Introduction
The WHO defines Cholera as an acute diarrhoeal infection aetiologically hinged on the contamination of water or food by Vibrio cholerae and ingested by individuals leading to dehydration and in worse situations, death.1 The Cholera outbreaks in Malawi have a long history of seasonal occurrence and of significant attention since the first quarter of 2022. Within 7 months covering March to October 2022, 6056 cases with 183 mortalities were reported and these were distributed across 27 out of the 29 existing districts of Malawi, implying a case fatality rate (CFR) of 3%. Within this period of the epidemic (EP-2022-000298-WI), five districts (Nkhata Ba, Nkhotakota, Rumphi, Karonga and Blantyre) were responsible for approximately 70% of cases and death.1 2 In the same first quarter of 2022 (January), there was an occurrence of tropical storm Ana (TC-2022-000161-ZWE). along with Cyclone Gombe (TC-2022-000184-MOZ) in March with associated massive floods leading to significant population migration due to displacement with previous evidence of low population immunity. This became worsened due to the consequential lack of facilities for water, sanitation and hygiene (WASH).2 3 The Cholera outbreak in Malawi officially reported between 2022 and 2023 became historically the most devastating with evidence of the highest mortality and morbidity in the country. The outbreak which started on 28 February 2022 had a total of 58 089 cases and 1741 deaths (CFR 3.0%) reported as of 21 April 2023 and all 29 districts of the country had reported one or several cases of cholera.4 In this same period, the highest number of cases were reported among males (58%) compared with females (42%), and the most affected age groups for whom sex and age were provided were 33.3% (10–19 years), 19% (20–29 years) and 15% (0–4 years) with varying degrees of protracted increased response workload on human resource for health that has witnessed multiple infectious diseases epidemics over the years across the districts.4 5
The devastating nature of the cholera emergency in Malawi became more aggravated by the hit of tropical cyclone Freddy (TCF) (TC-2023-000023-MDG) in the first quarter of 2023 which was witnessed in the Southern part of the country with a declaration of a state of disaster in fourteen districts. There is an uneven distribution of mortalities associated with the significantly characteristic TCF across the affected districts while many sustained varying degrees of injuries, and some were declared missing including multiple displaced households. Five districts (Nsanje, Chikwawa, Mulanje, Thyolo and Blantyre) were significantly hit by the TCF with close to 4000 households amounting to 19 000 displaced people in March 2023.6 To manage the impact (in terms of morbidity and mortality) of the recurrent and seasonal cholera outbreak in Malawi, Oral Cholera Vaccine (OCV) was introduced. A reactive campaign was conducted between March and April 2015 targeting 160 000 people of age 12 months and more residing across 19 camps, consequent to displacement by flood (FL-2015-000006-MWI) in the Nsanje district. It was regarded as an additional measure to complement impact-mitigating measures of improving WASH as a response to the cases that were confirmed through laboratory investigation.7
In this first round of the reactive campaign, 156 592 people were vaccinated against Cholera, which is approximately 98% of the target population of 160 482. The second round of the campaign which was conducted in April 2015 had 137 629 people being vaccinated with OCV, representing 85.8% of the target population. Out of this vaccinated population, 67.6% were people who received their second dose.7 It is noteworthy to state that the government of Malawi acted on the previous recommendations of WHO to mitigate the possible recurrence of cholera outbreak and these include the provision of potable water and sanitation structures where they were absent, active community engagement on campaign against open defecation, water and food hygiene, with a direct intensified focus on the most vulnerable population.6 The gains of these mitigating measures were minimal due to the pre-existing challenges centred around the lack of broken borehole maintenance, incessant disruption in piped water supply and considerably low coverage (less than 50%) of well-constructed pit latrines. This was compounded by low inhabitants’ compliance with relocation directives exampled by a continuous habitation around lakes by fishermen, all of which are attributed to social, cultural and economic reason.6 7
In 2023, the OCV campaign was also enacted in Malawi with vaccine donations from the International Coordinating Group and fully supported by the Vaccine Alliance. Because of these duo emergencies—TCF and Cholera in Malawi, there was a need to explore the impacts and the turn-out of events in the country about the consequences and the immediate humanitarian responses which can serve as a knowledge base for planning and implementing holistic disaster reduction measures and mitigate the impacts of similar events in Malawi, by all concerned stakeholders.
Population affected and impacted health and food security
14 districts were affected by the TCF with varying degrees of effects and they include Phalombe, Blantyre, Mangochi, Nsanje, Balaka, Chikwawa, Machinga, Mulanje, Mwanza, Zomba, Neno, Thyolo, Chiradzulu and Nicheu.8 The range of population proportion affected is 4.9%–6% with three districts—Phalombe, Nsanje and Chikwawa being the most affected. Although close to 600 000 people were unequally affected across the three most affected districts, a total population of 70 056 were heavily affected in all the thematic areas used in the disaster needs assessment.8 9 Chikwawa district ranked highest with a population proportion of 56.8% while Phalombe is the least affected with a population proportion of 14.3% (figure 1A).
