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By Dr Matthew Malone

By | Diabetic Foot Disease in the Solomon Islands: A silent, under-estimated problem accountable for the loss of many limbs. | No Comments

If the news reported that crocodile or shark attacks were to blame for 20 people losing their legs in 1 month alone, there would likely be a call to arms. This problem is actually occurring as we speak, except crocodiles or sharks are not to blame… Its Diabetes.

I was recently invited by DAISI to visit the Solomon Islands on a fact-finding trip to look into and report on the extent of diabetes related foot disease. I have worked across the UK, Middle East and Australia and further consulted across the globe in the area of diabetes foot disease. I have been exposed to varying levels of healthcare and worked in areas with different populations and incidences of diabetes foot disease. However, the extent of this problem in the Solomon Islands is disturbing. Diabetic Foot Disease, including foot ulcers are amongst the most common complications of uncontrolled diabetes. People with diabetes are more susceptible to developing foot ulcers that are slower to heal and more prone to infection. Currently in many Pacific countries, untreated, infected diabetic foot ulcers are leading to multiple amputations and sometimes death. The true extent of foot disease in the pacific islands is largely estimated, because there is no accurate record keeping.

I visited the National Referral Hospital in Honiara and had the opportunity to spend the day with a wonderful general surgeon Dr Rooney Jagilly. Dr Jagilly heads up the general surgery ward, a ward consisting on 50 beds. Alarmingly, such is the extent of the diabetes foot disease that 50% (25 beds) of the ward were solely dedicated to people with diabetes foot disease. Many patients had extensive leg amputations or surgery to remove large sections of the foot, secondary to infection and sepsis. The surgeons, the nurses and all ward staff work effortlessly, but are faced with significant challenges that include a never-ending tide of new people needing beds for diabetic foot disease, the lack of basic health infrastructure and support, and a lack of some basic woundcare necessities. In addition, the problem of managing diabetic foot disease in the out-patient setting paints a similar picture. I also spent the day working in the diabetes-wound clinic. The clinic treats between 30-50 patients with diabetic foot ulcers per day, with minimal resources. In the face of such adversity, I was overwhelmed by the nurses and doctors, that despite the inherent lack of equipment or support, strove to provide the best care they could for each patient, with so little.

What was glaringly obvious to me was that this is a massive problem in need of support. I am not the only person to recognise that diabetes and its complications are a scourge on the pacific islands. In 2015 the International Diabetes Federation reported the astonishing statistic that Pacific island countries or territories accounted for eight of the top ten in the world for diabetes prevalence. About 40% of the Pacific island region’s population of 9.7 million has been diagnosed with a noncommunicable disease, notably cardiovascular disease, diabetes and hypertension. These diseases account for three quarters of all deaths across the Pacific archipelago and 40–60% of total health-care expenditure.

The table below shows the change in diabetes prevalence for selected low- and middle-income countries of interest to Australia, with Australia included as a comparator.



Fig 1. Diabetes prevalence rates in Australia versus South-Pacific Nations.

With a doubling of diabetes in the South Pacific in the last quarter of a century it can only be viewed as an epidemic worthy of serious concern and consideration.

With this in mind DAISI has thought it necessary to begin to address the burden of illness particularly as it relates to inpatient admissions to National Referral Hospital, the major referral hospital in Solomon Island’s Capital Honiara.

Dr Matthew Malone is the current Head of Department for the High-Risk Foot Service at Liverpool Hospital in Sydney and a Senior Research Fellow with the Liverpool Diabetes Collaborative Research Unit at the Ingham Institute of Applied Medical Research Sydney. In December 2019 Dr Malone travelled to National Referral Hospital (NRH), Honiara, Solomon Islands to organise and conduct a two day diabetic foot clinic, as part of a pilot program intended to improved the management of the diabetic foot, and reduce admission and amputation rates.


By Dr Santee Santhanam

By | DAISI Ball sends another container to PNG Highlands | No Comments

I am pleased to announce that tonight’s DAISI Charity Ball raised sufficient funds to send another shipping container full of surgical equipment to Sopas Hospital, in the remote Highlands of Papua New Guinea.

Tonight’s DAIS Charity Ball was perfectly timed to coincide with the arrival of the last shipping container sent by DAISI to Sopas Hospital in the remote Highlands of PNG.  In fact we were able to play a special thank you video this evening at the DAISI Charity Ball from head surgeon Dr Elvis Japhlet (Sopas Hospital) thanking everyone at the DAISI Ball for their generosity.

Thank You video from surgeon Dr Elvis Japhlet shown at the DAISI Charity Ball. 


Dr Japhlet is also looking forward to receiving the next shipping container, which will be now be possible with the money raised from tonight’s Ball.

The other video shown this evening was created by fil maker Quentin Curzon, and depicts nicely the philosophy of DAISI.  It also shows how vibrant the Sopas Hospital Surgical Program is, with great enthusiasm and willingness to learn by local surgeons, anaesthetic officers and nurses.

Video documentary by Quentin Curzon describing the DAISI program at Sopas Hospital in the Highlands of Papua New Guinea.
Dr Santee Santhanam is a colorectal surgeon from Newcastle.  He is a DAISI member and in 2019 the elected DAISI Treasurer.  He has done a number of volunteer trips to various hospitals in the Solomon Islands (Munda, Gizo & Taro),  and will conduct a fact- finding mission to Alotau hospital, in Papua New Guinea in January 2020. 




By Dr Sepehr Lajevardi

By | Nation Mourns the Loss of a Great Friend and Health Advocate | No Comments

The Solomon Islands today mourns the loss of a great friend and health advocate, past Permanent Secretary (PS) for Health Dr Tenneth Dalipanda who passed away today at the young age of 52. He was a great physician, scholar, leader, strategist, friend and health advocate for the people of the Solomon Islands.

Although as Chair of DAISI,  I only met Tenneth briefly on two occasions, his intelligence and quiet unassuming humility was very noticeable.  Tenneth was an exceptional thinker, but also a practical man who understood the complexities but stated them in simple terms for all to understand.

Originally from Choiseul province, Tenneth was not born into wealth, but was a hard-working gifted student obtaining a scholarship education. Graduating with distinction from Goroka High School, in Papua New Guinea, Tenneth then completed his medical studies at Port Moresby, spent a year as the palliative care registrar at St Vincent’s Hospital in Sydney, then did his Masters of Medicine at the Fiji School of Medicine and in 2006 before returning to National Referral Hospital (NRH) in the capital Honiara as a Consultant Physician.

In a country spanning twenty eight thousand square kilometres, and more than two hundred islands, a key priority for Tenneth was making health care accessible for all Solomon Islanders.  Although himself, originally the Medical Superintendent, and then the Chief Executive Officer of NRH, in the nation’s capital, he advocated and promoted the delivery of locally accessible provincial health care services.   Tenneth achieved great success in treating the threats of HIV, tuberculosis, malaria and dengue, and well as the more recent rise in non-communicable diseases (NCD).  Despite his success, Tenneth was a modest man, disinclined to fan fair with few personal needs and a small carbon footprint.  In fact, he is well known as the only member of the Ministry who never had his air-conditioner turned on.

An intelligent, articulate man, Tenneth saw the importance of primary health care.  He was a highly regarded health practitioner and skilful clinician and co-authored several publications on tropical medicine.  Equally skilful was his ability to ascend the ranks on merit within the Ministry of Health and promote change through collaboration and unification.  He was a team player, and gifted communicator who would listen a lot and speak very little, but when he spoke it was with clarity and authority.  He was highly regarded by his peers and colleagues.

Tenneth, most popularly known simply as “PS”, served the Solomon Islands from 2014 until 2018 as its Permanent Secretary for Health.   Prior to this he was the Under Secretary (US) for Health, and the Minister for Public Health (MPH).  During his time in the Ministry of Health, he actioned great change and brought about substantial improvement in the health service delivery for his country.  He was the principal architect for the current Solomon Islands National Health Strategic Plan (SINHSP), and the Ministry of Health Role Delineation Policy (MHRDP) and many others.   Tenneth was Chair of the Non-Communicable Diseases (NCD) Taskforce, the HIV/STD treatment plan, and numerous other working groups and committees. During his tenure Tenneth chaired numerous international meetings including, the Asia Pacific Meetings for the World Health Organisation (WHO), and served on many regional and international committees including the World Health Assembly.

Tenneth’s strong faith, fairness and honesty made him a pillar of strength and visionary for the Ministry of Health.  In his last seven years Tenneth played a pivotal role in gaining support from neighbouring countries, DFAT and the World Health Organisation.  He was able to achieve where others could not, with the unification of aid organisations and countries including Australia, New Zealand, Taiwan, China, Japan and South Korea in a single strategic plan, despite their differing political agendas.

