Stopping cholera in Malawi: firefighting measures are not enough

As Malawi continues to face a rampant cholera outbreak, local activists call for long-term investment in the health system and more health workers to complement short-term solutions

February 18, 2023 by Peoples Health Dispatch
Malawi cholera outbreak
Health workers attending to a patient at Tukombo Health Centre. (Photo: UNICEF Malawi)

Malawi continues to struggle with a cholera outbreak that started in March 2022, which has claimed over 1,000 lives so far and continues to threaten tens of thousands of people. This is only one of the cholera outbreaks registered last year, along with those in Haiti, Syria, and Lebanon. As always, the disease has hit the poorest people the hardest, including those living in refugee camps and rural areas without access to safe drinking water and sanitation. The surge in cholera outbreaks has been accompanied by an increased concern about the availability of vaccines and the capacity of health systems in the Global South to respond to the flare-ups as they continue to deal with the pressures caused by the COVID-19 pandemic.

As the World Health Organization (WHO) warns about the possible impacts of the outbreak on the overall health system in Malawi, especially in the light of a surge in the number of cases towards the end of 2022, the People’s Health Dispatch met with Wilson Asibu from the People’s Health Movement (PHM) Malawi to learn more about the context in which the outbreak is unfolding.

Peoples Health Dispatch (PHD): Can you tell us a bit more about the context in which the cholera outbreak happened, especially taking into consideration the effects of the COVID-19 pandemic? 

Wilson Asibu (WA): As you will be aware, most of the health systems in sub-Saharan Africa are dealing with many challenges, especially when it comes to human resources for health. When the COVID-19 pandemic began, we saw huge gaps in our healthcare system exposed even further. For example, the deficit of over 7,000 community health workers (CHWs) in rural areas, where approximately 84% of people live, meant that the effects of the pandemic were all the harsher for those in hard-to-reach areas. 

At the same time, we were not dealing only with the COVID-19 pandemic, but also with the HIV/AIDS pandemic. That was a huge pre-existing challenge, and COVID-19 only added to the strain that was already there. We saw a downward trend in HIV/AIDS interventions as the COVID-19 pandemic began, and that was because there were not enough resources to deal with both at the same time. Because all the health resources got reallocated for dealing with COVID-19, we saw falling numbers of the people taking HIV/AIDS treatment, among other things. 

In that regard, the COVID-19 pandemic had a great impact on the health system in Malawi. It showed that we do not have the capacity to tackle multiple problems at the same time, and that long-lasting challenges get sidelined if something as acute as COVID-19 comes up. This was not the case with HIV/AIDS alone, but also with conditions related to social determinants of health. I think that this is one of the reasons why this cholera outbreak has picked up so intensively: because issues related to living conditions, such as access to water and waste management, fell down on the agenda in the period we are talking about. Simply put, the cholera outbreak is also a challenge that is coming from the strain that was perpetuated on the health system by the COVID-19 pandemic.

PHD: The ongoing cholera outbreak started in early 2022, but instead of being brought under control, it actually became more serious by the end of the year. There is currently no sign that it might end soon. What happened over the course of the past year that made things go this way?

WA: As of February 9, there were 36,943 recorded cases and over 1,210 deaths in the ongoing cholera outbreak. These are official figures; the real numbers might be even higher, both in the case of confirmed cases and deaths. And at this point, the outbreak has spread to all 29 districts of Malawi. It’s a problem affecting the whole country. 

One reason behind this is probably that the government treated this outbreak as a small-scale problem, thinking that it would not escalate. It has to be said that this is the usual approach to the problem in Malawi, because almost every year, we have an outbreak of cholera. My opinion is that the government’s response hasn’t been robust enough in the past, and has opened the doors to something more serious. I remember that even ten years ago, we struggled with the same issues, which means that the problem was not addressed in an adequate way. Since the beginning of COVID-19, this was perhaps in part due to the strain caused by the recent pandemic and the HIV/AIDS pandemic, but also because of changes in government, and other factors. To that we have to add a lack of adherence to sanitation and hygiene practices, as well as lack of awareness-raising on these issues by the government and the media. There’s been a serious lack of proper public health interventions about these issues.

