Darkness before the dawn

There are some things in Timor-Leste that are so easy.

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Yep, so easy.

Catching mosquitoes is easy. You just leave your car window down about four inches overnight and by morning you’ve caught two hundred of them. Buying phone credit, or ‘pulsa’, is also really easy. Every supermarket entrance is heavily fortified by a ring of hyper-vigilant sentries, lying in wait, ready to spring their ambush of pulsa vouchers as soon as you’re within range.

Finding the correct luggage carousel at the airport is really easy. There’s only one of them and it bears the unlikely distinction of being the only thing in the entire country that moves faster than it ought to: bags come flying off at the corners like toy race-cars from a vintage electric racetrack.

There are a few other easy things. It’s easy to park in the street because it’s generally considered acceptable to double-park and obstruct an entire lane of traffic. It’s easy to tell when it’s been raining because the ocean is stained with brown silt. And it’s easy to fall into a street drain or open sewer, if you’re not paying attention.

But most things in Timor-Leste are really not very easy at all.

 

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Even getting through doors can be problematic.

On the World Index of ‘Ease of Doing Business’, Timor-Leste ranks a lowly 178 out of 190. It sits in esteemed company amongst other entrepreneurial wonderlands like Syria and Congo.

 

That feels like an horrific exaggeration of Timor-Leste’s difficulties to be perfectly honest, but I would concede that it is generally not easy to get things done around here.

 

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Ease of Doing Business: “What can I get for ya?”

If you’ve been following this blog at all you know that I’ve been more than a little fixated upon the unfinished and rather troublesome matter of our MoU, or Memorandum of Understanding, with the Ministry of Health. And that has most definitely not been easy. As the CEO of a health NGO whose entire raison d’être is to work in partnership with government-run health services, I have been more than a little concerned by the delay in achieving the government’s formal agreement to work with us. Without an MoU we’re a bridegroom left standing alone at the altar. It makes for an awkward wedding ceremony.

In the previous post I described my somewhat harrowing experience of presenting to the Health Minister’s Council of Directors. It really didn’t go well for us, despite indications before the meeting that it would be a very positive and collaborative final step before the MoU signing. I came away from that meeting in genuine doubt as to whether our MoU would ever be signed, and that line of thinking precipitated a particularly dark night of the soul.

Perhaps we have come all this way for nothing. Perhaps we won’t ever break through. Through deep and uncomfortable introspection that night I arrived at a possible conclusion: perhaps we’re not meant to succeed. As a Christian I have a sense that God offers His hand to me – to us – to share in His work on earth, but I don’t believe for a moment that success is ever promised to us in this partnership. Sometimes all that is asked of us is to fail well, to bear up faithfully under frustration and defeat and not let that change who we are nor the motivations that drive us. Defeat doesn’t have to bring bitterness nor despair. There is such a thing as failing well.

Those were my thoughts that night and though they sound morose and depressing they carried no such weight of melancholy for me. I was lifted by these realisations. Yes, I can fail well.

ScoMo came to Dili. Even Australia and Timor-Leste – so often uneasy bedfellows – had managed a signed agreement, but there was still no news on our MoU.

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In 1650 a man named Thomas Fuller wrote prosaically that the darkest hour comes just before the dawn. It’s almost certainly nonsense, scientifically speaking, but it’s a fine description of human experience which was how he intended it. For us it seemed to be a night that might never end… but then dawn did break. And it was glorious.

It started as a rumour. The MoU would be signed next week. We’d heard that before and knew not to assume anything yet. Then more rumours from different sources, each confirming a similar story. It would be signed on Wednesday. We were advised to make preparations: a lavish afternoon tea would surely be required for the occasion. Then written confirmation arrived and we knew we were in good shape. We began planning the party for the Friday night too, but held the invitations back. It’s no good having an MoU party with no MoU as my kids reminded me, singing an adapted version of Dorothy the Dinosaur’s song about tea parties:

“To have an MoU party (an MoU party), you’re gonna need an MoU (you’re gonna need an MoU)…”

Late on the Tuesday afternoon we were interrupted by a peculiar omen. Maun Bo’ot (literally ‘Big Man’) was wandering up our street. Maun Bo’ot is Xanana Gusmao, Timor-Leste’s most famous freedom fighter, leader of the resistance, former President and de facto master of the current government. He was wandering down our street, mingling among the people in one of Dili’s most troubled neighbourhoods. We’d never seen him here before. On Bethany’s prompting we hustled our unwashed kids down the street and joined the throng and were quickly ushered through the pack as rather conspicuous outsiders. He was all too happy to pose for photos and reciprocate Micah’s crisp high fives.

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What did it all mean? A visitation by Maun Bo’ot on the eve of the MoU signing? Surely a portentous sign? The next morning we received a call of confirmation. It was really happening. “Bring afternoon tea and two blue pens.”

I was very nervous. Going back there meant I would have to give another speech, in the same room and to virtually the exact same audience as my disastrous stuttering oration only weeks earlier. At least this time it seemed that the stakes were reduced. The MoU would be signed however miserable my speech might be.

Our delegation arrived early and waited. We all looked happy and relaxed. Well, almost all of us.

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Our catered afternoon tea was an impressive spread. We had blue pens. All was in order. As the dignitaries gradually filed in my heart was racing faster. I really just want to get this speech done.

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The speech came and went. It was not good, but neither was it the twelve-car-pile-up that I delivered last time around. I got through it with minor scratches and a broken headlight, metaphorically speaking.

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Then there was much initialling and signing to do. Documents in English and Tetun were thrust in front of me and I signed each page as quickly as I could, trying to keep pace with the Acting-Minister. I’m pretty sure I beat him. Gotta take a win where you can get one.

Then there were hand shakes and photos, backslaps and that peculiar strained laughter that comes with the relief of prolonged suspense. Unbeknownst to us, one of our team had a mole at the ceremony, through a family connection. Someone was spying on us – taking photos and sending them through to our staff back at Maluk Timor headquarters as events unfolded in real time. While I was signing our staff were cheering.

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Sweet relief. Invitations went out and we threw a tremendous party at our home for staff and supporters.

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The staff are happy.

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The family are happy.

Even these kids are happy! All though I think that’s more because we let them in every Saturday morning to play in our pool and on our trampoline. They’re kids from the local neighbourhood and we sometimes have as many as forty of them in the yard throughout the morning. It gets pretty frenetic at times but it’s hard to resent kids for their enthusiasm and delight. I guess we’ll continue to grow our crowd of Saturday morning visitors.

Speaking of visitors, Bethany’s parents returned to Dili in late September with eleven friends from CWA (Country Women’s Association) to fix floors, build benches and paint murals for Dili’s various health centres and clinics. It’s great to see their work but I think my favourite part is watching my own kids take a genuine and sustained interest in helping out with these projects – a very constructive use of school holidays.

Back at Maluk Timor, we considered our months of imaginings that the signing of the MoU would be like the uncorking of a bottle, allowing Maluk Timor’s activities to really flow. Would it turn out to be true? We didn’t have to wait long to know the answer. In the ensuing weeks we’ve seen a number of our projects rapidly expand and we’re now enjoying something of a Golden Age.

The Family Medicine Program (FMP), which we deliver under the umbrella of the Royal Australasian College of Surgeons, has increased from ten trainees to twenty-four, necessitating a major expansion in the number of clinical placements and the size of our team of clinical supervisors. It’s a terrific opportunity for us to intensively train a group of this size: one of the biggest cohorts of Family Medicine trainees in the Asia-Pacific.