A devout Christian, Tenneth unfortunately contracted hepatitis from a blood transfusion early in life, and was diagnosed with liver lesions in 2013.  Despite his own personal health issues he remained a health advocate for others.  He was tenacious and a fighter until the end relinquising his role in the Ministry only last year. Tenneth’s condition deteriorated and could only be treated with a liver transplantation, a procedure not available in the Solomon Islands and very expensive overseas. Putting others before himself, Tenneth did not pursue this and paid the ultimate price, passing away from liver failure on  Thursday 30th October 2019 at 5:35pm at National Referral Hospital.  Tenneth leaves behind his lovely caring wife Nellie, and only son Cavanagh, and the legacy that is the Ministry of Health.

The funeral service for Dr Dalipanda will be at Kukum Seventh Day Adventist Church (Kukum Highway, Honiara) 9am this Sunday 3rd November 2019 led by Pastor Titus Rore.

RIP Dr Tenneth Dalipanda: 28th Feb 1967 – 30th Oct 2019.

Dr Sepehr Lajevardi is the co-founder of DAISI, and current Chair.  He had the opportunity to meet and collaborate with Dr Tenneth Dalipanda during his time as Permanent Secretary. In writing this article he consulted with a number of Tenneth’s close friends and colleagues, with special acknowledgement to Dr Aaron Oritaimae who provided much of this information.


By Ale Asa

By | Striving For Better Health Services | No Comments

Apart from Enga provincial government’s (EPG) successful education policy, it has now shifted policy towards health service to provide the best for its people. A state-of-art modern hospital with 300 patients’ beds designed by a US hospital expert designer is already under construction at Aipus in Wabag and administration is preparing in advance with up skills training. In preparation for the new hospital, international specialist doctors and country’s top doctors have visited the province’s hospitalsfacilities and the medical officers working in the province to prepare them. Doctors Assisting in the South Pacific Islands (DAISI) based in Australia have visited Sopas and Wabag hospitals last week on a three year agreement term with EPG and Enga provincialhealth authority (EPHA).

After DAISI, the director of the surgical training at the University of Papua New Guinea, professor Ikau Kevau and Dr Benjamin Thomas, a neuro surgeon at the Port Moresby General
Hospital also visited the province. The arrangement was made through medical supernatant, Dr Elvis Japhleth head surgeon at Sopas Hospital who is coordinating the DAISI program.
The two gentlemen were given a tour of the new hospital site by EPHA cheif execitive officer, Aaron Luai and Dr Japhleth. They also visited Sopas and Wabag hospitals and met with the Enga surgical team to develop surgical development and training programs. The team will do a final tour and presentation at Wabag General Hospital today before returning to Port Moresby.
Mr Luai said it was a privilege to have international doctors of DAISI team and head of surgical in the country, to establish partnership in the early stages and to up skill the local doctors in the province. He said this was also good for advance preparation for the new hospital and to further
discuss spossible training setting and medical research centre. Prof Kevau said Enga has top doctors in the country with one of them being Dr Thomas, a neuro surgeon.
He said Dr Thomas is one of them who has already made a surgical structure that can help set up surgical team in the speciality areas. Prof Kevau said he is happy to assist in whatever training in the field of surgical that Enga Province could take.

The new hospital will be a level 5 referral hospital that will deliver clinical service of general medicine, psychiatry, gynaecology, ENT/Head and neck surgery, ophthalmology, oral health
including surgery, anaesthetics, pathology, radiology and sexual health services. The hospital will also train doctors and nurses with the expert doctors from aboard and within the country and will be a ‘medical hub’ for the region.


Ale Asa is a journalist for the Papua New Guinea daily newspaper “Post Courier” with this article appearing page 3 of the Post Courier, Monday 17th June 2019.  

By Daniel Kozman

By | Packing of Shipping Container for Solomon Islands: A Team Effort | No Comments

A shipping container full of donated medical and surgical equipment was loaded today 19th January 2019, and will be shipped to the Solomon Islands later this month.

This was only possible due to the generous donations and support from the recent DAISI Charity Ball, as well as the support of our sister charity partners MedEarth, ANZGITA, Horten Medical and Berrima District Rotary.

Special thanks goes to Laura Taitz (7th from left) and Rebecca Truong from MedEarth, logistician Barry Barford (Berrima District Rotary), Mark Taffa and family (right) (Horten Medical), a number of DAISI volunteers, Teneki Friend and Dr Erick Fuentes) for planning and involvement on the day.

ANZGITA, also donated vital endoscopic equipment for use at National Referral Hospital (NRH) as well as contributing to the transportation costs.

The 20 foot shipping container of medical equipment will be sent to Honiara, and from there to National Referral Hospital (NRH) in Honiara, Gizo Hospital (Western Province) and Kilu ‘ufi Hospital (Malaita Province).

DAISI would also like to thank Sydney Cruise Ship Storage for their support and use of their warehouse space.

Although it was the original intention to also pack and send a container to the Highlands of PNG, due to the remoteness of the Highlands it was decided to instead send this equipment by air freight. An operating microscope from Horten Medical and laparoscopic equipment from The Wesley Hospital, Brisbane will go to Sopas District Hospital in the remote Enga Province Highlands of PNG by air freight in time for a planned laparoscopic training session which will be conducted by colorectal surgeon from Brisbane Dr Carina Chow in March this year.

Dr Daniel Kozman is a colorectal surgeon from  Sydney with a strong passion for developing world surgery and has done a number of DAISI teaching trips to the Solomon Islands introducing laparoscopic surgery. He can be contacted by email (

By Dr Daniel Kozman

By | DAISI's inaugural visit to Kiribati | No Comments

On the 16th July Dr Harry Lam and his children (Chiara and Lucas) and myself flew to Tawara, the largest island of the Pacific Island nation of Kiribati (pronounced Kiribas). This picture perfect nation sits on the equator and is made up of many small islands. The majority of the 110 000 population live on the main island of Tawara.

The first thing we noticed upon arriving (apart from the mud crabs walking around the arrival terminal) was how many people travel to Kirabati on business.  After collecting our luggage and proceeding through customs, we were pleased to find the hotel shuttle waiting for us (because there are no taxis in Kirabati). After a quick stop to buy SIM cards and recharge cards we headed off to the hospital.

We were warmly greeted by the Permanent Secretary Mrs Kaaro Neeti and the Acting Director of the Hospital Dr Kabari (also the head surgeon).  We underwent a tour of the hospital and were struck by the contrast between how basic the hospital was but how well stocked it was with equipment. Courtesy of the Taiwan Government, the is a 64 slice CT scanner, a state of the art Rehab centre as well as other equipment. However, there is a shortage of several medicines, adequate beds and ward space. None the less, the Doctors and Nurses do a wonderful job in caring for the patients and their families with the limited equipment.

On our four operating days we were welcomed by the nursing staff led by Sister Deny.  Dr Lam showed of some Ultrasound techniques for regional nerve blocks for the several patients undergoing surgery for diabetic foot sepsis. Dr Hilda and Dr Tekeua (registrar and head anaesthetist) were very receptive to these techniques.

There are 2 operating theatres, one clean and one for ‘dirty’   cases. Dr Migel (a surgeon from Cuba) was very welcoming to us and together we treated patients with Diabetic foot sepsis, often performing amputations from forefoot to below knee amputations and draining sepsis. We also operated on infant hernias, hemorrhoids, rectovaginal fistulae from birth injuries and several perianal fistula performing several LIFT procedures. We also performed endoscopy on a young lady with suspected gastric cancer. We performed transanal excision of a large polyp in a 2 year old child.

Dr Lam carried out Echo work shops for the local physicians and this was very useful. The hospital owns a very high quality Echo machine and so workshops on its use are very helpful.

The challenges we faced were firstly patients being reluctant to present for modern medical treatment, opting for traditional medicine till the pathology was quiet advanced. Secondly, we found that there was little preparation for this visit. We were glad to make close and valued friendships with the doctors and nurses and admin staff. We had very productive discussions about future visits including trying to source equipment needed especially laparoscopic equipment with the aim of running laparoscopic workshops in the future.

At the end of our trip we were blessed with new friendships, and look forward to further developing our working relationships in the future. We are extraordinarily grateful for the warm hospitality we were shown by all the nurses and doctors. We were treated to Cuban and Kiribati hospitality and look forward to returning to this island paradise soon.

Author: Dr Danny Kozman is a DAISI member and colorectal surgeon with a particularly interest in teaching laparoscopic surgery.  Dr Kozman has done a number of volunteer trips to the Solomon Islands, with this being his first trip to volunteer in Kiribati.

By Dr Harry Lam

By | Regional Anaesthesia in Kiribati | No Comments

My visit to the republic of Kiribati (pronounce Ki-ri-bas) was a delightful follow-up to my initial involvement with DAISI one year ago to the Solomon Islands.

