COVID-19 hit the world on a massive scale. Despite its presence as a global issue, nations are each responding to the pandemic differently. Those living in underserved countries have different perceptions of the virus and how their healthcare systems and country should respond.
Center for Vaccine Research’s interning physicians, Keiko Pempho Msusa and Nginache Victoria Nampota, share their experiences of working in the healthcare system in Malawi during the COVID-19 pandemic.
We spoke with the Center for Vaccine Research’s interning physicians, Keiko Pempho Msusa and Nginache Victoria Nampota, to share their experiences of working in the healthcare system in Malawi during this pandemic. Keiko and Nginache are currently completing the University of Siena’s Master of Vaccinology Program.
What has your experience been like with COVID in Malawi to date?
NN: When COVID was devastating the rest of the world, we as a country were a bit worried, thinking it would have the same effect here in Malawi. When the disease finally arrived, the government went into defense mode—restrictions happened quickly. Many of us were worried about the trends at the time, but we weren't getting that many cases.
People started thinking COVID was a political disease, not a real thing. People started to relax like life was back to normal. Then, around June/July, we saw a surge in cases and deaths. Only then did we start taking COVID more seriously.
Personally, I lost my dad to COVID just a month ago, so it's hit me quite hard. In general, it hasn't hit as hard as the western world. Many people are confused as to why.
KM: Our country experienced a surge in cases after the government decided to repatriate migrant workers from South Africa. As we know, South Africa is the worst-off country dealing with COVID in Africa. This also led to an increase in the number of COVID-related deaths. This surge in cases was met by election season, with mass campaign rallies every other day. That added to the numbers of active cases.
On a personal level, I lost my aunt to COVID in July. I don't think this pandemic truly hits you until you've had a personal loss. For me, it didn't really register until I lost my aunt. It was such a devastating loss for me.
Can you tell us about the challenges doctors like you face in effectively treating patients with COVID?
KM: While Nginache and I are both medical doctors, we don't work on the frontlines. However, we do have a lot of friends and colleagues who do. When Malawi started registering COVID cases, I recall that some frontline workers actually went on strike due to a lack of personal protective equipment (PPE) and risk allowances. As a result, two of the largest tertiary hospitals in the country closed down temporarily, because the frontline employees refused to work.
It was difficult to manage patients with COVID. The lack of ventilators, amongst other things, added to the problem. However, with time, and other organizations donating to the cause, healthcare workers felt more comfortable managing the COVID patients.
NN: It first started in cities and people on the ground were only partially prepared. The first issue was lack of the risk allowance. I'm not sure if it's the same all around the world, but I think in some countries, medical workers can acquire risk allowance to cover any accidents or anything that happens within the workplace.
For a long time in Malawi, the monetary amount for risk allowance had not been adjusted, even though the cost of living has increased significantly since the risk allowance was first introduced. I think it was the equivalent of $2 when it started. Health care workers were up in arms, expressing frustration over putting their lives at risk, having inadequate PPE, and no provisions in case they got sick.
Another issue they faced was a lack of information. The doctors and the nurses in urban areas had access to the Internet and information on COVID, but practices in rural areas of the districts didn't have as much access. They were scared. At the beginning of the pandemic if someone was a COVID suspect, healthcare workers would run away, actually refusing to treat people and touch them. A few people lost their lives due to inadequate care.
When we started getting severe cases, we couldn't treat them adequately. One of the main treatments for severe cases is ventilation. We, to date, don't have the ventilation that COVID-19 participants need. Even just basic oxygen wasn't readily available. Luckily, an oxygen plant was built at the largest referral hospital. We’re now able to deliver at least 15 liters of oxygen to the seriously ill. That’s still not ideal, but it’s the best they could do with what they had.
Why do you think people in your country thought COVID wasn’t real, or was more of a disease of the affluent? What problems could arise from that way of thinking?
KM: It took so long for African countries to register the COVID cases. The first COVID case on the continent was registered in February. In Malawi, the first COVID case was registered in early April. Initially, it appeared to be a disease of the affluent, largely due to the fact that they were the only ones with access to testing. People in rural areas may have been infected, asymptomatic or not, but the country did not have the testing capacity to reach the rural areas.
Due to the slow progression of the pandemic, in comparison to non-African countries, many people didn’t believe this could be a global pandemic.
When the previous ruling government made a decision for the country to go into lockdown, many people rejected this order. There was a nation-wide strike. The people went to court with it because they just didn't believe the pandemic affected the country to where a lockdown was necessary. Additionally, people believed a nation-wide lockdown was not going to be sustainable for such a poor nation.