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24 Timorese doctors squeeze into our training room for orientation

Our TB program is launching out on three new projects after a long period of treading water. Timor-Leste has the highest tuberculosis mortality rate in the Asia-Pacific, and the highest rate of catastrophic cost anywhere in the world. Catastrophic cost refers to the situation in which a person who becomes ill with a particular condition (in this instance tuberculosis) is forced to either give up their job, sell their goods or go into serious debt to pay for the treatment and its associated costs. In Timor-Leste the rate of catastrophic cost for tuberculosis is quoted as 83%: five out of six people diagnosed with TB will also be afflicted by life-altering financial hardship or even ruin. There is no shortage of motivation for us to work toward better quality diagnosis and care, and better support to those who are undergoing treatment. We’re delighted to finally have our TB projects up and going.

Then we received extraordinary news that our proposal to the Australian Government-funded PIDP grant was successful. We named it ASTEROID, or Advancing Surveillance & Training to Enhance Recognition Of Infectious Disease, and it’s the biggest project our organisation has ever been funded to deliver. For the next three years we will be rolling out infectious diseases training to more than 400 health staff right across Timor-Leste – all thirteen districts – and also equipping them with a fantastic new smartphone app to further their ongoing learning and help them maintain up-to-date clinical practice. We’ll be expanding our team yet again, and we find ourselves in previously uncharted territory with respect to our partnership with Australian Aid. Actually it feels a bit like we’re a minor division football team that just got promoted to the English Premier League.

That’s all well and good but as far as the kids are concerned the big news is the hatching of our 20 chicks. There had been a long build-up, with plenty of time spent scrutinising the incubator and ‘candling’ the eggs to see what was growing inside. When they finally hatched it was a festival event, and as they’ve continued to grow they’ve become the favoured pets of one and all.

Amidst the flurry of activity at Maluk Timor our kids remain a (mostly) soothing and levelling presence in our lives. They keep us grounded. They have a way of making incisive observations and drawing us back to what really matters, and they unwittingly hold a mirror up to each of us that reveals both the best and worst of who we are.

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Our hope is that Timor-Leste infuses into them a different sense of what life is all about, as we share the ups and downs of the Timor Seesaw. And we’re very thankful to those of you who also share this journey with us, inspiring and encouraging us as we go.

 

Almost

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It was the cheese crisis of 2019. It was not the first crisis of its kind in Dili, where the sudden unavailability of a vital commodity can drag the expatriate community into a downward spiral of acute withdrawal.

In 2014 it was the milk crisis: apparently almost two months with no milk. In 2016 there was the tonic water crisis. Gin and tonic – that crisp and refreshing salve of the tropical colonialist – is the dam wall that holds back the waters of pent-up and thinly-veiled insanity among some of the under-employed international inhabitants of Dili. When the tonic water runs out what follows is an indescribable torrent of madness engulfing the city.

There have been less severe but no less inconvenient crises. The onion hiatus of 2017. The bacon crash of 2018. This time it was a cheese famine.

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Taking it to the streets: the people cry out for cheese

As a parent of four Australian children living in a country with frustratingly limited culinary options the end of cheese is no laughing matter. Of course some would dispute that this crisis occurred at all because there was technically still small amounts of cheese to be found. There were rubbery slices of processed yellow plasticine from Indonesia. There were tiny packets of imported cheeses fetching per-kilogram prices normally reserved for rare minerals and illicit drugs. Those options only tantalise you and remind you of how much you miss being able to buy a one kilogram slab of the good stuff for under ten bucks.

 

It was a relief this week to finally receive a cooler bag from Darwin containing two kilograms of yellow contraband, and the resulting nourishment of body and soul has lifted me at last to make another attempt at updating this blog.

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Warning: consuming excessive cheese can lead to obesity

It’s been quite some time since I wrote. I would make the weak claim that the delay is due to busyness but in fact it has been more a case of not knowing quite what to write. Thinking on it now, the best way I can explain these past few months is through the analogy of motorsport.

I never watch motorsport, which is saying something because I’ll watch just about anything else. I would watch two toddlers fighting over a broken plastic mallet if only there were expert commentary, insightful statistical analysis and an occasional super-slow-motion replay. But motorsport remains incomprehensible to me. Those cars and motorbikes go round and round, make a huge amount of noise whilst doing it, and yet to the untrained eye of a distant observer it looks like nothing very much is changing from one lap to the next.

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However, I imagine if you’re within or atop one of those vehicles that it must be a rather different affair. Clutching the wheel and pumping the pedals, soaked in sweat and experiencing the extremes of acceleration through both your body and your vehicle – I’m sure each lap must feel uniquely different and that a driver could easily spend hours describing every little detail of what transpired in any given race.Image result for jamie whincup

It’s a fairly long stretch to make comparisons between my life and professional motorsport, especially as my life unfolds at a somewhat less spectacular speed.

Even so, I feel like I’ve been sweating at the wheel, hurtling around the track as fast as I can handle, swerving to miss potentially fatal obstacles and trying desperately to get the upper hand. Disappointingly, to the distant observer it must look like I’ve just been cruising around – rather noisily and pointlessly – in circles. For me to explain otherwise without inducing unbearable boredom would require a much more incisive literary mind than my own.

I can at least explain the basic lap pattern, I suppose. You all know I’ve been relentlessly pursuing the signing of Maluk Timor’s Memorandum of Understanding (MoU) with the Ministry of Health as the quintessential step in formalising our partnership with them. Our whole mission is about working shoulder-to-shoulder with government health staff in government health facilities so it is very difficult to for us to achieve our objectives without this agreement in place. This MoU has been the obsession of my last 18 months. It is the chequered flag that I’m racing for and it has led me round and round in laps ever since the race began.

Each lap begins with news that the MoU is very close but that we need to launch one final push to the line. Feeling that victory is within reach we accelerate down the straight and into the first corner. Around this corner comes a slow-down with the drafting of another new document, and around the next bend there is some slippery track with the need to arrange a crucial meeting. We always seem to hit the next hairpin bend a little too fast, as it turns out to be a lot tighter and narrower than expected. The meeting is generally cancelled or postponed, or the crucial person doesn’t attend and sends a representative in their place.  Regathering ourselves, we accelerate again. There are more twists and turns: documents, meetings, rumours, false hope, and then ultimately as we round the final corner and approach the line we discover that it wasn’t actually the last lap. We need to go around again.

I could write pages on each one of these little details which have been endlessly fascinating, thrilling, devastating and character-forming to me personally but it would make for some very tedious reading. So you’re going to have to accept your lot as the distant observer with the untrained eye who finds it hard to appreciate why we’re still driving furiously in circles around the same old track.

IMG_0895Needless to say, as I write this we are accelerating into the beginning of another lap with victory again in sight. I’m sure this is the final time around.

In spite of this perpetual circling we are still very much at work on our projects. Back in June we completed another 12 months of the Family Medicine Program. We deliver most of the training for this course, working under the Royal Australasian College of Surgeons. Bethany oversees our program while Drs Lindsay and Dianne Sherriff are the leading clinical supervisors. It was the end of our second cohort and saw another ten Timorese doctors achieve their Diploma of Family Medicine. These ten doctors have come a long way and will take the lessons learned into the next thirty years of their respective careers, hopefully teaching others as they go. It’s a very satisfying achievement.

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Drs Dianne & Lindsay with Dr Teo

I was the examiner for their final oral exam. Anyone who has ever had to sit an oral exam knows how extraordinarily stressful they can be. I remember back at medical school that some students would vomit before this exam while others had to take medication to control their heart rate or else face disabling palpitations and lightheadedness. But none of them had to face the unexpected difficulty encountered by one of our Timorese candidates in June. He was seven minutes into his exam when the room began to shake.

