As I reflect on Cyclone Freddy’s devastation in southern Malawi, a place I have called home for nearly three years, I’m struck by Martin Luther King Jr.'s words: "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane."
October 2020
During the pre-vaccine era of the COVID-19 pandemic, I chose to leave a job as a pediatric nurse practitioner in Boston to follow my lifelong passion for global health. I came to Malawi to work as a nurse educator to build capacity for pediatric critical care (PCC) nursing by developing the country’s first PCC nursing master’s program and establishing a PCC nurse preceptor program. Since then, I also began to pursue a Doctor of Nursing Practice degree at Duke University School of Nursing and a Global Health Certificate at Duke Global Health Institute.
Malawi is a landlocked, low-middle income country (LMIC) in sub-Saharan Africa with a population of 20 million people, half of whom are under the age of 14. Poverty in Malawi is a complex and multifactorial issue that has massive implications for the population’s health and well-being. Young children in this setting are particularly vulnerable to preventable death from birth asphyxia, pneumonia, diarrhea, and malaria. There is a desperate need for qualified pediatric experts to care for these children. Unfortunately, in 2017 the government enacted a hiring freeze for Ministry of Health nurses, leading to a staggering 63% vacancy rate. Employers in the healthcare sector rely primarily on donor funding to support the country’s health initiatives and responses to life-threatening epidemics like COVID-19 and recently, cholera.
March 2022
Cholera spreads during the rainy months (November to April) and kills an average of 100 people in Malawi each year. This year’s outbreak has been worse than usual. Since March 2022, there have been a total of 1,733 cholera-related deaths. This outbreak has a case fatality rate (CFR) of 3%, which is similar to the CFR of the first wave of COVID-19 in 2020.
October 2022
The World Health Organization supported the government in launching a campaign for the distribution of 4.9 million oral cholera vaccines and public health education about hygiene, sanitation, chlorine water treatment, and proper preparation of fruits and vegetables. While these were promising interventions, the worsening outbreak was unfortunately about to become even more dire.
Early February 2023
Cyclone Freddy formed off the coast of Australia, traveled thousands of miles across the Indian Ocean, and made its first landfall over Madagascar. The storm continued west, approached the coast of Mozambique, and hovered briefly over northern Zimbabwe. Suddenly, Freddy made a U-turn back out to the Indian ocean and regained strength from the warm waters and atmospheric pressures that feed big storms with powerful energy. Headlines about Cyclone Freddy emerged on local news outlets, and while I was teaching a class that Friday, I was also peeking out the window. Little by little, rain began to fall.
As Freddy rolled in from Saturday into Sunday, it brought a relentless, constant barrage of rain. The level of water in the lower streets rose, causing large waves when the 4x4 Land Cruisers tried to pass through. Photos and videos began to circulate of bridges and streets eroding, compound walls collapsing, trees falling, and downed power lines. All three hydroelectric dams in Southern Malawi became incapacitated due to trash buildup from flooding, and the local water board shut off running water indefinitely. The government shut down schools and declared a state of disaster. The staggering, sheer amount of water began to become unbearable in the densely inhabited areas of town. On Soche Mountain—one of Blantyre’s three surrounding peaks—the water could not be held back any longer. The ground became saturated with water, the rudimentary mud and brick walls of houses destabilized, and people began to be crushed by their homes. A breach in the barrier holding water back suddenly released a river of water that rushed down the hillside and directly plowed through the village, bringing houses, mud, sewage, concrete, rocks, destruction, and death in its wake.
In the days that followed, the storm dumped six months’ worth of rain in just six days. The continuation of the storm hindered initial relief efforts, but members of the community who remained safe and dry began to organize the immediate distribution of emergency supplies and aid. I reached out to my friends and medical colleagues at the central hospital—they were all hands on deck. Trauma patients were filling up the emergency departments along with relatives looking to identify the bodies of their loved ones. I reached out to contacts from the Malawi Red Cross Society, Médecins Sans Frontières, and my local nursing university to see where my skills as a nurse practitioner could be put to use, but it was difficult to identify gaps in the disaster response that I could fill in.
