By Wilmot James and Jeremy Orloff
When South Africans went to the polls on May 8, here as elsewhere voters were unlikely to have made up their minds based on foreign or regional issues. Still, they should reflect on the disasters that befell our neighbours Mozambique, Zimbabwe and Malawi.
SA has not been sufficiently forward-leaning as a regional power in preventing, mitigating, responding to and helping the recovery of its neighbours, which are among the world’s poorest countries. Inaction will rebound in terms of having larger refugee and migrant populations, and poorer economic performance on the domestic front. Smart investments in regional disaster preparedness will save SA money and bring returns over the long haul.
True, the UN declared the storms that pummelled Mozambique to be “unprecedented in recorded history”. Even if it had a cutting-edge disaster risk plan, the country would have been stretched beyond capacity to cope with such monumental natural events. The World Meteorological Organisation observed that “there is no record of two storms of such intensity striking Mozambique in the same season”.
A fact-finding mission is assessing the “impact of climate change and sea-level rise on Mozambique’s resilience” because this is a sign of more things to come. With more than 1,000 dead, miles of destruction and an unbridgeable gap to fill in the public health response, Mozambique, the world’s seventh-poorest country with a GDP smaller than Cape Town’s, will need all the help it can get. It cannot deal with the problem alone, nor should it have to.
Most people are unaware that Mozambique has been remarkably proactive in its efforts to upscale disaster preparedness. It was one of the first three African countries to subject itself to scrutiny by the World Health Organisation. A joint external assessment was completed in April 2016 and a mission report of findings was published that ranked Mozambique, with a few exceptions, poorly overall.
The exception was Mozambique’s emergency response system, which received the highest score there — five out of five. It had “strong emergency operation structures for natural disasters”, the report read.
But Mozambique had “no similar capacity for public health events”, which is needed to contain disease outbreaks and stop them spiralling into national and regional disasters. Mozambique faces a complex risk environment — cholera outbreaks, foodborne illnesses, chemical accidents, radiological events, floods, drought, fires and cyclones — but it does not have an all-risk plan. Its health systems are weak and a surge capacity in public health, something that must be activated within hours of a catastrophe, requires a robust backbone.
Determined to tackle its challenges, Mozambique developed and launched a national action plan called the strategic partnership for international health regulations and health security in October 2017. It partnered with the Public Health Agency of Sweden, the UK’s Department for International Development, the US Centres for Disease Control and Prevention and USAid. Embracing a “one health” approach that includes human, animal and plant aspects, the Mozambique government’s task was to build systems in the core technical areas of surveillance, laboratories, workforce development and emergency response.
Since the plan’s release, Mozambique has held an after-action review, simulation events and developed plans for dealing with flu, antimicrobial resistance and health emergencies. A bridging platform to connect humans and animals and a plan to advance universal access to health care were established. The country set about finding donor partners to help finance its plan to upscale preparedness and build resilience in its public health systems. How much it will cost to plug the gap is unclear.
As support to national developments, the Africa Centres for Disease Control and Prevention (Africa-CDC) was established three years ago. Led by John Nkengasong, a virologist with 20 years’ experience at the Atlanta-based CDC, the Africa CDC came at the urging of the AU Commission.
Nkengasong summarised the challenge in the March 14 edition of science magazine Nature, saying that “fewer than 15 African countries on the continent have institutions that can perform the functions of an effective national public health institute”.
That the continent needs public health operational structures is self-evident. The last five years have seen a significant increase in disease outbreaks. Since 2018 there has been a resurgence of ebola, notably in the DRC. The death toll there is poised to soon surpass 1,000. Armed this time with an effective vaccine, response to the outbreak has been complicated by ongoing armed conflict.
In 2017 Madagascar experienced an outbreak of plague that infected more than 2,000 and left hundreds dead. Angola stared down a yellow fever outbreak in 2008, with hundreds of cases confirmed despite millions being vaccinated.
Even after thousands were killed by cholera in Zimbabwe in 2008, that country again struggled to contain a similar outbreak in 2018.
Refugee populations in East Africa and the Horn of Africa, displaced by drought and famine, are threatened by epidemic disease in camps that do not have even rudimentary sanitation and infection control systems. Outbreaks of cholera and measles have been the norm in these places over the past few years.
The combination of conflicts with droughts, cyclones and other extreme weather events that have hit African nations recently has shown how interconnected different areas of preparedness truly are. In each of these cases, public health responses have been tested and stretched to breaking point.
Five years have passed since the UN security council passed the historic resolution on the 2014-2016 West African ebola outbreak that ultimately ended the epidemic. The WHO and World Bank Global Preparedness Monitoring Board will deliver their first set of recommendations in 2019. The bottom line is defined by the International Group on Financing Preparedness, which estimated it will cost $4.6bn a year to address capacity gaps globally in epidemic preparedness.
It is a lot of money, but this is why it is worth it. Sierra Leone, Liberia and Guinea collectively sustained an estimated loss of $2.8bn in GDP in 2015. In 2003, global GDP fell $40bn in the aftermath of severe acute respiratory syndrome, while the H1N1 flu epidemic cost $45bn-$55bn. Pandemics are as disruptive as natural disasters and can cause long-lasting fiscal shocks.
Upper- and middle-income countries should pay for their own health security. Poor countries such as Mozambique simply lack the resources. The World Bank has played a leading role in partnering with low- and middle-income countries on the road to greater health security. The bank is considering expanding its crisis response window into a crisis readiness and response window, with the authority and resources to make dedicated grant funds available to poor countries to protect against epidemics.
Nothing is more important than finding and sustainably investing significant funds in preparedness. Both domestic resource mobilisation and finding new financial instruments such as the World Bank’s are necessary.
• James is a visiting professor at the Columbia University’s Irving Medical Center and School for International and Public Affairs. Orloff is a clinical researcher at Weill Cornell, New York City.