The republic of Kiribati (population ~120,000) is between Fiji and Hawaii of USA. Basic development indicators for health, education and life expectancy in Kiribati are among the poorest in the Pacific region. Their medical graduates are from Cuba, Fiji or Papua New Guinea.

After an exciting and nervous initial contact with the Director of Hospital services on the first day, it was apparent my visit became a regional anaesthesia workshop for the local anaesthetists and a cardiac ultrasound workshop for the local physicians.

harry lam 2

Dr Harry Lam performs transthoracic ECHO looking for valvular disease. 

Although I had brought a portable echo/ultrasound machine, their hospital was blessed with a nerve block machine donated by another Australian organisation and their echo machine from the Taiwanese team who regularly visits.

Regional anaesthesia workshop – Sonoanatomy of the upper and lower limb (peripheral nerves and plexuses) was demonstrated to the attendees. Needle techniques were practised and learnt by local staff quickly in order to provide complete Anaesthesia for numerous diabetic-related Debridements and multi-level amputations.

harry lam 3

Dr Harry Lam with patient who had lower limb surgery under regional anaesthesia.

Cardiac ultrasound workshop – the combination of rheumatic heart disease and high rates of infectious diseases gave us plenty of opportunity to demonstrate How to perform a comprehensive echocardiogram to assess and grade valvular pathologies and to look for echo signs of infective endocarditis to the local physicians. They do have the ability to then refer these patients out of Kiribati for definitive treatment in India, Fiji or Taiwan.

After more than 10 years of overseas aid work, it still never ceases to amaze me that there are lot more facets of medicine to offer to different parts of underdeveloped countries. We aim to continue this relationship with Kiribati in 12 months time for more transfer of skills including the aim of introducing laparoscopic surgery.

Author: Dr Harry Lam is a DAISI member and cardiac anaesthetist, with a particular interest in the use of ultrasound for cardiac assessment and as an aid for performing regional anaesthesia. Dr Harry Lam has extensive experience working in developing world hospitals, with a number of Nepal and South- Pacific missions to Solomon Islands and Vanuatu.

By Andrew Probyn

By | Australia Ramps Up Talks of Support For South-Pacific Islands | No Comments

PHOTO Australia must also engage with the US in the region, Penny Wong said.

Australia should consider establishing an investment fund to help Pacific Islands tackle their “acute” infrastructure deficit, shadow foreign minister Penny Wong says.

In a speech in Sydney, Senator Wong urged the Australian Government to consider following the lead of the United States and New Zealand by establishing a regional infrastructure body.

“It was encouraging to see the announcement last November of a memorandum of understanding between the US Government’s Overseas Private Investment Corporation and the Japan Bank for International Cooperation to increase investment in infrastructure throughout the region,” she told the US Studies Centre.

“Last month we saw the announcement of a new Strategic International Development Fund by New Zealand Foreign Minister, Winston Peters, aimed at increasing the flexibility and responsiveness of New Zealand’s infrastructure funding in the Pacific.

“I welcome these announcements as important steps to addressing the deficit in infrastructure investment in the region,” Senator Wong said.

The Australian Government would do well to seriously consider similar initiatives.”
Senator Wong said during her recent trip to Washington DC there had been growing anticipation that further development of the US policy on this front was “imminent”.

China relationship isn’t broken
China relationship isn’t broken
Australia’s relationship with China is not in crisis, but no-one would blame you for thinking that.
In recent years, China has ramped up infrastructure spending in the Asia-Pacific as part of its One Belt One Road initiative which is viewed with some suspicion by regional rivals.

Beijing has funded roads, ports and other infrastructure across Asia, the Pacific and Africa but its methods have been criticised for compromising political processes, capturing ruling cliques and debt entrapment of impoverished nations that leads to equity transfer.

Australia recently agreed to build a $200 million undersea communications cable connecting Papua New Guinea, the Solomon Islands and Sydney, rather than have a Chinese company build it.

In February, German Foreign Minister Sigmar Gabriel urged the European Union to contest China’s “Silk Road” strategy by offering an alternative infrastructure program targeting Eastern Europe, Central Asia, Africa and other places being courted by the Chinese.

US holds ‘integral’ role in the region, says Wong
Senator Wong, who has previously described Donald Trump’s election as US President a “change point”, said there remained an important role for the United States in the region.

“It is clear we and others in the region must work together to ensure that the US recognises that it is integral to the region we collectively seek,” she said.
“US policy to support the objective of a free and open Indo-Pacific is, to some extent, a work in progress.”

She said whether the US remained “top dog” in economic and military might was “perhaps beside the point” for the region.

“What Asia is looking for is less a contest about who should be top dog than a partner of enduring connection and relevance,” she said.

“As their economies develop and prosper, due in no small measure to the economic strength of China, they are looking for the reassurance than comes from an engagement mindset built around creating opportunity and collaboration rather than competition and conflict.”


By Stewart Firth

By | Instability in the South Pacific: a status report | No Comments


The challenges to internal resilience in the South-Pacific Islands are both structural — in the form of issues arising from population growth, urbanisation, land, immigration, health, and gender relations — and particular to the political situation in each Island nation.
The inability of South-Pacific states to match service provision in cities with their growing populations is a major challenge to resilience.
Of all political issues in Papua New Guinea, loss of customary land is the most likely to provoke protest and conflict.
The South Pacific Islands are highly diverse in political status, population, development, migration prospects, and potential for instability. Resilience is most under challenge in western Melanesia: Papua New Guinea, Solomon Islands, and Vanuatu are states-in-formation characterised by extraordinary linguistic and group diversity giving rise to weak consciousness of nationhood. Fiji is different: a weak democracy but a strong state. Many observers see increasing tensions, disputes, and violence over land in South-Pacific urban areas as people’s traditional connections with rural villages diminish and landlessness becomes more common.

The ‘new Chinese’ in the region tend to be resented, and the potential for a return to conflict between South-Pacific Islanders and Chinese remains. Health systems vary in effectiveness across the region and are least effective in Papua New Guinea. Life for women in many South-Pacific countries is routinely constrained by fear of men, and women experience a high level of personal insecurity. Democracy has survived since independence in most South Pacific countries, with the key exception of Fiji. Nauru has recently lurched towards authoritarianism and Fiji’s stability is too dependent on one man, Prime Minister Frank Bainimarama. PNG’s elections continue to be dominated by money politics. Bougainville is internally divided in the lead-up to the 2019 referendum

The challenges to internal resilience in the South- Pacific Islands are both structural — in the form of issues arising from population, urbanisation, land, immigration, health and gender relations — and particular to the political situation in each Island nation. The total population of the Pacific Islands is forecast to grow from 11 million to 17.7 million or more than 60 per cent by 2050, mostly in just four countries: Vanuatu, Kiribati, Solomon Islands, and Papua New Guinea. This growth will present particular problems for development — disputes over land, for example — in PNG.

The South Pacific Islands are highly diverse in political status, population, development, migration prospects, and potential for instability. The region consists of dependent territories, states in free association with either the United States or New Zealand, and fully independent countries. The American Samoa affiliated with the United States; French Polynesia, New Caledonia and Wallis and Futuna with France; Tokelau with New Zealand; and Pitcairn Islands with the United Kingdom. They are extensions of metropolitan states, whose considerable subsidies underwrite high standards of living and guarantee domestic stability. One possible exception is New Caledonia, where its political status remains disputed ahead of a referendum on independence in November 2018.

The freely associated states, Cook Islands and Niue, which share associated status with New Zealand) possess a safety net in the form of access to wealthier economies. Micronesians from the American part of the South Pacific are free to live and work in the United States without visas, and Cook Islanders and Niueans are New Zealand citizens, mostly choosing to live there. As many as 80 000 Cook Islanders live outside the Cooks, which has a population of 11 700, and around 20 000 Niueans live outside their home island, compared with just 1611 living on Niue.[1] Altogether, the people of the territories and freely associated states account for about a tenth of the region’s total population of 11 million.

The independent countries of Micronesia (Kiribati and Nauru), and Polynesia (Samoa, Tonga, and Tuvalu) are in a second category of Pacific countries with small populations, high aid dependence and — for the most part — post-independence histories of political stability. Possible exceptions are Tonga and Nauru. Tonga experienced serious rioting in the capital Nuku’alofa in 2006, but adopted a democratic constitution in 2010 and appears to have returned to its earlier pattern of long-term political stability. After years of frequent changes of government and states of emergency, Nauru’s politics is characterised by an authoritarian approach to parliamentary oppositions, public demonstrations, and freedom of speech but could not be described as unstable or likely to become so.

