Health service far from well

Few beds are occupied at the hospital in Gabu, a bustling town in eastern Guinea Bissau, close to the border with Guinea Conakry. It is not that the locals are particularly healthy. They are as wracked by malaria, malnutrition, cholera, TB and AIDS as every one else is in this country, one of the world's five poorest. "My people don't go to the hospital because they get nothing there, they must buy everything," said Kalifo Djallo, the region's regulo, or paramount chief. When PlusNews visited, the only patients in the adults' ward were a young man bitten by a cobra and another with cerebral malaria. In the children's ward were a toddler badly burnt with scalding water and two with diarrhea. Patients bring their own bedding and food. Except for a handful of essential drugs, medication must be bought at the pharmacy. If a patient requires constant care, a family member must move in. The roofs leak, toilets are blocked, electricity and water are erratic.

Fact Box

Population: 1.4 million Human development: 172 out of 177 countries on UNDP index Infant mortality: 126 per 1,000 live births Child mortality: 203 per 1,000 live births (2004) One-third of all under fives is undernourished. Forty percent of all adults are in chronic nutritional deficiency, especially in the north. Malaria is the main killer. Source: UNDP/World Bank

Transport is another problem. In the rainy season, muddy rural roads quickly become impassable. By the time the snake bitten man reached Gabu, his foot had become gangrenous. Gabu hospital is not an exception, it is the rule. In Bafata, the second largest town, 100km east of the capital, the hospital is arguably worse. The state of Guinea Bissau's health facilities reflect a postcolonial history of weak governance, political instability and minimum investment. "In colonial times, health was for free and transport from the tabankas [villages] was assured," said Alahadi Serifo Baldé, 82, the regulo of Algodão neighbourhood, in Gabu. "Today, people die in hospital because they cannot afford treatment." The derelict buildings and crumbling pink and ochre paint echo staff morale: they are only marginally more affluent than their patients, and demotivated after decades of low and late pay. With 18 years of service, the chief nurse at Gabu hospital, who did not want to be named, earns a salary of CFCA 48,000 (US$96) - and was owed three months back pay. Sometimes, however, the passion for the job shines through. "Sorry I can't greet you with a big smile but my cheek muscles are tired," said midwife Salima Tutoré. She explained she has to suck the secretions of babies born in distress because the hospital lacks an aspirator. She sucks and she spits and massages the baby's chest, until the baby breathes. "It feels like I earn one million a month when I save a baby," said Tuturé, a widow with two young children. "The baby cries and the midwife smiles, and this is why I studied, to save lives." The maternity ward has eight speculums, "from the time of the Russians", to deal with between 80-90 hospital births every week in a region of 200,000 people. Most of the time, sterilization is done by flame; Gabu has electricity only in the evening between 7.00 pm to 12.00 pm. The simple equipment to pull out babies in fetal distress has long been broken. "This is why we do so many caesarians," explained Tutoré: two this morning, hence the muscle ache. Premature babies are wrapped in cottonwool and cloth, and held by their mothers until they either survive or die. Anesthesiologist Augusto Djada studied in Cuba and has worked in Gabu for 18 years. In the operating room, Djada points out that only three of the six bulbs in the overhead lamp work, so he supplements the light with a reading lamp that quickly overheats. In the maternity ward, surgical gloves just washed lie by the sink. The word "disposable" is a joke here. Tuturé and Djada fashion their own protective aprons out of plastic bags. They worry about the risks of HIV infection because they handle body fluids without adequate protection. "I am afraid to take an HIV test because I run so many risks, not on my personal life, because I am a widow, but as a midwife," said Tuturé. "It is a sad life for a midwife without protection, no equipment and little money." After Bissau, the capital, Gabu and Bafata have the highest rates of HIV-1 infection - 3.9 percent and 5.8 percent respectively - and three percent for the less virulent HIV-2 strain. Because of the civil war in 1998/99 and ensuing political instability, the national response to AIDS has been slow and haphazard. Less than 100 patients are on antiretrovirals, with testing, counselling and treatment available only in Bissau. Training on HIV/AIDS for health professionals is recent, and limited. Catarina Baio, an Angolan nurse, coordinates Cida-Alternag, a community-based AIDS center in Bissau. "Even us, the health staff, sometimes we fail to perceive the risks [of infection] we run." Health staff at regional hospitals live at the margins of Guinea-Bissau's weak, dysfunctional state, far from the capital and the NGOs and development agencies. "I never see them at training sessions," said Baio. Even doctors in Gabu are ill equipped to deal professionally with HIV/AIDS. In the absence of a protocol and training on HIV testing and counseling, doctors are reticent to broach the subject with a patient. There are no testing facilities in Gabu. The best that doctors can do is suggest to the patient to go to the capital, three hours away, with no guarantee of finding help there either. So instead doctors often keep quiet, and in that silence HIV can thrive.