Malawi’s Market Mamas and Papas – Why neither lockdown nor herd immunity is an option

 

On April 2, 2020, three weeks after declaring a nation-wide state of emergency and well behind the reporting curve elsewhere, Malawi’s government publicly reported the country’s first cases of the coronavirus disease (COVID-19).  Within that first week, 16 confirmed cases and two deaths were attributed to COVID-19.  In the last week of December 2020, the rate of weekly infection was running at a reported 193 new cases, adding to the now total 6,377 people infected and 188 deaths although, as in so many countries, the full number of infections and deaths from the coronavirus disease will probably never be known, in part because of low testing rates.  But the ongoing rate of infection has been concerning enough that on December 23, 2020, the authorities announced a 14-day closure of the landlocked country’s international borders although shying away from an internal lockdown. The move recognizes the importance of restricting connectivity and travel in containing or circuit-breaking the spread of the disease, and borne out by several recent urban planning studies that weigh the impacts of urban density and connectivity in transmission.

Malawi does not make it into the international news very often.  A landlocked country in Central Africa, it is known, if at all, through its tourism byline as “the warm heart of Africa”.  But compounding the alarming coronavirus news is that festering behind the warmth and friendliness shown to all travelers, is a people smitten by one of the highest poverty rates in the world and a history of poor governance that have meant little progress in addressing poverty and inequality over the past decades.  And whilst a child born today might have a three-times greater chance of surviving to the age of five and a 17% higher probability of finishing primary school than if they had been born 15 years ago, GNI per capita remains an impossibly meagre US$380/year.  Nearly three out of four Malawians somehow subsist on less than US$1.90 per day – insufficient to meet a basic daily calorie intake.  In a country that is only 17 percent urbanized, rain-fed agriculture and fishing-based livelihoods are routinely afflicted by insect plagues and weather shocks such as droughts and floods which have been noticeably increasing in intensity and frequency due to climate change.

Add to this that Malawi and its neighboring countries lie along the north-south trucking corridors through Africa and have faced a multi-decades long HIV/AIDS epidemic.  By mid-2006, WHO was reporting HIV/AIDS as the leading cause of death in the region amongst the productive age groups. Today, around 70 percent of people in the world living with the disease are in Sub Saharan Africa.  One in ten adults in Malawi are infected and the country has anywhere between 500,000 (WHO) to two million orphans and vulnerable children directly related the AIDS epidemic (see Paul Mkandawire’s thoughtful “Vulnerability of HIV/AIDS orphans to floods in Malawi”).  As so poignantly documented (in Kenya) in Andrew Tkach’s and Christiane Amanpour’s Where have all the parents gone?, deaths and the reduced ability for physical labor amongst working-age people further impoverishes families.  Generations of grandparents are now having to work longer hours and shoulder the ongoing obligations of family breadwinner, care-giver and child-carer.

The ‘fifth-risk’ – the risk of an international viral outbreak that had been worried about by some but ignored by most, has swept across the globe in 2020.  In less than four months, it had touched every country on the planet.  Now, in December 2020, and after close to a year of the world learning to live with the coronavirus pandemic, we have all become armchair epidemiologists, but it is only the most perverse who continue to maintain that livelihoods vs. health is a binary choice.  So, back in April 2020, when Malawi’s then ‘Tipp-ex President’ Mutharika announced a mandatory 21-day nationwide total lockdown that would close food markets and non-essential businesses, restrict hours for (outdoor) farming, and only allow health and emergency services workers to use public transport, it was not unsurprising to hear on international news stations that Malawi’s market vendors in Blantyre and Mzuzu were angrily protesting in the streets and that they had joined forces with the Human Rights Defenders Coalition to successfully challenge the lockdown order in court.  Similar news stories of dramatically enforced total lockdowns have emerged from cities across the Global South from India to South Africa to Nigeria, highlighting the plight of informal and casual workers who form the majority of many of the countries’ workforces and who, even under pre-pandemic circumstances, faced daily food shortages and lived from hand to mouth with no buffer to weather shocks.  