In Melanesia, however, resilience is weaker. Papua New Guinea, Solomon Islands, and Vanuatu are states-in-formation characterised by extraordinary linguistic and group diversity giving rise to weak consciousness of nationhood. Within each state, national development is also hampered by geographical barriers to easy communication between different parts of the country. Safety nets in the form of seasonal access to foreign labour markets or emigration to the Pacific Rim are less developed than elsewhere in the Pacific, except in Vanuatu which in recent years has made good use of seasonal labour schemes to New Zealand and Australia. Bougainville is a special case, having gained autonomy within Papua New Guinea after the conflict of the 1990s and promised a referendum on political status in 2019.

The other country customarily classified as ‘Melanesian’ is Fiji, which is quite different from its Melanesian neighbours to the west. When the British returned Fiji to its people at independence in 1970, they left behind the most sophisticated state apparatus anywhere in the Pacific. It remains largely in place today, giving Fiji the distinction of possessing an effective state administration. Fiji might be a weak democracy, as its succession of coups suggest and as might be concluded from prime minister and former coup leader Frank Bainimarama’s dominance over the parliament. However, Fiji is not a weak state. The potential for future instability arises from the position of the Fiji Military Forces in the distribution of power, and the possibility of another military intervention in the democratic process. Even then, a breakdown of law and order as seen in Solomon Islands that led to the deployment of the Regional Assistance Mission to Solomon Islands (RAMSI) is unlikely. Instead, ‘instability’ would take the form of a changing of the guard at the elite level, with the government of the country continuing.

Among this diversity, some key common challenges stand out. This Analysis addresses six of these challenges: demography; urbanisation; immigration; health and health systems; gender relations; and governance. It is by no means an exhaustive list, but these challenges have been prioritised over others because, taken together, they have the greatest potential to check the region’s development and undermine its resilience.

The total population of the South Pacific Islands is forecast to grow from 11 million to 17.7 million or more than 60 per cent by 2050, mostly in just four countries: Vanuatu, Kiribati, Solomon Islands, and Papua New Guinea.


Population in 2014 (’000s)

Projected population in 2050 (’000s)







Solomon Islands



Papua New Guinea

7,300 (2011)


Source: UNFPA, Population and Development Profiles: Pacific Island Countries(Suva: UN Population Fund, Pacific Sub-Regional Office, 2014)

The outlook for the other South Pacific Island nations is for either very slow population growth over the coming decades or no growth at all. This is the case in Tuvalu, Samoa, Tonga, Fiji, Niue, Cook Islands, and Nauru. The population of the Cook Islands could even decline as people continue to leave for the prosperity offered in the United States and New Zealand.

Life expectancy rates in the South Pacific Islands are evidence of differing levels of development. They are highest in Cook Islands, Samoa, and Niue. In Melanesia life expectancy rates are far better in Vanuatu, Fiji, and Solomon Islands than in Papua New Guinea, which ranks far behind the rest of the region. In Papua New Guinea, a man can expect to live to 54 years, and a woman to 55. This is in contrast to Vanuatu, where life expectancy is 70 years for males and 73 for females.[2] According to Save the Children, almost half the children of Papua New Guinea suffer from malnutrition, shortening lives and undermining future prosperity.[3]

The most important consequence of a fast-growing population is the creation of a youth bulge, which is a large proportion of people between 15 and 24 years of age. Youth bulges can be found in populations across the South Pacific region. However, they have the potential to undermine stability mainly in countries with low emigration and limited job opportunities for the young, such as Papua New Guinea, Vanuatu, and Solomon Islands.

The new Pacific Labour Scheme, commencing in July 2018, makes a breakthrough in policy, establishing non-seasonal access by South  Pacific Islanders to the Australian labour market alongside the existing Seasonal Worker Program. The admission of workers for up to three years is the kind of scheme that Pacific leaders have been requesting for more than a decade, and the initial focus on Kiribati, Tuvalu, and Nauru appropriately targets small Island states with few economic prospects. The program will be extended to other Pacific countries during 2018. South Pacific Islanders need better preparation for participating in the Australian labour market, support in skills training, and pastoral care while they are in Australia. The South Pacific Labour Scheme will include a Pacific Labour Facility that will take into account what employers want and upgrade Pacific Islanders’ skills.[4]

One of the most serious conflicts in the South Pacific region over the past two decades was the five-year civil conflict in Solomon Islands from 1998 to 2003. The Solomon Islands tension, as it is called, had its origins in the explosive mix of rural-urban migration from Malaita to Guadalcanal, disputes over land ownership in the peri-urban area of the capital Honiara, and an urban population of unemployed youth available for mobilisation into competing militias. Young men with little to do were readily recruited as foot soldiers by competing sides in the struggle over land and identity. Initially an urban phenomenon, with disastrous, wider implications as it spread into rural parts of Guadalcanal, it demonstrated the vulnerability of western Melanesian cities to the eruption of conflict.

Urbanisation magnifies the effect of growing populations because Pacific urban populations are growing faster than national populations, especially in Melanesian countries. If anything, the rate of urban growth in the Pacific is under-estimated in official statistics.[5]

The inability of states to match service provision with growing urban populations is a major challenge to resilience, often in national capitals.

More than half the people of Fiji live in towns, and more are making the rural-urban shift. The urban growth rate in Solomon Islands is double that of the country as a whole, and PNG’s urban population is expected to reach two million by 2030. Papua New Guinea has the lowest rate of urbanisation in the Pacific at 13 per cent of the population but the highest absolute number of urban citizens, now more than one million. PNG’s urban population is greater than the total populations of the Pacific’s sub-regions of Polynesia and Micronesia. Some small island states are as affected by urbanisation as larger ones. South Tarawa, home to more than half the population of Kiribati, has a population density similar to that of Hong Kong, and its population grew from 50 000 to 56 000 between 2010 and 2015.[6]

Pacific towns or cities typically engulf a number of traditional villages as they grow. The villages remain, often with traditional forms of governance intact and with their people harbouring ambitions for compensation for land lost. The cities then expand as rural migrants create informal and squatter settlements, typically consisting of people from the same rural kinship or language group, and constituting in themselves systems of mutual support and protection based on kin loyalties. Port Moresby has been home to such settlements since the 1960s, which number around 100 and constitute a huge informal urban sector, one that probably contributes to the city’s security overall because of its kinship group structure. Kinship ties have so far proved strong but are gradually loosening under the impact of individualism. Similar developments in Fiji have created a connected series of settlements from Suva to Nausori.

The Pacific city, then, is a patchwork of modern urban centres, villages, informal settlements (where residents informally lease land), and squatter settlements (where residents simply occupy land) with complex and overlapping issues of land ownership and governance. Municipal regulations, often originating in colonial times, are directed at development in situations where orderliness has long since been replaced by the jumble of makeshift houses built by people seeking a better life or, in the case of Fiji, also people whose rural land leases have expired. Settlements reverse the priorities of conventional urban planning, with land occupied first in the absence of tenure, dwellings built in the absence of regulation, and services supplied last or in some cases not at all. As researchers have noted: “Many urban settlements are without services or basic infrastructure. Linkages to villages are fading as new generations grow up in settlements. Urban-based informal safety nets are being stretched as costs of living escalate, and many struggle to gain steady wage employment.”[7]

Political commitment to urban reform in the Pacific is weak. Melanesian governments, with the possible exception of Fiji, tend to see rural-urban migrants as illegitimately in the city and subject therefore to periodic harassment and even eviction. Official recognition of the informal economic sector in Port Moresby, for example, has been slow and betel nut markets in particular have been under siege from authorities. The National Capital District Betelnut Control Law 2013bans the sale and consumption of betel nut in public places within the National Capital District, including villages and settlements, a measure that contributes to ‘cleaning up the city’ but at the same time places barriers in the way of an economic activity that supports the livelihoods of numerous urban residents.[8]

Under these circumstances, the potential for conflict in Pacific cities is considerable. Land boundaries are often ill-defined and contested by competing groups. Landowners may object to development proposals by the government; squatters, who may have informal arrangements with landowners, may be subject to eviction; popular protests may be staged against evictions; issues of compensation are ever-present; and, at least in Papua New Guinea, the authorities are unable to create the conditions of law and order expected of a modern city. The response has been the growth of private security companies, which guard residences and businesses, patrol mining sites, and even provide security for the PNG government. By some estimates private security guards outnumber police in Papua New Guinea three to one.[9]

Many observers see a trend towards increasing tensions, disputes, and violence over land in Pacific urban areas as people’s traditional connections with rural villages diminish and landlessness becomes more common. As noted in an Australian National University report on land transformations in Melanesia: “It is a tired romanticism that everyone has land to ‘go back to’ or, indeed, wishes to return to traditional villages.”[10] Increasingly, kin connections between city and village are either weakening or being severed (although mobile phones counter this trend), and some urban residents are in the city precisely because there is little village land for them.

