Thirty-six-year-old Robin Balo is bleeding out.
His friend has two hands pushed against his thigh, trying to stem the flow of blood from his femoral artery.
His wife strokes his head, begging him not to die, as health workers run to set up a surgery.
Six weeks ago, Robin was pierced through the leg with an arrow.
Less than a month ago, this hospital had closed because of a lack of funding.
Two hours ago, there was no doctor on site.
Five minutes ago, Robin’s artery dramatically burst open, spilling litres of bright red blood onto the pavement outside.
As the health team rushes to try to save him, a nurse casually says: “Welcome to Etep.”
The hospital with no money
The Etep Rural Hospital sits on top of a hill, overlooking the ocean on one side and surrounded by mountains and thick bush on all others.
Like a lot of rural PNG, it’s cut off from the majority of the country. To get to the nearest major centre you must go by boat, on a trip that takes at least a day.
For the past year the hospital hasn’t received the government funding it needs to run, surviving on what little patients can pay.
An online fundraising page dubbed “Save the Etep Hospital” was set up, but it wasn’t enough. In November last year the hospital was forced to close, and the doors remained shut for six weeks.
“Everyone was devastated for the closure,” health extension officer Bradley James says.
The funding is meant to be supplied by the National Health Department, via Christian Health Services, to Lutheran Health Services, which runs the hospital.
The Health Department and Lutheran Health Services have not responded to the ABC’s questions about why the money has not been delivered.
The hospital still hasn’t received its funding, called an operational grant, but reopened anyway because “lives were at stake”.
“We had to reopen, but we opened with no funds, no basic consumables — like oxygen — so we have to improvise when cases come in,” Mr James says.
“It’s frustrating for health workers to try to provide the best they can, without anything to support them.”
It’s estimated Etep services around 100,000 people from the surrounding villages and towns. Robin Balo is one of them.
Crawling through the jungle to find help
As Etep was debating its future, a group of men attacked Robin Balo in a dispute over who owned a piece of land — all too common in a country where land is the most prized and treasured possession.
The men shot arrows at Robin as he ran away, but before he could escape into the jungle, one pierced his thigh.
He thought he was going to die there, at one point even telling his friends to roll him into a grave.
After they cut the arrow from his leg, he crawled for days, down one mountain and up another, to reach the small town of Kabwum. But the health centre there couldn’t help.
Last year, the Kabwum health centre was demolished to make way for a new facility. So far, a slab has been poured.
A temporary facility comprising three buildings has been set up, but staff say it doesn’t have basic facilities like toilets and a laboratory. Several staff have left.
“I am finding it very difficult to help the patients,” says Maike Genam, the officer in charge.
“The old hospital was enough for me to do my job, this temporary one is not OK.”
Robin was referred to Etep for help. He had to wait for his wife to arrive with money to pay for a car to drive him three hours on a rough bush track.
It cost 200 kina — about a fifth of the yearly earnings of many people in the region.
At Etep, Mr James advises Robin he’ll need emergency surgery.
The arrow nicked his femoral artery — the main blood vessel that supplies blood to the leg. The wound has been clotting and slowly ballooning.
It’s possible Robin’s leg will need to be amputated. There is also a very real risk he won’t survive the surgery.
Paracetamol, and bite your teeth
The doctor who will perform Robin’s operation is Simon Ganal, a volunteer surgeon from Germany who lives in Etep with his family.
But Dr Ganal isn’t in Etep. He’s visiting Braun Hospital in the neighbouring district.
Braun has also been struggling with funding shortages and supplies regularly going out of stock — at one stage they had to wash and reuse surgical gloves. Right now, the hospital’s only doctor is away giving birth.
Dr Ganal has been performing surgeries at Braun for the past two weeks.
The hospital doesn’t have any strong pain medication, so patients are told after their operations it’s “paracetamol na kaikai teeth” — they’ll get standard painkillers, but otherwise will have to bite their teeth.
Nevertheless, the recovery room is full. Everyone still wanted their operations, and they all look happy and relieved to have had them, despite the pain.
One woman spent several days with a bone protruding from her elbow before she was able to get help.
A helicopter lands in Braun to collect Dr Ganal and take him back to Etep, so he can perform Robin Balo’s surgery.
It’s the second visit to Braun Hospital within days for the chopper. It had just flown in an emergency patient, Muse Terry.
A week ago, Muse gave birth to her eighth child, a little girl named Delda. But it was not an easy labour.
“I lost consciousness four times before I gave birth to her, I felt I wasn’t going to stay alive for long,” she says.
In their village, her sister Debra Joshua watched on in horror.
“The health centre closed last year and there are no roads for vehicles to pick us up.”
It’s thought around half of the region’s village aid posts are currently closed.
As Muse slipped into unconsciousness, a helicopter was called to evacuate her.
Local company Manolos Aviation runs the service between its commercial work, but it often has to wait months, or sometimes years, for the health bills to be paid.
“I’ve built up a buffer, basically from the commercial work we have some savings, so we use our profits to go back into providing a health service,” CEO Jurgen Ruh says.
“Over the years, sadly to say, we’ve grown accustomed to being paid a year late, two years late, three years late.”
Muse Terry had a retained placenta, which Dr Ganal and the team at Braun could treat. She’s still weak and groggy, but she is looking forward to taking baby Delda home to her siblings.
The helicopter is packed with basic supplies needed at Etep: an oxygen tank, reagents to test for blood type, and small sutures. Also on board with Dr Ganal is a live chicken he received as payment from a patient.