The strongest health advocates recognize that in countries and parts of countries where the populations are largely ignored by their governments, calls for lockdowns are nothing more than political virtue-signaling by politicians if they are not accompanied by equal or greater commitment to roll out testing/ tracing/ containment (a.k.a. quarantine, self-isolation) protocols, ramp up woefully under-resourced health treatment facilities with additional adequately protected staff, and provide basic services and  income support for those most affected by the restrictions.  In short, lockdowns are a measure intended to buy time where basic preventative measures (social distancing, mask wearing and where possible, regular hand washing) have not been achieved and until mass vaccinations are possible.    

Throughout 2020, many countries – rich or poor, democratic or centrally planned, large or small, led by women or men, and densely or less densely settled have cautiously and responsibly managed to find a balanced approach to protecting lives whilst at the same time stimulating lower risk economic activities and providing profligate support to affected and vulnerable groups.  Countries such as Australia, New Zealand, Singapore, South Korea, Japan, Vietnam, Germany, Finland, Norway, Vanuatu, Samoa, Kiribati, and many more will have lessons for all of us in the years to come, including of governments communicating clear and unambiguous health messages and providing equitable basic services and economic support measures, and of citizens being concerned for and helping their own families and neighbors.  For every crazy that this year has thrown up, there have been countless examples of resilience in action where countries, communities and individuals have embraced measures “ to effectively manage their own layer of risk”.

At the time of writing this blogpost (December 2020), several countries - including wealthier ones with less enviable records of COVID-19 management, are developing policies and commencing vaccine delivery for  healthcare and essential workers, vulnerable groups and the elderly.  Populations are eagerly anticipating that safe and effective vaccines can be rolled out, for free, to those that want them over the coming weeks and months and in the hope that by mid-2021, life for people living in these countries might “return to normal”.  We also know - but do not speak enough about, that vaccination roll out will be a logistical nightmare and will require recruitment and multi-year funding for huge numbers of trained health workers to administer the cold-stored vaccines.  Widespread vaccinations in countries with the least buffers (including most of Sub Saharan Africa and South Asia) are unlikely to be available any time before 2024, even if funding were assured through the COVAX alliance (which it is not).

Tinkering with one of the online  models or browsing the Surgo Foundation’s comprehensive COVID Community Vulnerability Index (above) one gets a chilling picture of the numbers of people in the world’s poorer regions who are at almost inevitable risk of becoming seriously ill and or dying from the coronavirus disease before vaccinations reach them.  The Food and Agriculture Organization has estimated  that the number of undernourished people has increased by up to 132 million people in 2020 due to the pandemic. The World Bank predicts that extreme poverty is rising for the first time in 20 years and that the pandemic is pushing between 88-115 million people into ‘extreme poverty’ (less than US$1.90/day) and doubling the number of ‘new poor’ (less than US$3.20 per day).  In fact, losses in well-being are being felt against all metrics and even worse than predictions that were being made by the OECD less than six months ago (see below).   Along with growing inequality within and between countries, this also raises the potential for civil unrest and armed conflict.

This should worry all of us.  As a world, we are no closer to resolving the 2,400-year-old ethical dilemma captured in Plato’s Gorgias dialogue between Callicles and Socrates.  As wealthier societies debate their Calliclean "natural right" to be first in line for COVID-19 vaccines versus the tempered Socratic view that we would all be better off ensuring that everyone, everywhere had the same right to return to a pre-pandemic normal as soon as possible, the urban poor - as exemplified by Malawi’s Market Mamas and Papas, are not waiting for outside help.  Everywhere, very simple but effective measures of making and wearing masks (see pattern), contact tracing and messaging, and (where possible) handwashing are in use.  Urban planners, myself included, are digging through long shelved lessons on how to more efficiently deliver basic services such as water and sanitation, prepare more strategic guided city expansion plans, and scale-up affordable, well-located sites and services new subdivisions, and cheap and efficient transportation services to accommodate the expansion rather than continual containment and densification that in turn has forced unplanned, unserviced sprawl of rapidly growing cities.

Are there limits to what can or should be expected and will the impacts of COVID-19 be one burden too many for some communities and families? The question of how to respond to the world’s urban and rural poor is not a question of if, it is rather a question of will each of us, and how?  As we excitedly await vaccine rollout over the coming months, let’s spare a thought and possibly even some charity for those who may only receive vaccinations sometime around 2024 and may otherwise buckle before then. 

    Photo credit: https://www.imvelosafarilodges.com/hwange-needs-you.html