Stamina and seaplanes

Seven-year-old Nicola rubs her lifeless left leg continuously as her father explains how she contracted polio when an outbreak struck PNG several months ago. “We are going through a lot. We don’t have enough money as the illness has affected us and we spend more time at home. This is a big expense for us,” says Nicola’s father, Jeffrey. He adds that although Nicola and her three siblings, who live in a village in East Sepik Province, received some routine immunizations, they did not receive the polio vaccine before the outbreak hit.

Polio returned to this vast, diverse South Pacific nation of around eight million people last year after an 18-year absence. Twenty-five other young people were affected, with PNG accounting for just over 20 per cent of the 128 cases reported worldwide.

The Government declared a national public health emergency last June. Several rounds of immunization were planned to target 3.34 million children, aged 15 and under, with the first mass vaccinations taking place in October and November of 2018 and in February 2019. The aim was to achieve 95 per cent coverage nationwide. But carrying out a mass vaccination campaign is uniquely difficult in PNG, one of the world’s poorest countries, where many live-in isolated communities. The country’s poor infrastructure was further weakened by a devastating earthquake in February last year and frequent tribal fighting creates additional security risks. Many remote clinics have no way of keeping vaccines cold, adding an extra dimension of difficulty for health workers.

Because of these challenges, the campaign is estimated to cost at least US$18 million, making it one of the most expensive in the world. Like Nicola, many children live in isolated settlements, cut off from access to roads, services, electricity and running water. About 85 per cent of people here live in rural areas. A UN agency, as one of the leading stakeholders, alongside the NDoH and the World Health Organization (WHO), has obtained 14.4 million doses of the oral polio vaccine (OPV) and is supporting logistics, social mobilization and the printing and distribution of materials.

It is hoped that the nationwide polio campaign will also boost routine immunization coverage, which has fallen to as low as 20 – 30 per cent in some parts of the country.

Setting a target of zero child deaths

UNICEF Country Representative, Mr. David McLoughlin, said the agency’s goal is to reach zero deaths from preventable childhood diseases and to strengthen the overall immunization infrastructure, especially in terms of supply and procurement.

“In 2019 polio and measles should really be unheard of,” said Mr. McLoughlin. “It is simply because we let our guard down to vaccine (against) preventable diseases.”

In recent years, the national routine immunization rate plummeted to around 60 per cent, against a target of 98 per cent. Preventable diseases have increased because of low immunization rates, an ill-equipped health system that is unable to deliver a full range of services to children, as well as security challenges, poor sanitation and a widely dispersed population. At the launch of the second phase of the polio immunization campaign on 25 February, the Minister of Health and HIV, Sir Dr. Puka Temu, said people needed to spread the word about the importance of vaccinations. He called on faith leaders, teachers, parents and health workers to unite to make sure all children receive their vaccinations. Mr. McLoughlin said faith leaders were key allies, as more than 50 per cent of schools, and many clinics, were run by churches.

Leaving no child behind requires amazing logistics …and people

Reaching maximum coverage rates in PNG, which claims only 1 per cent of the world’s land mass but more than 850 languages, requires stamina, skilled logistics and sometimes luck. The country’s estimated 25,000 health workers have to use four-by-four vehicles, boats, seaplanes and helicopters to reach communities. Sometimes there is no other option but to walk for hours. Sometimes the obstacles can seem insurmountable and authorities

must work hard to keep up morale.

“It is important to keep (the health workers) motivated because they are the ones who know the population,” said one expert. Shelly De, a health extension officer in Hela Province in the Highlands region, is typical of the dedicated professionals who work tirelessly to ensure that no child is left behind. She often walks several hours in a single day to get to remote villages. She has had to cope with tribal fighting and opposition from parents who sometimes fear vaccinations. She does her best to convince them that immunizations are both safe and necessary. “Once I explain about the complications of polio, I am able to convince them,” she says. New Ireland is the country’s most north-eastern province and is dotted with small islands, thick tropical rainforests, towering hills and rivers. Health workers must drive for hours over bumpy jungle paths to reach some communities. In the rainy season, roads become impassable and drivers live in fear of getting stranded.

But it is not just the health workers who struggle to get to the remote clinics. For many mothers, the journey might entail several hours of walking. Public transportation is scarce and too expensive for many families. And even if health workers do make it to remote clinics, there are further challenges. At the inland Messi Sub-Health Centre, which serves around 7,000 people, there are no functioning refrigerators. The vaccines must be brought in from

Kimadan, more than an hour’s drive away over a bumpy road and used quickly.

“Last year, I didn’t do any immunization because my fridge wasn’t functioning. And one of my two vehicles is out of action. We have a lot of problems connected to transport and the cold chain,” said Sister Lucy Hayai, who oversees the church-run clinic. “I feel that we are left out. Maybe it is because the geography and location of this place. But even if I write in my monthly report that my cold chain system isn’t working, I don’t get a response. It is a pity as the parents keep asking us when we will provide vaccinations. I have to tell them we still have a problem. It is costly for mothers to take the minibus and bring their children here,” she said.

One way of reaching children in New Ireland is to vaccinate in schools, which saves time and money and makes record-keeping easier. On a recent March morning at a primary school two hours’ drive from the provincial capital Kavieng, dozens of children proudly showed off the marks they received on their fingernails to show that they had taken the polio drops. Most mothers interviewed during a two-day tour of the region said their children had received at least two or three doses of the oral polio vaccine. 

On the other side of the country, in East Sepik Province, a small airline plays a critical role in delivering vaccines to isolated communities along the sprawling river basin. Samaritan Aviation, run by Mark Palm from the United States, flies up and down the river every day to provide vaccine outreach and to ‘medevac’ patients to the provincial capital of Wewak. When the Cessna splashes down, villagers and health workers flock to the plane,  riven by curiosity and a desire to help ferry the vaccines to shore. 

“You couldn’t do what we did today without an airplane,” said Palm, after an intense day flying vaccines, cold storage equipment, and UN experts. The regular air deliveries have improved reporting by field workers, and the high coverage rates documented in several provinces over February and March show that the Government and its immunization partners, with support from UN agencies, have reached record numbers of children during the current campaign.

To build on this success, investment across the health sector must be increased and sustained, including in improving the cold chain by using solar-powered refrigerators, bolstering human resources and educating communities about health risks. Last year, Australia committed AU$16 million to support the polio vaccination campaign and routine immunization to help combat other infectious diseases. Against incredible odds, PNG has made remarkable progress in achieving almost universal coverage with polio immunizations. It will now be critical to maintain those gains and boost routine vaccinations to ensure a better future for the country’s children.