit still in the individuals’ own homes. Thus, we could bear down heavily on those who have been identified as they are likely to pose a risk.
Similarly, while we cannot shut down all markets, we can reduce the number of people who need to go there by encouraging communities to reconfigure themselves through pooling how they buy their produce.
In its simplest form, this would involve:
. Connecting pools of buyers with seller representatives;
. Making payments using mobile money, and;
. Creating food delivery schemes and networks that draw on the Kabaza network. We would also need to apply similar ingenuity to how we; pray, play, marry, bury our dead, initiate our children, learn, work, travel or socialise at the weekend. At the heart of all this is an acceptance that whether we like it or not, Covid-19 is likely to be here for a long while and that the pandemic is set to change the way we live and transact forever. Therefore, we cannot simply borrow from others how we will live with it. We have to come up with a fundamentally Malawian way of making peace with this new disease.
While this sounds complicated, we have already shown our ingenuity in developing community-based solutions—neighbourhood watch schemes, or banki m’khonde. It is possible and it is the only way.
Finally, to be successful, a Malawi Covid-19 response needs to transcend the political divide. It is worth pointing out that the way our political leaders have tackled Covid-19 is less than impressive, if at times laughable. For instance, the government appeared aloof and unconcerned, until the opposition started to take charge of the agenda.
By now, Malawians should expect the government and the opposition leaders to have consulted each other on this, and to be sending united and crystal clear messages. Their failure to do so highlights the whole point of this article… A call against the piece meal, non-contextual, isolated and copy paste approach to policy that has plagued many of the key issues we face beyond health. Malawians deserve better.
—The author is a specialist in public health and epidemiology, and she has expertise in implementation science, including advising large public sector organisations around successful implementation of evidence-based public health interventions. Currently, she is a Senior Officer at the University of Oxford