The Cost

COVID-19 has taken the entire world by storm with almost nowhere left untouched. It has altered all our realities. And for the public health sector, it has left some of us with our heads spinning.

According to the CDC, "Older adults, 65 years and older, are at higher risk for severe illness and death from COVID-19.” [1] Those with underlying health conditions are also more vulnerable to severe illness. These populations especially must be kept safe. But what does that mean for others? The CDC states that "based on available evidence, children do not appear to be at higher risk for COVID-19 than adults. While some children and infants have been sick with COVID-19, adults make up most of the known cases to date.” [2] Around the world, over 350,000 people so far are known to have died from COVID-19. On the African continent, there have been 119,454 confirmed cases with 3,592 deaths as of 27 May 2020 [3] with the country of Malawi (population approx. 18 million) having 101 cases and 4 deaths.

To ensure deaths do not climb higher and health care services do not become overrun, the world has decided by and large to lock down, reduce and stop service delivery in many different sectors. Interestingly enough, the COVID-19 health response has also impacted other critical public health programs. It wasn't just added to the health response but it came with a trade. And so I ask myself, what is the cost of a good health response to one virus at the expense of another?

Only history will show what was right. In the middle of this crisis the numbers I am presenting today will most certainly change even by tomorrow. And everything presented could be wrong. But I have found myself constantly rebelling against the dire and apocalyptic COVID-19 predictions for the African continent [4] and perhaps that's the lens I take today. And yet at the same time I wonder, what if Malawi escapes the projected doom of COVID-19 only to enter into another? I am not an epidemiologist. But I do work in public health and after 7 years in Malawi I've seen the devastation that forgotten diseases and parasites have wrought. What could be the cost if we allow COVID-19 to push them even more into the background?

To note, this blog may present concepts and movements that have also been seen in the Western context but throughout I will maintain that there are vast differences between the costs in high income versus low and middle income countries. I acknowledge losing a job during a lockdown is devastating. But what if that loss expanded to acute malnutrition and complete bankruptcy within only a matter of days? Or expanded to death from a parasite that was not treated in time due to a lockdown? We may all incur costs and losses during this time but I argue that in certain spaces, they accrue exponentially faster and higher.

As we dive into some specifics of the African continent and the country of Malawi my intent is not to portray the stereotypical poverty narrative. Know in advance that every disease and challenge discussed here has large numbers of people behind it fighting bravely to bring a better tomorrow and that historically there has been much progress. The continent of Africa and even the country of Malawi are incredibly diverse and no one statistic can be taken to represent the whole. Statistics after all are just numbers- they don't explain the history or context behind them. At the same time we do need to be honest in presenting the challenges this place faces. Poverty and disease cannot and should not be ignored. Just remember throughout this blog they are only part of the story and not the whole. There's always so much more. . . [5]

The last few weeks have been interesting for me. I've yet to come across or know anyone who is a suspect for or has the corona virus that they know of. But I've come across so much else. One of my former students texted me that she is with her mum in the hospital as her mum is fighting tuberculosis (TB) and is very ill. The same week another dear family member of ours was ill with high blood pressure and seizures. The hospital unfortunately had run out of the medicine he needed and without it he suffered greatly. The next week a friend in Lilongwe informed me one of her family members might have a cancerous tumor but they were having trouble getting a diagnosis from the central government hospital since some routine clinics had closed due to COVID-19. The tumor was causing much pain. And lastly hospitals around the central region of Malawi continue to be full of malaria cases. On top of this schools in Malawi are currently closed. Many children receive meals through school feeding programs and without this it's been a scramble to ensure children maintain a nutritious diet. We've heard the call for assistance far and wide from many people doing good work in response to this challenge.

LIVELIHOOD.

Malawi has approximately 18 million people who reside within the borders of a landlocked country which presents many challenges including a high cost of commodities. According to the World Bank, agriculture employees nearly 80% of the population and the majority of the population remains rural. Currently only 11-12% of the population have access to electricity which is extremely low. The IMF estimates 50.7% of the population live below the poverty line ($1.90 per day) and 25% live in extreme poverty. In 2013, 65% of all households reported experiencing food insecurity for at least 1 month out of the year. This percentage can fluctuate due to rain and harvest patterns but it remains unstable.