A few weeks earlier I had experienced my first earthquake, though hadn’t initially realised what it was. It was over so quickly. It just felt like my office chair had momentarily lost its balance, lurching ever-so-slightly to one side and then returning to equilibrium. I thought I had imagined it but others detected it too and the news reports confirmed their suspicions.

This time there was no doubt. If there had been cups and saucers they would have been rattling and tumbling from the shelves. Everybody very quickly vacated the building. We waited outside, smiling and laughing about it, unsure how long one is supposed to wait after an earthquake before re-entering a building. We decided a couple of minutes was more than enough. Our poor candidate, who presumably had been thanking his God for divine intervention of the most spectacular kind, had to sit himself down and carry on as though nothing had happened.

IMG_1108It was reported as magnitude 7.5, but was later revised down to 7.3.

A few days later we were back in Australia taking a pitstop from the endless circling. Adjusting our tropical thermostat to winter – even the mild Western Australian winter – is always an experience for us. This is a photo of the kids getting prepared for Australia.

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And this is us on our family’s first visit to the Perth Zoo. It was 24C.

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No that’s not true, it was actually pretty cold. And it was cold at night when we were camping by the Murchison River, though gloriously sunny during the days. Camping with four young children takes a lot of investment but it pays a terrific dividend.

We count ourselves so very fortunate. We live an exotic and fascinating existence in a raw and beautiful country called Timor-Leste…

…and then twice a year return to friends and family to enjoy the idyllic holiday life of Australia. Admittedly Bethany works quite a lot when we’re back and I find it hard to disconnect from Maluk Timor, but there’s enough of the good times for it to feel like a holiday. There’s no doubt about it as far as the kids are concerned.

The contrast is stark. We held several birthday parties for our children in Dili back in June and watching our Timorese friends participate was surely the best part. They have never played party games before. They’ve never had birthday cakes. Estela once described her own childhood experience: when it was her birthday her family would allow her to eat the entire boiled egg, instead of having to share it with her many siblings as was usual. That was her birthday present and party all in one.

If only you could hear the shrieks of delight and cries of laughter from our friends as they experienced their first ever games of Musical Chairs.

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Of course life here isn’t always delight and laughter any more than it is anywhere else. We have our struggles. I had a recent encounter with an old nemesis of mine that returned very predictably at a most unwelcome moment. My stutter.

Many people don’t believe me when I tell them I have a stutter, though anyone who knows me well is left in no doubt. As a six-year-old I could scarcely get a word out. Even with my parents’ persistence in engaging a speech therapist (against medical wisdom at the time, which advised waiting until I turned ten), I was very much afflicted throughout school. I have vivid memories of standing in front of my Grade 4 class trying hopelessly and unsuccessfully to deliver my lines during a rehearsal of Rinse the Blood Off My Toga. I can only imagine it was as painful for them as it was for me.

Even into adulthood I carried a lasting weakness: I avoided answering phones, was often unable to speak my own name when introducing myself to someone and suffered countless other social and professional humiliations at the hands of this old enemy. With the passage of the years I’ve generally gained the upper hand but having to learn Tetun has left me once again exposed. In English I’m well-practiced at substituting words in a split-second to avoid the blocking of my speech: I have a sense of anticipation of where the pitfall of the block or stutter will be, so can sidestep it by rephrasing my sentence at the last moment. In Tetun I am much less nimble, crippled by a very limited vocabulary and my heightened anxiety at being on unfamiliar ground. I walk straight into the traps and get stuck.

I was asked to give an impromptu thankyou speech at a ceremony at Comoro Community Health Centre. Having no time to sweat on it I got up and delivered a fairly effective if somewhat blundering and uninspiring address in Tetun.

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However, in late July I had to address the Acting-Minister for Health and his entire Council of Directors. Virtually every senior figure in the government’s health sector – many of the people I’d spent the last two years trying to impress  was sitting attentively around a large horseshoe of tables. I knew that all I had to do was to get through a handful of introductory sentences, mostly just paying respects to the various dignitaries in the room, before I would hand over to my General Manager who speaks Tetun fluently. She would carry the rest of the presentation. I had rehearsed over and over in the car on the way there. It was easy. I could speak those words fluently and accurately. If only they would come out of my mouth.

And they didn’t. Suddenly I was in Grade 4 again trying hopelessly to deliver comical lines about Brutus and Julius Caesar. It was horrible. I could see them glancing uncomfortably at one another wondering what to make of this hapless mute foreigner. There were smiles and an audible gasp of relief when one of my sentences finally came unstuck and flowed but the verbal constipation soon resumed. My face was burning hot as my staccato words eventually staggered and stumbled their way to their painful conclusion before my General Manager took over and delivered her polished address. I took shelter and hid under the desks until it was all over. I didn’t come out again until mid-afternoon.

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Sometimes you can only shake your head. Who knows what to make of such an experience? Maybe it helped us – the aftermath of that meeting seems to have been a change in attitude toward us, a change for the better. Perhaps I should have burst into tears and soiled myself too: they might have signed the MoU right there and then.

For now we live in the land of ‘almost’. We’ve almost got the MoU, we’re told. Apparently it’s on the Vice Minister’s desk, approved by all of his departments and ready for a signature. We’ve almost got our Family Medicine Program extended from 10 trainees to 24 for the upcoming year, though nothing has been confirmed. We’ve almost got the news on whether our major funding application to the Australian government was successful – it was supposed to be revealed in July but I guess they’ll announce the winners when the Prime Minister makes his first visit to Dili at the end of this month.

My Kluger – broken down since December – is almost fixed, they tell me. The final missing part has arrived from Australia and the repairs are almost complete. I had the chance to view the car last week.

I tried not to be discouraged when I found that it still looks like a prop from a sci-fi film about a dystopian world, after the nuclear apocalypse.

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You can’t let these things get you down. There are so many other good things going on. For example, today our Maluk Timor rheumatic heart disease (RHD) team is in the hills of Ermera with Menzies School of Health Research conducting echocardiography (ultrasound) screening of school children for RHD. For the next two weeks they will be scanning around 2,000 kids and finding new cases, each of whom will be followed up with penicillin treatment that should prevent an early death.

Better still, this particular study (RECARDINA) is setting out to prove that Timorese ‘rookie’ scanners – having only been trained in basic echocardiography over the last few weeks – can reliably detect children with abnormal hearts and send their images for review by cardiologists. If this is successful it will be of worldwide significance and will usher in a new era of national screening by indigenous Timorese, moving beyond the reliance on occasional visits from international teams of specialists. There are at least 300,000 children in Timor-Leste in need of screening, so developing local capacity to begin that work would be a major leap forward.

We wish the RECARDINA team well and hope they can blaze a trail that will ultimately save thousands of lives. We’re almost there.

 

 

 

When the rain comes

Human beings are incredibly adaptable to their circumstances and surroundings. Things that are at first surprising and unfamiliar are soon taken to be normal. I suspect our lives in Dili are not nearly as remarkable as some of you imagine them to be but nonetheless it is strange how one’s perception of things can change so much.

Very often it’s incremental, creeping up unnoticed. It’s hot here much of the time so the drinking of hot coffee becomes far less appealing. I tend to let it sit. Daily distractions ensure that the coffee cools to ambient temperature anyway so, just as many of you surely are, I am accustomed to swilling down my coffee cold.  Time passes and the foul bitterness of cold coffee becomes part of its charm. Giving in to defeat I have taken to brewing my coffee cold and I now rather like it that way.

It’s also evident in our adaptation to speed, or lack thereof. We become very used to things moving slowly here so when they don’t it can be both surprising and exhilarating. You recognise that a change in perception has occurred because the occasional sensation of hurtling along a Dili street at 45km/h provides an adrenaline surge normally reserved for F1 racing. Hard to believe I know, but I’m quite serious.