A total of 2 267 458 (1 110 639 male and 1 156 819 female) people were affected generally by the TCF in Malawi with a high risk for more exposure to cholera disease. This represents female (51%) and male (49%) inhabitants. As shown in table 1, the under-5 children have the highest proportion (45%) among the vulnerable population affected. The health facilities’ structural damage by the TCF consequently disrupted service delivery to the affected population as there were losses of drugs, and damaged medical equipment, including loss of medical records and other supplies.
Disruption of education, WASH and movement logistics
A total of 624 schools across 22 education districts were affected by the TCF, with a total of 724 709 learners. As shown in figure 1B, among these, 50.8% were girls and 49.2% were boys. These statistics reflect the national higher proportion of the female population (10.2 million, 51%) than that of the male population (9.67 million, 49%) in Malawi as of 2021.10 The physical assessment report8 also revealed damages to classroom blocks, dormitories, teachers’ houses, administrative blocks, boreholes (deep narrow holes that are dug in strategic locations to provide potable water for catchment populations), shelters (living accommodation for the displaced populations), and kitchens including damage to teaching and learning materials and a high number of textbooks. Further findings showed that 944 784 people did not have access to WASH services due to the devastating effects of TCF as a total of 90 809 latrines collapsed. As shown in figure 1C, most of the affected categories of latrines are those located in various households (98.7%) while the proportion of other public spaces’ latrines was the least (0.5%). Almost every household in the historically flood-prone districts reportedly used non-sanitised shallow pit latrines with less-monitored WASH practices before the TCF with some populations known for open defecations.11 The reason for the small proportion of the affected public space latrines may be due to the improved quality of construction of public latrines over those of households as they are facilitated by experts and financed by the government, as stated by researchers who also advised a need for increased commitment to improving quality of household latrines for Malawi to achieve Sustainable Development Goal (SDG) 6.2.12 13
Distribution of TCF effects on districts, education, WASH and roads. TCF, tropical cyclone Freddy; WASH, water sanitation and hygiene.
Major roads were grossly affected. Blantyre roads (especially the major roads and bridges that provide access for economic and humanitarian activities) were damaged by floods and landslides disrupting the delivery of essential humanitarian supplies.14 Several affected areas in Chikwawa, Mulanje, Phalombe and Zomba districts required secondary but longer routes to access, and the entire Nsanje district was completely cut-off as roads were fully flooded and inaccessible by humanitarian vehicles for 2 weeks after the TCF.15 The evacuation of people was facilitated using special humanitarian missions’ rescues by boat—the mission coordinated by the National Transport and Logistics Cluster to the nearest temporary shelters provided.14 15 Vehicle access to secondary roads throughout the region was highly restricted, hindering the transportation of relief materials within the districts. A total of 44 roads were damaged and as represented in figure 1D, the secondary road has the highest proportion (38.6%) while that of the tertiary road, though the least but also of appreciable proportion (25%). Over 40 bridges were damaged in the 15 councils and power transmission lines (132KV and 66KV), and distribution infrastructure (poles and conductors) were damaged.8 15.
Impact on shelter and livelihoods
It was estimated that 146 506 households amounting to 659 278 persons were internally displaced in 14 councils across the affected districts of southern Malawi, consequent to the TCF. Close to 90% of this population were accommodated in various places—health facilities, designated camps, community childcare centres and schools including churches and mosques, with associated humanitarian needs. Approximately 202 096 hectares of cropped land belonging to 467 958 households were severely impacted. Consequently, 467 958 lost their crops (maize, cotton, groundnuts, rice, soybeans and sesame) to the complete wash-away effect of the TCF or submersion. Also, 1 428 584 combined livestock animals owned by 104 565 livestock keepers were either killed or injured by the floods.8
District-specific relationship between TCF and cholera
As shown in figures 2 and 3 with data sources from the Public Health Institute of Malawi, there were varying degrees of cholera cases and deaths across the TCF-affected 14 districts. However, the two districts of Nsanje and Chikwara were seen to have experienced an immediate increase in the number of cholera cases and deaths in the same month of March 2023 when the TCF occurred in Malawi. The increase in the number of cases and deaths may be directly or indirectly connected with the TCF impact-promoting factors as the two districts are in the lowest part of Malawi with the Ruo River flowing into them bringing heavy flooding during disasters. The situation has reportedly proved more difficult to improve due to the refusal of people heeding government’s directive to move to higher ground and the existing low WASH facilities, and open defecation in the two districts.11
Epigraphs showing the distribution of the number of cholera cases across the TCF-affected districts. TCF, tropical cyclone Freddy.
