SYDNEY -- Papua New Guinea long appeared to have escaped the worst of the coronavirus crisis. But a surge in cases since February has brought the remote Pacific island's largest hospital to the brink of collapse.
For the nation's much larger neighbor, Australia, the outbreak is considered a serious threat as well as a critical moment in a broader "vaccine diplomacy" campaign.
"If infections continue at the same rate ... it won't be long before we get down to a level of staffing where it is not possible to continue the health service," said Professor Glen Mola, a senior gynecologist and long-time staff member at Port Moresby General Hospital in the capital. "It is absolutely mind boggling."
Papua New Guinea has around 500 doctors for its 9 million people, or one for every 17,000. Coronavirus cases have tripled in a month, bringing the total to 5,349 with 49 deaths, and low testing rates may be hiding the true scale of the outbreak. Prime Minister James Marape believes a quarter of the population might be infected.
The virus is now engulfing hospital personnel. In a single week, 120 staff members at the General Hospital contracted COVID-19 and were forced into isolation.
After a photograph of a woman dying in the hospital's parking lot circulated on social media, the facility's CEO warned more such deaths were a possibility.
The risks extend beyond Papua New Guinea's shores: To the south, Australia's state of Queensland has seen record numbers of cases in its hotel quarantine program and has the most active infections anywhere in the country. The majority of positive cases in hotel quarantine are people who returned from Papua New Guinea.
While Australia has handled the pandemic well, outbreaks in its hotel quarantine system have highlighted the precarious nature of that success. In the state of Victoria, quarantine failures were blamed for 768 deaths, more than 18,000 infections and months of hard lockdown in Melbourne last year. When it comes to Queensland, the state's cultural, geographical and economic connection with Papua New Guinea means the island's struggle poses a real and present danger.
The Australian government has vowed to help Papua New Guinea contain the outbreak. It has sent almost 8,500 vaccine doses to immunize frontline workers in its former colony and is considering distributing more once it begins to ramp up local production of the AstraZeneca shot.
These efforts are just a small part of Australia's vaccine diplomacy in the Pacific. As a member of the Quad -- an informal but increasingly high-profile grouping with U.S., India and Japan -- it has committed AU$100 million ($76 million) to help distribute 1 billion vaccines to Asian and Pacific Island nations by the end of 2022. This is on top of Australia's AU$523 million Regional Vaccine Access and Health Security Initiative for the Pacific and Southeast Asia.
Even after the crisis on its doorstep is addressed and the pandemic wanes, some analysts expect Australia to play an integral role in helping the Pacific region repair the economic damage and move forward. It is vying for influence with China, which in January expressed a willingness to supply vaccines to Pacific states as well.
The Australian government already has its "Pacific Step-up" initiative, unveiled by former Prime Minister Malcolm Turnbull in 2016. The policy aims to boost regional engagement in the region and counter Beijing's growing clout.
At the heart of this "step-up" is the Australian Infrastructure Financing Facility for the Pacific, which will bankroll infrastructure through a combination of AU$1.5 billion in loans and AU$500 million in grants. Operational since 2019, it has already backed three major projects: a solar farm in Papua New Guinea, a hydropower system in the Solomon Islands and an undersea cable in Palau. Canberra is due to sign off on AU$300 million in funding for other projects in the coming months.
The Asian Development Bank estimates the Pacific needs $30 billion worth of infrastructure investment by 2030. The challenge is identifying projects that are commercially viable, according to Jonathan Pryke, director of the Lowy Institute's Pacific Islands Program.
Many investors are wary of bankrolling projects in small, remote economies. China does not seem to share these concerns. "But the reality is these projects [backed by China] have now been produced and it turns out they are overpriced and variable quality," Pryke said. "I think Pacific governments have become much savvier, because they only have so many bites at these projects due to their limited access to debt."
He said that infrastructure has become "a contested space" between China and Australia, and that vaccines are another "geopolitical battleground." While welcoming the Quad's vaccine commitment, he said the reality is that the rollout across the Pacific will likely be "messier, much more bilateral, and driven by individual parties."
Either way, island states need vaccines -- and quickly.
"The economic devastation in the Pacific is severe and Papua New Guinea is a genuine health crisis," Pryke said. "These countries can't afford to wait, their economies are going to be started on the back of travel, and that is not going to happen until there is a significant vaccine rollout."
But like China, Australia could run into skepticism of its foreign policy ambitions.
In the past, Australia has been criticized for only engaging with the Pacific in times of crisis. Australia's action on climate change domestically, or lack of it, is also seen negatively in island countries that are among the most susceptible. Last year, 14 Pacific leaders condemned Australia's Paris climate target as "one of the weakest" in an open leader to Prime Minister Scott Morrison.
"There is a fair degree of skepticism in the region that the only reason Australia is showing interest now is because China is showing interest, and if China was to go away, Australia would forget about the region again," said Tess Newton Cain, project leader for the Griffith Asia Institute's Pacific Hub.
Newton Cain believes there is not only an economic opportunity, but a moral imperative, to work with China in supporting Pacific development. She said Australia should not allow geopolitical concerns "whether they are driven from Canberra or Washington, to get in the way of countries which are dealing with a humanitarian crisis."
Newton Cain suggested further loosening labor mobility laws to boost regional economies. This could expand upon an existing seasonal workers program that allows people from eight Pacific island countries and East Timor to work in parts of Australia facing personnel shortages.
It is a view shared by one of Australia's top banks, ANZ, which also advocates a faster regionwide vaccine rollout and infrastructure support to spur a tourism-led job recovery.
But these are matters for Australia to ponder another day. Right now, time is running out for Papua New Guinea. Mola at Port Moresby General Hospital says the country faces huge logistical challenges, when it comes to distributing vaccines and stopping the outbreak. Few reliable roads link Port Moresby with rural corners of the country.
With most of the elderly population living in the latter, the country will be in serious trouble if the outbreak spreads.
Another complication is growing vaccine skepticism -- especially after the opposition leader called for suspending Australian-donated shots over safety concerns.
Mola believes the situation is so dire that Australian Defence Force personnel may have to be deployed to assist Papua New Guinea, as in previous crises. Ultimately, he sees no easy solutions.
"It is difficult to see how it is all going to work, actually," he said. "Pray for us."