Reva-Lou Reva is worried. For the first time he can remember, he says hospitals around the Pacific Island nation of Papua New Guinea (PNG) are so overburdened they are closing their doors to patients.

“This is very frightening, to know that you don’t have any medical facilities open, or very limited, and you cannot easily access them because of the restriction,” says Reva, 48, PNG assistant country director of program support for humanitarian non-profit CARE International. “I’m breathless, I can’t explain how difficult it is.”

Until recently, PNG had largely managed to stave off a major coronavirus outbreak. At the end of February, the country had only reported 1,275 cases, according to Johns Hopkins University.

But over the past month, cases have more than tripled. PNG has now reported at least 4,660 Covid-19 cases and 39 related deaths, including that of MP Richard Mendani, who died age 53 earlier this month, according to a Radio New Zealand report. On Friday, the country reported 560 new infections — its highest for a single day — with Prime Minister James Marape admitting there is “rampant community transmission.”

While those figures might not seem high compared to other countries, they pose a major issue in PNG, where the government says there are only about 500 doctors for an estimated population of 9 million people. At the best of times, the country’s health system is fragile — now NGOs are warning it could be on the “verge of collapse.”

Low testing rates also mean PNG’s case load is likely much higher — something authorities acknowledge. Meanwhile, rampant misinformation in the country means some people are still not taking the threat seriously.

Onlookers warn the crisis could worsen next week as people in the predominantly Christian nation travel home for Easter — and are calling on neighboring Australia and New Zealand to do more to help.

“Papua New Guinea’s health crisis has now reached the level we feared it would a year ago with a surge in cases,” Amnesty International’s Pacific researcher Kate Schuetze said earlier this month. “A combination of an ailing health system and inadequate living conditions has created a perfect storm for Covid-19 to thrive in the country’s overcrowded informal settlements.”

PAPUA NEW GUINEA’S OUTBREAK

For almost a year, PNG seemed to handle the outbreak well.

The country confirmed its first case on March 20 last year — an man who had traveled from Spain. Within two days, the Prime Minister declared a state of emergency, stopping all incoming and domestic flights, and limiting travel between provinces.

Onlookers and the government were concerned an outbreak in PNG would be disastrous.

“Our country does not have a health system that is capable of defending our people in this time of emergency with the threat of the coronavirus entering and spreading in our country,” Prime Minister Marape said in Parliament on April 2. At the time, he said PNG had 500 doctors, fewer than 4,000 nurses, under 3,000 community health workers and only 5,000 hospital bed spaces. “Our existing health capacity is insufficient to fight this battle,” he added.

PNG has one of the lowest ratios of doctors per 1,000 people in the world. According to 2018 World Bank figures, the country had 0.07 physicians per 1,000 people — well below the 2017 average among small Pacific Islands (0.5), the 2017 world average (1.6), or the 2017 level in the United States (2.6).

For a while, PNG’s measures appeared to work. It took until February this year for the country to reach 1,000 cases. But Covid-19 was likely circulating under the radar, says Justine McMahon, PNG country director for CARE.

“It’s been here for months,” McMahon said. She added that up until a month ago, people were quite ambivalent about the Covid-19 pandemic, but “there’s a growing sense of trepidation everywhere.”

It’s unclear what sparked the outbreak. The country shares a land border with Indonesia, which has reported almost 1.5 million coronavirus cases, according to Johns Hopkins University data. The border between the two countries is closed, although officials said earlier in the pandemic that some people were defying the closure, according to Radio New Zealand.

The outbreak may have also been exacerbated by funeral gatherings held earlier this month to honor PNG’s first Prime Minister Michael Somare, who died age 85 in late February after being diagnosed with advanced pancreatic cancer. Thousands gathered at a state funeral in Port Morseby, but few mourners wore masks at the service, Australia’s ABC reported. Crowds also gathered along the street as a hearse carried his coffin, and a number of mourning events were held for representatives from the country’s provinces.

“I’m pretty concerned. The number of people who came together for the period of mourning, if it goes like any other country, it’s just going to spread like anything,” McMahon said.

WHAT’S THE SITUATION NOW?

One year ago, PNG responded aggressively to the threat of Covid. But now cases have surged, restrictions are weak or not enforced, according to McMahon and Reva.

Authorities announced restrictions on travel between provinces and mandatory mask wearing. They also said they would ban mass gatherings, close schools, and may order burials in a “designated mass grave,” according to a Reuters report.

But Reva, who lives in Goroka in PNG’s Eastern Highlands province, estimated Thursday that only “about 20%” of people he sees are wearing masks.

Reva also worries for his family, who live in the capital, Port Moresby, which is in the National Capital District where about 47% of the country’s cases have been reported, according to government figures. Reva said family members told him mask wearing and social distancing measures aren’t in place, and six people had died over the past week in their urban village of 30,000. So many deaths in a week is unusual for his village, Reva added — but because of limited testing, it’s unclear whether the six died from Covid-19.