In addition to farming, many Malawians engage in peace works (ganyu) and other small-scale income generating activities (IGAs) to earn money. This can include road works, domestic help, bike taxi, selling charcoal, selling vegetables, weaving baskets, etc. Many of these activities bring in a small daily wage that is counted upon to buy relish for supper or address other needs. A 2010 study by Catholic Relief Services (CRS) looked at the earnings for such work. They estimated ganyu earned people about 100 to 1,000 Malawi kwacha per month (2010 exchange rate of 122 MWK to $1 USD means $.81 to $8). IGAs earned people 200-300 MWK ($1.63-$2.45) per month. Fishing families earned about 500 MWK per day ($4.09). The conclusion was that this was insufficient income to buy enough food and their food situation was critical. The 2017 Malawi Demographic Health Survey (MDHS) found that 37% of children under 5 years were suffering from chronic malnutrition and stunted height for age.

From looking at this data, one can see quickly how even a week of lockdowns can leave a family vulnerable with high risk of hunger, disease, poverty. When so many rely on a daily earning to use for food, transport, hospital bills, etc. (commonly known as “hand to mouth” living), that daily earning cannot simply be taken away. Times news in Malawi reported that 8.7 million Malawians could face hunger during a lockdown [6]. And The Nation posted findings from an Afrobarometer survey showing that “only 21 out of every 100 Malawian have enough food throughout the year.” They also noted at “76% of Malawians go hungry with increased frequency than other counties on the African continent.” [7]

The UN has reported that in West Africa "an estimated 12 million children under 5 years old could be acutely malnourished in the lean season from June to August [2020] up from 8.2 million in the same period last year." They also say an additional 20 million people could struggle to feed themselves due to the socio-economic impact of COVID-19 over the next 6 months with a total of 43 million food insecure in the region [8]. The World Food Programme (WFP) has also estimated that the lives and livelihoods of 265 million people in low and middle-income countries will be under severe threat unless swift action is taken to tackle the pandemic, up from a current 135 million [9]. The numbers are astounding right? Almost too much to comprehend or process.

When Malawi announced a 21 day lockdown the country from north to south took to the streets and declared there would be no lockdown in Malawi. Not because they did not care about each other but because they did. And not because they don't have concern for the corona virus. Because while the virus could become a threat, the lockdown was for sure a certain threat. Coupled with low trust in the current administration to help carry them through, the loss of daily livelihoods they knew would ensure disaster. With only 12% of people having access to electricity there is no way to properly store or refrigerate food for large amounts of time. There is also not enough capital to buy the food to store. Lockdowns- now we see perhaps they are a privilege.

"Covid-19 is potentially catastrophic for millions who are already hanging by a threat," said Dr. Arif Husain, chief economist at the World Food Programme. "It is a hammer blow for millions more who can only eat if they earn a wage. Lockdowns and global economic recession have already decimated their nest eggs. It only takes one more shock- like Covid 19- to push them over the edge. We must collectively act now to mitigate the impact of this global catastrophe." [10]

A Global Food Crises Report suggests “chief among worries are countries across Africa and the Middle East — with shutdowns exacerbating poverty, more people are expected to die from the economic impact of COVID-19 than from the virus itself. . . In countries such as Afghanistan, the Democratic Republic of Congo, South Sudan, Syria, Yemen and Zimbabwe, “national health systems are already overstretched, with an alarming dearth of equipment, medicines and trained staff”.” [11]

The chief of health at Unicef has cautioned that "indiscriminate lockdown measures do not have an optimal effect on the virus. . . if you're asking families to stay at home in one room in a slum, without food or water, that won't limit virus transmission. . . One size fits no one. The objective is to slow the virus, not to lockdown people. We need to lift our eyes and look at the total picture of public health." [12]

As we speak, many low-income countries are under lockdown. What is the cost? Stop lockdowns in less-developed countries. Unless we are ensuring everyone has food to eat? Are we willing to ensure the cost of COVID-19 is not starvation?

MALARIA.

The Ministry of Health in Malawi says on their website that malaria accounts for 18% of all hospital deaths in the country. And the President’s Malaria Initiative (PMI) said in 2018 there were 6.2 million presumed and confirmed malaria cases in Malawi annually with 3.2 million being children under 5 years. The World Health Organization estimated there were over 8,000 deaths with PMI stating there were 18,875 inpatient malaria deaths in Malawi. Whoa. It’s reported Malawi has the 5^th highest number of malaria cases in eastern and southern Africa. [13]

When I came to Malawi as a Peace Corps Volunteer the one drug I had to consistently take was the malaria prophylaxis which helped ensure the parasite was not able to reproduce in our systems and make us sick. Over the years we’ve heard of other volunteers across the continent dying from the disease in horror stories. But it only took a few months living in this country to very easily see the effects just around us with our neighbors and friends. Malaria is a killer and one especially that comes for children.

