Covid-19 in Malawi: The last mile
By Nyovani Madise:
Almost every country in the world has active or recently recovered Covid-19 cases. Yet, although we are all fighting a common enemy, every country is different, and must adopt strategies that are workable in its context.
This does not mean that countries cannot learn from one another— they must, but each country must look at the evidence of its Covid-19 epidemiology and create strategies that are appropriate for its socio-economic, political and cultural environment.
It was while I was serving on the World Health Organisation’s Strategic Advisory Group on Malawi Eradication, between 2016 and 2019, that I fully understood the analogy of the “last mile” when dealing with elimination or eradication of epidemics.
Any long-distance athlete will tell you that the last mile is often the hardest. The end is in sight, but you are tired and really want to give up, yet you must find some inner reserves to push hard to reach the end.
As a public health researcher, I have followed with interest the different approaches that countries have adopted to fight the Covid-19 pandemic. I have been most intrigued by Iceland, which to date has tested nearly 15 percent of its population of 364,134. It has recorded 1,801 cases, 98 percent of whom have recovered and only 10 people (0.56 percent of those confirmed) have died.
Currently, Iceland is having zero, or single digit new cases per day. Iceland, very early in February, adopted a policy of mass testing, tracking to find and isolate infected people even when they had no symptoms. Random testing contributed to Iceland’s Covid-19 policies since they found that about 50 percent of those who tested positive had no symptoms, yet they contributed to the spread of the disease.
The UK, on the other hand, was late in providing mass testing and out of the 251,260 confirmed cases as of May 9, 14.6 percent have sadly died. New York City also conducted random testing of 3,000 people and found that at least 20 percent of New Yorkers may have had the virus without being aware.
In France, re-testing of old samples from pneumonia cases has found that the virus was already in Europe in December, more than one month before the first cases were detected there.
These are important lessons that we can learn from. Closer to home we have seen mostly lockdown policies or movement restrictions and border closures. Malawi currently has 71 confirmed cases after more than one month since its first case. Though this number may appear low compared to neighbouring countries, there is no room for complacency since there could be many more cases in Malawi that we do not know about.
The country must use the “last-mile approach” and adopt the resolve of not wanting to see new Covid-19 cases. It must invest resources in mass testing, contact tracing and isolating cases. This will ultimately be cheaper in terms of lives lost and the effect on the economy, than waiting for the apocalypse to happen and then attempting to deal with that.
Malawi’s “last-mile” approach to Covid-19 simply means fast-forwarding the mitigation approach as if we have already experienced the thousands of Covid-19 cases and deaths, and we are now down to manageable numbers of new infections— the end is in sight.
This means we must work hard to prevent the known cases from infecting others by emphasising respiratory hygiene and isolation of positive cases; we must test all who enter our country; we should emphasise social distancing; and we need to understand our Covid-19 epidemiology better through random testing.
There is no vaccine for Covid-19 and scientists say that it may take up to two years before a vaccine is found. Thus, we must find other ways of getting out of this situation that recognise that this is not a short-term challenge.
Malawi does not need to follow to the letter the early steps that Europe or the United States of America (USA) took, for example widespread lockdowns to “flatten the curve”. Malawi needs to fast-forward and implement future measures that countries in Europe and USA will need to implement in order to lift their lockdowns.
The practical steps are:
1.Widespread testing: We must significantly invest in mass and random testing to identify cases as this is a cheaper strategy in the long-run than dealing with many sick people. Let me emphasise the importance of random testing since this gives you population-based parameters which you cannot get through facility-based testing.
The Malawi Population-based HIV Impact Assessment is an example of efforts to get population-based data for the fight against HIV. Our universities are ready and willing to support testing—a handful of testing centres are not sufficient for a population of 18 million. We should also learn from South Africa and introduce mobile testing units. We can use our community health workers, making sure of course, that everyone involved in this has appropriate personal protective equipment.
- Isolate positive cases: Self-isolation has not worked, so this should be compulsory isolation. How you communicate and do this is important because without isolation of positive cases, the battle is lost. Isolation centres for those who are positive, but asymptomatic, need to be appropriate for non-incarcerated people so that they can enjoy good quality of life during the time they are in isolation until they are cleared to be Covid-19 negative.
Other countries are using facilities such as universities, hotels and hostels to house those found to be positive, but not needing hospitalisation. A related issue is de-stigmatising Covid-19 since stigma can be an even greater virus than a corona when people who suspect to have the virus do not come forward for testing, thus driving the virus underground and further into communities. We learnt about the destructive power of stigma in the fight against HIV. We must preserve anonymity, but another good way of de-stigmatising is to allow high-profile people who test positive to come forward to share about their experiences.
3.Protecting our health workforce: The lessons from Europe and USA, where many health workers have been infected and sadly died, shows how virulent the disease is such that even in the most sophisticated healthcare systems with adequate sanitation, health workers succumb to the illness.
Our health system is nowhere near that of the rich nations and frankly, the rest of the world is expecting our system to collapse. It does not have to. We must invest in PPE for our frontline staff and have adequate disinfecting measures in the facilities. Most importantly, let us intensify prevention so that the epidemic in Malawi does not reach the predictions of thousands of cases in our hospitals.
4.Contact tracing: Since Covid-19 transmission is mostly through personal contact, and given that the average Malawi household size is 4.5, this means that a person who tests positive might have already infected up to 4 members of their household before they are discovered.
Clearly, if there is no full isolation and in crowded urban areas and markets a single case can infect dozens. We can achieve significant contact tracing by using lay civil servants who are being paid by the government, but staying at home because of current restrictions on going to work. With 5—10 tracers per case we would get significant information about the contacts in the network of a positive case to help prevent further spread of the virus.
5.Testing all arriving at our borders: It is vital that all people arriving at the border get tested and obtain results within minutes. Closing borders would not work. Moreover, as a land-locked country, border movement is inevitable since Malawi is reliant on its neighbours for the transportation of its essential supplies.
By accepting that some traffic is necessary and that our borders are too porous anyway, the message should be that, ‘if you are coming into Malawi, you must accept to be tested or be quarantined for 14 days’.
- Use of face masks: Social science evidence tells us that people cannot sustain lockdowns for months on end—pictures of hundreds of New Yorkers sunbathing this weekend when the city is in lockdown is a case in point. Stopping people from attending religious meetings or funerals of loved ones may be the correct approach, but it is not socially or culturally desirable and it does not appear to be working anyway.
Furthermore, politicians have been among the first to disobey these rules because they are holding political rallies to big crowds of people in the run-up- to the fresh presidential election. If we cannot stop such gatherings where it is impossible to social distance, we should ensure all attending such functions wear masks. Otherwise, we should expect to see an exponential growth of Covid-19 cases and disastrous consequences for our health and economic situation during the presidential election campaign period and after the election.
*Nyovani Madise, PhD, DSc, is the Country Director of the African Institute for Development Policy (Afidep). She has advised WHO on epidemics and also sits on strategic advisory groups of the UK Department of Health and Social Care, Department of International Development, and Medical Research Council. The views expressed in this opinion piece are the author’s and do not necessarily reflect those of Afidep.
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