Emergency surgery on a shoestring budget
Upon landing in Etep, Dr Ganal joins health officer Bradley James to check in on Robin Balo. He is propped up in bed, with his wife Stella by his side.
They examine his wound and talk him through the surgery. Robin is helped into a wheelchair, and Stella takes her husband towards the surgical building for an ultrasound.
They wait outside while the medical team treats another patient. But Robin’s wound will wait no longer.
The artery suddenly bursts open. Bright red blood rushes from his bandaged thigh, pouring over the wheelchair, pooling, and spreading along the pavement at frightening speed.
Stella begins to wail, gut-wrenching sobs from deep in her chest.
“Doctor, he’s bleeding!” the call goes out and the medical workers come running. Hands grab at Robin’s thigh, willing the flow of blood to stop.
The other patient who was being treated is quickly helped from the room. Staff rush to get Robin in and on a bed.
His friend dons surgical gloves and is instructed to keep pressure on the leg, while staff connect an IV and monitors, and others race to set up the surgery.
Robin is shifted into the operating theatre.
His wife and friend retreat outside to wait with other family members near the red pool and the empty wheelchair.
Two bags of blood and makeshift clamps
As the operation gets underway, there are only two bags of matching blood available.
It’s not ideal, but Dr Ganal is hopeful they can make do.
“From the surgical side, the situation is complicated,” he says, standing over a now-unconscious Robin.
“There’s considerable risk, but we’ll do our best.
“Of course, it would be better to have more blood. It’s a major artery that can bleed immensely, but at least we have now stabilised the patient and we have some blood available.”
The team begins the operation, making an incision higher up the leg, gaining access to the artery to control the bleeding, so they can examine and hopefully repair the aneurism lower down.
It is slow, painstaking work.
As they operate, a staff member from the helicopter that flew Dr Ganal into Etep has her blood type checked and discovers it is universal. As the surgery continues, she donates 500ml. There are now three bags of blood to use.
The medical team doesn’t have small enough clamps, so they get creative. Sections of suction tubes and small ties are used to stop the blood flow.
They can now start trying to repair the actual wound, which is surrounded by necrotic flesh, a sign of the six weeks between injury and treatment.
The sun has slowly set over Etep and the team continues to work as night sets in.
“If someone wants to say a prayer, now is the time,” Dr Ganal says.
They are about to allow the blood to flow back through the artery to test if it holds or not.
The team bow their heads and clasp their hands together, as one of the nurses calls upon “Papa God” to help them.
One day at Etep exposes deep chasms in PNG’s health system
As the blood starts to flow through Robin’s repaired artery, it doesn’t leak.
The medical team decides to leave the wound open, to help treat infection and to allow them to check the artery again tomorrow.
They are still cautious about risks to the leg and to Robin’s life, but say “it looks promising”.
“We’re grateful that the hospital was opened, despite all the shortfalls, we are thankful that it was open,” Mr James says.
“Should we close for another month, we would have lost this person.”
Every day these health workers find incredible workarounds and stopgap measures to treat their patients. But the situation exposes the huge chasms in health provision in PNG.
Unpaid bills, logistical issues, complex bureaucratic structures, remoteness and questionable government contracts have all contributed to issues with supplies, staffing and funding.
The issues are not confined to remote health centres. This week the country’s biggest hospital, Port Moresby General, reported a severe shortage of medications. The lack of supplies cost one pregnant woman her life.
As the COVID-19 pandemic pushes health systems across the world to breaking point, some people argue parts of PNG’s health system were already broken.
“No remote facility should be operating without any funds, it’s surely the responsibility of the government, the people higher up to make sure that funding is distributed on time, that human resources and medical consumables are provided,” Mr James says.
PNG’s COVID-19 pandemic controller, David Manning, recently said he was “not prepared” for what he found to be the “true nature of the health sector” in the country, describing the Department of Health as “little more than a shell … controlled by a cabal of multilateral agencies and international NGOs”.
It’s hoped the spotlight of COVID-19 and a new national health plan will lead to improvements.
While the health workers on the ground here are worried about COVID-19, the people, perhaps understandably, are not.
“If one presents with [COVID-19 symptoms], they wouldn’t go for testing … for the fear of their people, their family rejecting them.”
With minimal testing and the difficulties people face getting health care, it’s believed many people will have died in their villages, without ever being diagnosed.
Braun Hospital recently lost all its vaccine doses after constant power outages and a broken generator meant their refrigerator turned off for a long period.
Etep Hospital is yet to receive any of the COVID-19 funds that have poured into PNG. Outreach clinics it was running that included COVID-19 vaccinations had to stop because of broader funding problems.
The hospital doesn’t even have additional PPE. It’s perhaps unsurprising that 16 of its staff tested positive during the country’s last surge.
‘I feel like God has saved me’
The day after his surgery, Stella is standing by her husband’s bedside when the health team comes to check on him.
He is awake, and even manages a brief smile.
“When I saw the blood pouring out like that I thought, ‘My husband will die,'” Stella says.
“It was unbelievable how the blood shot out like it did, my heart was beating so fast.”
In the days that follow, Robin’s wound is inspected and eventually closed. The pulse in his foot is strong, a good sign that the leg will survive.
Incredibly, it seems he will walk again.
“I feel like God has saved me,” he says through tears.
As Robin looks to get back on his feet, the hospital remains on its knees, still waiting for its funding.
“Without it, I don’t know how we’ll continue care. Our internal revenue is not enough to cater for our daily needs,” Bradley James says.
“I don’t know … it’s a tough question for me to answer, I really don’t know.”