The children of course adapt faster than any of us due to their highly plastic brains that adjust to almost any situation. You know your kids are different from their cousins when you see them point at four stationary cars queued up at intersection and hear them exclaim, “Look! Traffic!”

I’ve noticed now that I neither flinch nor pause when the power goes out: I simply finish my sentence as though nothing unusual has happened. I’ve also appropriated the local habit of trying to catch mosquitos in a single hand – the trouble being that it’s very hard to tell if you’ve crushed the pest or only interned it within the hollow of your fist. Very often the opening of the fist in hope and anticipation yields great frustration as the savage creature free once again, but at least then the sport can continue.

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It’s been harder and harder to get back to this blog in recent months. As if life wasn’t busy enough, I’ve started studying a Master of Health Administration and it has chewed into my evenings and creative opportunities. I’m still not entirely sure why I started such a thing but it seemed the logical approach. One day I’m going to return to Australia and look for a job in some kind of health leadership and my mysterious adventures in Timor-Leste will make little sense to someone reading my lightweight CV. I hope that bolstering it with an MHA will make sense of what I’ve been doing, undergirding my experiences with some theoretical basis. Perhaps it will help me do a better job here in Timor-Leste? It’s too early to know.

IMG_0862As I write this section I am travelling again, viewing Dili from the air. And it’s a picture – colourful roofs sprinkled among the verdant green of a landscape washed and revitalised by six months of regular heavy rain. Not visible from this height is the damage wrought by that rain: the destruction of mudslides, the washing away of roads and the flooding of homes. I lay in bed one night in February listening to the rain pounding upon our roof. It was unusually heavy and, unlike the typical pattern of the late afternoon downpour that quickly passes by, it was very much sustained. It was 3am and I told myself that if it didn’t ease off in the next five minutes I would get up. It didn’t, so I did.

Heading outside with a torch and a Dora the Explorer umbrella that wasn’t quite up to the task I found the entire yard in at least 15cm of water. The water was just lapping at the doorstep of our rear apartment. The tarpaulin awkwardly slung over our pool was burdened like an overripe pregnancy, with perhaps 100kg of water in it. One of our electrical cords was running through a pool of water. I worked in the dark to remedy some of these problems and though the rain didn’t abate for another half hour, during which time our power understandably went out, major flooding was averted.

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Our HIV care centre at Vera Cruz was not so fortunate. A thick coat of mud inundated the building. How many other homes in low-lying Dili, with its blind-ended city drains that don’t always lead to the sea, must have been flooded that night? Beds are a luxury in Dili: for many people it’s a floor mattress or a bamboo mat, on a concrete or earthen floor. You can imagine how well that fares when the rain comes.

The heavy rains bring sickness too: I see my Timorese colleagues sharing knowing smiles about the inevitable stomach complaints that accompany the overflowing of city drains. The rains give the mosquito populations a sizeable boost too.

Over the summer one of Miriam’s Timorese classmates had suffered a terrible bout of encephalitis and was hospitalised with seizures and coma for many weeks. She was not expected to survive and Miriam was understandably distressed. Against all hope she began to recover and Miriam was the first student from the class to visit her in hospital. It was pitiful to behold her emaciated little body, down to perhaps half its healthy weight, but to see her smile as she recognised Miriam and then on the next visit get out of bed and walk, was truly heart-rending.

 

IMG_6024In early 2017, our first wet season, our entire family contracted dengue so we’ve had to be careful about mosquitoes. A second bout of dengue can occasionally be much more serious, presenting as either shock (with generalised swelling due to leakage of vascular fluid into the tissues) or haemorrhage (due to falling platelet counts).

During school holidays, after fixing the play-pool and building a chicken coup, we took the family back to Atauro Island and had a much-needed break for a few days. Micah, aged five, went for his first snorkelling venture at ‘the drop off’, where the stunning coral reef plunges sharply into the depths. Levi played with his school mates who were also there, including an unusual game involving a partially submerged fibreglass dinghy and a competition to see who could remain in the boat longest while it was rocked from side-to-side by the inimitable Barry (of Barry’s Place, the Atauro eco-resort).

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We took a surreal boat trip to the remote northern-most beach (Akrema), notable for its clean white sand, but we were overtaken by a surprising turn in the weather. After a hair-raising 90-minute voyage in a motorised fishing canoe in decent swell we ended up huddled near the beach trying to find cover from the unexpected heavy winds and drizzle, and roasting marshmallows on a fire.
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But then Levi burned his foot on a hot coal and I was stung by a scorpion. I was cursing our decision to leave the idyllic beach at Beloi. It felt like one of those bad nights out when you’ve found a perfectly good nightspot but there’s some restless fool among the group who convinces you all to leave it and line up outside some other seedy overcrowded club that turns out to smell of urine and vomit, with music loud enough to make your ears bleed. That’s probably a little unfair to the picturesque beach at Akrema, but we definitely didn’t see it at its best. It might be the scorpion bite talking, which along with a perforated eardrum was making me more than a little irritable. With the high headwinds and mounting swell we were dreading the voyage back down to Beloi in our rickety canoe. Thankfully the winds dropped away as we prepared to leave and by the time we were back at Barry’s Place we were once again bathed in warm tropical sunshine and my foot no longer hurt: it was as though it had all been some kind of strange dream.

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Miriam was having strange dreams of her own, having developed a fever on the first evening on Atauro. She was clearly not herself and upon returning to Dili we were pleased to find the explanation with what appeared to be a positive test for a urinary tract infection. It was not her first, and we were confident that a course of antibiotics would mop it up quickly as usual. However, the fever remained and she developed a rash the following evening. She was tested for dengue and to our dismay it was positive. Her platelet count was down to about half of the lower limit of normal but she was not yet into serious danger. Specialist advice suggested we could wait and repeat the test the following day but we had the insurance company on standby for a medevac to Darwin just the same. Ironically, by this time Levi and I were both in Darwin for other reasons and it was left to Bethany to help Miriam through the daily blood tests. Thankfully the fever abated, her platelet count stabilised and recovered, and the trip to Darwin was rendered unnecessary.

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On the beach, celebrating my birthday

Bethany and I both had our birthdays, either side of Easter. I turned 41, which seems to be a very large number in the minds of our children. Micah drew me a lovely picture for my birthday: I’m a hulking bald blob of a man with a monobrow.

IMG_0774The picture shows him jumping on my enormous shapeless belly. He assured me that the very large protuberance from the left side of my head was a good thing, it is my ‘lucky ear’. If by that he meant that in a couple of weeks’ time that same ear would be so full of fluid that it would burst the drum then he was truly prophetic.

Meanwhile Levi created a Minecraft ‘skin’ for me, though why he had to go to such detail to include ‘lots of sun damage’ and my bald spot (complete with a mole on top) is a little unclear to me.

He then proceeded to create me a character in FIFA Street soccer: a 41-year-old grey-haired man weighing 209 pounds, attired in a polo shirt and baggy tracksuit pants (while everyone else in his team was a chiselled athlete in slick sportswear). I guess there’s no hiding from the realities of advancing age. My children see it how it is.

Birthdays aren’t really all that spectacular in Dili, it has to be said. It’s close to impossible to buy a decent birthday present, though Bethany has certainly crafted some fine gifts for me since we’ve been here. The kids know that birthdays are less exciting than homecomings: that time when one of Mum or Dad returns from a trip to Australia. We’ve had several this year for various training courses and conferences and the kids’ excitement about seeing us on return is quickly overshadowed by the question bursting from their lips: “can we open the suitcase?”

