KEREMA, Papua New Guinea — Six-year-old Elisa Iboro did everything she could to avoid swallowing the 14 pills held out on a hand in front of her. She squirmed in her mother’s arms. She cried. She looked sideways and simply ignored the life-saving drugs.
“Let’s go, you know this is important, come on,” pleaded Dorothea Deslandes, a French nurse with the medical charity Doctors Without Borders (MSF). Elisa has tuberculosis (TB), a highly infectious but curable disease that leads to fever, fatigue, chronic cough and possibly death if left untreated. But even with medication, her situation is precarious: She has developed a multidrug-resistant strain of the disease, the result of an earlier interruption in her treatment.
One of the world’s oldest-known diseases, tuberculosis (TB) has essentially been eradicated in the developed world. But it remains a serious danger in poorer regions, where a staggering 1.5 million people die every year of the illness.
Papua New Guinea has the highest rate of tuberculosis in the Pacific region, where 60 percent of new cases originate, according to the World Health Organization. The epidemic there is being described as a national emergency. In many parts of the country, including vast swaths outside of the capital, health services are scarce, the result of chronic underdevelopment, along with years of government neglect and mismanagement.
Elisa’s situation highlights the difficulties of eliminating TB from one of the most underdeveloped corners on Earth. At the time she stopped receiving treatment for her initial case of TB, seven other members of her family were bedridden with the disease, and too ill to make the seven-hour journey from their remote mountain household to the coastal hospital to restock on pills for her.
“We just couldn’t return to the hospital to get another supply, when I was also sick,” said Linda Paul, Elisa's mother.
A national emergency
In Papua New Guinea, approximately 30,000 people every year are newly infected with TB, and in many regions of the country, cases of multidrug-resistant strains are on the rise.
Gulf Province, where Kerema Hospital is located, was identified by government officials as one of three “hot zones” where the disease has spiked. The TB incidence rate there can reach 1,450 per 100,000 people — more than 12 times the global average.
“Tuberculosis is a constant,” said Elvis Pyrikah, the provincial disease controller for Gulf Province. “Patients come every day.”
Treatment for the bacterial infection usually lasts six months, but with drug-resistant strains it can last a grueling 24 months and require several rounds of drugs, ongoing medical supervision and daily injections.
Nearly half of TB patients, like Elisa Iboro, don’t complete their course of treatment, according to the World Health Organization, leading to a much greater risk of developing a drug-resistant strain.
One of the main reasons is access. More than 85 percent of the population lives in rural areas — the highest percentage in the world — and medical facilities can be hours or even days of travel away. In the country’s vast landscapes, getting a correct diagnosis and monitoring treatment can be nearly impossible.
After nearly 30 minutes of coaxing, Elisa Iboro, with tears still fresh on her cheeks, eventually swallowed the bitter-tasting medicine — but only after the MSF nurse ground the pills into a fine powder and dissolved them in honey-infused water.
Elisa’s neck was crisscrossed with keloids, thick scars that developed after the disease escaped her lungs and infected her lymph nodes. Her mother lifted her onto a gurney for a painful injection, and the crying began anew.
It is a daily routine that will await her for another two long years.
For many in the country, access to decent health care remains a broken promise. In principle, all primary and public health care in Papua New Guinea is free of charge.
But the country has only one doctor per 17,500 people, compared with 302 in neighboring Australia. The vast majority of those doctors live and work in the capital Port Moresby. And despite recent economic gains, many in Papua New Guinea simply don’t have enough money to afford treatment.
Per capita GDP in Papua New Guinea has nearly quadrupled in the past 10 years, the result of a resource boom that brought the country into middle-income status. New liquid natural gas projects were recently announced, including a $6 billion investment by Inter Oil in Kerema’s Gulf Province, near the hospital. The International Monetary Fund estimates the country will have the fastest-growing economy in the world in 2015.
Yet development has stagnated at the local level, and in many areas, poverty and inequality has deepened. Nearly 40 percent of the population still lives below the poverty line, according to the United Nations.
“Most of them here, they don’t have money to come and access the hospital,” said Paul Warren, a doctor at Kerema Hospital. “This place is surrounded by swamps and a river. They can’t even afford to buy food.”
Warren sat in one of the only air-conditioned rooms at the hospital, and explained that he is one of only two doctors at the health facility, responsible for the entire province of 160,000 people. The hospital’s head doctor was evacuated last year after he was infected with TB of the spine, and without a qualified supervisor, Warren said, his teams can perform only the most basic medical procedures.
“The quality of health care that we provide is maybe 10 to 15 percent,” said Warren. “That means it’s not good.”
Analysts say the lack of quality health services across Papua New Guinea points to systemic corruption at the top, and a long pattern of state neglect.
A 2013 World Health Organization review of one district indicated that health systems were “grossly dysfunctional, characterized by weak leadership and ineffective management structures and practices,” according to the country’s National Strategic Plan for Tuberculosis Control.
The same report said that maintenance of health infrastructure across the country was a “major concern,” with the majority of health facilities having intermittent or no access to electricity and water. Many remote aid posts — nearly four in 10 — have simply stopped operating, the report said.
“We have these stories of people dying of curable diseases, of people who are not having access to medical drugs, not having access to specialized doctors. It’s happening on a daily basis," said Sam Koim, chairman of Papua New Guinea Anti-Corruption Task Force, which investigates corruption within the health department. “We have so much money, but that money is not trickling down to the real benefits that the people need at this time.”
In recent years, the government has taking steps to reverse the situation, experts say, by rebuilding the health system from the bottom up.
Recording and reporting practices are improving, and the disease is being caught earlier and more often, with case detection increasing to 89 percent in 2013 from 61 percent in 2010.
Foreign governments and international donors have also stepped in to help develop Papua New Guinea’s health facilities, despite the flow of cash entering government coffers. The Australian government, which is concerned about the growth of TB on its doorstep, recently pledged assistance, as well as the Global Fund and Doctors Without Borders.
Alex Paouke, an elderly subsistence farmer from the village of Koaru, sat sweating in an unventilated wood and tin shed at the rear of Kerema Hospital. It was a makeshift isolation shelter for patients like him with contagious or drug-resistant strains of the disease.
He pointed to swollen, black splotches on his shoulder and back where the infection was still active, remnants from when he caught TB from his son, who died of the disease. Paouke said he had made several trips to health centers in the capital Port Moresby and near his village without ever receiving a correct diagnosis.
“Some of my relatives finally told me to go to Kerema,” explained Paouake. “They said, ‘There are some white doctors there. Maybe they’ll be able to help you.’”
Doctors Without Borders is providing additional doctors, nurses and laboratory facilities to the hospital. Since arriving in Kerema in May 2014, they have diagnosed about 50 new cases of TB per month, they said, and are experimenting with novel approaches including using drones to transport sputum samples and medicine from outer health clinics to the Kerema laboratory.
The charity is also helping build a new TB ward in Geru Hospital, in the capital Port Moresby, where about 25 percent of TB patients seek treatment.
“It’s a very difficult situation,” said George Gede, hospital manager at Geru. “If everybody thought about it and prioritized the problem, TB is a glaring problem and everybody would be helping us to do this work.”
“It hasn’t happened,” he added.