Another thing we learned when first coming to Malawi was that for any fever we must suspect malaria. It is common for malaria messages in communities to emphasize visiting the health facility as soon as possible if there is a fever. With coronavirus guidance urging caution before visiting healthcare facilities especially with symptoms such as fever, it could affect rapid malaria care as people delay their visit. With malaria imminently still causing so much sickness and death especially among children this is a critical paradox that must be urgently addressed.

In 2018, 228 million people globally were sick from malaria in 89 countries. It is now being predicted that “malaria deaths in sub-saharan Africa could jump to 769,000. That’s twice the number of deaths reported in the region in 2018. And to put that number into perspective, total malaria deaths worldwide were 405,000 in 2018.” [14] Of course we’ve seen such predictions with COVID-19 and many of us still believe the continent will use its resourcefulness to not reach such devastating heights. But you can’t help but wonder if globally the response to corona virus could in turn help fuel such further challenges for malaria endemic countries. “Severe disruptions to insecticide-treated campaigns and in access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa.” [15]

Is this cost acceptable in light of our COVID-19 response? Or is there a better way? There can never only be one way. . .

VACCINES.

We’ve come a long way thanks to vaccines. The Expanded Programme on Immunizations was established in Malawi in 1979 and has been largely successful. Viruses like polio are now rare in Malawi.

But due to COVID-19, measles and polio vaccine campaigns have now been suspended in many different countries. “Many public health experts say they are worried that deaths from diseases including cholera, rotavirus and diphtheria could far outstrip those from Cvoid-19 itself.” [16] UNICEFF has called for vaccinations to continue saying “Children missing out now on vaccines must not go their whole lives without protection from disease,” said Dr. Seth Berkley, CEO, Gavi, the Vaccine Alliance. “The legacy of COVID-19 must not include the global resurgence of other killers like measles and polio.” They have sent critical vaccine supplies and PPE to countries like the Democratic Republic of Congo to ensure the programs can safely continue. [17]

“Mass vaccination campaigns against a host of diseases are already grinding to a halt in many countries. For many children, these campaigns are the only chance to get vaccines. Some 13.5 million have already missed out on vaccinations for polio, measles, human papillomavirus, yellow fever, cholera, and meningitis since the suspension began,” Berkley says. “I tell you those numbers will be much larger than what we see today.” [18]

Can one virus hold the others at ransom? It’s a question we all must answer. What will be the cost of stopping such critical services?

HIV/AIDS & TB.

In 2015 TB Alert estimated there were 24 deaths per day from TB in Malawi. “In 2014, TB surpassed HIV as the world’s leading infectious disease killer . . . in 2017, 1.3 million people died from TB . . . it remains the leading cause of death among people living with HIV.” [19] UNAIDS states in 2018 there were 13,000 AIDS related deaths in Malawi and 38,000 new infections. Another disease where donor fatigue and loss of media attention has threatened funding and continued progress. And yet amazing progress has been made in Malawi and across the continent in diagnosing and treating HIV/AIDS. Millions of people now live full, healthy lives. We cannot loose these gain nor can we afford to increase the TB burden.

It is being predicted that “death could increase in sub-saharan Africa from 470,000 to 550,000 due to a 3-6 month interruption of services.” Reports from South Africa and Zimbabwe show some clients are already having trouble accessing needed medications and missing their antiretroviral (ARV) appointments. [20] Higher defaulters of clients needing ARVs could be a dangerous development in the HIV response. Alongside HIV, TB deaths could also increase between 2020 and 2025 to an additional 1.4 million “as a direct consequence of the COVID-19 pandemic.” [21]

“But restrictions implemented worldwide because of coronavirus mean TB cases detection has “dramatically fallen,” treatments have been delayed, and those with drug-resistant TB risk the interruption of treatment, added the organization. The fight against TB could be set back five to eight years, the study suggests.” [22]

Are we willing to risk the gains made in both TB and HIV? How can we ensure they remain sustained? What will be the cost of clients unable to access medicines or diagnosis?

PROTECTION.

