First published in ITIJ 134, March 2012
The Republic of The Gambia is maturing as a holiday destination, with a growth in demand, and a trend towards more upscale tourism. But what can visitors expect from the local healthcare system and what have international assistance companies to say about their dealings with local medical providers?
From its short Atlantic coastline, The Gambia stretches almost 400 kilometres inland, occupying both banks of the Gambia River. It is mainland Africa’s smallest country, and was one of the first nations on the continent to appeal to mainstream holidaymakers from Europe. But since the first charter flights arrived from Scandinavia in the 1960s, The Gambia has been outstripped by an array of other holiday destinations in Africa and elsewhere.
With sandy Atlantic beaches and year-round average temperatures of around 30˚C, The Gambia’s tourism industry was built on the tried and tested sea-and-sand formula, with the added appeal of guaranteed winter sun, prices that compared well with many familiar Mediterranean destinations, and a relatively short flight time (around six hours) from many key European travel sources. In more recent years, The Gambia has faced strong competition from other medium-priced, medium-haul winter sun destinations such as Egypt, Morocco, Tunisia and Dubai, all of which can offer a more multi-faceted tourism product, combining winter warmth with culture, heritage, shopping, ecotourism and a wide range of sporting and activity holidays. With many operators seeking alternatives to troubled destinations in North Africa and the Middle East, and price-conscious customers looking for affordable winter sun, however, The Gambia could benefit both from Egypt’s troubles and from Europe’s economic woes.
European tour operators are divided on The Gambia’s prospects, however. Some are betting on an increase in the destination’s popularity, but others are more circumspect.
"Gambia's tourism sector is very much dominated by just a few large European package tour operators"
The Gambia has slowly begun to diversify and develop its tourism product, with specialist operators seeing potential for bush-walking and birding excursions, and small-ship river cruises. There is also a growing interest in holidays that combine The Gambia with Senegal.
By 2010/2011, annual visitor numbers had reached a plateau of around 100,000 a year, around 50 per cent of whom come from the UK, with most of the remainder coming from Germany, Scandinavia and other EU countries. At present, The Gambia’s tourism sector is very much dominated by just a few large European package tour operators, notably the Anglo-German Thomas Cook group, the UK-based specialist The Gambia Experience, and British company Cosmos, which expanded its charter flight capacity by 50 per cent for winter 2011/2012.
Late last year, German carrier Condor – absent from The Gambia for some four years – returned to the capital, Banjul, with a schedule of four flights a week, and at least two other European carriers also planned to start flights in 2011/2012.
According to the Gambian Civil Aviation Authority, Russian carrier Euro Airline has also shown interest in flying to Banjul via Switzerland. Euro Airline has reportedly won fifth-freedom rights from Switzerland, so the service could boost the Swiss market as well as opening The Gambia up to Russian holidaymakers.
As visitor numbers to The Gambia grow and travellers explore deeper into the country’s hinterland, its peculiar geography, together with deficiencies in the country’s health and transport infrastructure, could pose challenges for assistance companies and air ambulance operators, however.
The Gambia has a population of around 1.7 million, crammed into a total land area of little more than 10,000 square kilometres, but it boasts a coastline that is around 80kilometres long and features some expansive beaches popular with tourists. The Gambia is nowhere more than 48km wide, and is surrounded on three sides by its much larger neighbour, Senegal, a former French colony. The two countries share some common factors (beyond the accident of geography). Islam is the prominent religion in both, and Wolof, the majority language of Senegal, is also spoken by a substantial minority in The Gambia. However, the history of the two countries diverged during the colonial era, when The Gambia fell into British hands, while Senegal was seized by France. As such, The Gambia has been a member of the British Commonwealth since independence in 1965, and uses English as its official language; Senegal has retained close links with France. An attempted merger between the two countries to create the ‘Senegambia Confederation’ in 1982 was short-lived, with The Gambia leaving the federation in 1989.
Despite the huge disparity between the relative wealth of foreign visitors and the poverty in which many Gambians live, the crime rate is relatively low. However, the UK Foreign and Commonwealth Office warns that attacks on tourists and theft from vehicles are on the increase. In 2002, the government formed a special Tourism Security Unit (TSU) to police the coastal Tourism Development Area (TDA) and in particular to address the frequent complaints about the activities of ‘bumsters’ – youths and young men who approach and harass tourists with requests for money in exchange for a variety of services, including sexual favours. How effective the TSU has been in curbing crime is open to question.
Until recently, only a tiny number of visitors travelled far beyond the stretch of Atlantic coastline that was originally designated by the government as a TDA in 1970, and which today boasts some 3,000 hotel rooms in fewer than 50 properties. There have been token efforts to develop eco-tourism, with a few safari-style lodges on the banks of the Gambia River aimed at attracting wildlife enthusiasts to a handful of nature reserves. Some specialist tour operators report a trend towards multi-centre holidays and accommodation further from the main development area, but in practice The Gambia will never compete on equal terms with destinations such as Kenya, South Africa, or Tanzania, all of which can offer not only superb wildlife viewing but also sophisticated accommodation and excellent beaches.
"it could be argued that The Gambia offers many of the downside aspects of Africa"
Despite the importance of tourism to the national economy, foreign exchange facilities are rudimentary. Credit cards and travellers’ cheques are not widely accepted, so tourists must carry substantial amounts of cash, making them more vulnerable to theft or robbery. Travel insurers must, therefore, be prepared for more claims relating to cash thefts than might be expected in better developed destinations. Most clinics and hospitals also require cash payment.
