Ideas & Insights / All Grantee Impact Stories / Ideas & Insights Grantee Impact Story

Turbocharged by Climate Change, Malawi’s Cholera Outbreak Is Worsened by Covid-19 Misinformation

The patient did not seem near death when he was dropped at Malawi’s Area 25 Health Center. So when doctors reported only a day later that cholera had killed him, family and friends responded with first shock, then suspicion—and finally violence.

A crowd ransacked the center, located in a densely populated neighborhood in Lilongwe, Malawi’s capital city. They threatened healthcare workers, injured police officers and blocked traffic with stones and tree branches.

After two days of clashes in February, the government shuttered the facility indefinitely, transferring all patients further from their homes.

A cholera camp in Malawi. (Photo courtesy of UNICEF Malawi)

It’s undeniable: misinformation about Covid-19 is contributing to the worst cholera outbreak in Malawi’s history—one fueled by extreme weather.

Community Engagement is the Antidote

The February confrontation also pointed clearly to the importance of community engagement to build trust, noted Rachel James, who serves as Interagency Risk Communication and Community Engagement Coordinator for Collective Service in east and southern Africa.

Collective Service, whose work in Malawi is backed by a grant by The Rockefeller Foundation to the United States Fund for UNICEF, supports collaboration between organizations to increase the scale and quality of community approaches, particularly in response to public health crises in underrepresented communities.

The Collective Service is a partnership between the International Federation of Red Cross and Red Crescent SocietiesUnited Nations Children’s Fund (UNICEF), the World Health Organization and the Global Outbreak Alert and Response Network, and as well as key stakeholders from the public health and humanitarian sectors.

“We have found that, by and large, people in Malawi know how to prevent cholera,” said James, based with UNICEF. “But mistrust and misinformation around Covid-19 has impacted their willingness to take any vaccine, or even seek medical care.”

That’s why Collective Service’s work is so critical, noted Estelle Willie, The Rockefeller Foundation’s Director, Health Policy and Communications.

  • Community Dialogue in Salima, Malawi, after cinema screening on cholera prevention, transmission and treatment. (Photo courtesy of UNICEF)
  • We too often focus on the problem of misinformation without acknowledging that it is a symptom of a much wider issue of trust. Acting on insights from in-depth community listening is the antidote.
    Estelle Willie
    Director, Health Policy and Communications, The Rockefeller Foundation

“But like most aspects of emergency response, countries do not have the capacity and resources to engage with communities as deeply as they need to. Building confidence requires significant investment over the long term,” Willie said. “Collective Service’s feedback loops allow first responders to better serve the community by meeting them where they are with the right information and resources at the right time, creating a more informed, engaged, and trusting public.”

Climate Change Triggers and Worsens Cholera Outbreak

Cholera, an infectious bacterial disease of the small intestine, is relatively easy to treat if caught in time, but can kill within hours if untreated. Malawi’s outbreak, worsened by climate change, has touched all of the country’s 29 districts in this country of 20 million, causing more than 1,600 deaths and more than 51,000 cases.

Malawi is a hotspot for cholera outbreaks in Africa. Communities located along Lake Malawi, Lake Chilwa, and in the flood plains of the Shire Valley, as well as urban centers of Lilongwe and Blantyre, are regularly affected. Globally, cholera transmission has been linked with seasonal trends in rain, and especially extreme weather events such as abrupt and heavy rainfall. Rising temperatures, both ambient and water temperatures, also increase the growth of Vibrio Cholerae.

Students practice a drama showing handwashing as a way to prevent cholera. (Photo courtesy of UNICEF)

The Malawi outbreak began in districts hit by Tropical Storm Ana and Tropical Cyclone Gombe, which together damaged or destroyed scores of water systems, flooded large areas, and displaced 190,000 people.

This week, Cyclone Freddy killed more and did additional damage. Cholera can spread rapidly in regions with contaminated or inadequate treatment of sewage and drinking water.

Floods after Tropical Cyclone Ana in Lowershire. (Photo courtesy of WHO Africa Regional Office)

“Cholera thrives in poverty and conflict but is now turbocharged by climate change,” Inas Hamam, a regional spokeswoman for the World Health Organization, said in November 2022. “Regional and global health security is in jeopardy.”

“It’s the worst outbreak in our history. It is something we have never seen,” said Dingaan Mithi, a Malawi journalist who is part of AVAC’s Media Science Cafés program, which is supported by The Rockefeller Foundation. “It is worsened because there is a lot of misinformation, and that is something we need to work on.”

To better understand community mindsets, Collective Service traveled to cholera hotspots to listen to religious leaders, local leaders, youth, older Malawians, women, and healthcare workers.

The team discovered generally high levels of knowledge about how severe cholera is and how it is transmitted. But major myths and misinformation were revealed around the effects of vaccines.

Rachel James explores community beliefs around cholera during a focus session with Malawian woman. (Photo courtesy of Rachel James)

Turning to Community Leaders Instead of Healthcare Workers

“Multiple groups shared their concerns that the government has taken funding to reduce the population in Malawi,” the team reported. “Strong belief was expressed that if you go to a health facility, you will die or be killed.” Healthcare workers also fear for their personal safety.

  • The strong rumor was, if you go to a health facility, you will be given a poison and die. This is why it’s important that we establish a community feedback mechanism so that we can correct misinformation, and defuse frustration before it erupts into violence.
    Rachel James
    Interagency Risk Communication and Community Engagement Coordinator for Collective Service in east and southern Africa

During her recent listening session in Lilongwe, James said, “every single person knew people who had died. One person said, ‘my neighbor died yesterday and we couldn’t go to the funeral.’ This makes them wary.” Traditional Malawian funerals often involve entire villages and are a shared time of mourning.

In response to information gathered in the focus groups, the Collective Service team suggested focusing on religious and community leaders as trusted influencers, and moving beyond basic messaging to address specific concerns and questions. The team is also working to collect, collate and analyze interagency feedback from various engagements to deepen shared understanding on current and evolving community concerns.

There are other challenges beyond misinformation. One is vaccine access, even for those willing or eager to take it. A strained global supply of cholera vaccines has obliged the International Coordinating Group (ICG) — the body which manages emergency supplies of vaccines — to temporarily suspend the standard two-dose vaccination regimen in cholera outbreak response campaigns, using instead a single-dose approach.

“People know they are normally supposed to take two doses, so being told they will only be given one also raised suspicions,” said James.

  • Malawi Red Cross volunteers working at Oral Rehydration Point in a cholera hotspot. (Photo courtesy of the Malawi Red Cross)

The Malawi Poverty Index Report 2021 designates 61.7 percent of Malawi’s population as multidimensionally poor, with the highest poverty incidence in rural areas at 70 percent. Inflation currently stands at about 25 percent. With 80 percent of the population dependent on agriculture, the economy also is highly vulnerable to climate change.

“People struggle to have access to portable water,” Mithi said. “But extreme weather events, including tropical storms and floods, are going to continuing to damage water structures. It’s becoming a repeated cycle.”

Mithi noted that issues of mistrust are costing lives, and “there is a lot of work we need to do as a country.” He also called on his government and others to invest in climate resilient water and sanitation structures. “Otherwise,” he said, “I can’t see the cholera outbreak subsiding as long as climate change is with us.”