On World AIDS Day in December, The Salvation Army's Ela Beach House of Hope in Port Moresby, Papua New Guinea, held a memorial service, which was attended by more than 150 people. The tragic reality of the country's HIV crisis was represented by both those present and those absent—of the participants, nearly 100 were children who are living with HIV or have lost their parents due to AIDS.

Emotional testimonies were shared, and at the end of the service, those attending lit candles for their lost loved ones.

“It was really hard to watch,” shares April Barthau, a nurse and Canadian Salvationist serving in Papua New Guinea. “These were kids who were six, seven, even younger, and they were crying because their parents are gone. And it was heartbreaking for me because if there was more awareness and treatment, we could end the epidemic. We could prevent this from happening.”

Medical Ministry
Barthau and her husband, Dr. Marco Herrera Lopizic, have been ministering in Port Moresby since September 2016, where they oversee the Army's health services. On a two-year medical mission, they manage the Koki Clinic, Ela Beach Clinic and several rural health outposts within a few hours of Port Moresby, Papua New Guinea's capital city.

Of the country's 7.6 million people, about 400,000 live in the capital area. A natural resource boom has brought new wealth to the city, but poverty is still widespread and almost half of the residents live in makeshift slum villages known as settlements.

“In the settlements, people struggle to have basic human rights such as water, food, clothing and health care,” Barthau notes.

Dr. Marco Herrera Lopizic treats a young patient at the Koki Clinic (Photo: April Barthau)

Koki Clinic, the Army's main medical site, is located near several settlements. These areas are densely populated, with as many as 30 people living in one home. “This poses a great risk with respect to spreading tuberculosis and other communicable diseases,” Barthau explains.

Herrera and Barthau see outpatients at Koki Clinic, which provides the services of both a walk-in clinic and an urgent-care centre.

“Each day, we collect 30 clinical files, up from 10 when we first got here,” Barthau says. “But when you collect a file, it could be for a whole family, so you can end up seeing 80 patients a day.” For Barthau and Herrera, this translates into more than 1,100 patients a month.

Fighting the HIV Epidemic
While the medical issues they see at Koki Clinic range from colds and flus to cancer, a significant number of patients are dealing with sexually transmitted infections (STIs) and HIV-AIDS. This reflects the funding the clinic receives from the United States Agency for International Development through the FHI360 program.

“This funding allows us to focus on treating HIV and STIs in our key populations, which are at-risk persons, transgender persons and sex workers,” explains Barthau.

In Port Moresby, 1.57 percent of the population has HIV-AIDS. As Herrera and Barthau have observed, several factors contribute to the epidemic, including societal norms around marriage and sexual relationships that lead to a higher number of sexual partners. “Marriage in Papua New Guinea is still polygamous, so one husband could have as many as seven wives,” Herrera says.

“And it is normal for people to live together, in the family home, without being married,” Barthau adds. “They need to have children first—until they have kids, they're not actually married.”

In Port Moresby, 1.57 percent of the population has HIV-AIDS.

Attitudes toward prostitution also contribute to the spread of STIs. “We have multiple women coming to our clinic who are sex workers—even though prostitution is not allowed in the city—but they are 'seasonal' prostitutes,” Herrera explains. “For example, if they need to buy clothes, they engage in prostitution for a few days to get the money and then they stop. But they are not seeing the risk of their behaviours.” A 2010 study found that 17 percent of sex workers in Port Moresby were HIV-positive.

At Koki's HIV clinic, Barthau and Herrera see between five and 10 patients a day.

“Our HIV clinic is quite comprehensive with an anti-retroviral treatment (ART) nurse who prescribes HIV medications, counsellors who do the HIV testing and case managers who ensure that our retention rate stays high by following up with patients,” says Barthau.

The clinic also has a laboratory on site and a lab technician who is one of three people in the country qualified to do HIV viral load testing. “However, having a multidisciplinary team is not sufficient, especially with the challenge of self-stigmatization,” Barthau continues, “so our ART nurse also does a monthly support group for people living with HIV.”

Support groups and peer educators play a vital role in ensuring that patients continue their treatment. “They talk about how they should keep taking their medicine because that's the biggest problem—people default and that's when they get sick,” says Barthau. “People die of infections; they don't die of HIV.”

By March, Herrera and Barthau had registered 220 HIV patients who now have caring counsellors and case managers who try to ensure they receive the best support and treatment possible.

Safe House
Elsewhere in Port Moresby, the Army's satellite clinic at Ela Beach brings STI and HIV treatment directly to a population that desperately needs it. “Ela Beach is a hot spot where many transactions for sex take place,” Herrera says.

Nurse April Barthau, right, takes Lt-Col Dina Ismael, chief secretary, Papua New Guinea Tty, and Comrs Tracey and Floyd Tidd, national leaders of The Salvation Army in Australia, on a tour of the Ela Beach Clinic in Port Moresby (Photo: Colonel Kelvin Alley)

On the second floor of the clinic is the House of Hope, which provides programs for vulnerable women and children—food and education for AIDS orphans and children living with HIV, and a refuge for women who have experienced gender-based violence (GBV), including human trafficking.