For the most part, the South Pacific Islands are countries of emigration rather than immigration. Chinese immigrants are the exception, making China the only development partner whose citizens migrate to the Pacific Islands region. Estimates of the total population of Chinese and Chinese-descended people in the Pacific Islands vary enormously, but their social and economic impact on the region’s small states has been considerable. Some are ‘old Chinese’, descendants of those who arrived a century or more ago. Others are ‘new Chinese’, including the descendants of migrants re-migrating from countries such as Malaysia and Singapore, and the new entrepreneurial migrants from mainland China — mainly from Fujian province — who have migrated since the 1990s in what are, for Pacific Islanders, large numbers.

The new Chinese are ‘sojourners’, those with no intention of staying or becoming citizens. They migrate in order to get the documentation to enter more developed countries such as Australia, New Zealand, and the United States. They also arrive as workers for Chinese companies with investments in the Pacific such as the Ramu Nickel project in Papua New Guinea.

The largest group are new entrepreneurial migrants, who typically arrive on tourist visas, pay bribes to immigration officials, or walk off fishing boats at Pacific ports. Most are poorly educated, have no professional or trade qualifications, and could not legally enter Pacific Island countries. They start small trading concerns, investing in bakeries, low-end restaurants, and clothing stores — trading activities usually reserved for Pacific Islanders. The occasional police raid has little impact on these Chinese small businesses, particularly as they often provide a service that would not otherwise be available.

Many South Pacific Islanders resent the presence of the new Chinese, seeing them as non-Christian interlopers monopolising construction jobs and small business opportunities at the expense of the locals, and corrupting local politicians. Chinese employers sometimes confirm these prejudices by treating local employees with contempt and lack of trust, sitting on high stools in their tradestores to supervise, monitor and discipline those who work for them. Even the Chinese authorities disown Chinese migrants of this kind. An official inquiry into the 2006 Honiara riots by the Guangdong Office for Overseas Chinese Affairs concluded that the Solomon Islanders’ assaults on Chinese stores was the fault of their owners: “They have neither the personal skills nor the capacity to overcome barriers to doing business … ‘Improper’ behaviour has drawn the contempt not only of the old overseas Chinese community, but more seriously it has transformed local people from respecting the Chinese to resenting their presence.”[11]

During the Honiara riots in 2006, China was forced to charter aircraft to evacuate its citizens. Later that same year, riots in Tonga, in part anti-Chinese, led to a short-lived intervention by Australia and New Zealand. Further anti-Chinese agitation followed in parts of Papua New Guinea in 2009.

Although the era of major anti-Chinese riots in the Pacific appears to be over, anti-Chinese sentiments endure. Following a series of attacks on Chinese shopkeepers in Tonga in 2016, the Prime Minister ‘Akilisi Pohiva apologised to the Chinese community, yet a few months later he was warning that Chinese businesses paid no tax and would take over the country. As Samoan MP Lealailepule Rimoni Aiafi noted in early 2017: “The truth is it’s so hard for our people to compete with the Chinese shops. Our people used to own supermarkets and run their own stores. But it’s so hard for them to compete with these Chinese businesses. As you can see all around Samoa, most of the supermarkets and wholesales [sic] are owned by Chinese.”[12] At the same time there are periodic labour disputes between Chinese companies and their Pacific Islander employees, as happened twice in 2017 during a restoration project for Malapoa College by a Chinese construction company in Vanuatu.

The potential for a return to conflict between Pacific Islanders and Chinese in the region therefore remains. The most likely source of future problems is land ownership. It has been argued, for example, that the introduction of the Torrens title land system in Samoa since 2008 might open the way to the alienation of customary land. One Samoan village, Salelologa, has already prohibited any Chinese-owned business on such land in their jurisdiction, fearing they might lose it.[13]

Poor health and health systems undermine development and weaken the legitimacy of governments even as they represent a considerable cost to national economies. In relation to health and stability in the Pacific Islands, Papua New Guinea looms as the country where these effects are most evident. It has the highest maternal mortality ratio in the Pacific, the lowest proportion of births attended by skilled professionals, the highest infant mortality rate, the highest prevalence of HIV, and the lowest life expectancy at birth. These are structural factors with no immediate connection to political stability. Nevertheless, they constitute an underlying cause of political and economic vulnerability, as well as being the face of much human suffering.

Health systems vary across the South Pacific Islands. They are best in the American and French territories and in the New Zealand associated states, where metropolitan standards of health care and infrastructure apply. They are good in one of the American freely associated states, Palau, but less impressive in the other two, the Marshall Islands and FSM, where infant mortality and life expectancy are poor when compared with the United States. They are worst in western Melanesia, especially Papua New Guinea, where the health system bequeathed at independence by Australia has been allowed to deteriorate, and where the absence of medicines and equipment in aid posts and even hospitals is common. Port Moresby General Hospital and hospitals in Kimbe, Daru, Rabaul, Mt Hagen, Buka, Kerema, Vanimo, and Mendi have all experienced serious shortages of drugs and basic medicines. For example, in mid-2017, in an administrative deficit typical of Papua New Guinea, pharmaceuticals were available but had not been distributed as suppliers said they had not been paid by the government.[14]

Food security is not a problem for South Pacific Islanders in Fiji, Polynesia and Micronesia, although it may arise in the future due to climate change and the looming problem caused by the over-exploitation of coastal fisheries. For the moment, people have plenty to eat. Things are different, however, in Papua New Guinea, where perhaps a million people lack sufficient protein. Experts estimate that “approximately 45% of PNG children are stunted, 18% are underweight, 5% severely underweight and 5% have wasting malnutrition”. A survey by 16 provincial hospitals from 2009 to 2014 found that 11 per cent of hospital admissions were suffering “severe malnutrition”.[15] While food insecurity is not yet a major problem in Papua New Guinea, it occurs periodically because of frost and drought, as in 2015.[16]

Non-communicable diseases are the principal health problem for Pacific Islanders. One estimate is that non-communicable diseases account for 70 per cent of all deaths in the South Pacific, many of them premature (that is, before 60 years of age).[17] This is in part due to the transition from traditional foods to rice and processed foods, resulting in Vitamin A deficiency, diabetes, hypertension, heart disease, and obesity. The nine most obese nations in the world are all in Polynesia or Micronesia — American Samoa, Nauru, Cook Islands, Tokelau, Tonga, Samoa, Palau, Kiribati and the Marshall Islands — and the health of their people is suffering. Although estimates of the prevalence of diabetes vary, it is a particularly serious health problem in Nauru. A paper prepared for the Joint Forum Economic and Health Ministers Meeting in 2014 argued that, “NCDs are already causing a health crisis in the Pacific, with most of the trends and risk factors pointing to a substantial worsening of the situation”.[18] The Ministers “underscored the gravity of the NCD situation in the Pacific, with significant and long-term negative effects on both the health and the economies” of Pacific nations.[19]

At the same time communicable diseases such as tuberculosis and HIV/AIDS continue to afflict Pacific Islanders across the region, especially in Papua New Guinea. The country has a far greater incidence of HIV infection than anywhere else in the region and a consequently high rate of Tuberculosis (TB) infection, including both Multidrug-Resistant TB (MDR) and Extensively Drug Resistant TB (EDR).[20] Western Province, National Capital District and Gulf Province are hotspots of MDR infection, and Daru Island has been a particular concern to specialists in the field, with a concentration of people suffering from drug-resistant forms of the disease. PNG’s TB epidemic became a border problem for Australia in 2011, when the federal and Queensland governments closed health clinics in the Torres Strait to Papua New Guinean TB patients in favour of strengthening the health system on the PNG side of the border. Since then Australia has allocated $60 million to combat TB in Papua New Guinea, with a focus on upgrading Daru Hospital, training health workers, buying drugs, and strengthening the PNG government’s TB response.[21]

Women are a tiny proportion of members of parliament in independent Pacific Island countries (the situation is different in the French territories). Under reforms that applied to the 2016 election, Samoa has five female MPs, one of whom — Fiame Naomi Mata’afa — is now the country’s deputy prime minister. But Tuvalu, Nauru, Tonga, and Solomon Islands each have only one female MP while Papua New Guinea, Vanuatu, and FSM have none. The PNG parliament passed an act in 2011 to introduce 22 reserved seats for women but it failed to clear constitutional hurdles.

The gender imbalance in Pacific parliamentary representation betrays a deeper social phenomenon across the Pacific Islands: male violence. Life for women in many Pacific countries is routinely constrained by fear of men, and women experience a high level of personal insecurity. Domestic violence in Papua New Guinea has been described as a “pandemic, equalling something in a war zone”.[22] Most adult women in Papua New Guinea have been raped at some time in their lives, and the incidence of gang rape is extremely high by international standards. The Fiji Women’s Crisis Centre revealed in 2015 that 43 women in Fiji were injured in domestic violence incidents every day, and of those ten would lose consciousness and one would become permanently disabled.[23]

Changes in the direction of gender equality, however, will inevitably take place over a long period of time in the Pacific as international awareness of gender issues is felt and acted upon, as Pacific women organise, police forces change, and a new consciousness has its effect on legislation and behaviour. A long-term commitment of the kind made by Australia in its aid program is an essential element in improving the status of women in the region and therefore enhancing its development prospects.