The suitcase contains all kinds of wonders. Cheerios. Gingernut biscuits. Packets for making yoghurt. Socks! “Hallelujah praise the Lord! I’ve been waiting for this day!” exclaimed Levi, overcome with delight that he would no longer have to go ransacking the dirty clothes basket each morning looking for socks. New bathers. Colouring in books. Easter eggs. Sometimes a few gifts and toys. It’s like Christmas. The kids are usually a bit disappointed that half of the space is filled with medical donations or laptops but they’re used to that now.

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The socks were good. The cricket bat is better.

I’ll have to bring home the goods when I return from this visit. I’m on my way to Sydney to speak at the IMPACT Christian Medical & Dental Fellowship conference.

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For me it’s like a homecoming: 17 years ago this annual conference connected Bethany and I with a community of Christian doctors and dentists who have become our lifelong friends, and who played no small part in the trajectory our lives have taken since that time. Before coming to Timor we were inspired and mentored by others who had gone before us, having undertaken similar ventures in Africa, Asia, or the Pacific. It’s a privilege to be going back to see old friends and to meet the next group of students and recent graduates embarking on their careers.

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This photo above is from last weekend when we had the chance to meet with the leadership of the Medical Association of Timor-Leste. It was a great opportunity to hear their objectives for the next three years in developing a Medical Council, a membership database and a structured program of CME (Continuing Medical Education) to support the 950 doctors scattered across the country.  They’ve asked us to help support them in these aims, which is very pleasing because these are exactly the kinds of things we’ve come here to do.

Above is a photo of a colleague of ours training Timorese doctors in ECG and another of Bethany assisting Timorese doctors in learning ultrasound. It’s a really exciting time for us as the opportunities continue to open up: there’s so much to do and we now just need to be wise in how much we attempt all at once. Thankfully we’re not alone, with a great team of internationals (a dozen in Dili, and many more outside of Timor) and 46 Timorese staff that make Maluk Timor what it is.

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I have been delaying the publishing of this blog, in part because I had really hoped that I would be in a position to announce at least one of the following:

(i) we have signed our much-awaited MoU with the Timorese government (we haven’t, though there’s possible movement coming up this week); or

(ii) my car with the dismantled engine stuffed in the back of it is finally repaired and back on the road (it isn’t, but I remain hopeful); or

(iii) my TEDx talk is finally posted online (it’s not).

So, with no big finale up my sleeve, I’m just going to have to distract you with a cute photo from the Mothers’ Day morning tea at Annika’s school.

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Inside the disarray

Every year life in Dili gets a little bit easier, and it’s not only because we’re now used to it and know where to find the help we need.

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The city is changing in front of our eyes and the goods and services at our fingertips are ever expanding. This is, after all, a nation rising from the ashes. The difference between Dili and Australia remains stark, especially to our children. Over the summer we were generously treated by a member of the extended family to a day at ‘The Maze’ on Perth’s outskirts. Miriam was in her bathers and knew we would be swimming there, but when she rounded the first bend within the park and beheld the towering waterslides in front of her (which are only moderate by today’s standards) she was overcome: “We’re going to swim on that!? This is too much!!”

 

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Perth Waterpark
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Dili Waterpark

Though Dili continues to develop and improve, there is always a surprise just around the corner. We arrived at the airport back in January amidst a tremendous tropical downpour.

IMG_0454To get to the car, which was only 30m from the cover of the terminal, it was ‘shoes off’ to splash through the ankle-deep puddles in bare feet. Arriving home a few minutes later we were stunned to find the smouldering ruins of our guard hut at the front of the house, which had burned down only moments earlier, presumably due to an electrical fault.

An inferno in the torrential rain was unexpected, to say the least. The hut is only a metre or so from our house, so we were pretty relieved to have escaped without serious loss. The downpour did its work.

The next surprise was to see my Toyota Kluger again, which had been in the workshop since early December. Evidently that particular workshop had been unable to source the required parts so I had arranged to have the car taken to another workshop that I hoped was more likely to succeed. IMG_0485When it arrived at the second workshop I was there to witness the gasps of dismay as they inspected it.

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Ummm… where’s the rest of the engine?
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Oh. There it is.

As a doctor it’s hard not to think of this being like transferring a patient to another hospital with an enormous open abdominal incision and most of the organs tucked in a grocery bag hanging from the side of the gurney. That’s not usually how it’s done.

The surprises continue here in Timor-Leste. Last week a bus tried to traverse a section of makeshift road through the Comoro River after heavy rains and was washed away, with several lives lost. The next day the local airline lost a plane which crashed on a roadside just out of Dili – thankfully all passengers were unharmed.

Less dramatically, this week our bore pipe slipped from its connection and plunged down into the bore-hole. So we had no water. Before that it was the electricity being off for three evenings running (and again today). Then it was two of our international volunteers going down with dengue. But life meanders on: this is the everyday disarray of Timor-Leste. We are relatively shielded because of our affluence and international connections. We can buy our way out of most problems and protect ourselves when we need to. Not so the locals, who face the flooding, the mosquitoes, the sickness and disadvantage with no buffers nor insurance.

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The War on Dengue

And this is the sad truth for Timor-Leste: though life in Dili is improving all the time, it is mostly improving for those of us at one end of the spectrum. For the average Timorese person, especially for those outside of Dili, life remains the relentless struggle that it has been for many decades.

These struggles have been weighing on us as we wrestle with the question of how Maluk Timor can be most effective with our limited resources. The challenges here in healthcare delivery are all around us and sometimes it is hard to know where to begin.

One recent paper published by the Lancet Global Health Commission has brought this into sharper focus for us. This paper argues that around 8 million people die unnecessarily each year in low- and middle-income countries of treatable conditions. Worse still, of those 8 million deaths, it is estimated that 60% of the deaths are attributable to poor quality care rather than lack of access to care. Stop and consider that for a moment: that would mean that in countries like Timor-Leste, people have been dying not so much because they couldn’t get to a doctor, but because the care they received when they got there was of such poor quality that it was unable to save them anyway. And that’s only accounting for the deaths from treatable conditions: conditions that people shouldn’t really be dying from at all.

46150745475_884ffeaa1b_kThis realisation came just in time for me as I received a last minute call up to give a TEDx talk in Dili. Several of the first choice speakers had pulled out, so like that wedding reception guest who gets a second round invitation and is flattered nonetheless, I gratefully accepted. However, with less than 48 hours until the event, I was at a loss as to what I would say: TED talks are supposed to present innovative ideas that inspire people and transform the way they live their lives. The talk should be on a subject in which the speaker has some expertise (that at least shortened the list), and have some factual evidence behind it. It should be locally relevant to the largely Timorese live audience yet still be meaningful to an international audience online. It must be less than 18 minutes, non-religious, non-political, and not simply an informercial for a product or organisation. After sweating on it for a day or so, I decided I would say something about my observations of health in Timor-Leste, and how the people of this country can take matters into their own hands. I’m yet to see the video as it hasn’t been uploaded to YouTube yet. I’ll post a link when it goes live and you can find out whether or not I pulled it off.

But this realisation – about quality healthcare – also tells me so much about what we need to do and why we need to do it. It makes sense of what we see around us here everyday: that there is a skeleton of a health system now in place, but everything that should be covering those bones is yet to materialise. The muscles that should allow those bones to move and respond to challenges: not there. The nerves that communicate messages from one part of the body to another: not there. The arteries and veins that distribute crucial resources and supplies to the distal parts of the body (and carry away the refuse): not there. The skin that gives everything its pleasing appearance and makes people want to take hold of what they see: not yet.

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Bethany (right) and Nurse Dea (left) presenting new equipment to our local health centre

In time we will see this frame covered in flesh and brought to life but until then there is so much to do, and we’re just glad to be right where we are, with a frontline opportunity to do it. If you want to find out more about what that looks like, check out our new website which has had a major facelift. There should be a lot more content with videos and stories appearing on there each month throughout this year.

