The convergence of health system, climate, and social pathways in Malawi's 2022-2024 cholera outbreak - A qualitative assessment

Climate-related disasters increase cholera risks, yet their contribution to outbreaks is often explained through microbiological, epidemiological or ecological lenses, limiting our understanding of system convergence. Examining the 2022-2024 cholera outbreak in Malawi, we explore how healthcare providers in two rural districts perceived the interconnected pathways that transformed a seasonal cholera outbreak into a two-year epidemic. Drawing from field visits in Neno and Chikwawa Districts of Malawi, we conducted 24 in-depth semi-structured interviews with first responders. We identified three converging pathways: tropical cyclones that disrupted traditional disease patterns and recovery capacity; health system vulnerabilities characterized by growing unpredictability and infrastructure destruction; and social and economic determinants of health including mass displacement, inadequate water, sanitation, and hygiene infrastructure, and cross-border transmission. The convergence of these pathways amplified acute climate impacts and chronic structural vulnerabilities. These findings highlight the need for integrated system approaches that address pathway interconnections rather than isolated interventions in cholera containment, essential for meeting 2030 elimination goals.