Why isn’t Guinea-Bissau prepared for Ebola?

The government of Guinea-Bissau has known for months about the risk of Ebola entering the country, but it hasn't done enough to prepare. Now there is a cluster of cases just across the border. Residents say it will be good fortune rather than good planning if an outbreak is avoided.

“I don’t know why we haven’t gotten Ebola yet,” said Edimar Nhaga, who lives in the capital, Bissau. “It certainly isn’t because of prevention measures taken by the government because they haven’t done enough to avoid the epidemic. I believe it’s been luck so far because, to be frank, we just don’t have the capacity for a proper response. No one should believe that our country could face a hypothetical Ebola outbreak.”

As of mid-May, Guinea-Bissau had implemented just 59 percent of the minimum preparedness tasks, including having measures in place for proper epidemiological surveillance, public awareness campaigns, case management, contact tracing, and safe and dignified burials, according to the latest data from the World Health Organization (WHO).

The country has not yet identified funding sources or developed a framework in case an Ebola outbreak should occur, WHO reports, and just 20 percent of minimum preparedness activities related to budgeting, including the creation of easily accessible contingency funds for immediate response to a potential case, have been completed.

“Guinea-Bissau is definitely a matter of concern,” said Doctor Unni Krishnan who heads Plan International’s Disaster Preparedness and Response program. “If a case arrives, this could either go the way in which Ebola was contained in Nigeria because of quick action and good preparedness measures, or it could go the other way, like how we saw in Guinea and the other (worst-affected) countries.”

What Guinea Bissau will struggle to cope with will be the already weak health system and limited number of medical experts and public health specialists.

The concern over Guinea-Bissau’s ability to react to an Ebola case is not new, but has been heightened in the past week, following, for the first time in almost seven months, a cluster of cases just across the border in neighboring Guinea’s Boke prefecture, where traders cross daily to sell their wares and farmers come to work their fields.

Violent protests in the northern Guinean town of Kamsar have also raised fears that aid workers will be impeded in their efforts to stop the virus crossing the border.

The situation, should Ebola actually arrive, is particularly worrying as Guinea-Bissau is among the least developed countries in the world, according to the United Nations Human Development Index. More than 15 years after the end a year-long civil war, which displaced hundreds of thousands of people, the country still suffers from political instability, a fragile economy and poor infrastructure.

The public health system is especially weak, with neither enough trained doctors and nurses, nor resources and supplies, to offer quality care during even regular times.

There are just seven physicians per every 100,000 people, according to WHO. This is lower than the ratio of doctors that Guinea had before the outbreak began.

“What Guinea-Bissau will struggle to cope with (should Ebola arrive) will be the already weak health system and limited number of medical experts and public health specialists,” Krishnan told IRIN. “Looking at the health facilities in Guinea-Bissau, when it comes to disaster preparedness and response, we should be on the higher side of caution, rather than taking it lightly.”

Scaling up

In light of the recent cases just across the border, organisations such as the International Federation of Red Cross and Red Crescent Societies (IFRC), WHO and Médecins Sans Frontières (MSF) have begun increasing their presence on the ground.

“It’s no longer preparing for something that eventually will come one day,” said Youcef Ait Chellouche, IFRC’s Deputy Head of Regional Ebola Operations. “It’s now pushing up the level of preparedness. We call it ‘increased readiness for imminent risk’.”

Chellouche said IFRC would be deploying additional staff to Guinea-Bissau this week to take part in social mobilisation campaigns in the border areas, including volunteers who worked in Liberia and Guinea. They also plan to train more local teams on how to safely put on and remove the Personal Protective Equipment (PPE) outfits, as well as educate both local authorities and communities about safe and dignified burials.

If a case is identified in due time and isolated in due time, then the potential of containing the contamination is quite high. But if it’s late and if there is already contamination of other populations, it will be tougher.

WHO says it has also sent community engagement experts to the border region to strengthen surveillance measures and early warning systems, two epidemiologists, and a logistician to make an inventory of available resources. It has also replaced more than 1,500 PPE kits that were lost in a recent warehouse fire. WHO says they plan to simulate outbreak-response exercises to test the actual level of preparedness to deal with an outbreak, but no date has been set.

MSF has trained a six-person medical team of frontline workers, who will be among the first to respond if there is a suspected case. It has also prepositioned Ebola safety kits and set up a six-bed isolation unit in the Simao Mendes National Hospital, in Bissau, which has the ability to scale up its capacity to 24 beds if needed.

“The biggest concern is to have even one case,” said the head of MSF’s West African unit, Stephane Doyon, who explained that Ebola can be difficult to contain even in countries with strong health systems. “If a case is identified in due time and isolated in due time, then the potential of containing the contamination is quite high. But if it’s late and if there is already contamination of other populations, it will be tougher.”

The Portuguese government has also helped set up a laboratory, so that blood samples from potential cases no longer need to be sent elsewhere.

Challenges remain

Despite these recent efforts, it won’t be easy.

Ebola response workers say they are worried about the potential of resistance among local populations.

“I think the concern, or rather, the anticipated challenge, that we’d like to avoid – is the problems we had in other countries in which rumors and lack of clear information about Ebola led to more rumors and then community resistance against humanitarian service providers,” Chellouche said.

Many locals told IRIN they still don’t know what exactly Ebola is or how it is transmitted.

“Honestly, I don’t know what the symptoms of Ebola are,” said Bissau resident Samba Balde. “But I am scared because we border with Guinea Conakry, a country where the epidemic has arrived.”

Donor funds are also lacking.

“The way the world works today, it is not ready for disaster preparedness,” Krishnan said. “The world pays attention when the tolls starts going up. But unfortunately donors are not that forthcoming when it comes to boosting preparedness and resilience.”

The authorities haven’t met even the minimum conditions to defend us against Ebola, even with support offered by international partners. They still need to do a lot more.

MSF’s Doyen told IRIN that there have been regular meetings between the health ministry and partners to discuss Ebola preparation and response and that “there is good collaboration.” But if a case does arrive, he said the government “will definitely have a need for good support from the outside.”

Less than six percent of Guinea-Bissau’s gross domestic product (GDP) is currently devoted to health care, according to WHO.

But even with more outside help, many people in Guinea-Bissau say they have little faith it will be enough.

“The authorities haven’t met even the minimum conditions to defend us against Ebola, even with support offered by international partners,” Bissau resident Ernest Higinio Correia said. “They still need to do a lot more.”

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