In Central African Republic, a colossal struggle against COVID-19

Before dawn in a suburb recovering from war, Fanny Balekossi awakes and heads into the centre of Bangui. A radio broadcaster specialising in health issues, Balekossi survived years of sectarian fighting in the Central African Republic (CAR) during which her older sister and close friends perished.

Now, she is facing a new struggle to pull her country back from the brink once more.

In a studio at Radio Ndeke Luka, CAR's most popular station, Balekossi puts on her headphones, turns on the mic and begins speaking to her listeners in a country that the United Nations calls one of the least prepared to cope with a coronavirus outbreak.

"Welcome to your Health Magazine show," she says in her gentle, reassuring tone. "Today we're talking about the importance of handwashing during this health crisis that is rocking the world. "

From hygiene tips to interviews with top medics, Balekossi's broadcasts from the capital go out on 100.9FM to citizens across CAR, whether they live in areas held by the government or by rebels. Her public service programme is part of wider efforts to prevent the coronavirus pandemic engulfing a country where only three ventilators are available for a population of almost five million.

The challenge is colossal. Armed groups control large swathes of territory while doctors already struggle to treat existing cases of malaria, measles and tuberculosis, let alone a new virus with no known vaccine or treatment. As healthcare systems in wealthy nations buckle under the strain of COVID-19, the disease caused by the coronavirus, medical professionals fear an even greater impact in vulnerable countries such as CAR.

"My mission is to inform the public," Balekossi, 35, says. "I work in a media organisation which advocates peace, development and human dignity. I have to work for the benefit of listeners."

A 'blue helmet' soldier guards the outer perimeter of UN peacekeeping base in the town of Bria [File: Jack Losh/Al Jazeera] 

As of April 22, CAR had confirmed 14 coronavirus cases, a far lower number compared with the 1,163 infections registered in neighbouring Cameroon to the west and the 359 in the Democratic Republic of the Congo to the south. But a lack of testing and medical equipment could be allowing cases to go under the radar. Jack Ma, the founder of the Chinese retail giant Alibaba, has recently donated tens of thousands of masks and testing kits to CAR, but the country still faces critical gaps.

The country has only one dedicated COVID-19 treatment centre with just 14 beds, according to a report by the UN's Office for the Coordination of Humanitarian Affairs (OCHA), along with a nationwide total of three ventilation kits, one oxygen concentrator and zero isolation units to treat milder cases to provide quarantine. A fraction of the country's entry points has functioning health controls. The World Health Organization (WHO) has warned that a lack of qualified personnel, proper waste disposal and hygiene equipment will make it difficult to prevent infections within healthcare facilities.

"COVID-19 has the potential to tear through the Central African Republic at lightning spread if the country doesn't get the support it needs to adequately protect itself against the virus," says David Manan, the Norwegian Refugee Council's country director in CAR.

"This could be replicated across the world's poorest countries, where health infrastructure is virtually non existent."

A woman exits the hospital in Bossangoa next to a sign that prohibits people from bringing in weapons [File: Jack Losh/Al Jazeera]

Even before war broke out in 2013, CAR's health system had been weakened by decades of mismanagement and political turmoil. Years of fighting since then have ravaged what is left of it.

The conflict erupted after a coalition of rebel groups from the lawless and largely Muslim north of the country fought their way into the capital, Bangui, and deposed the president. In response, mostly Christian militias known as the Anti-balaka struck back, exacting revenge on Muslim civilians.

The ensuing chaos has displaced almost 700,000 people inside the country and spawned a hotchpotch of armed groups as the rebel coalition disintegrated. A peace deal signed last year has eased the bloodshed, although this lull has come too late for the country's healthcare infrastructure as COVID-19 gains a foothold across the continent.

Today, the average life expectancy in CAR is less than 53 years and half the population depends on humanitarian support. This year's response plan to critical humanitarian needs, which existed even before the threat of coronavirus, faces a funding gap of more than $300m. The UN is now looking to raise an additional $2bn worldwide to deal with the outbreak without prejudicing other humanitarian operations for pre-pandemic crises.

CAR's population has proved its resilience by weathering repeated conflicts and outbreaks of disease. The region's healthcare workers have also gained expertise by tackling other epidemics in this challenging environment. But charities such as Doctors Without Borders (MSF) warn that COVID-19 is very different from others it has faced in recent decades, citing among others the impact of high hospitalisation rates and the disruption of medical supplies on fragile healthcare systems due to lockdowns.