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Some of our Maluk Timor gang

Planes and Drains

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Dr Bethany, in our minor operating theatre (kitchen)

 

 

 

We were attacked tonight! It’s late on New Years’ Day as I write this. I’ve driven home this evening with Bethany and the kids in the car and have been pelted by large rocks from unseen assailants in the roadside bushes, causing some significant damage to the car. Disenfranchised youth in Dili are often known to hurl rocks at passing cars under cover of darkness. There isn’t a lot of other entertainment to be had. There are certain roads best avoided at night.

However, on this occasion it was the youth of a far more dangerous place – Geraldton – who have had their fun at our expense. I am thankful that we spend most of the year in the relative safety of Timor-Leste.

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Perils of Timor-Leste: another fatality on the backyard slippery slide

We arrived back in Australia just before Christmas, after some airport difficulties.

Have you ever missed an international flight? Probably… many of us have. We missed a flight out of Heathrow in the winter of 2014 with three very sick kids and 150kg of luggage despite having made it to Check-In with what seemed like plenty of time. That’s a story all of its own, ending with us arriving into the wrong Swiss city in the middle of the night without our luggage. Actually I was somewhat relieved when it didn’t arrive – I could carry it no further anyway.

 

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Airport Farewells: Alico is going to Australia. Annika is not pleased.

I was having flashbacks of that memorable evening as we were trying to fly out of Dili before Christmas. Again we had arrived at Check-In with plenty of time, many kids and much luggage. I was expecting trouble with Passport Control as I had knowingly overstayed my visa by three days and would surely be taken aside to pay a fine. What I hadn’t predicted was that we would be denied Boarding Passes because my two sons both had passports with only five months of remaining validity. I protested of course – we were flying to Australia, why did we need six months validity to go home? Ahhhh… because we were flying through Bali and, due to the quirks of the Denpasar Airport, would be forced to go through Passport Control before checking in again for our flight to Perth. Indonesia would deny us entry and we would be stuck. I explained that we were only in Bali for three hours and showed them the itinerary to prove it.

Hmmmm… the previously impassive airline attendant now looked perplexed. She decided to phone Denpasar Airport for clarification, so told us to wait. And wait we did, as every other passenger passed us by and proceeded to the departure lounge. Still we waited. I anxiously searched for alternative flights on my phone. Yes, potentially I could stay back with my two offending sons, aged nine and five, and send Bethany ahead with the girls. Those of us remaining in Dili could take a later flight through Darwin but there were none available for two more days and we would be facing additional costs of $3,000-4,000 all told. Bethany and I, parked with our luggage and four bewildered children next to Check In, formulated strategies about which suitcases would go and which would stay. Every few minutes I checked in with our impassive airline attendant, who shrugged and asked us to keep waiting.

An hour passed. Check In was closing. There were no more passengers, only us. It was now likely that our entire party would miss the flight and that those costs would rise higher still. Just as it seemed all was lost the impassive airline attendant broke into an enthusiastic smile and said we had been approved. We loaded the luggage on to the conveyor and waited for our Boarding Passes. The remaining airline staff looked delighted to see our relief and we weren’t surprised when they began taking photos of us. We’re quite accustomed to this, being something of a novelty here.

I sent the other five through Passport Control and, with my heart in my mouth, placed my own passport on the counter. The clerk spent what felt like ten minutes flicking through the many pages, decorated with years of Timorese visas and stamps, trying to confirm his suspicions that I had indeed overstayed. Nonchalantly he reached his eventual verdict and directed me away with another attendant. I was led through the airport to a remote office and asked to wait. I had expected this. What I hadn’t expected was that I would already be so late, and that from my particular vantage point at the office entrance I would be able to view my wife and four young children walking out on to the tarmac and boarding the plane without me. They had been hurried through by the stewards.

For several minutes it wasn’t clear what I was meant to do. The attendant had disappeared down a corridor with my passport and I had been left standing unattended in a doorway. I paced about, looking this way and that for any clue as to whether I would be processed in time. I couldn’t see anyone, nor any activity. Actually from there I could have run on to the tarmac and climbed on to the plane, but it would have been madness without my passport. The minutes passed and I widened my search, wandering into a few different corridors and offices desperately hoping to see someone – anyone – who might be processing my passport. Finally, through a heavily tinted window I caught a glimpse of an older man with a painfully slow hand scratching out details on to a carbon copy sheet. It was the receipt for my fine. Moments later he was done, and I took the receipt as briskly as I could without succumbing to the almost irresistible desire to snatch it out of his tremulous hand. Turning to run back through the airport I found the clerk at Passport Control and he quickIy stamped my passport. Beyond that I could see everything was now closed. The X-Ray machine in security had been turned off. I thought I could sneak through but a security guard with his back turned swung his head around and noticed me, and insisted on restarting the machine to scan my shoulder bag. Precious moments lost. Departure lounge was also empty, so I ran straight through it and out on to the tarmac.

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The front door of the plane was already closed. The rear door was ajar, and Bethany was standing in the doorway with a broad smile on her face and a phone in her hand, recording the moment for posterity.

It was upon arrival in Denpasar that the photos taken earlier made sense. The staff in Dili had sent photos of our family ahead to Denpasar where we were intercepted by airport staff and whisked straight through transit to avoid Passport Control altogether. Sweet relief.

Running across an empty tarmac in a sweaty fury is not really suitable behaviour for a man of my standing. After all, I am a dignified gentleman in Dili. Not only am I one of the tallest men in the country, at almost six feet, but I have a very smart oiled leather shoulder-bag and distinctly silver hair to prove my exceeding wisdom.

My staff at Maluk Timor treat me with great deference: they insist that I speak first at formal events, that I eat first at meals, and they never allow me to carry anything heavy. They don’t like me riding a moped because it is unbecoming. Even sweating is beneath me.

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Maluk Timor Christmas Party

However, even the most respectable gentlemen are prone to mishaps. The cheap doorhandles in our office have caused their share of problems and just recently I spent an uneasy twenty minutes locked in the toilet at Maluk Timor. The staff were mortified at the indignity of it all and gathered around the door to try, one after the other, to open the door where others had failed. It was one of those great comedic moments, as I waited with a smirk on my face, sensing the extent to which they were all horrendously embarrassed on my behalf. The urgency in their efforts was quite palpable, and it ended with the complete destruction of the offending doorhandle (a fitting punishment for such impudence). As I eventually emerged it was smiles all round, though I can only imagine that my reputation has taken something of a trashing after such an event. I don’t walk quite as tall as I once did.

We celebrated our 18th Wedding Anniversary at the Hotel Ramelau. Some couples get matching tattoos, but we preferred to mark the occasion on our son’s forehead. He swam into the submerged pool ledge you can see in that photo. 

The contrasts in Timor between the haves (who are very few) and the have-nots remain as confronting as ever they were. Sometimes I have to really stop and deliberately notice what I see all around me. As I drive each day along my street, from our relatively affluent home toward the premier shopping precinct in the country, I am struck that those contrasts are very much on view.

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This is a photo I took from my car window while driving along our street. This is the intersection nearest our home where microlets (minibuses) very often stop to collect passengers before turning the corner. It’s a narrow, busy four-way crossroad that has been undergoing drainage works for the last two years: note the concrete drain at the bottom right.

It’s hard to tell from this photo but that large puddle you can see is more like a pit. I’ve walked past and peered into the murky water enough times to know that it is at least fifty centimetres deep. It’s been like that for approximately 18 months since it was dug up for the drainage work. The drains are being dug either side of our street, running toward the ocean, but this particular section remains a drain to nowhere, and the water that accumulates from farther up the road stops and make its home right here.