“I am worried for them,” he says of his family. “The national directives have been handed down but the law enforcement is not in place.”

According to the World Health Organization’s health situation report for the first week of March, in some facilities around the country more than 30% of coronavirus test results in PNG were positive. At Rita Flynn hospital, one of two major hospitals in the capital, almost 40% of tests are coming back postive, Médecins Sans Frontières (MSF) said in a statement Friday.

High test positivity rates tend to indicate not all cases are being detected — WHO has previously advised governments to avoid reopening until test positivity rates reach 5% or lower. But some places in PNG have no testing capabilities at all — McMahon says there is no testing available in Goroka.

Ghulam Nabi, interim head of mission for MSF in PNG, said a “substantial number” of the country’s healthcare workers had tested positive, meaning they have to isolate and can’t go to work. That has consequently restricted health care services, Nabi said.

“This is a huge setback, because the country does not have enough health staff to begin with,” said MSF medical manager Farah Hossain, adding that of 86 staff running MSF’s tuberculosis program in the country, 30 had tested positive for Covid-19.

Some hospitals around the country have closed — they may accept maternity or critical emergency cases, but otherwise people are being turned away, McMahon said.

BATTLE AGAINST MISINFORMATION

All this is being exacerbated by the spread of misinformation.

On Thursday, leader of the opposition, Belden Norman Namah, demanded the government follow other countries in suspending the rollout of AstraZeneca’s Covid-19 vaccine, and downplayed the threat of the pandemic.

Namah said in a statement the government was “exposing citizens to potential serious harm and offering them up as laboratory rats or guinea pigs for further testing of the virus.”

McMahon and Reva say these sentiments are common. Reva says he has heard people say they are afraid of dying if they take the vaccine, and others believe their Christian faith will be enough to protect them from the coronavirus.

McMahon says when she was in Port Moresby three weeks ago, some taxi drivers she spoke to were dismissive. “Because they didn’t see it here, they said ‘no, it doesn’t come here,'” she said. “A lot of people think as well, ‘God will protect us.'”

Prime Minister Marape on Friday appealed to “rumormongers” to stop.

“I did not manufacture Covid-19 in a lab somewhere, I did not import Covid-19 into this country,” he said. “Just like viruses that transfer from person to person, from human to human, Covid-19 has arrived in our country despite us doing our best to keep our borders safe.”

UNFOLDING CRISIS

In a place like PNG, where the CIA says about 85% of the population lives off subsistence farming, lockdowns can be challenging. Many rely on going to busy markets to sell their produce. Marape noted that “fine balance” on Friday, saying the government was trying not to stifle economic activities.

Even so, Reva wants to see a lockdown: “Everywhere, anywhere we go, we don’t feel safe anymore.”

MSF’s Hossain says more can be done. Testing needs to be escalated, health advice promoted and the country needs more vaccines, she said.

And that’s where other countries come in.

PNG’s largest donor, Australia, has provided 8,000 AstraZeneca vaccine doses, which Marape said would be rolled out from next week. Earlier this month, the New Zealand Defence Force donated 4,400 kilograms (9,700 pounds) of PPE. China — a major investor in PNG — has offered a batch of vaccines, according to a Xinhua state-run media report.

PNG is also part of the United Nations COVAX scheme, which aims to give equal vaccine access to all countries.

But PNG is yet to accept China’s offer. In February, acting foreign minister Rainbo Paita told Australia’s ABC the decision to introduce the vaccine was subject to formal discussions.

Amnesty International’s Schuetze says Australia and New Zealand’s pledges of assistance are “woefully inadequate” and PNG’s experience speaks to the “deeply unequal global rollout.” She wants to see New Zealand and Australia “urgently step up” and provide help to PNG.

Throughout the pandemic, both countries have been concerned about the virus spreading in the Pacific. For the most part, Pacific Island countries have avoided a major outbreak — some, including Kiribati, Tonga and Tuvalu, are yet to report a single case.

Australia plays a big role in supporting Pacific countries, and an outbreak there would impact it too. Australian Prime Minister Scott Morrison said earlier this month helping Papua New Guinea wasn’t just to support “our Pacific family” but also about “keeping our nation and people safe.”

Only a small strait separates the tip of the Australian state of Queensland from PNG, and Morrison noted the outbreak carried a risk to his country through incoming travelers. A new strain from PNG makes up 60% of active cases in the Australian state, CNN affiliate Nine News reported Friday.

McMahon sees other challenges in the future — the difficulty of a vaccine rollout in the country, the possibility people won’t return for the second dose, and the issue of vaccine hesitancy. The crisis is also taking focus and resources away from other major health issues, such as the fight against tuberculosis.

“It’s out of the box now,” said McMahon. “The only thing they can do is have widespread vaccination of the population.”

To Hossain, it’s an unfolding humanitarian crisis.

“(It’s) a fragile health system, and then the medical staff are getting positive, and then you have case numbers piling. So this is like one on top of another. So unless we try to contain it, unless we support the treatment and the testing, it can become a catastrophe.”