By Titus H. Divala:
The month of July has so far been the most devastating in terms of new Covid-19 cases and deaths, and August 2020 promises to be worse. If not foreseen by authorities, this spike will further worsen the current burden on the health system, limitation of attention on all non-Covid-19 conditions (maternal and child health, HIV, malaria, tuberculosis, immunisations and many others), and lead to an unprecedented rise in preventable mortality.
The unprecedented rise in the Covid-19 burden will also worsen the current economic slowdown, job losses, education stagnation, hunger and poverty, all which will bring in more deaths and long-term social and economic injury to the society. I call all this Covid-19 collateral damage.
Currently, the best known chance of putting a complete stop to Covid-19 lies in pharmaceutical interventions: effective vaccines or treatment. Unfortunately, effective pharmaceutical interventions will take time to become available and once available, will also take even more time to reach Malawi due to global-health politics.
Meanwhile, our population is suffering serious social and economic consequences and our children have already lost months of school. We cannot stay closed forever; it now is time to quickly focus on how we can open while still managing to keep transmission and mortality to a minimum. At this point, I would urge the government to invest in research that can lead to locally brewed solutions for moving forward.
In my opinion, we are at a time where we should draw battle lines between the pandemic and the population’s routine productivity. The key and urgent pillars for such successful co-existence with Covid-19 include having a clear roadmap to the lifting of restrictions, putting a good legal framework in place, strengthening the health system and ensuring workforce safety and remuneration, detailed community engagement and stimulating local evidence generation and innovation. I will now discuss each of these and why I think they should be fixed as a matter of urgency.
To successfully strike a co-existence balance with Covid-19, the first key step is having a clear roadmap to the trigger, increasing, or lifting of Covid-19 interventions in which clear answers already publicly exist for questions like: when can schools open? This kind of roadmap however, is only possible with good quality real-time epidemic status monitoring, which we are yet to have at the moment.
The daily statistics which the Public Health Institute kindly puts together (an enormous task!) may not adequately represent the true status of the epidemic as would a deliberate system that examines random subsets of individuals. For example, to know the status in Blantyre, we would divide the district in segments and test a certain number from each segment, or we would sample at a selected number of health facilities and communities.
If such sampling is repeated over time, one would know whether the cases and deaths are increasing or not, and whether to implement or stop interventions, and monitor their success. Without data of this quality, no one can tell you whether closing schools, or offices back in March, helped the country in any way; nor can anyone confidently prove that political rallies worsened the epidemic; more importantly, we cannot say when the right time to reopen schools will be. Co-existence with Covid-19 will require accurate data and I urge the government to invest accordingly.
Despite getting Covid-19 pretty late and with all data at hand, we, as a country, have not managed to fully utilise the interventions in part due to weak governance but perhaps mainly due to lack of a legal platform. Imagine up to now, mask wearing (a month-old intervention) is not mandatory on the streets.
Epidemic management without guiding legislative framework is very challenging, more so in a democratic society where people’s voice matters. In most democracies, government scientists had to spend the beginning of the epidemic presenting their national response plans to members of parliament, and governments’ Covid-19 budgets had to be subjected to similar scrutiny by the people’s representatives.
Key in such legislation would be allocation of resources that allows the health sector to manage the pandemic, and all its functions as it was before Covid-19. Another challenge that I have observed and can be addressed through legislation is the governance structure being too long and too slow for epidemic-style decision-making and implementation. And at times the Presidential Task Force on Covid-19 would make decisions that are not obeyed by government departments. A clear relationship between Covid-19 management and existing government structures needs to be spelled in such legislation is critical as we map our way to co-existence with Covid-19.
The next and most important, yet underutilised gem for successful journey to co-existence with Covid-19 is community engagement. Note that I am not referring to health education, civic education, or public awareness, but “mphamvu kwa anthu.” There is no better way of managing Covid-19 than using community structures because both transmission potential and prevention efforts target and act on communities.
It is very depressing that community health has not featured in most response agendas. Co-existence with Covid-19 will only be possible if we successfully equip and empower communities to manage their local epidemics. We need to help communities establish local committees that decide on, implement and enforce Covid-19 prevention interventions, case finding, contact tracing and mortality minimisation by identification and shielding of individuals at a high risk of dying from the virus (those with age 60+, hypertension, diabetes, HIV, chronic heart and lung disease).
Communities can also be supported to set up systems for rapidly identifying and channelling people with severe illness to treatment facilities for timely commencement of oxygen and other care options (triage system).
Once cases leave the community, we will need a strong health system that offers them timely services. The current state of the health system is only half of what we need for a healthy and successful co-existence with Covid-19. We need to boost our health workforce, boost the morale of health workers and expand our equipment and supplies access.
For budgeting and planning purposes, the health system goal is to ensure that we have enough resources to manage Covid-19 and all other conditions at the same speed as before the pandemic. Unfortunately, both Democratic Progressive Party and Tonse budgets of June/July 2020 missed these much-needed investments.
Covid-19 is very demanding in terms of human resources. The health system has had to reallocate most of its limited human resources to Covid-19 thereby suffocating the other departments. In addition, the rising numbers of health-worker infections, the frequent need to quarantine and indeed the extreme fatigue due to high workload, are all killing our already limited capacity.
Malawian health workers are the least paid in the region and this status has not changed with Covid-19 where even the little pay is deliberately delayed for no good explanation. Regarding equipment investments, the bulk of Covid-19 life-saving hinges on timely access to oxygen therapy, a very expensive gas unless you have a plant.
Only one such plant exists, thanks to Malawi-Liverpool Wellcome Trust and College of Medicine. Th second set of very critical equipment are personal protective equipment (PPE). As we re-expand the health service to bring all services back to full speed, seeing every patient will have to be done in PPE. PPE costs can be driven down if investments into local manufacturing are done.
The success of co-existence depends on the foregoing changes and interventions which in turn are as good as how much research and continuous monitoring goes into them. Fortunately, solutions to all the above challenges already exist in the country and are just dying for government investment. As of 22 March 2020, the Kuteteza Project, a collaboration of University of Malawi’s College of Medicine, Malawi Liverpool Wellcome Trust and Society of Medical Doctors, had already developed the community-led interventions needed to reduce the burden on secondary and tertiary care levels, reduce overall mortality and streamline care for the very sick.
The School of Public Health and Family Medicine at College of Medicine has the capacity to facilitate rapid development of Covid-19 public health law. The College of Medicine has the technical capacity to monitor the epidemic and provide real-time epidemic status data. The University of Malawi’s Polytechnic has huge and proven potential to significantly cut our PPE bill. The Malawi University of Science and Technology also does have a lot of potential which, if invested in, is bound to cut a lot of our co-existence costs.
I therefore urge the Malawi government to quickly man up and start footing local research and development costs if co-existence is to be successful. The management of the epidemic demands local evidence and local innovation, without which our battle will be short-sighted.
As we all play a role to slow the pandemic and minimise direct and indirect damage and curb associated harms on our society, the state must open its eyes to the equally threatening build-up of forms of Covid-19 collateral damage. Success in the Covid-19 fight should therefore not be viewed in isolation, but as part of the full context, which includes all the indirect harms and concerns described in the foregoing. It is the foregoing discussion that compelled me to recommend the following to the Tonse government: pay attention to the worsening Covid-19 collateral damage and seriously consider a co-existence pathway.
The author is a medical doctor and an epidemiologist