Timor-Leste is a tropical country with distinct wet and dry seasons. The dry season runs for six or seven months through the middle of the year. During this time a pool of water like this will stay stagnant, as a general hazard and breeding ground for mosquitos. During the wet season it frequently overflows, capturing the drainage from the street which includes whatever trash and detritus is gathered by the running water from a city with serious litter and sanitation problems. You can see that it wouldn’t take a lot for the rising water to create additional problems, and this photo was taken before the tropical rains arrived.

This particular corner is actually a shopfront. It sells fresh vegetables and a range of other foodstuffs. On a busy corner like this I expect it did a decent trade until someone dug a moat in front of it. Moats are not typically good for business. Version 3If you look closely you can see tubs of legumes and chilis on a table behind the moat – how exactly are the customers expected to access these? Who knows what effect this has had on the livelihood of this family, who may very well be squatters anyway.

Look at the green vegetables on display. These are sold for 25c a bunch. They are delivered several times a day by growers and the vendors splash them with water every few minutes to keep them moist and fresh. Water from where…? Clean drinking water is expensive, so it’s unlikely to be that. Very likely the water comes from somewhere very nearby, where it is pooled and easy to scoop up. You join the dots. It was unsurprising when in 2017 almost all of our Maluk Timor staff contracted cyclospora from eating salad greens such as these. At least I lost four kilos.

It’s easy to joke because I’ve got four kilos to lose. The children – and most of their mothers – most certainly don’t, and diarrhoea is still a major cause of preventable death in Timor-Leste.

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Speaking of children, look again at the photo. Where do the little children play? A single roomed house squeezed in against a busy road has no yard to speak of, and this is the common predicament of many who live in Dili. The children spend much of their playtime in the roadside gutters. Timorese children typically can’t swim, especially these very little ones. Fifty centimetres of sludgy water is more than enough should one of them slip and fall, particularly in the darkness of night when they are still very often at play and the noise of the passing traffic obscures any sounds that might alert the family. Who knows how many Timorese children drown each year? No one does, but we know of at least two who died in our neighbourhood last year.

Version 2And then there is the man on his motorbike. Aside from being a hazard to the kids nearby, he is in danger himself. Not now, in the daylight, but at night when these streets are in darkness. Many motorcyclists ride without headlamps, even with their unhelmeted family aboard the bike, because they believe it saves fuel. At a busy crossroads like this a simple misjudgement in trying to avoid a pothole or stray dog could send a motorbike plunging off the road and into this water, potentially striking the partially submerged concrete drain in the process. The injuries being tended by Bethany in the first photo were those of a friend, sustained during a motorbike accident at night – he hit a stray dog. Thankfully he didn’t end up in this drain.

The point of all this is that life can be very marginal here for your average Timorese. A simple shopfront on a busy corner is not an exceptional example – I single it out because it is utterly unexceptional, so unexceptional that I almost don’t notice it myself in spite of driving past it each day. This is normal life here, where the poor are waging a constant battle against the uncertainty of low income, disease, injury and exposure to the elements.

We can respond with feelings of pity but that doesn’t get anyone anywhere. Bethany and I are still learning, but the only way we know how to help is to roll up our sleeves and get in alongside our Timorese healthcare colleagues and work with them, shoulder-to-shoulder. The responsibility is theirs and the solutions will need to be theirs too, but we can offer ourselves in support along the way. We’ve got another year of Maluk Timor beginning, and let’s hope we can help Timor-Leste provide the quality healthcare that her people so sorely need. Happy New Year!

Our Family Medicine trainees have graduated at last. Now they’ve been sent back to their district health centres to put their knowledge and experience to use. 

Order & Chaos

Last week I opened my smartphone and began to type a question into Google:

“Can you use 1% lignocaine for eyes?”

A friend had a fleck of steel in his cornea and we didn’t have the usual amethocaine anaesthetic drops available. Then I noticed that the previous webpage saved in my phone contained a similar search:

“Can you use transmission fluid for power-steering fluid?”

And then it dawned on me just how often I ask Professor Google these kinds of questions in Timor:

“Can you use coconut cream for pasta sauce?”

“Can you use household bleach for pool chlorine?”

“Can you use superglue for wounds?”

“Can you use beach sand in a pool filter?”

“Can you use cable ties for fixing… well… everything?”

(If you’re wondering about the answers, they are: yes, best not to, yes but it’s not great, yes, yes, no – it blasts straight back into the pool, and absolutely.)

DSC_4601I’m not exactly MacGyver but I am learning that there are a lot of things you can do without, and a lot of things that can very reasonably be substituted for others. Your kids’ finger-paintings make great gift-wrap paper, cream plus lemon juice makes sour cream, and a pair of smartphones negates the need for genuine marital conversation. For a while at least. However, there is no substitute for a good doctor.

IMG_9830I’m not doing any medical consulting here at the moment, which might be for the best because I’m not a particularly good doctor, but occasionally I am asked to see a patient as a favour. Bethany sees many, and reluctantly provides an informal Facebook Messenger pregnancy helpline.

This particular patient, a young Timorese woman, came to see me with a thick folder of medical records and test results which she had accumulated in Indonesia at great expense in trying to find an answer to her symptoms of tiredness and headache. I spent quite some time thumbing through the notes. It seemed she had ultimately diagnosed her with angina – a very serious condition – and she had been commenced on six very potent, even dangerous, medicines which she was told she needed to prevent a premature heart attack or death. She was understandably anxious, tearful, and wasn’t sleeping. Her headache and tiredness were both worse as a result.

Having interviewed and examined her and then reviewed the results I drew the conclusion that this woman was in fact suffering from the utterly mundane affliction of tension headache, probably due to sitting at a computer all day. I found no evidence whatsoever of any heart condition and I instructed her to stop all but one of the medicines. She burst into tears in relief, and insisted on hugging me.

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She should have saved her money and just asked our magical Fairy

As she left, I was struck by the harrowing thought that people like her are being misdiagnosed, mistreated and overcharged for the privilege every day, all over the world. Even in Australia it’s rare to meet someone who hasn’t got a story of having been completely misunderstood and misdiagnosed by a doctor, and having been put on some needless or even harmful treatment. It should be surprising that this is happening in a country where doctors have each had at least ten years of high-quality, closely supervised training, with rigorous examinations and professional standards imposed. Every doctor in Australia is also compelled to maintain a high level of ongoing education, and yet still there are quite some number who are simply not very good, and even the good ones make mistakes.

 

In fairness, it’s not all that easy being a doctor. I would guess that in my own experience as a GP and emergency doctor  I’m not certain of the diagnosis in at least one third of my cases. This means that often I end up having to focus instead on what the diagnosis is not – i.e. making sure I’m not missing something really serious – and then making my best guess and tentatively suggesting some kind of low risk treatment whatever it might be. And that’s with the very best of medical technology at my disposal.

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“So… what you’re saying is that you don’t know?”

The trouble is that patients don’t much like it when the doctor doesn’t know what’s wrong. And as the doctor, I don’t much like it either. Over time, one develops all kinds of different manners of explaining it to patients in a way that preserves one’s dignity, but sometimes it just has to be an honest shrug of the shoulders: Sorry, I don’t know.

It’s even worse if you have to admit that not only are you unsure of what their problem is, but you are pretty confident that it’s not important and that they shouldn’t worry about it. Now you’re not only incompetent, but you’re insulting: invalidating their illness that they thought was serious enough to justify missing a farewell party at work, waiting for an hour reading gossip magazines from 2012, and putting up with your nonsense.  If you really want to upset them, you can give them the triple whammy: no diagnosis, your problem is not important, and I’m not giving you any treatment.