The governance systems of the Pacific Islands need to be understood in their cultural context, one that historically placed high value on kin connections and kin loyalty and a distribution of power, wealth, and opportunities according to these principles. For many Pacific Island countries, the state as the modern form of political organisation came with colonial rule. After a century or so of colonial administration, the foreigners departed, leaving behind a Westminster or American presidential system of government. The system had only been introduced to the Pacific Islanders in the last few years before independence and was supposed to run along Western lines after independence. Pacific Islanders soon adapted these imported systems to their own expectations and assumptions, creating the contemporary forms of Island government seen today.

The imported and adapted systems of government worked better in Fiji and Polynesia than elsewhere in the Pacific region, possibly because they were superimposed on hierarchical societies and after a longer period of colonial rule. They worked least well in western Melanesia, where hierarchy was far less common, languages and societies were legion, colonial rule was briefer, and cultural assumptions about rulers and ruled strong.

Yet the democratic record of South Pacific Island countries is impressive and stands in stark contrast to the sub-Saharan African experience, where military coups became the norm within a short period after independence. Except for Fiji and Solomon Islands, regular democratic elections have determined who governs independent Pacific countries.

Kiribati, Tuvalu, and Samoa have been politically stable over many decades. Indeed, some regard Samoa as too stable, with the Human Rights Protection Party winning every election for the past 30 years and Tuilaepa Sa’ilele Malielegaoi holding the position of prime minister for more than 20 years. Tonga experienced riots in the capital in 2006 but the democratic reforms of 2010 appear to have returned the country to long-term stability. The decision of King Tupou VI to dissolve parliament a year in advance and to call fresh elections in November 2017 was entirely constitutional and did not reignite unrest;[24] in fact, it confirmed the position of the Democratic Party of the Friendly Islands under ‘Akilisi Pohiva. In recent years prime ministers of Vanuatu have come and gone rapidly in parliamentary votes of no confidence. Ten changes of leaders have taken place in nine years, and the present government of Charlot Salwai is unusually long-lived, having survived since early 2016. Yet Australia changed prime minister five times in eight years, and Vanuatu has the distinction of having taken strong court action against corruption by members of parliament, 14 of whom were jailed for bribery in 2015 and banned from returning to parliament for ten years. The events of 2015 “suggest a degree of underlying strength and resilience in Vanuatu’s governance framework”.[25]

Nauru: The suppression of dissent

Nauru is going in the opposite direction. Nauru’s recent political stability has come at the cost of increasing authoritarianism. As host of the Australian detention centre, the Nauru government has entrenched executive power in the knowledge that criticism from Canberra will be low-key at most. Its three targets have been the judiciary, opposition MPs, and freedom of speech.[26] Nauru’s example may serve to demonstrate to the region that the commitments of the Biketawa Declaration to democracy and the rule of law do not have to be taken too seriously, and that an authoritarian approach to parliamentary opposition pays dividends.

Fiji: A democracy by military permission

Fiji has only partially returned to democracy since the elections of 2014. Fiji is a democracy by military permission, and the military forces are charged to intervene once again if necessary. The 2013 constitution provides that “It shall be the overall responsibility of the Republic of Fiji Military Forces to ensure at all times the security, defence and well-being of Fiji and all Fijians”, a capacious definition of the military’s role that could easily be invoked to justify another coup.[27] A series of decrees from before 2014 remain in force, including the Media Decree, which encourages self-censorship by media outlets and curbs their freedom, and the Public Order Amendment Decree, which requires political parties to seek official permission to hold meetings.

As for parliament, it has become the means by which Bainimarama dominates. His ruling party Fiji First holds 32 of the parliament’s 50 seats, and uses its majority to silence and exclude opposition MPs, three of whom have been suspended for trivial offences or expressions of unwelcome opinion. Social Democratic Liberal Party MP Ratu Naiqama Lalabalavu was suspended from parliament for two years for criticising the Speaker. His party colleague Ratu Isoa Tikoca was suspended for the rest of the parliamentary term for naming Muslims serving as state officials, and the then leader of National Federation Party, Roko Tupou Draunidalo, was suspended for two years for calling the Minister for Education a fool. All three suspensions were in defiance of Standing Orders.[28] The Parliamentary Powers and Privileges Bill, not yet enacted, promises stiff penalties including imprisonment for anyone who, outside Parliament, defames, demeans or undermines “the sanctity of Parliament, the Speaker or a committee”.

For the moment, stability reigns in Fiji. The economy is likely to grow by 4 per cent in 2018 as Fiji rebuilds after Cyclone Winston. Fiji’s diplomatic connections have been restored, and it is now a recognised small player on the UN stage and in climate change diplomacy. Smaller parties are proliferating in advance of the 2018 elections, but Fiji First is likely to leverage Bainimarama’s charisma and its own incumbency to secure another victory.

Yet the present order in Fiji depends to an extraordinary extent on one man, Frank Bainimarama, whose eventual departure from the scene is likely to thrust the country into another political crisis.

Papua New Guinea: An adapted Westminster system

Governance in Papua New Guinea is characterised by a lack of party discipline and ideology, strong obligations to kin in political power, gendered political representation, a limited state with poor service provision, and the primacy of politics in the calculations of ambitious people, given that the state is seen as the principal source of resources.

Under these circumstances, direct government funding of MPs has become an additional characteristic of governance. A growing proportion of government funds is being directed to MPs for them to spend on their constituencies, rather than being funnelled through national departments responsible for different areas of government such as education or health. The state-citizen relationship is being mediated as much through individuals who can use it for personal patronage as through state bureaucracies. The system is not new, and has existed in the form of Electoral Development Funds in Papua New Guinea since the early 1980s, but it has mushroomed in recent years (as it has in Solomon Islands). Whether this system is likely to contribute to political instability is a matter of debate. Some see it as undermining a central tenet of the Westminster system to distribute government goods and services through dedicated bureaucracies. Other observers are investigating whether direct spending systems can be harnessed for development.[29] Direct funding of MPs to some extent accords with what Melanesian voters want, which is immediate access to a pipeline of government resources. At the same time it weakens and distorts the implementation of government policy and programs.

Elections in Papua New Guinea have long been rough-and-tumble affairs, with inaccurate and incomplete electoral rolls, uneven supervision of the voting, buying and selling of votes, and tampering with results. The 2017 election drew international attention for living up to this reputation. The normally reserved Commonwealth Observer Team, while satisfied that the election broadly reflected the nation’s wishes, nevertheless drew attention to “the significant number of eligible voters whose names were not on the common roll” and “reported incidents of alleged vote buying, including through using state resources and provincial and district development funds made available to incumbents”.[30] Money politics will continue to be central to the electoral process in Papua New Guinea.

Nevertheless, PNG parliamentary politics is no longer plagued by frequent votes of no confidence and changes of government. For the past five years, and again following the 2017 election, PNG governments have had the vast majority of the 111 members of the House of Assembly on their side.

Of all political issues in Papua New Guinea, loss of customary land is the most likely to provoke protest and conflict. The Special Agricultural and Business Lease (SABL) system, which dates from 1979, was designed to make customary land available for development on terms that suited the landowners. SABLs were originally seen as giving landowners security while their land was temporarily being put to productive use by leaseholders. In fact, SABLs were subject to high levels of corruption and became little more than an easy route to a wholesale land grab by unscrupulous operators. A 2013 report concluded that “over 5.2 million hectares of customary land around the country had been alienated, mostly for ‘special agriculture activities’ over virgin forest tracts containing tropical hardwoods”, and recommended that SABLs be abolished.[31]

The PNG government has been slow to respond, repeatedly announcing that SABLs have been cancelled when in fact they have not. Prime Minister Peter O’Neill told parliament in November 2016 that he was “pleased to say that all the SABL leases are to be cancelled, instruction has now gone to the Lands Dept and as of today … I can assure you that leases are now being cancelled and where there are projects now existing, we’ve encouraged the landowners to renegotiate many of those lease arrangements that they have made with the developers”. O’Neill repeated that assurance in March 2017, claiming that all SABL licences in Papua New Guinea were illegal, and following the election a few months later the new Lands and Physical Planning Minister Justin Tkatchenko announced the establishment of a government committee to cancel all fraudulent SABLs. When journalists pointed out that “prime minister Peter O’Neill and others in the government had repeatedly promised to cancel the fraudulent SABLs, but nothing had happened”, Tkatchenko claimed that “the committee would finally put words into action” and that 90 per cent of SABLs, which account for 12 per cent of the country’s land, would be reviewed with a view to cancellation.[32] By October 2017, Tkatchenko was admitting that there had been “stealing of public, customary, and other land, where no consultations had ever been done, but his ministry would get to the bottom of the issues before the New Year”.[33] Similar assurances were being given in January 2018.