Epigraphs showing the distribution of the number of cholera deaths across the TCF-affected districts. TCF, tropical cyclone Freddy.
Humanitarian response in the camps
Consequent to the palpable magnitude of the humanitarian needs following the emergency, there were donations from various individuals, governments, organisations, humanitarian partners, companies and multilateral organisations. As of 6 April 2023, a total of 2 243 081 514.87 Malawi Kwacha (converted as approximately US$1 323 611)16 has been donated towards the emergency response. Findings also revealed multiple in-kind donations (quantified and unquantified) from many local and international organisations towards providing humanitarian services to ameliorate the negative impacts of the emergencies on the affected population.17 In the quest to facilitate the provision of temporary accommodation, the coordination of the required humanitarian response was led by the government working in conjunction with an established clusters coordination team to facilitate the establishment of camps at strategic locations. This was achieved by the creation of the emergency operation centre strategically located in Blantyre in the second week of March 2023 for effective emergency preparedness and response.18 The findings from a rapid assessment of seven major camps where internally displaced persons were accommodated, conducted in the first week of April 2023 revealed the distribution of the population being offered humanitarian services as summarised in table 2.
The proportion of the female population under humanitarian service in the seven major camps is 62.4% as represented in figure 4A, while the proportion of under-5 children was 69.2% among the vulnerable population as represented in figure 4B. The considerably high proportions of females and children among the affected population may not be unconnected with the fact that the female population are higher than that of the male population in Malawi and children are commonly affected population, needing humanitarian interventions along with their mothers during emergencies, implying that more female and children reside in camps during the emergency event.8 10 14
Distribution of the population in camps by gender and vulnerability categories. IDPs, internally displaced persons.
Health services emergency response in prioritised districts
With active coordination of the Ministry of Health, supported by the WHO and other humanitarian agencies, the peculiarity of the two most affected districts was identified and health services were rendered in a district-specific manner. In the Chikwawa district, a total of 1028 under-5 children were treated for common health conditions (mostly malaria, pneumonia and malnutrition) while 1487 received family planning services—being a district with notable barriers to maternal health service use.19 20 In Nsanje district, 2287 children received primary health services including 1115 people (children and women) who received various antigens of routine vaccination. Special health services were also carried out in the targeted districts. Close to half (44.6%) of the population (3273) that received HIV counselling services in Mulanje and Chiradzulu districts are adolescents with 26.1% of the same population being children.19 Table 3 shows that among these, 5 cases of HIV were newly detected and 121 infants and 221 pregnant and lactating women (PLWs) were linked and reconnected to HIV treatment services, respectively. These special services might have been rendered as part of the humanitarian intervention due to the impact the flood has had on the health facilities at the original locations of the affected districts from where the population were displaced and may also be associated with the fact that the southern part of Malawi, where most of the affected districts are located is more endemic with HIV.21 22
To bring the impacts of the cholera situation into control post-TCF, purposively selected villages within five selected districts (TCF and non-TCF affected) with the historically highest number of cholera cases and mortalities were targeted for OCV. Overall, 1.4 million doses of OCV were received for the campaign which was conducted between 24 April 2023 and 28 April 2023. In total, 881 855 people were vaccinated representing 62% of the targeted population. Salima district recorded the highest coverage of the targeted population for OCV (91.3%) while Thyolo has the lowest coverage (52.7%). Two of the TCF-affected districts (Thyolo and Mangochi) were among the five selected districts for OCV.23 24 In facilitating the amelioration of the effect of the emergency on the food supply of the displaced population who resided in various camps, the United Nations World Food Programme in collaboration with the local authorities provided immediate life-saving food supplies which included soya blend—a fortified food that has been precooked.25 Trucks were also made available for the humanitarian community for the transportation of supplies and the provision of boats for the purpose of ‘search and rescue’. This led to the rescue of 500 TCF-affected people. Airlift of medical supplies, fuel and food, and other humanitarian supplies were also facilitated.25
The implication of the humanitarian TCF-cholera situation in Malawi
The findings in this narrative study revealed that various aspects of human life were negatively impacted by the TCF. The cyclone impacted the lives of affected people in health, housing, nutrition, WASH, agriculture and livelihood, transport and logistics, and food security—all of which are closely linked to SDGs.26 Many researchers have emphasised the importance of the SDGs, associated facilitating factors, and the feasibility of achievement by 2030, emphasising the use of the proactive measures as paradigm shift suggested by WHO in the health emergency and disaster risk management framework.27 Experts also stressed the various steps to be taken by the Member States to achieve the set goals and the inherent challenges along with the progress reports.28–31 The impact of the previously experienced disasters in the African region has been well researched along with the need for adoptable mitigating policies.32–35 Also, the exposure of vulnerable populations—especially women and children to different lacks following the TCF in the affected districts—is of significant public health importance. Researchers have shown that women are often faced with making difficult decisions during disasters which can put them in difficult situations while faced with death or being abused—the duo potential consequences of disasters.33 35
