Trying to work a miracle

A shocked Paulo Mendes surveyed the wreck of his office. Burnt files, broken cabinets, ripped documents were strewn across the yard. Every computer, fax and telephone had been stolen. The national programme against AIDS in Guinea-Bissau was virtually wiped out. That was during the civil war of 1998. In Bissau, the capital, heavy artillery, followed by looting soldiers, razed the national laboratory, the blood bank, a large hospital and the health ministry in one of the world's poorest countries. "To see the effort of many years destroyed in a few moments was traumatising. We had to start from zero," recalled Mendes. The conflict displaced 350,000 people - 20 percent of the 1.4 million population - and professionals fled to Portugal, the former colonial power. Dr Serifo Emballo, of the National Secretariat for the Fight against AIDS (SNLCS from its Portuguese name), estimated that about a quarter of all nurses and doctors in Guinea Bissau did not return. "The war set back the AIDS response 10 years," Mendes told PlusNews. He was the only doctor left at the national programme, and entered the new millennium working on an old typewriter, with carbon paper, in a bare office. A DYSFUNCTIONAL STATE The civil war was followed by years of political and social instability, characterised by corruption, stagnant economic growth, repeated strikes due to unpaid salaries, the dissolution of parliament and, finally, a coup d'etat in September 2003. After elections in July 2005, a new government was sworn in October. In June 2006 the Economic Community of West African States had to bail out the beleaguered authorities so they could pay the salaries of civil servants, teachers, doctors and soldiers, already three months in arrears. The roots of the crisis, said a briefing pack by Office for the Coordination of Humanitarian Affairs (OCHA), were "a dysfunctional and weak state, inefficient governance, a fractured political elite, and a highly divided and interventionist military". In these conditions, how do you organise a response to AIDS? SITTING ON A CRISIS The level of infections from the HIV-2 strain of the virus is estimated at 4 percent nationwide; adding infections from the HIV-1 strain raises the seroprevalence rate to 7 percent, and many suspect it is higher. Like Senegal, Guinea-Bissau's first wave of infections in the 1980s and early 1990s was caused by the less virulent, less infectious HIV-2 strain. After the war, HIV-1 infection rose. HIV-1 is more aggressive, more infectious, has a shorter incubation period and leads to death more quickly. Epidemiological projections for 2001 had 33,900 people infected with HIV-1 and 13,500 with HIV-2. By 2008, 100,000 people will be infected by HIV-1 and 11,000 by HIV-2. "Frightening figures," said Mendes, who now heads the SNLCS. "With this kind of devastation from AIDS, let alone malaria and TB, Guinea Bissau is sitting on a developmental disaster," said Maloke Efimba, an American epidemiologist with the World Bank in the capital. Things are looking a bit better now. In 2003, a national strategic plan laid out a roadmap for action. Around the same time, the United Nations thematic group on AIDS, led by the UN Children's Fund (Unicef), started coordinating the work of its various agencies. SPENDING THE MONEY Today, money is pouring in to combat AIDS - US$7 million from the World Bank, $4.5 million from the Global Fund to Fight AIDS, TB and Malaria. The problem is that the country is ill-equipped to spend it: poorly presented proposals, demotivated civil servants, lack of technicians, institutional and authority vacuums, and wrecked infrastructure. Only 80 people are on antiretroviral treatment, with drugs donated by Brazil; treatment, testing and counselling are only available in the capital. At the hospital in Gabu, in the eastern region, NGOs and the church run centres to treat TB patients, anaemic pregnant women and malnourished babies. But because no one is tested for HIV, the patients may recover from TB or low weight, go home, unknowingly keep infecting others, and miss the appropriate treatment. The best doctors can do is suggest that a patient to travel to Bissau, three hours away, and be tested for HIV. The first testing and counselling centre outside the capital will open later this month in the town of Bafata, between Gabu and Bissau. FINDING WHAT WORKS Guinea-Bissau has been in more or less permanent crisis since the liberation war against Portugal, which began in 1962. After independence in 1973, the country sank into deep, chronic instability. "A structural emergency," said OCHA, with the state incapable of delivering services to its citizens. "Every model I had was not going to work in this post-conflict situation," said the World Bank's Maloke Efimba, who was born in Cameroon. Efimba looked at what was working in Guinea-Bissau and found the Health Project of Bandim, one of Africa's longest-serving health data collection programmes, which had been running uninterrupted since 1978. During the civil war it moved offices to the Catholic hospital in Cumurra, outside Bissau, and paid staff with food when there was no cash. According to Efimba, Bandim has survived because of strongly motivated workers, a well-defined target group, a quality control system, building an acceptance of data collection among communities and keeping the system simple. In his cramped office at Bandim, Dr Zacarias sits crunching numbers for a study comparing HIV infection rates in 1995 and 2005. The Bandim project follows 75,000 people in five suburbs, or 30 percent of all the capital's residents. He pointed out that HIV-1 infection more than tripled between 1995 and 2005, especially among the young. Still, many people do not believe AIDS exists. "The incredulity of people is the main obstacle for the response," he said. "Something is missing in our approach."