The Southern Highlands of Papua New Guinea remains a centre of unrest. Roadblocks arising from local grievances have plagued the Highlands Highway since the 2017 election; the Wabag–Porgera road was blocked for two weeks; there have been more roadblocks at Surunki, Jiwaka, and Chuave, disrupting the Barrick Niugini’s mine operations at Porgera; and hijackers torched two of the company’s trucks near Laiagam.[34] Typical grievances are the death of people in road accidents or at the hands of police, and claims for compensation.

Disturbances of this kind, common as they are, do not threaten the system of governance. They might prevent hundreds of trucks from reaching their destinations, and do economic damage even as they discourage investors. But they do not bring the stability of the whole country into question. The same is true of inter-group fighting in the Highlands, where thousands have been killed in the last decade. Tragic as these events are, there is no evidence that they threaten the stability of the nation.

Bougainville: Countdown to the Independence Referendum

The scene of a destructive civil war in the 1990s, Bougainville confronts an uncertain future. The 2001 peace agreement between Bougainville and Papua New Guinea promised Bougainvilleans a say on their political status, and the independence referendum is due to take place in 2019. A Bougainville Referendum Commission will oversee the vote. The two sides have now agreed on key outstanding issues, above all the payment by Papua New Guinea of outstanding restoration and development Grants worth US$132 million.[35]

Bougainvilleans, however, cannot agree on the future of the copper mine at Panguna, which bankrolled the province and Papua New Guinea itself until its forced closure in 1989. John Momis, president of the autonomous province, can see no viable economic future for Bougainville without mining, but protests by landowners against Bougainville Copper Limited — now reconstituted as a company partly owned by the Bougainville government — erupted in 2017, leading Momis to declare an indefinite moratorium on mining at Panguna for fear that its opening might “ignite another war”. To operate, Momis said, Panguna would need a “social licence”.[36] The episode echoed the original conflict, with government revenues boosted by mining and landowners, in this case the Special Mining Lease Osikaiyang Landowners Association, exercising a veto over it.

The lead-up to the referendum in 2019 is likely to see increasing tensions within Bougainville, and between Bougainville and Papua New Guinea. Under the terms of the 2001 peace agreement, Papua New Guinea is not obliged to grant independence to Bougainvilleans even if they vote in favour of it. If it does not, the impact on stability on both sides of the border is likely to be substantial.

Australia’s commitment to the security of the Pacific Islands region over the past two decades is clear: Australia deployed peacekeepers to Bougainville from 1998 to 2003, brokered peace between Papua New Guinea and Bougainville in 2001, and joined New Zealand in the Joint Task Force of troops and police sent to Tonga in 2006. Australian Federal Police were despatched to act as support staff in Nauru, Samoa, Solomon Islands, Tonga and Vanuatu, as well as under the Papua New Guinea–Australia Policing Partnership, and Australia participates in a Defence Cooperation Program with the PNG Defence Force. The 2013 National Security Strategy affirmed Australia’s “enduring interest in the security, stability and economic prosperity of the Pacific Islands region”, and successive Defence White Papers have defined Australia’s second-highest defence interest, after the defence of the continent, as having “a secure nearer region”.[37] The 2017 Foreign Policy White Paper devotes an entire chapter to this region, arguing that the “stability and economic progress of Papua New Guinea, other Pacific island countries and Timor-Leste is of fundamental importance to Australia”.[38]

Australia remains the key external state to which Pacific Island countries turn for assistance in times of emergency, and retains its historical significance for the region through myriad commercial, aid, diplomatic, and personal connections, amplified in recent years by growing contacts in sport and seasonal labour schemes.

Yet East Asian political, investment, trade, and commercial presence in the Pacific Islands is now on such a scale as to reshape the region. Pacific Island governments enjoy a new freedom in foreign policy. But liberal democratic norms might well come under increasing threat. Democracy in the Pacific Islands has never been a carbon copy of its Western counterparts, but the divergence is set to grow wider under new pressures.

Under these circumstances, domestic developments in Pacific Island states matter more than ever to Australia, and Canberra can do more to move events in the right direction. The six challenges to stability described above can be met with six responses from Canberra:

Population: Australia needs to craft its policy in the expectation that the 60 per cent increase in regional population by 2050 will be concentrated in four countries: Papua New Guinea, Solomon Islands, Kiribati, and Vanuatu. Youth bulges in those four populations are predicted. Australia has already made a breakthrough on labour mobility by introducing a new non-seasonal labour scheme alongside the existing Seasonal Labour Program.That is to be welcomed and should be extended beyond Kiribati, Nauru, and Tuvalu as soon as possible.
Urban service provision: Assisting Pacific countries with urban development and the provision of urban services should be an Australian policy priority. The impacts of population growth are magnified in urban centres, and vulnerability to conflict has already been demonstrated in Solomon Islands.
Border control: Australia should step up its existing cooperation with Pacific governments, especially Papua New Guinea, on tightening border controls and immigration systems, because illegal immigration fosters anti-Chinese sentiment in the region.
Health: Australia should make an even greater contribution in the health field. Much is already being done, especially on tuberculosis in Papua New Guinea. The situation is nevertheless serious enough in Papua New Guinea to warrant an even greater commitment.
Gender equality: A long-term commitment to gender equality of the kind already made by Australia in its aid program is essential to improving the status and safety of women in the region. Australia should incorporate policies into its overarching strategy that aid a smooth transition towards more gender equality in the region.
A focus on governance: Australia should do more to indicate its disapproval of Nauru’s recent curbs on the judiciary, the media, and the opposition; should work with Papua New Guinea and Solomon Islands on realising the development potential of direct constituency funding of members of parliament; and should encourage the PNG government to enforce its promise to cancel many of the Special Agricultural and Business Leases. Australia will need to employ deft diplomacy with both Bougainville and Papua New Guinea in what could be a serious security crisis in the lead-up to and after the 2019 independence referendum.
Any analysis of resilience in the Pacific has the potential to focus on the negative rather than the positive, and runs the risk of defining the Pacific Islands in terms of their perceived deficits, a besetting temptation for Australian policymakers. As anyone who has lived in the Pacific knows, the region is also characterised by notable cultural strengths, including the bonds of family, community and church, and the remarkable vitality of language, dance, feast, celebration, and sense of belonging. Not least significant is the persistence of Island forms of democracy across most of the Pacific since independence. These things should be borne in mind as Australia seeks to step up its development engagement with a region that enjoys the sympathetic support of most Australians.

[1] Figures are based on Cook Islands Statistics Office, Cook Islands Population Census, 2006 (Rarotonga: Ministry of Finance and Economic Management, 2006), xvi,; Statistics New Zealand, QuickStats about Pacific Peoples:2006 Census, 2, qstats-about-pacific-peoples-2006-census.pdf; and Department of Immigration and Citizenship,The People of Australia: Statistics from the 2006 Census(Canberra: Commonwealth of Australia, 2008), Table 3,, which lists residents of Australia by birthplace; New Zealand Government, “Cook Islands Populations by Place of Residence 2010s”,

[2] UNFPA,Population and Development Profiles: Pacific Island Countries(Suva: UN Population Fund, Pacific Sub-Regional Office, 2014), 58, 94.

[3] Save the Children, “New Report Reveals Child Undernutrition Cost the PNG Economy Up to $1.5 Billion in a Single Year”, Media Release, 22 June 2017.$1.5-billion-in-a-single-year.

[4] Department of Foreign Affairs and Trade, “Pacific Labour Scheme”, March 2018,

[5] Asian Development Bank, The Emergence of Pacific Urban Villages: Urbanisation Trends in the Pacific Islands(Manila: ADB, 2016), 14,

[6] National Statistics Office, 2015 Population and Housing Census, Preliminary Report (Tarawa, Kiribati: Ministry of Finance and Economic Development, 2016),

[7] Meg Keen and Julien Barbara, “Pacific Urbanisation: Changing Times”, State Society and Governance in Melanesia,In Brief2015/64,

[8] Timothy Sharp, “Fear and Loathing in Port Moresby: Chewing Over the Betel Nut Ban”, State Society and Governance in Melanesia, In Brief2013/10,

[9] Sinclair Dinnen, “Internal Security in Papua New Guinea: Trends and Prospects”, in Papua New Guinea; Seven Snapshots of a Nation, Jonathan Pryke ed (Sydney; Lowy Institute, 2017),

[10] Sarah Mecartney and John Connell, “Urban Melanesia: The Challenges of Managing Land, Modernity and Tradition”, in Kastom, Property and Ideology: Land Transformations in Melanesia, Siobhan McDonnell, Matthew G Allen and Colin Filer eds (Canberra: ANU Press, 2017), 60.