NN: COVID is a disease that came by plane to Africa, and there's not that many people who fly. The people who traveled were mostly affluent, so COVID was more prominent in the affluent areas. It was also more prominent in the Asian community within our country.
People here actually thought it was an Asian disease. I know the Asian community received a lot of stigma in the beginning—they were the only ones getting sick at the time. The Asian community shut down their businesses and put themselves on lockdown, but eventually it spread to everyone else.
Can you tell us about perceptions of vaccines in Malawi and challenges in getting vaccines to broader masses there?
NN: From a research perspective, I work at a research clinic where we get involved in some vaccine studies. Here, I saw the perception of the general public towards vaccines is actually quite positive.
When we conducted a typhoid vaccine trial, people would show up on their own in large numbers to receive the vaccine. We even had to turn back participants who wanted to participate in this trial just because they trust health interventions. People in general get their children vaccinated in Malawi. When it comes to adult vaccination, like maternal—that one is a little more challenging. I guess they don't see the need anymore for vaccination when they are adults. But people are certainly eager to get children vaccinated.
KM: From a clinical perspective, when I worked in the hospital, I felt like the population in Malawi is trusting towards healthcare workers. If you explain to them that their children need to get vaccinated and the advantages of it, they will do it. Some may question you, but most will not.
I have worked with many pregnant women. A majority of them, if notified upon discharge, would come back after six weeks for the next round of vaccinations for their newborn babies. As a country, we also utilize health surveillance assistants. They travel around the rural, hard-to-reach areas, advocating for and administering vaccines. These health surveillance assistants usually live within the rural communities and are also trusted.
I noted that the overall coverage is quite high for childhood vaccination, however, for the maternal vaccinations, I found that healthcare workers would experience more resistance from pregnant women when advised to get vaccinated. Pregnant women ask a lot of questions. They would like to know how the vaccine would affect them or the baby.
How is COVID affecting Malawi’s neighboring countries? How is COVID affecting Africa’s population in general, and how are different countries governments responding?
NN: In Malawi, cases have been going down. We hit our peak sometime in August—since then, the case positivity rate is low. We had three tertiary hospitals admitting the worst COVID patients, and two of them are currently empty. Only one still has a few patients. So, for us, it's looking good right now.
For the surrounding countries, South Africa is the hardest hit, as we mentioned. Tanzania is the only country I am aware of who is managing COVID differently. For some time, the Tanzanian president said that they didn't have the disease and that they had a miracle cure, so people were not getting sick and their numbers were very low. Tanzania hasn’t reported cases for the past three months, so whether that's true or not is debatable.
In general, numbers throughout surrounding countries are similar. Our neighbor Mozambique has under 7,500 cases. Our other neighbor Zambia has under 15,000 cases.
KM: We're seeing a decline in cases. It's promising to see a decline in the daily reported cases as well as the deaths. But in Malawi specifically, I feel like we still have a high number of cumulative active cases as compared to the past few months. We haven't fully reached the other side of the curve yet as a country, so we still need to be proactive in testing and managing the cases. I think the gradual rise in the number of cases has made it difficult to identify a specific peak in the curve.
I feel like other African countries copied what South Africa did, going into lockdown without considering the local context. That’s another reason why people in Malawi protested against a lockdown. It didn't seem sustainable, especially in April when we only had a few cases.
As for nearby countries, I understand Tanzania decided not to report any more cases. I’m not sure if this is because they actually have no cases to report, or they just decided to keep it internal. Personally, I think they're just going by the notion that if you ignore it long enough, it'll go away, which is a wrong approach to take for any pandemic.
NN: I also think Malawi has done well in terms of controlling COVID. It’s because we started implementing preventive measures early. As soon as the disease started, the government made sure they communicated the numbers. People started doing simple things like social distancing, hand washing, and reducing the number of people at work. Unfortunately, we had a change in government, which derailed the efforts quite significantly. That's when we lost control of the pandemic investment.
Now that we’re politically stabilized again, all the measures are back in place. Even though we don't have all the resources we need, we’ve been able to stay afloat in the pandemic.
Do each of you have any takeaways from your experiences with COVID? What should the rest of the world consider regarding the pandemic?
NN: The smallest things make the biggest difference. I know people around the world are getting tired of their lockdowns and the social distancing. People have been locked inside for a long time, but social distancing, hand washing, and all those protocols do matter. Just look at Malawi!
KM: I think for us, our biggest worry was how we might overwhelm our already fragile healthcare system. We were so worried, but with the measures that were put in place early on, we minimized the pressure on our healthcare system.
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