But I think we cannot ignore the fact that this particular disease is a disease of poverty, and it has been spreading because of that also. A lack of efforts to improve sanitation infrastructure and the availability of safe drinking water, especially in the rural areas, has also contributed to the situation we are facing today. I believe that a combination of these factors—a long-lasting failure to improve living conditions and implement public health interventions, the failure to address the outbreak in its early stages, including through instilling good hygiene practices, and the pressure on the health system caused by COVID-19 and HIV/AIDS—have led us to the point where cholera cases are found all over the country and are putting people’s lives at risk.

PHD: Looking at what can still be done, would you say there is still space for meaningful intervention? What should be done at the local and international levels to help the people and communities affected by the cholera outbreak?

WA: Right now, I believe we need international support for the Malawi government in terms of resources to contain the outbreak. Failing that, the outbreak could even intensify and cross the borders to Mozambique, Zambia, and also Tanzania, making this a regional problem. I think Malawi should be given the resources to fight the outbreak, but it should also be provided with technical support on how to handle the situation. This is the short-term part of the solution. But we have to look beyond that. Organizations like the People’s Health Movement (PHM) Malawi have been working on raising awareness about cholera and other poverty-related diseases among the people, since there was no real attempt to do that by the government. Supporting those efforts is also important for addressing the current situation. 

In the long term, we have to work on addressing the poverty aspects of cholera outbreaks. We need to improve access to safe drinking water. It is unacceptable that it is taking so long to ensure that everyone has access to potable water. The same goes for waste management. Some cities in Malawi, for example Lilongwe, still don’t have proper sites for waste disposal. Finally, we need to ensure that there are enough health workers in the health system. Not only should we have enough health workers in general, but we need health workers who are trained to respond in emergencies like this one. Of course, we have seen that a deficit of such a health workforce is not a problem particular for Malawi, but is shared by most countries in Southern Africa. 

I believe we have to give proper attention to the long-term aspects of the response. Otherwise, these issues will keep re-emerging, they will keep coming and claiming people’s lives. Right now, we are talking about over 1,210 lives lost. Should we wait for more to die? Now is the time for governments and international organizations like WHO to provide resources to contain the problem and to strengthen the local health system.

PHD: Do you see any particular areas of the health system where interventions can be implemented to counter, and perhaps prevent, outbreaks of other poverty-related diseases in the future?

WA: For that, I think we have to rethink the health system that we have at the moment. The health system should not be all about reacting to diseases, but should instead focus on prevention. Robust strategies should be put in place by governments and international organizations, including WHO, to prioritize prevention and promotion of health instead of the firefighting method we have witnessed during the COVID-19 pandemic. We have seen that some of the diseases that are claiming a lot of lives are preventable in nature. If we can support the prevention of these diseases and look at health promotion, we could make sure that the number of lives lost is significantly smaller than now. Of course we need to have good curative services for the immediate issues at hand, but, without prevention, our problems will continue.

Second, especially in low- and middle-income countries like Malawi, governments should find a way to make the most of the technology we have today. We need to see how this technology can help us increase access to good quality health care. 

Finally, as I have already said, many of the diseases we are fighting against are diseases of poverty. We are actually witnessing an increase of this kind of disease, and governments should address the elements that are driving or exacerbating these problems. This means strengthening health systems, but it also means fighting against unemployment, corruption, or lack of drinking water. We still have a long battle to fight when it comes to poverty-related diseases, and we will be defeated if governments do not begin to address the root causes of poverty.

To change the current status, we need to see much more cooperation and joint action. COVID-19 has provided us with good illustrations of what happens if people work in their own silos and ignore what is happening around them. We cannot say that the cholera outbreak in Malawi is only a Malawian problem, or just an African problem. These problems must be dealt with in cooperation between countries, organizations, and movements, otherwise we will fail. In order to bring about change, we need to see a lot more solidarity on the global scale.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.