In their 15 years together, Maimuna Catchura had not known her husband to be ill. But one night in late January, 39-year-old lawyer, activist and musician Bernardo Catchura could not sleep, and complained of severe stomach pain.
The pain forced Catchura from his bed at his house in Bissau, Guinea-Bissau’s capital. That night he would navigate the country’s medical care maze, visiting pharmacies, clinics and hospitals. Before the night was through, he even considered crossing the border into Senegal to get help.
But wherever he looked, no one was available to help the father of three, and less than 24 hours after his pains began, he was dead. It was a sad fate for the man who had spent decades campaigning for improvements to Guinea-Bissau’s healthcare system.
Catchura was a leading member of the activist band Cientistas Realistas, which used music to reach and mobilise young people and protest against government failings. “What happened was exactly what he was always talking about in his songs about the health system,” says his widow, Maimuna.
A country with a population of 1.9 million in west Africa, Guinea-Bissau boasts well-conserved environmental parks and a proud history of hard-fought national liberation. But its people face chronic instability and economic inequality. Almost 70% of the population live on less than $1.90 a day and more than 10% are food insecure. The life expectancy is 58 years.
Healthcare experts say that at every step on the road to medical attention patients face potholes such as fake medication, shortages of equipment and medical expertise, and frequent strikes by health workers.
When painkillers were not helping, Catchura called a private clinic. No one answered the phone so a friend drove him and his wife to the public military hospital in Bissau.
Most roads are unpaved, but because January is in dry season, the drive only took 20 minutes and was relatively smooth. In rainy season, torrential downpours leave craters in the city’s red earth and make travel difficult.
At the military hospital medics said Catchura needed surgery, but that they had no facilities to operate. They sent him on to the country’s largest public hospital, Simão Mendes.
But Guinea-Bissau was in the grip of a national health workers’ strike, and despite its status as a referral hospital that should offer specialised treatment, no one at Simão Mendes was qualified to treat Catchura, his family say.
Aissatu Forbs Djalo, a doctor at Simão Mendes and member of the national health workers’ union, says salaries are too low and often go unpaid. Doctors are paid on average £250 a month and nurses up to £130.
“The government budget does not allow the health system to pay the doctors what they need,” says Djalo.
Political instability has crippled public services, especially healthcare. In 2016, Guinea-Bissau had one doctor for every 10,000 people.
There have been 10 completed or attempted coups in the country since independence in 1974.
“Until we have a stable government, which can complete its tenure, we will not be able to stabilise the public sector,” says Dr Magda Robalo, high commissioner for Covid-19 and a former health minister. “For you to have money to pay workers, you need to be able to collect money.
“There is no supervision and performance reviews. There is no meritocracy.”
A doctor who owned a private clinic advised Catchura to go there. But when he arrived at the one-story, blue and white building, the lights were out. The clinic had closed for the evening.
Catchura considered embarking on the four-hour car ride to neighbouring Senegal. Travelling outside the country for even mild health complaints is commonplace but he was, by now, in intense pain.
“A lot of people die from diseases that can be prevented,” says Djalo. “If someone has a cardiovascular illness, they may die due to lack of specialists, and we do not have diagnostic equipment.”
Simão Mendes had a partnership with a hospital in Senegal where it could send patients, but Covid restrictions ended it.
At 7am, Catchura and his wife returned to the private clinic, where he waited four hours to be admitted. Maimuna went home to make soup for her husband. She was sure he would be hungry when he returned from surgery. But there was no operation.
Catchura died and Maimuna still doesn’t know the cause. Failure to identify reasons for death are another common occurrence in Guinea-Bissau, where Djalo says there are few pathologists.
Robalo says there are many hurdles to fixing the broken system, but one approach would be to bolster community health provision, which has worked in other countries. “We can build a bottom-up system that can take care of people far away from the hospitals,” she says. According to Unicef, 66% of the population live more than 3 miles from a health centre.
What happened to Catchura amounts to negligence, says his friend, fellow activist and band member Lesmes Monteiro, but the circumstances are all too common. “There are a lot of Bernardos.”
Maimuna, dressed in widow’s black, has tears streaming down her face as she talks about her husband. He wanted their three children to study, she says. “Bernardo was always focused on school.”
School is cancelled because of Covid-19 and teachers’ strikes, but under the mid-morning sunlight the two oldest children study on the veranda, heads buried in books, as their father’s once had been, hoping to improve his country.