By Adamson Muula:
I have titled my article as a question asking whether there are reasonable (public health) grounds for a national lockdown in Malawi to prevent widespread transmission of coronavirus.
Do we have enough public health grounds to justify a national lockdown? What would happen if Malawi does not institute a lockdown now? What would happen if Malawi institutes a national lockdown? What are the costs of implementing a lockdown now? What are the costs of not implementing the lockdown now?
In terms of the costs to implementation of any lockdown, we need to consider the financial, economic and human costs? What are the costs that we should put much premium on? Either decision we make (to lock down or not to lock down now) will have costs. Cost in money, costs in human life and costs to reputation and how people view the State and the government.
Where am I coming from?
As I try to answer this question, I wish also to highlight my academic and professional backgrounds, which I believe have informed how I understand and interpret what is going on in Malawi.
I studied Media and Journalism at The Polytechnic of the University of Malawi. This was through part-time study while I also studied Medicine at the College of Medicine (CoM). I joined CoM from Chancellor College where I studied Biology for three years which included the study of viruses and other germs. From studying medicine, I went on to study Palliative Care (care of the dying) at Makerere University and spent four years studying Public Health. Studying Palliative Care can be both depressing and empowering. Life is precious but in the end, we all die and death is inevitable. Thereafter, I studied Global Public Health (this has some differences with Public Health which I also studied), studied Public Health Ethics (different from medical ethics or ethics in general) and studied Epidemiology.
I know that in bringing all the above areas of study I have been privileged to have in an article such as this, some readers may interpret my position as an exercise in vanity and arrogance. Why did he have to tell us all the certificates and diplomas that he has? Did we have to know all of that to just write about Covid-19?
Some could argue, and perhaps legitimately so, that they also did their own education and it was self-serving for me to present my background publicly. I do understand that. However, my reason for bringing these issues up is that I have learned that journalists oftentimes see things differently from medical practitioners. I trained in journalism and medicine and I should know this.
Let me also state that I am a 100 percent government employee. People that are employed by the government in general behave differently compared to those who do not have the same restrictions as would obtain elsewhere. That said, I am not in a category of civil servants who experience greater restrictions. Individuals in the civil service may hide their opinions especially if the opinions are in conflict with the governing party or the civil service leadership. I believe I have none of these restrictions and fears, but that could also be naïve.
Medical doctors often see things differently from public health experts and public health experts who are not medically trained may also see things differently from those who are also medical doctors. I studied medical ethics in becoming a medical doctor. I later found out that to be a public health professional, I needed to study public health ethics and in part, I learned that medical ethics were in serious conflict against public health ethics I am also convinced that while global public health is a branch of public health, it may differ in its scope. It is impossible to come to a consensus as to what is the best to do under the current circumstances in Malawi.
If I take my journalism hat, I may come to a different conclusion compared to when I take my medical practitioner’s hat. Further, when I take my Public Health Ethics hat, I find that I have to contend with slightly different issues when I take on my epidemiologist hat. I wish things were easier and I could toss a coin heads or tails and get the answer for such a consequential decision such as locking down the whole country.
Some facts about Covid-19
Let me state what I would call as facts regarding Covid-19 in Malawi as at now (April 19 2020). There have been 17 people so far confirmed as having been infected by the coronavirus in the country. Sadly, two of these have since died leaving 15 people, of whom three have been certified as cured.
Patient number three in Lilongwe was a primary school pupil. In order to ascertain whether any of the other pupils potentially exposed to coronavirus were infected themselves, the government instituted a rigorous contact tracing and tested among these contacts. None of these other pupils were confirmed infected.
Virtually, all of the infections in Blantyre and Lilongwe (except about four) are among a specific socio-cultural group within a localised area. Infection has hardly been confirmed outside these two main areas. I raise this fact because we can together craft up an intervention which could prioritise the so called “hot-spots” if a national lockdown is not deemed acceptable. To be fair, the sort of lockdown the Minister of Health directed was nothing as restrictive as has been implemented in other countries. That said, do we want to achieve anything, and what was it, with such kind of a loose lockdown?
Is the government listening?
There is understandable frustration by citizens as to whether the government is listening to varied voices in order to make decisions. In part, this questioning comes up because the government is not able to, cannot and should not publicise each and every meeting that it has with everyone. In that case then, people who do not know what sort of consultations have been going on in the background are justified to ask for more information.
Personally, I have been privileged to be a member of CoM group that interfaces with government and through our leadership at CoM, we have been part of the national and the Blantyre conversation. I have also been privileged to be among representatives of the Society of Medical Doctors in meeting with the Chairperson of the Special Cabinet Committee on Covid-19 and some of its members.
There are some agreements that our group made with the ministers and most of the agreements were in keeping with President Peter Mutharika’s statements. That listening ear is appreciated. Action on the other hand, has been taking long in several of such agreements. At least, there is progress on the recruitment of health workers as directed by the President. The risk allowances of the health workers have also been adjusted upwards.
The health workers were asking: when it came to the lockdown, this was about to be implemented with almost speed of light. When it came to their allowances and hiring new staff, it was taking forever. In fact, many are still complaining that they do not have enough personal protective equipment in the face of Covid-19.
I also participate in the Blantyre District Health Office-College of Medicine Joint Taskforce on Covid-19. I am sure there are many interfaces that the government is using to get views and inputs. While such multiple and varied conversations at the disposal of Cabinet minister Jappie Mhango, the question is whether all those interfaces have the technical know-how to advise on the specific questions that we should prioritise.