In short, it could be argued that The Gambia offers many of the downside aspects of Africa – including infrastructure deficiencies, political insecurity, and a menu of infectious diseases – without the glamour and excitement of well-developed safari destinations. Nowhere is this more apparent than in terms of health and medical care: for local people, resident expatriates and holiday visitors.
Three main state hospitals and a handful of clinics provide 1.13 hospital beds per 1,000 head of population, and there are only 11 physicians per 100,000 people. Gambia is heavily dependent on foreign doctors, many of them from Nigeria and Cuba. Public expenditure on health is less than two per cent of GDP, with private sector expenditure equivalent to around five per cent of GDP. Foreign medical advisers say The Gambia’s economy simply does not generate enough money to meet with the level of demand on the public health system, which has been reported to be close to breaking point. The risk of major infectious diseases – notably hepatitis A, typhoid, malaria, schistomiasis and meningococcal meningitis – is also said to be high.
The country’s main referral hospital, in Banjul, is the 650-bed Royal Victoria Teaching Hospital (RVTH). Built in 1853, the hospital is underfunded, though efforts are being made to modernise it and to develop a cadre of Gambian health professionals to reduce the country’s dependence on foreign surgeons and doctors. Elsewhere, there are referral hospitals at Bansang and Farafenni, but none are capable of dealing with serious cases to international standards. According to the World Health Organisation (Bulletin of the WHO, August 2011), all the facilities in Gambia have only limited ability to perform trauma, obstetric and general surgical procedures: “Major gaps exist in the physical and human resources needed to carry out basic life-saving surgical interventions,” the WHO concluded.
Despite President Yahya Jammeh’s assertion that improving the health sector is high on his development agenda, Gambian hospitals and clinics remain heavily dependent on aid agencies, NGOs, foreign charities and individual philanthropists from countries such as the UK, and from Gambians working abroad for donations of basic medical and pharmaceutical supplies and equipment.
Private hospitals are also thin on the ground. In Banjul, the UK Medical Research Council’s Gambia unit is primarily a clinical research and training facility, but also has a clinic and outpatient department offering high-quality, efficient diagnostic and treatment services. Medical cases are managed at the unit, while surgical cases are stabilised before referral to RVTH or a private hospital.
Other private medical facilities in Banjul include the not-for-profit Africmed Clinic, which offers general surgery and emergency care, 24-hour ambulance services, including air evacuation to the UK, where it has a patient referral agreement with London’s King’s College Hospital. Africmed also has referral agreements with hospitals and clinics in Dakar and in Ghana. Also in Banjul, the Westfield Clinic, which is strongly supported by the Scandinavian charity Scanaid, is a referral facility often used by assistance/ travel insurance companies. Furthermore, limited first aid is provided free at clinics within 13 fire stations operated by the Gambia Fire and Rescue Service, which also carries out sea and river rescue operations.
With the vast majority of visitors concentrated on the coast, close to the capital and the country’s only airport, there would appear to be few serious challenges in terms of medical evacuation cases. Beyond Banjul, however, the transport infrastructure is deficient. There are no regional airports (or even airstrips or helicopter landing pads). A single publicly-owned bus company (slated for privatisation) provides unreliable services, and public transport needs are mainly met by communal ‘bush taxis’ carrying up to 12 people, and by conventional taxis. A combination of poorly maintained and sometimes unroadworthy vehicles, reckless driving and poor roads contributes to a high rate of road-traffic fatalities. A road improvement programme is underway, but less than 1,000 kilometres of the 3,742-kilometre road network are surfaced, presenting problems for urgent road ambulance transfers, especially during the rainy months when some roads can become impassable due to flooding or landslips.
"Beyond Banjul, however, the transport infrastructure is deficient"
The tiny Gambian Air Force, formed in 2002, is still in its infancy, with only handful of Ukrainian-trained personnel, and it does not at present have any medical evacuation capability. Furthermore, there are no fixed-wing or helicopter rescue operators based in the country.
One option is to fly evacuation cases to the Canary Islands, only around 1,600 kilometres from The Gambia, where several private clinics offer an adequate range of treatments, and where Aeromedica Canaria, based at Gran Canaria, operates a fleet of Fairchild SA-227, SA-225 and ATR-42-320 aircraft with fully equipped life support units. Aeromedica’s Miguel Valdivieso reports no technical or bureaucratic obstacles to medical repatriation operations from The Gambia. “We have organised several repatriations [from there] in recent years without problems,” Valdivieso said, “Government bureaucracy accords with normal values.”
Another option is to fly patients to Dakar, capital of neighbouring Senegal, only 165 kilometres from Banjul, where several private hospitals – notably the Clinique du Cap, Clinique de la Madeleine, and Clinique Casahous – offer international standards of treatment and care. While this could be an attractive option for Francophone clients, there are some bureaucratic obstacles, and most non-French insurers opt to evacuate more complex cases direct to hospitals in the UK or other home countries.
In short, The Gambia’s health infrastructure is not well able to cope with foreign patients requiring advanced treatment, and in many cases repatriation to Europe is called for. The lack of locally-based emergency evacuation facilities poses logistical challenges for travellers in need, and as the country’s tourism offering diversifies and visitor numbers increase, demand for international air ambulance operations is likely to expand considerably in the near future.