[11] Graeme Smith, “Chinese Reactions to Anti-Asian Riots in the Pacific”,Journal of Pacific History47, Issue 1 (2012), 97.

[12] Sarafina Sanerivi, “Samoa MP Raises Alarm about ‘Influx of New Chinese Businesses’”, Samoa Observer, 27 January 2017.

[13] Iati Iati, “The Implications of Applying the Torrens System to Samoan Customary Lands: Alienation through the LTRA 2008”, Journal of South Pacific Law(2016), Issue 1, 66–88; Ilia L Likou, “Savai’i Village Bans Chinese-Owned Shops”, Samoa Observer, 17 February 2017.

[14] Gorethy Kenneth, “Hospitals Out of Drugs”, Post-Courier, 30 August 2017,

[15] Michael Landi et al, “Severe Malnutrition in Children in Papua New Guinea: Effect of a Multi-faceted Intervention to Improve Quality of Care and Nutritional Outcomes”, Paediatrics and International Child Health37, No 1 (2017), 21–28.

[16] Mike Bourke, “The Worst Frost and Drought in Papua New Guinea since 1997: What Happens Next?”, The Interpreter, 3 September 2015,

[17] World Bank, Non-Communicable Disease (NCD) Roadmap Report (Washington DC: World Bank Group, 2014), 7,

[18] Ibid, 6.

[19] “Joint Forum Economic and Health Ministers Meeting Outcomes Statement”, Honiara, Solomon Islands, 11 July 2014, Meeting_Outcomes_Statement_July14_approvedbyMinisters1.pdf.

[20] Georgia Eccles, “Papua New Guinea’s Tuberculosis Pandemic”, The Diplomat, 28 March 2016,

[21] Australian Government, “Australia’s Support for Tuberculosis Control Initiatives in Papua New Guinea”, 19 November 2016, FACTSHEET_NOVEMBER 2016_UPDATED.pdf.

[22] “Papua New Guinea’s Rates of Violence at ‘Pandemic’ Levels, Australian Federal Police Officer Says”, ABC News, 19 February 2015,,-afp-officer-says/6150064.

[23] Kalesi Mele, “PM Cracks Down on Domestic Violence”, Fiji Times, 18 December 2015.

[24] Jamie Tahana, “Dissolution of Tonga Parliament Rouses Democracy Concerns’, Radio New Zealand, 13 September 2017,

[25] Miranda Forsyth and James Batley, “What the Political Corruption Scandal of 2015 Reveals about Checks and Balances in Vanuatu Governance”, The Journal of Pacific History51, Issue 3 (2016), 255.

[26] Stewart Firth, “Australia’s Detention Centre and the Erosion of Democracy in Nauru”, The Journal of Pacific History51, Issue 3 (2016), 286–300.

[27]Constitution of the Republic of Fiji, section 131(2).

[28] Avinash Kumar, “Suspension of Opposition MPs in Fiji’s Parliament”, State Society and Governance in Melanesia,In Brief2017/13, Avinash Kumar.pdf.

[29] David Craig and Doug Porter, “Political Settlement in Solomon Islands: A Political Economic Basis for Stability after RAMSI?”, State Society and Governance in Melanesia Working Paper No 2013/1, 6,

[30] “Papua New Guinea National Parliamentary Elections 2017”, Interim Statement by Rt Hon Sir Anand Satyanand, Chair, Commonwealth Observer Group, Port Moresby, 10 July 2017, 3, Interim Statement – PNG Elections 2017.pdf.

[31] John Numapo, Commission of Inquiry into the Special Agriculture and Business Lease (SABL): Final Report(Port Moresby: Government of Papua New Guinea, 2013), 2; Colin Filer, “The Formation of a Land Grab Policy Network in Papua New Guinea”, in Kastom, Property and Ideology: Land Transformations in Melanesia, Siobhan McDonnell, Matthew G Allen and Colin Filer eds (Canberra: ANU Press, 2017), 169–203.

[32] “PNG Government Cancels All Special Agricultural and Business Leases”, The National, 7 November 2016; Barney Orere, “PNG PM Confirms Cancellation of All Special Agriculture and Business Leases”, Post-Courier, 14 March 2017; Jonny Blades, “New Minister Aims to Clean Up Corrupt PNG Lands Dept”, Radio New Zealand, 25 August 2017,

[33] Matthew Vari, “Announcements on SABL to Be Made this Week”, Post-Courier, 9 October 2017.

[34] “Ongoing Unrest Affecting Porgera Mine Operations”, The National, 20 September 2017.

[35] “Bougainville and PNG Reach Deals at Key Meeting”, Radio New Zealand, 21 December 2017.

[36] “Mining Panguna Requires ‘Social License”, Radio New Zealand, 5 January 2018.

[37] Department of the Prime Minister and Cabinet, “Strong and Secure: A Strategy for Australia’s National Security”, 2013, 38,; Department of Defence, Defence White Paper 2016(Canberra: Commonwealth of Australia, 2016), 69, par 3.7,; Joanne Wallis, Pacific Power? Australia’s Strategy in the Pacific Islands(Carlton, Victoria: MUP Academic, 2017).

[38] Department of Foreign Affairs and Trade,2017 Foreign Policy White Paper(Canberra, ACT: Commonwealth of Australia, 2017), 99,


By Prof. Peter Hewett

By | Laparoscopy and Colorectal Surgery at National Referral Hospital, Honiara | No Comments

Prof Peter Hewett, with general surgeon and head of department of surgery at National Referral Hospital (NRH), Dr Scott Siota (left) along with local surgical registrars during a formal rectal cancer surgery tutorial.

I had been asked to visit Honiara by DAISI to assist with operations for rectal cancer. On the 13th of April I boarded flights to deliver me to the National Referral Hospital in Honiara. I was met by Dr Scott Siota who was the sole general surgeon for the hospital during my visit.  The plan was to perform rectal resections for 2 patients with rectal cancer. One who had been seen a day prior to my arrival did not attend opting to try traditional medicine. However the second patient a 29 year old man with a lower 3rd rectal cancer proceeded to operation. The procedure, an ultralow anterior resection with covering loop ileostomy, was performed with left colonic mobilisation and division of IMA&V via the laparoscopic and rectal dissection was performed open. Fortunately I had been advised to bring a lipped St Marks pelvic retractor which made the dissection possible. A primary anastomosis at the level of the anorectal junction was performed and a covering stoma formed.
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Prof Peter Hewett (right) with general surgeon Dr Scott Siota (centre) and surgical registrar Dr Stallone Kohia at NRH doing open part of pelvic dissection using St Mark’s pelvic retractor.
In addition an emergency procedure was required for a 60 year old female with an obstructing tumour of the sigmoid colon with disseminated disease. An extended right hemicolectomy was performed.
I had brought disposable laparoscopic trocars, Alexis wound protectors and staplers with me.  On seeing these Scott showed me three cartons of disposable items that had bee donated previously.  We spent a happy 3 hours sorting these out. The outcome of this is that there are a lot of disposable lap trocars to be used. The surgeons currently use non disposable trocars and given the uncertainty of medical waste disposal this seems to be reasonable. I would suggest no further trocars are donated. There are a large number of Weck and Hem O Lock but no applicators. Numerous tissue staplers with reloads are present. Disposables for urology and orthopaedics were also discovered and sent to the relevant departments.
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 Prof Peter Hewett (left) with surgical registrar Dr Stallone Kohia  (centre) and Dr Scott Siota (right) doing laparoscopic anterior resection at NRH.
A new endoscopy room has been built and will be fitted out by American and Australian GI societies. This appears to be an well built facility which should improve the endoscopic service considerably.
I was also able to give a tutorial on rectal cancer to the surgical department. This seemed to be well received.
The visit gave me an insight into the difficulties of surgery in the Pacific Islands. The main challenge is the epidemic of surgical complications of type 2 diabetes. Two thirds of the surgical beds were occupied with such cases mostly amputations. Despite what minimal diagnostic services the work carried out at NRH is done enthusiastically and is of high standard.
Thankyou to DAISI for giving me such an interesting opportunity.
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Dr Scott Siotta looks on during laparscopic anterior resection.
Author: Prof Peter Hewett, is a DAISI member and a colorectal surgeon from Queen Elizabeth Hospital in Adelaide, and has been instrumental in establishing laparoscopic colorectal surgery in Australia, being a lead investigator of the ALCAS & A La CaRT laparoscopic colorectal surgery trials.  Prof Hewett volunteered at National Referral Hospital (NRH) in Honiara in April 2018 on the specific request of local surgeons, with the emphasis on teaching basic diagnostic laparoscopic skills and open rectal cancer surgery.  Prof Hewett is keen on teaching and establishing formal teaching sessions aimed at educating the next generation of surgeons in the Solomon Islands, with the next trip planned for November 2018.