“Gender-based violence is a huge problem in Papua New Guinea,” Barthau says. “It's currently an accepted norm, though we hope that one day it will not be.”

A recent UNICEF study reports that two-thirds of women in the country have suffered domestic abuse. Even more troubling, a 2016 Doctors Without Borders study found that one in 10 adult GBV survivors had experienced repeated sexual violence, and this increased to two in five for children. Of child survivors of sexual violence, one in six were younger than five years.

Along with providing food and shelter, the House of Hope offers support groups, literacy classes and skills training to help the women recover from the violence, escape their abusers and become financially independent.

“When they are ready to go back to their homes, the House of Hope will do repatriation,” says Barthau. “They work with the community and the family to make sure that they'll go back to a safe environment.”

Herrera and Barthau play a key role in providing medical care to these women and connecting them with Salvation Army programs to help them end the cycle of abuse.

Challenging Terrain
Last fall, the Army's medical ministry in Papua New Guinea received a significant boost, thanks to the Canada and Bermuda Territory. With the donation of a new truck, Herrera and Barthau have been able to expand the Army's health services into rural areas near Port Moresby. Being able to provide care in the villages is particularly important in Papua New Guinea, as approximately 80 percent of the population lives outside cities.

Thanks to the Canada and Bermuda Tty, Barthau and Herrera have a new truck to help them visit patients in remote villages

Herrera makes a monthly visit to one of three Salvation Army health outposts, rotating between Boregaina, Kokorogoro and Papa. The purpose of his visits is twofold—to provide health care to patients and to train health workers, who typically have anywhere from six weeks to two years of formal training. Herrera teaches the workers in the morning and sees 10 to 20 patients in the afternoon—complicated cases that the health workers are not able to treat.

With a population of around 10,000 people, Boregaina is a two-hour drive from Port Moresby. As the village does not have a continuous supply of electricity or running water, The Salvation Army provides a generator and an emergency supply of water to keep the clinic running year round.

Though the clinic has six health workers, Herrera's initial visit in February was the first time a doctor had come to the clinic. “There are no doctors in the rural villages, generally,” Herrera says. “So the health workers do everything that they can, even delivering babies.”

An hour past Boregaina, Kokorogoro is a remote village high in the mountains, accessible by rough dirt roads. The country's mountainous terrain makes it difficult for many people in rural areas to obtain health care.

“Transportation is a huge issue, especially in the rainy season when dirt roads turn to mud,” says Herrera. “It is often a challenge to get complicated cases from these rural areas to the city.”

Patients wait for medical treatment at a Salvation Army health outpost in Boregaina (Photo: Colonel Kelvin Alley)

While health workers do the best they can with limited resources, Papua New Guinea's under-five mortality rate remains high—about 57 per 1,000 live births, compared to just five in Canada. “About 60 percent of people don't have access to any antenatal care, nor do they deliver in a health-care centre,” says Barthau. Mortality rates are improving in the cities, with better access to vaccines and doctors, “but out in the rural areas, kids die from things like pneumonia and diarrhea.”

There are fewer than 400 doctors in the entire country, and most do not practise in rural areas.

“I have treated older patients who have never seen a doctor in their life and that shocked me,” says Herrera. “In Canada, we have easy access to care. But here, I have patients who come from 10 hours away. They have walked for hours, taken a dinghy down a river and taken buses to get to Koki Clinic because they know a doctor is here. When I hear that, I realize what we are doing here is really important.”

Warm Embrace
While The Salvation Army's health services face many challenges, Barthau and Herrera are encouraged by the positive results they are seeing.

“The best part is seeing the patients get better,” says Barthau. “Now that we've been here for several months, we're starting to see some repeat patients so we're journeying with them.”

One of these patients is a GBV survivor who visits the clinic frequently with her child. “When we first arrived, her baby was two months old and had really bad pneumonia, so we treated her and got the mom into the House of Hope,” says Barthau. “Since then, she's doing better but when something happens, she will come back for counselling.”

Because of the relationship that has been built, the mom will visit the clinic, even when she does not have medical issues. “When her baby's first teeth came in, she came to the clinic just to show us,” Barthau smiles. “It's nice to see those milestones. She's in a hard situation but we're glad that she feels safe to come and see us and talk through those issues.”

There are fewer than 400 doctors in the entire country

Beyond their clinical work, Barthau and Herrera attend the Koki Corps where both have joined the band and Herrera has taken on the role of bandmaster.

Channelling their experience with banding at Toronto's North York Temple, the couple has started a school of music, with dozens attending within the first few weeks. “They're so happy to learn,” says Herrera. “I've never seen so much concentration from kids. They come for an hour and still want it to be longer.”

Grateful for how they have been warmly embraced by their patients, staff and fellow Salvationists, Herrera and Barthau are eager to keep building relationships and learning from the people in the months ahead. “Our experiences here have moved our hearts to love Papua New Guinea more every day,” concludes Barthau.