The Covid-19 pandemic has had a profound impact globally, with more than 114 million cases and 2.5 million deaths. With 1365 cases and 14 deaths, Papua New Guinea has fared better than most, even though experts believe the infection rate is much higher than reported. The recent rise in reported cases is prompting additional concern.
PNG’s Health Secretary Osborne Liko has said widespread vaccination is the most effective intervention to fight the virus. In a recent World Health Organisation survey included in the PNG national deployment and vaccination plan for Covid-19, of 1332 Papua New Guineans, 85% were happy to receive a Covid vaccine. However, this data does not distinguish between urban and rural populations who have had different pandemic experiences.
Considering the pandemic’s limited impact in non-urban areas, motivating residents to accept the Covid-19 vaccine may be challenging. For example, in rural Western Province, not much has changed since the pandemic began. Markets are still occurring, gardens are being cultivated, and sago is still being made – life continues much as it did before Covid-19 arrived.
I began work as a doctor in rural outreach patrols in Western Province in January 2020 and returned to Australia in March when the government ordered citizens home. At that time, amid warnings of “bodies in the streets”, the outlook for Covid in PNG was grim. Luckily these predictions have not eventuated.
High vaccine uptake in rural PNG is essential to prevent more aggressive disease and protect its neighbours such as Australia.
In January 2021, I was granted a special exemption to return to Western Province one year after leaving. While Australia has seen multiple lockdowns, border closures and behavioural change, not much evidence of that can be seen here.
In Balimo Hospital, Middle Fly, the Covid-19 ward remains empty. Although some nasopharyngeal swabs are available, as yet no tests have been performed.
In rural aid posts, the health workers wear masks to attend to patients, but they did this before Covid-19 due to the high rates of multi-drug resistant tuberculosis (MDRTB). Patients are seen in well-ventilated rooms with ripped fly screens and broken windows, or the traditional wood panels held open by sticks, ensuring good ventilation and keeping healthcare workers safe from MDRTB, and likely Covid-19.
The Covid-19 education we deliver focuses on cough etiquette, social distancing, mask-wearing and handwashing. The messages are received calmly, despite almost certain widespread community transmission. At the end of the session, the same question is always asked: “What do we do if we have no soap?” The majority of these villages find it challenging to access shops and do not have a consistent supply. Sustainable Development Project and OkTedi Development Fund have been providing soap since the beginning of the pandemic. Anecdotally, mothers have found diarrhoea, skin disease and “simple cough” have decreased in their children since soap was introduced (diseases that contribute 10.96% and 4.55% of all disability-adjusted life years in PNG).
From a front-line worker’s perspective, it is unclear exactly how 80% of the population that lives rurally will be vaccinated. Polio and measles “surge” patrols saw some villages receiving excess doses of vaccines, with incorrect timing of injections and poor record keeping, while many other villages missed out. Avoiding the same mistakes with the Covid-19 vaccination will be essential.
The lack of electricity and refrigeration in most aid posts and the use of cold-chain portable cooler boxes will limit the vaccines’ geographical reach. In 2012, only 41% of PNG clinics physically had a refrigerator, and as few as 40% had any electricity.
Covid-19 vaccine patrols may also generate resentment. Many communities already feel neglected by only seeing maternal and children’s health clinics (MCH) with nothing being done for the MDRTB, leprosy and other chronic disease sufferers. Arriving with another vaccine clinic for a virus that seems inconsequential in day-to-day life will not be received well.
Many mothers already avoid vaccination patrols due to fears around their children having too many injections, and feel they do not require medicine as “they are not sick”. This is despite long term education and promotion of PNG’s extended program for immunisation. These same beliefs will likely translate into adult vaccine hesitancy. Only 49% of children in Western Province receive any vaccination, it is unlikely we’d achieve better results for the adult Covid-19 vaccination.
Without widespread, efficient vaccination there will be ongoing transmission of the virus leading to new variants, as has already been seen in the United Kingdom and South Africa. This may cause an increase in the severity of illness in PNG and may render vaccination campaigns in other Pacific nations less effective, as a new PNG strain could act as a site of re-infection. High vaccine uptake in rural PNG is essential to prevent more aggressive disease and protect its neighbours such as Australia.
Despite the omnipresence of the virus, life in rural Western Province has remained unchanged. Considering the many other health threats rural communities face, it may be hard to convince rural communities to prioritise Covid-19 vaccination. A lack of uptake of vaccines could jeopardise PNG’s ability to reach herd immunity, preventing open international travel and remaining a re-infection risk. Any vaccination campaign must complement existing efforts to strengthen healthcare systems, or it will likely lose the support of the community it is meant to serve.