For instance, is the meeting with the clergy or traditional leaders going to advise whether a lockdown should be implemented? Should the media or human rights organisations alone be the group to agree to or oppose a lockdown? I would propose that if and when the decision for the lockdown is made (which should be on public health grounds), the religious leaders and human rights groups can be consulted to assess human rights implications and mitigations that need to be implemented in order to get an effective response.
The Public Health Act
The Malawi Public Health Act from which the Minister of Health drew his authority to direct the lockdown is dated 1948. We are now 26 years after resumption of democracy in 1994 and the Act has never been revised. Each successive government has come, mobilised the Law Commission to review the Act but things continue to not be completed.
The public deserves to be informed as to how we can get the revised Public Health Act completed, passed by the National Assembly and assented to by the President.
To lock down or not
The decision to lock down the country as had been decided by the government is not an easy one. Even among medical doctors here in Malawi now, there is no general consensus whether this is the right or wrong decision. There also are those who just do not know which way we should take. If you add politics to this, then you have a Tower of Babel.
However, decisions have to be made one way or the other. As a nation, we can agree as to whether such a technical decision should be made through the courts or whether we want these proposals to be made by technical experts who have considered the various options, their goals and the costs involved. The Ministry of Health itself has the Knowledge Translation Platform which can be tasked with this responsibility of weighing the different options, their costs and expected outcomes.
Dr Mary Mkandawire, the Change Management expert we have in Blantyre, posits that change happens when people are dissatisfied with the current state and they have a vision of what things ought to be. For us now, we should be unhappy with the 17 Covid-19 cases. Or the current situation can be viewed as no lockdown while the future desired goal is a national lockdown.
There has to be a process planned on how we get to move from the current state to the future. If the goal is the lockdown, what processes do we have to take in order to reach that goal? Finally, Mkandawire suggests that we pay attention to the costs: financial, emotional energy and time. I have heard people say we should not politicise Covid-19. Good luck. I suggest it is naïve to leave politics out as we deal with the pandemic. Bring the politics and the politicians to the table for us to reach a consensus. Otherwise, we risk politics joining the discussion at the table but clothed in borrowed garbs. The sooner we appreciate that the current toxic context is so political that politics is everything, the better we achieve national goals. Politics is everything in Malawi and things will not just suddenly change because there is Covid-19.
There are people who believe that the directive to lock down the country was motivated by the government’s dislike of the repeat presidential election as directed by the Constitutional Court. I am not sure these people are right. But I am also not sure the government does not have such motivation. One thing though that I know for sure is that holding an election during a Covid-19 pandemic cannot be business as usual. There are risks of transmission of the coronavirus.
On the other hand, having a “care-taker” government run by a Head of State constantly being faced with incessant court losses and an emasculated vice-president now heading an opposition party is not doing any good to decisive coronavirus battle.
What questions need answers?
Whether by the end of the week we will have a nation on lockdown or not, there are several questions whose answers we must have. What are the different options that we have considered including the lockdown? If we cannot have the lockdown, what is option number two, three, four or five? If we have only one option and that is lockdown, then we have not thought hard enough.
Secondly, what are the costs that we are bound to incur in human life and other costs if we have not implemented a lockdown? How can these losses be minimised? What are the costs of the lockdown itself? Are we going to hire more health workers, post and train them while we are on lockdown?
What safety net measures do we put in place to ensure that vulnerable citizens do not further slip into despair? Is it true that central hospitals in this country have each been given ‘meagre’ amounts of money to fight Covid-19? How much should they be given compared with security agencies which have reportedly been given larger chunks? If we have a full-blown national epidemic, will our health system cope with the excess burden? Malawi also needs to engage in a conversation as to when our end game looks like. How much longer can we postpone the lockdown, if that is the ultimate solution?
If we do not implement the lockdown, what triggers will convince most people that it is now inevitable that we implement the lockdown?
How should public health decisions be made?
Public health decisions are best made anchored in data (data, data and more data). Public health also recognises that in some cases, decisions must be made in the absence of comprehensive data. It is like fire-fighting. The primary task or goal when a building is on fire is to douse down the fire. However, that also needs to be done knowing what is on fire to inform whether plain water, carbon dioxide or other extinguishers must be used.
The investigations as to what caused the fire will happen later after the fire is conquered. I learned this when I trained as a fire-fighter at Blantyre City Council Fire Department in the 1980s under Mr Stanford Namfuko, the Chief Fire Officer at the time.
The national lockdown that the minister directed could not have been implemented without the consent of the State President. So it is not that presumptuous to ask as to what sort of briefing and documents were given the Head of State. Was the President just given an oral presentation or a well-thought-through dossier with the different scenarios regarding where we were going to get into and perhaps when?
There are people who have stated that public health experts like me should call the shots and make the decisions for a lockdown. In fact, such a view is myopic and naïve, at best. Technical experts can advise the government; but they are not government. Technical experts also come in different sizes and do not tell me they do not have their biases.
I have already attempted to highlight that I come to slightly different conclusions if I take my journalism hat compared to my public health ethicist hat. We will have done our jobs if we presented all the conceivable scenarios, their ups and downs and the expected outcomes to the government. The political leadership will be the ones calling the final shots. They have the mandate derived from the people of this country to do so.
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