Mid-March 2023
The storm finally dissipated. Through one or two social media posts, I was able to quickly increase awareness of the disaster and raise some relief funds of my own to put to immediate use. My colleague Patricia Swagart (Certified Nurse Midwife) and I began corresponding with Tamara Nyahoda of Better World Charitable Organization who was in charge of the Manja Camp, a primary school close to one of the major landslides that was converted into an emergency displacement camp for approximately 3,000 survivors. She sent us lists of needed supplies and medications and we set off to procure them from the grocery stores and pharmacies in town.
On the first couple of trips to Manja, we distributed supplies and performed health assessments on the children and pregnant women. On another trip, we provided medical aid while friends of ours who are teachers played games with the children, in desperate need of laugher and a reprieve from their grief. Using some of the donated funds, I supported the reconstruction of houses for five ICU nurses and supplied a good friend who lost all of his crops with enough food for him and his family for a year. It felt like we could do everything and nothing, all at once.
Today
After the storm and the initial rush of support, the Internally Displaced People (IDPs) are desperate for a long-term solution. Outbreaks of infectious diseases like syphilis and tuberculosis—on top of the existing cholera epidemic—have begun to creep into the crowded living quarters of the camps. Those who have been temporarily resettled sleep on concrete floors every night, wondering how long the donations of food and supplies will last. The end of rainy season is referred to as “hunger season” because it is the month or two before the maize harvest when provisions from the previous year’s harvest are dwindling. With the destruction of maize crops due to the storm, hunger season is about to become much, much longer. Today, people are still buried in mud, loved ones and family members waiting to be recovered, identified, and properly laid to rest. Thousands of Malawians are struggling to get by day to day, waiting for a solution and hoping for survival.
The injustice of climate change and its intersection with global health has never been more apparent. In general, LMICs contribute the least amount of the carbon emissions that are responsible for climate change. Malawi itself emitted a mere 1.8 metric tons of CO2 emissions in 2021, which is a trivial 0.0% of the world’s share. This, compared to the cumulative impact of high-income countries (United States, China, the EU27, India, Russia, and Japan) that account for a staggering 67.8% of annual CO2 emissions. Although high-income countries are responsible for the majority of historic emissions of CO2 and other greenhouse gases, once-in-a-lifetime climate disasters are becoming more and more frequent everywhere in the world. The difference is that when tropical storms of the size of Cyclone Freddy—with winds of 39-73 mph—make landfall on the shores of high-income countries like the United States, they tend to be less destructive due to advances in protective infrastructure and expensive technology that are not accessible in more vulnerable places like Malawi—one more way in which poor countries disproportionately bear the impact of climate change. Further, Malawi’s ability to respond to climate disasters—termed ‘adaptive capacity’—remains low due to its dependence on agriculture and other public health crises as described.
Cyclone Freddy became the longest lasting storm on record at 36 days, breaking the previous record of 31 days set by Hurricane John in 1994. It is also the strongest in terms of the accumulated cyclone energy (ACE), which refers to the amount of energy released over time, intensifying a whopping total of seven times—more than an entire typical United States hurricane season. It’s peak strength over the Indian Ocean was that of a Category 5 storm. Luckily, the storm de-intensified by the time it made landfall as a tropical storm, but I shudder to think of the catastrophic impact that a Category 4 or 5 storm with wind speeds of 140-170 mph would have.
Blantyre, where I live, was the hardest hit area. There are more than 500 dead, 530 missing, 1,700 injured, and 500,000 IDPs living in more than 500 camps. It is difficult to imagine what the future holds for countries like Malawi if the world is not able to pull away from critical climate tipping points in the next few years. The injustice will undoubtedly be—in the words of Martin Luther King Jr.—“the most shocking and inhumane.”
Kelsey Renning, MSN, RN, CPNP-PC, is a pediatric nurse practitioner in Blantyre, Malawi. She is a member of Sigma’s Beta Epsilon Chapter.