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.
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.
CAR's health system had been weakened by decades of mismanagement and political turmoil. Years of fighting have ravaged what is left of it. The country has only one dedicated COVID-19 treatment centre with just 14 beds and nationwide a total of just three ventilation kits, a solitary oxygen concentrator and zero number of isolation units to treat milder cases to provide quarantine. 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. "This could be replicated across the world's poorest countries, where health infrastructure is virtually non-existent."
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 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.
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.
"Most Central Africans do not believe in the existence of coronavirus in CAR, even if we talk about it every day," says Fanny Balekossi, a presenter at Radio Ndeke Luka, CAR's most popular station . "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 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. Many communities live outside of government supervision and face entirely different social and environmental circumstances to each other. In a bid to minimise the spread of the coronavirus, a 14,500-strong UN peacekeeping force deployed across the country to prevent attacks on civilians has now suspended most internal travel and stopped rotating in new contingents.
Even in the relative safety of Bangui, where the government still has authority, sprawling shantytowns and scant physical distancing are an epidemiologist's nightmare.
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.
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. The sheer numbers, though, are overwhelming.