The last area I will mention is protection. There’s been much mentioned in the press lately about the rise in domestic abuse cases across the world. And unfortunately Malawi is not immune. I volunteer at a local all-girls secondary school which provides a safe environment for girls to learn with boarding facilities. When we found out all the girls had to be sent home some of the teachers were worried. What would happen to the girls?

The 2017 MDHS found Malawi’s rate of teen pregnancy was at 29% and had increased from 2010. Malawi also has the 12^th highest rate of child marriage with UNICEF finding in 2017 42% of girls were married by age 18 and 9% by age 15. The Malawi Adolescent Girl and Young Women (AGYW) Strategy states that HIV incidence is 8x higher in girls than boys. And in sub-saharan Africa, 4 times as many adolescent girls acquire HIV compared to boys their age. Sometimes this is fueled by violence as the Violence Against Children and Young Women Survey (VACS) in Malawi showed one in five females are sexually abused before age 18 and 38% reported their first sexual experience before age 18 was forced.

In the education field, less than 20% of girls who complete primary school enter into secondary school. A study released in 2015 done in Botswana showed a link between girls staying in school and reducing their risk to HIV. For every additional year of school their risk decreased by 8%. [23] School can be a critical tool to help prevent early marriage, pregnancy, violence and HIV. So with schools closed and education delayed, what could be the cost?

YONECO in Malawi published an article titled, “Bring back children to school!” The NGO Coalition on Child Rights (CCR) said “In some districts, cases of child abuse have increased during the Covid-19 school holiday period; cases of incest and sexual abuse violence or gender are largely feared on the child and the girls child in particular.” [24] Anecdotally I’ve heard teachers from many different schools have written the Ministry of Education asking them to put proper safety measures in place to allow children to safely return to school. While there have been attempts at online and radio learning, in a country with only 12% access to electricity, this leaves many out. In large rural, low income areas access to tablets, private radios, smart phones and internet data come at a high price and are not easy to afford for full-time schooling. Especially families with multiple children.

In a culture where staying indoors all day is largely against the norm, especially in rural and crowded areas, children end up congregating together anyways in large groups to play. While in a Western context not going to school means staying isolated with your family many times indoors all day, the context here is different. Many parents earn a daily wage outside the home and must work. Some parents are also illiterate and may be unable to help their children with school work (Malawi has a 62% adult literacy rate according to UNESCO; for comparison the US has 99%). [25] Many do not have electricity or the technology needed for “online” learning. Save the Children articulated this in an article titled “Coronavirus (COVID 19) is a Devastating Blow to Children in Poverty” where they stated that “Whilst the coronavirus has so far resulted in less severe cases among children, it can decimate their lives in a different way.” [26]

So how do we best protect our children during this time? Are our current interventions really protecting everyone? Or are some being put at an even higher risk? Are we going to ignore these conversations because they are uncomfortable or maybe against the prevailing “stay at home” narrative? What is the cost to our children and their future?

I’ve presented here some of the worst case scenarios presented in models and research. But no one can predict the future and if COVID-19 has taught us anything it’s that we must remain humble to what we do not know or understand. Perhaps sometime far in the future this might all make just a little more sense. But for now, we must care and empathize with our neighbor. And we must act where we see something is wrong. While the entire world may be experiencing the effects of the COVID-19 pandemic, as seen in this blog we are indeed not all in the same boat. The situation in Malawi comes with many compounding risks that require ingenuity and creativity to solve. And I’m proud to say I’ve seen many friends and neighbors stepping up to the challenge to care and look after their communities.

We won’t deny there is a need and call to action. Food assistance is a great one. And ensuring continued access to healthcare services for many of the diseases still common in this place. If you are interested in partnering with Malawi to ensure school children and adolescent girls remain safe and healthy and their families supported feel free to reach out. We know some wonderful Malawian organizations doing fantastic work on the ground during this crisis.

Let us not become single minded but remain open to the realities other parts of the world face and the severe vulnerability the COVID-19 response, shut-down and requirements has placed them in. Let us not be led by panic blind to its consequences. Let’s listen to the calls for action, hear other stories and ensure in our response we don’t drown out other requests and needs. We do not necessarily have to sacrifice other important public responses for the sake of one. This is a call to the brilliant and the bright to re-think and re-create. How else can this response be done? How can we improve it? How can we listen and respond to vulnerable voices? How can we recognize our own privilege in this pandemic? And let us count the total cost. Perhaps the currently unseen cost. Is it worth it? If not, let’s do better.