On top of this, complacency and conspiracy theories complicate the already challenging situation.

"Most Central Africans do not believe in the existence of coronavirus in CAR, even if we talk about it every day," says Balekossi, the radio presenter. "Some say it's a ploy for the government to extract money from the WHO. Others believe this disease won't affect Central Africans. Several preventive measures have been taken by the government but unfortunately are not observed by the population."

The government has restricted internal travel and ordered new arrivals from abroad to quarantine for up to 21 days. Schools, bars and places of worship have been told to close, and gatherings of more than 15 people have been banned. But recently published photos show daily life in Bangui continuing as normal for many, with people crowded in markets and congregating inside bars that, from the outside, purport to be closed.

"If things continue like this and the population continues to disregard the instructions, the disease could spread and wreak havoc," Vicky Wackoro, a young student who took the photos, told France 24.

The obstacles are even larger in rebel-controlled areas, which account for some three-quarters of CAR's total territory. There, the government's power to impose coronavirus containment measures is practically non-existent. OCHA warns that the "weak and limited presence of national authorities to enforce prevention and restrictive measures" could aggravate the virus's impact.

Some observers suggest that blanket lockdowns across Africa may not be the answer, arguing instead that local communities must be consulted when devising ways of coping with an outbreak. Alex de Waal, director of the World Peace Foundation at Tufts University, says an initial period of lockdown is the ideal time to hold such talks and find "locally-suitable versions of transmission control".

"Every epidemic is different; government responses are usually the same regardless," he writes. "There is no time to lose: community consultations should begin now. Communities may well find creative ways of protecting the most at risk."

This opportunity certainly exists in CAR. Many communities live outside of government supervision and face entirely different social and environmental circumstances to each other. Just take the Bayaka hunter-gatherers in CAR's lush, forested southwest and the Peul cattle herders in the arid northeast: two distinct communities leading utterly disparate existences that would elude a one-size-fits-all lockdown.

Meanwhile, the economic impact of sweeping lockdowns in many African countries is set to be dire. In CAR, where average earnings are just more than $2 a day, people can only dream of the support packages prepared by wealthier states for workers hit by the crisis. The absence of a functional welfare system, a decline in remittances from abroad, disruptions to supply chains and the knock-on effects of a global downturn will only exacerbate the daily grind. With most international flights suspended, Cameroon's border shut and the country dependent on imports, humanitarian coordinators in CAR warn of a spike in food prices.

And then there are fears that COVID-19 could undermine security, too. In a bid to minimise the spread of the coronavirus, a 14,500-strong UN peacekeeping force deployed across the country to dissuade attacks on civilians has now suspended most internal travel and stopped rotating in new contingents. This, according to the OCHA, "poses significant challenges to its ability to implement its protection mandate".

A roadside sign in Bossangoa advocating against using children in armed groups, reading: 'Children not soldiers' [File: Jack Losh/Al Jazeera]

Overcrowded camps housing people fleeing violence present the perfect conditions for pathogens to spread. In CAR, one site may house upwards of 40,000 people living under dusty tents in close confines and often surrounded by hostile armed groups.

UNHCR, the UN's refugee agency, says it is installing more water points in camps, informing inhabitants on the importance of handwashing in the fight against COVID-19 and distributing hygiene kits containing soap and other items. The sheer numbers, though, are overwhelming.

"We don't have enough but we will do our best," says Pierre Atchom, UNHCR's deputy representative in CAR overseeing protection. "Our fear is that this pandemic spreads to the camps. If it does, it will be very difficult for us to stop it."

Even in the relative safety of Bangui, where the government still has authority, sprawling shantytowns and scant physical distancing are an epidemiologist's nightmare.

Back at Radio Ndeke Luka, Balekossi ends her health show with a dispatch filed from far-flung Obo, a small, southwestern town some 1,200km (750 miles) from Bangui. Obo is so isolated that it has been dubbed as Africa's "Pole of Inaccessibility"  that is, one of the continent's toughest places to reach, where road convoys of aid can take months to appear. Even here, health workers are encouraging regular handwashing and other measures to prevent the virus from spreading in a community cut off from the rest of the world. 

The correspondent in Obo ends his report and the show's soothing theme tune fades in. "Thank you for listening," says Balekossi. She removes her headphones and turns off the mic, concluding her broadcast to a country braced for the unknown.