The exposure to inadequate hygiene and reduced quality of living caused by lack of toilet facilities and shelters has also been revealed to cause violence and health risks during emergency events including increased cases of infectious diseases like cholera for women and children.36 The situation was found to be more aggravated when there is lowered access to quality health services which often accompany disaster events with unavoidable psychological impacts.37 38 The total or partial damage to 63 health facilities in the TCF-affected districts may slow down the pace of achieving the targets of the health-related SDG3 in the affected districts. This implies the need for taking proactive measures by all public health actors, including community members to proactively adopt disaster risk reduction measures that are multicriteria in nature and with public acceptance as suggested by researchers.39–41 The 98.7% of the latrines damaged across the TCF-affected districts were of households with palpable unpleasant impacts on the affected population, a factor that has been well recognised by researchers to be closely related to many SDGs especially SDG1 and SDG6 with a focus on ending poverty in all its forms everywhere and availability and sustainable management of WASH for all, respectively.42 43
The grave consequences of this on the population, as regards the possible increase in waterborne diseases including cholera, have been well established by researchers.44 45 It is then important for all stakeholders to engage in public education on effective policy development and implementation, using the whole-of-society approach to improve the situation.46 An increase in the number of cases and deaths in the Nsanje and Chikwawa districts in the same month (March 2023) that TCF occurred in the fourteen affected districts is of indispensable interest. This may not be unconnected with previous reports from humanitarian organisations which established the two districts as the most affected as regards population displacement and consequences during the cyclone-related floods.47 48
Controlling the situation has proved difficult as one of the livelihoods of the inhabitants of the two districts is fishing. This facilitates permanent settlement in the flood-prone areas with poor WASH facilities, and little or no compliance with resettlement plans from the relevant authority, making the government and humanitarian intervention more reactive rather than proactive.11 The peculiarities of the two neighbouring districts as regards the increased cholera cases and deaths after the TCF may be attributed to the special features of the districts having the presence of Ruo and Shire Rivers with recurrent overflowing during flood-related disasters associated with constant environmental and health impacts evidenced by vulnerability assessment reports and recurrent events.49–51 It is noteworthy to state that the various emergency responses towards addressing the immediate consequences of the TCF along with the associated cholera epidemic in terms of donations from governments and humanitarian agencies, provision of temporary accommodation/camps, health services including OCV of selected districts and life-saving responses are good, but stricter measures should be considered by all stakeholders to reduce the risk of flood-related disasters in the future using the relevant WHO disaster risk management framework.27
This multidimensional approach is hinged on the need to urgently adopt a disaster management cycle and ethics to reduce the possible biopsychosocial effects on the affected population and most specially to reduce the morbidities and mortalities to the lowest possible level as shown by various humanitarian response investigators.52–55 Generally, this paper revealed that the consequences and humanitarian response outcomes are more skewed towards women and children. It can further be seen that the gender with the highest population receiving humanitarian services across camps in the TCF-affected districts is females, confirming the higher proportion of female population in Malawi.10 In the same vein, PLW are more prominent among the core vulnerable population who were in various camps. Specifically, in the Chikwawa district, females are of the highest population under humanitarian services while children occupied the same population category in the Nsanje district, a common scenario in most of the humanitarian situation. This humanitarian situation agrees with multiple research findings that have recognised the vulnerability of women and children to the effects of disasters, especially cyclone-related floods.56–60 To facilitate a more coordinated disaster risk reduction and response to future related emergencies in Malawi, box 1 shows suggested experts’ recommendations.
Recommendations
Experts along with relevant stakeholders conduct district-specific assessments for future disaster impacts on the high-risk districts for flood-related disasters in Malawi and use the findings to deliberate, determine and implement actionable measures to mitigate the future impacts in Malawi using the district-specific assessment reports.
Government, in conjunction with relevant stakeholders, should provide lasting solutions to the devastated social determinants of health in the tropical cyclone Freddy-affected population.
Special measures should be put in place by all stakeholders towards ensuring disaster risk reduction to the barest minimum level on the vulnerable population in Malawi most especially women and children.
Conclusion and future action
The recurrent cyclone-related floods and epidemics of cholera have frequently resulted in the loss of lives and factors for good living for the population of Malawi, with a threat to the capacity to achieve multiple SDGs. It will, therefore, be beneficial for all if the concerned stakeholders could have a paradigm shift in the approach towards mitigating and responding to emergencies in the country in order to collectively move towards achieving more on the triple billion target goal of ‘one billion more people better protected from health emergencies.’
