Papua New Guinea (PNG) has a population of about 5 million people, 85% of whom live in rural villages.1 Since becoming independent in 1975, PNG has experienced problems common to emerging nations of starting from a subsistence base and simultaneously seeking to achieve economic sustainability and nationhood as well as build systems of governance, defence, transport, communication, education and healthcare. Health system development has not kept pace with changing demands in PNG. Instead, primary health services have faltered, placing a heavier burden of disease on struggling secondary care facilities as opportunities for prevention and early treatment are lost because aidposts have closed or vaccination rates have fallen.

Port Moresby, the capital and largest city, has a population of over 300 000. Port Moresby General Hospital (PMGH) is the country's major teaching and referral hospital, with 600 beds. Hospital-based studies of the causes of death and patterns of admissions to PMGH confirm that infections remain the major cause of adult hospitalisation and deaths in hospital, and that HIV/AIDS is now a leading cause of death in adult inpatients. Moreover, there has been no reduction since 1980 in the mortality rate of children under five years, and infectious diseases, predominantly pneumonia, are also the main cause of childhood deaths.

Adults: Studies of medical records in the 1980s and again in the 1990s determined causes of death in adults admitted to medical wards and the intensive care unit at PMGH.2,3 The findings of these two studies are summarised in the Box. Malaria, tuberculosis, typhoid and pneumonia were the leading causes of death in patients in whom aetiology was determined. In addition, these same infections were suspected on clinical grounds to be the cause of death in more than half of those dying without confirmation of the cause.

A further study in 2000 looking at reasons for medical admissions to PMGH (Dr G Tau, Chief Medical Officer, PMGH, personal communication) found infections remain the most common reason for admission, with tuberculosis being the most common (27%), followed by malaria (23%), pneumonia (15%), dysentery (12%), typhoid fever (8%), and HIV/AIDS (3%). According to statistics of the PNG Health Department, the reported national prevalences of tuberculosis, malaria, typhoid and other infections have not declined in the past three decades.1 Thus, the dramatic recent addition of HIV/AIDS has occurred against a background of no change in the high prevalences of other infectious diseases.

As a result of cultural resistance, autopsy rates in PNG are very low, and, at the time of the two studies of causes of death,2,3 autopsy was performed in less than 3% of deaths. Needle autopsy, which, compared with full autopsy, is accurate in 77% of cases, appears to be an acceptable alternative for Papua New Guineans and could be applied to determine cause of death in the large numbers of patients who currently die from undiagnosed causes.4 In addition, better diagnostic facilities in microbiology laboratories would assist in diagnosing and treating infections earlier and more effectively.

As economic prosperity increases, non-communicable diseases are becoming more apparent. New diagnostic facilities at PMGH — ultrasound, echocardiography and a private computed tomography facility — have markedly enhanced the ability to diagnose chronic, non-communicable diseases. Even allowing for this enhanced diagnostic capacity, the prevalence of these non-communicable diseases is increasing.1

Children: Reports on child health in rural areas of Papua New Guinea similarly indicate a dominance of infectious diseases. The major infectious diseases causing child mortality in PNG include pneumonia, measles, meningitis, malaria and neonatal sepsis. Between 1960 and 1980 the mortality rate for children under five years of age in PNG fell by an average of 3% per year, from 204 to 122 per 1000 livebirths. No improvement has occurred since then. By contrast, the mortality rate in this age group in East Asia and the Pacific region has fallen by 2.5% per year. The most optimistic figures for the current infant mortality rate, and the mortality rate in children under five years, puts the national rate at 77 per 1000 livebirths and 100 per 1000 livebirths, respectively; this represents no progress during the past decade. According to UNICEF, only four countries in the world have failed to improve the mortality rate among children under five years since 1980: Burma, Niger, Zambia, and PNG. The high child mortality rate is attributed to collapse of health service structure, law and order problems, closure of aidposts, deteriorating roads, and inadequate administrative assistance and support.

Vaccine-preventable diseases, such as measles, whooping cough and Haemophilus influenzae infection, still kill children in PNG. Vaccination coverage is low and differs from province to province. According to figures in the National Health Plan, vaccination coverage averaged 64% for diphtheria–tetanus–pertussis and 60% for measles, while, in the Western Province, these proportions were only 30% and 27%, respectively.1 In a highlands province in 1997, coverage was about 33% for immunising doses of any vaccine.5,6

HIV/AIDS: The first case of AIDS in PNG was diagnosed in 1987. HIV in PNG is heterosexually transmitted and equal numbers of men and women are affected. Unprotected sex and a rising incidence of other sexually transmitted diseases and promiscuity have contributed to the rapid rise in cases of HIV/AIDS to epidemic levels. By the end of December 2001, 4700 cases had been reported.7 About A$200 million was committed to healthcare in the 2001 PNG National Budget, including $650 000 earmarked for HIV prevention and care. In addition, $20 million is being put into the National HIV/AIDS Support Project by AusAID. Some antiretroviral therapy is becoming available through UNAIDS. PNG faces the danger of following the experience of African nations, with the potential to lose half of its adult population to this disease.

Investing in the future of the nation: PNG manifests the challenges facing many tropical nations where communicable disorders remain major causes of mortality and morbidity, but non-communicable diseases are becoming more apparent. This is in sharp contrast with Australia, where cancer, ischaemic heart disease and stroke are the leading causes of death (27.8%, 20.7% and 9.6%, respectively).8 In PNG, this background of infectious diseases is being overlaid by non-communicable diseases — hypertension, coronary artery disease and diabetes (Dr G Tau, personal communication).1 Declining health service efficiency has meant that HIV/AIDS has now taken hold, placing additional stress on an already skeletal system. The commitment of public resources to the control and alleviation of these problems needs to be seen as an investment in the future of the nation. Those responsible for the administration of healthcare may be encouraged from international experience that control of infectious diseases and lowering child mortality are achievable and worthwhile goals.

Australian aid to PNG has been generous, with the estimated total aid to PNG for 2002–2003 being $351.4 million.9 Special attention should now be given to enhancing primary care services provided in the village aidposts and rural district health centres. At the same time, PNG requires continuing support from experienced clinicians and public health experts. It would be wise for Australian aid to support this and related workforce development. Australia has a special relationship with PNG. This should be used to work with PNG in the development and implementation of the PNG National Health Plan. Australian aid must be sensitive to the PNG political environment, and should not be provided without an explicit purpose or without clear accountability for its expenditure. In controlling the spread of HIV, tactics used in other countries to good effect, including the judicious and appropriate use of antiretroviral medications, need to be examined for their applicability in PNG.