This article was chosen as the 1st place winner of the 2020 Eye on Global Health Writing Competition.
In Guinea-Bissau, a small country in West Africa, the rainy season has just ended. It is hot in the country’s capital Bissau. Pigs are seeking shade below the mango tree in front of our house, the air shimmers of heat and dust. From afar, we hear voices of our neighbours gathered in front of a house. Drums are echoing through the neighbourhood. A mourning ceremony. Somebody has died. Yet again.
There seem to be a lot of funerals lately. “When you’re going to a funeral, don’t take your phone with you. It will ring, and you’re called to another one. And then you don’t know which one to attend”, our local friends joke.
“Is the current number of deaths normal?”, we keep asking ourselves. It is hard to know. Although the registration of deaths is mandatory in Guinea-Bissau, most deaths remain unregistered. The Bandim Health Project, where we work, therefore collects mortality data in its nationally representative Health and Demographic Surveillance System. Yet, due to Covid-19 control measures, most of our routine data collection has been suspended since March. Thus, no recent reliable data documenting deaths across the country are available.
The subjective rise in deaths we notice may be normal and explicable by seasonal effects. After all, the rainy season has only just ended. This time of the year brings more disease and death than the dry season. This has been shown by studies on seasonal variations in child mortality in rural and urban Guinea-Bissau.
Yet, many of our local friends seem to doubt this explanation. “So many people are dying at the moment”, a local friend tells us. “There seems to be more death around compared with previous years,” one of our European colleagues thinks out loud.
Curious to find out more, we drive to the biggest cemetery in Bissau in the neighbourhood of Antula on the other side of the city. It is a beautiful Saturday morning, just a couple of weeks after “All Saints’ Day”. At the eastern side of the cemetery, where Christians are buried, most graves are freshly painted and decorated with colourful artificial flowers. To the west, thousands of small signs standing in a field of wildflowers and grass tell us this is where Muslims are buried. In the shade of a mango tree, we meet gravediggers. “Tarbadju ten tchiu” – “there is so much work,” they tell us. “Normally, we dig around three to six Christian graves per day and another four or five Muslim ones. This year, we dig around 20 graves every day, sometimes more.”
We take a walk through the cemetery’s eastern side where the gravediggers just finished working. Here, graves are assigned in a chronological order. We pass a few rows of graves from 2018 and 2019 before reaching the 2020 section. Indeed, the section seems huge. A lot larger than the ones we just passed. We notice a lot of freshly dug graves.
The gravediggers’ estimates worry us. If reflecting true numbers, there could be a current excess mortality of around 100% in Bissau. Might this be connected to Covid-19? And if so, how? Did recently deceased die of Covid-19? Or of something else because they feared going to hospitals where Covid-19 patients are treated? Or do the additional graves just reflect that fewer deceased were brought to their home villages due to mobility restrictions during the country-wide lockdown? More and more questions arise.
It seems obvious to consider whether Covid-19 may be linked to a potentially higher number of deaths. After all, we are in the middle of a pandemic. Yet, relatively few Covid-19 cases have been recorded in Guinea-Bissau since the first two cases were confirmed at the end March. As of November 26th, a total of 2,422 cases have been confirmed along with 43 Covid-19 deaths and case numbers keep declining. In November, just nine cases and two Covid-19 deaths were reported.
“Coronavirus kaba li” – “there is no more Coronavirus here,” our neighbours and local colleagues confirm, enthusiastically. This perception is also reflected by the day-to-day life in the streets of Bissau: Although facemasks are mandatory outside the home, it is more common to forego using them. Meanwhile, people run their errands on Bissau’s busy markets as usual, use the crowded minibuses as usual and gather in small bars for football matches – as usual. Since the local curfews and other restrictions have been lifted in July, life seems to have largely returned to normal.
But do the official statistics reflect the true situation? Is there almost no more community transmission of Covid-19 in Guinea-Bissau?
Limited possibilities for testing in the country’s remote areas might leave a lot of Covid-19 cases unrecorded. When visiting one of Guinea-Bissau’s bigger islands off the Atlantic Coast, Bubaque, over a weekend, our host echoed the perception of our neighbours and local colleagues from the mainland: “There is no Corona on Bubaque.” “But are there tests?”, we asked. “Well, not that I know of”. The same may hold true for a lot of other regions in Guinea-Bissau. Road conditions are generally poor in the country. Ways are thus long and a lot of villages very hard to reach.
We cannot help but think that this may affect the official statistics. Perhaps the narrative that Covid-19 has already passed also reflects a tacit social agreement. Covid-19 seems both stigmatising and imposes difficulties on daily life in Guinea-Bissau, and things may run more smoothly if its existence is denied. Perhaps it just reflects a preoccupation with other problems, which here are legion – be it other health concerns such as Malaria, Tuberculosis or Diabetes or the daily fight against poverty.
So, is the current number of deaths normal? It could be. An article in Science suggests Covid-19 has spared Africa and resulted in fewer deaths here than elsewhere. The gravediggers in Bissau would probably disagree. But in absence of reliable data, our answer to this and all our other questions must be:
We don’t know – yet.
Sabine Margarete Damerow and Andreas Møller Jensen are PhD students at the University of Southern Denmark and are pursuing research on the impact of health policies on maternal and child health at the Bandim Health Project in Guinea-Bissau. Anders Solitander Bohlbro is a medical student at Aarhus University currently on leave to pursue research into Tuberculosis at the Bandim Health Project in Guinea-Bissau, the Department of Infectious Diseases, Aarhus University Hospital, and the Center for Global Health at Aarhus University.