“And by the way, that’ll be eighty bucks. Be sure to leave a tip.” (wink)

It’s much easier as a doctor to pretend you know even when you don’t, and to prescribe a treatment that they almost certainly don’t need. You save face, they walk away feeling validated with their antibiotic script in hand, and whatever the heck was wrong with them doesn’t really matter because they’ll be over it in a week anyway and they’ll then assume you were correct. You’ll be their favourite doctor. Everyone wins, right?

This temptation becomes much more pronounced if you happen to live and work in a culture where shame and honour, or the sense of preserving ‘face’, is of the highest concern. It’s generally accepted that this is case in most Asian cultures. If I explain something to an Asian colleague and then ask if he understood me, he will say ‘yes’. To admit otherwise would be embarrassing not only for him, but also for me, as it would mean that my explanation must have been inadequate. Everyone is better off if he just says ‘yes’. In such a place, if you tell the patient that you don’t know what is wrong with them it is bad for everyone. Everyone loses face. It’s not an option. You can see where this might lead, when it comes to an uncertain diagnosis.

In Australia, everyone has a story of misdiagnosis. We might then wonder how much more commonly it occurs in countries with lower quality medical education, countries that lack well-established professional standards, and particularly those countries that value ‘face’ above honesty.

We are working hard in Timor-Leste with the local doctors to improve the quality of their medical care. Even so, a colleague of mine remarked recently, “We went around the ward and found that every one of the patients had a diagnosis of gastritis and a bag of IV fluid hanging up. As we took our Timorese doctors around and re-assessed each of the patients together we discovered that none of them needed IV fluids, and that none of them had gastritis.”

I don’t tell this anecdote to denigrate my Timorese colleagues, who are quite simply remarkable to have learned Medicine in their fourth or fifth language, and who now practice without any of the resources or support that an Australian doctor expects to have at his or her disposal. I tell it to illustrate the scale of the task. It is no easy thing to train a good doctor – we know what we are aiming for will take many more years than we can possibly offer. But we hope to make a start.

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As you can see, I’ve grown approximately eight inches in height since moving to Dili. I think it’s the Timorese coffee – it’s amazing. 

When we look around us we see chaos. There are many people trying to make a meaningful difference – it’s not only us – but the chaos remains. However, I have been reflecting lately that I should take this to mean that we are in exactly the right place.

I just finished Dr Jordan Peterson’s book, 12 Rules for Life, and in it he has a lot to say about order and chaos. He draws heavily on an idea from Daoism (or Taoism, if you prefer), that will be familiar to most of you in this image:

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The Yin and the Yang.

First, my disclaimer. I’m no Daoist, and I’m going to be writing a paraphrase of a paraphrase. What I know about Daoism would fit on the back of a napkin. What follows may not be entirely accurate, but even so, what little I’ve understood has some utility.

Dr Peterson explained that the Yin and the Yang represent, among other things, the balance between chaos and order. And he explained that when it comes to living a life of meaning or significance, the very best place you can find yourself is to be walking along the curved line between the two, with one foot on either side.

Too much chaos and we are overwhelmed, our lives unravelling around us. Too much order and we are stunted and stifled, without challenge and without growth. We need battles to fight and opportunities to exert ourselves in trying to set things straight. This is where we find purpose, meaning and fulfilment.

I’m a Christian and not about to become a Daoist, but I find this picture vividly describes the life I’m trying to live right now. Used in this limited way, I don’t find this concept to be at odds with my own beliefs. Christians live with the God-given imperative to seek and promote truth, justice and mercy where deceit, injustice and cruelty prevail. It might be described as desiring God’s will to be done on earth as it is in heaven, or establishing righteousness (order) where evil (chaos) reigns. The only place that this can really happen is where order and chaos meet.

When Bethany and I moved here we consciously attempted to balance order and chaos, though we wouldn’t have described it in those terms. Work was clearly going to be chaotic, so home had to be a refuge for us. We set our life up so that it would be just that. We chose to keep one foot planted in Australia – heading home twice a year, and sending our kids to an international school with a strong Australian flavour – whilst planting the other foot firmly in the mayhem of Timor. Even the way we designed Maluk Timor includes an orderly headquarters from which we send our program teams out into the chaos.

The chaos is easy to see. There are no street addresses, and no postal service. The electricity supply is unreliable. There is no enforcement of road rules. Last week a guy on a motorbike came flying past Bethany (in the Prado), and got a little too close, scraping the side of our car and kicking off the mudguard. Last month they closed services in our bank, and we’ve had to try to open a new bank account. There are regular shortages of just about everything you can think of, sometimes minor (it’s almost impossible to find a diet soft drink of any persuasion here at the moment), and sometimes more significant (our health centre has had no IV antibiotics this month).

I think this might be partly why we feel so very fulfilled in what we’re doing here, even though to so many it must look like madness. We enjoy the stability of an ordered household (if you can call four children under ten “order”), and the support of a strong organisation (our Maluk Timor crew are terrific), whilst loving the challenges we face each day to establish order amidst the chaos all around us.

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One of our nurses setting up Triage services at Formosa Health Centre, so that patients are seen in order of need. 

Whilst thinking about establishing order, I’ve also been reminded that I am clearly an INTJ on the Myers-Briggs personality test. I won’t explain that in depth except to say that an INTJ loves strategic planning and problem solving, which is me all over. The downsides of being an INTJ are that the ‘I’ stands for introvert, and that INTJs tend to have the personality of a bowl of porridge. There’s always a Yin to every Yang I guess.

* * * * * * *

Bethany’s parents visited in October with a group of volunteers from the Country Women’s Association. They worked furiously for ten days on fixing, building and painting – thanks everyone.

Miriam can’t quite claim full credit for these grand murals in the health centres.
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Maubisse

We took the opportunity with her parents here to head up to Maubisse in the mountains. We’re nearing the end of the dry season, so it was brown and dusty for most of the way, but at least that meant the roads were in decent shape. We stayed at the Pousada, an old Portuguese residence set on a fortified hilltop. The hospitality was warm, the night air was cool, and the tranquility was refreshing… if you can ignore the thundering noise of the diesel generator that was needed once the power all went out.

 

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The next morning we visited a nearby waterfall, and plunged into a cold pool. We jumped from about half way up the rock wall, whilst the local kids leapt from the top.

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Yes, it was that cold…

 

On our travels through rural Timor, we were struck again by the simplicity of how so many people in Timor-Leste still live. We were also struck by how heavy our children are, particularly when being carried along a rocky river-bed, and how dependent they are upon travel sickness medicines. And these were the good roads.

Maluk Timor celebrated our one year birthday last week. Whilst we’ve often felt frustrated that things seem to take so long to get where we want them to go, this celebration was a timely reminder that we ought to be grateful for how far we’ve come.

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We started with a team of seventeen people in October 2017, having endured a traumatic and unanticipated change of course. We have almost tripled in size since then, with 46 staff and more to come. We had two and half programs then, now we have nine. I was on a teleconference recently in which I had to describe what Maluk Timor is, explaining our nine different programs. Having given my usual spiel I was then asked for our annual reports. Sheepishly I explained that we hadn’t yet turned 1, and that we therefore didn’t have any annual reports. It was a moment of a little embarrassment and a lot of pride, in that we really have come a long way in a relatively short time.

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And this is our team, or most of them anyway. These are the future leaders of health in Timor-Leste, and we’re proud to stand with them.

Running

You know you’re living in Timor when…

  • You convince yourself that you can judge the extent to which a tub of ice-cream has been pre-melted by rocking it from side to side, determining its centre of gravity.

  • You reach the point of accepting that the pale-coloured juvenile flour bugs (or weevils) that come in all your packet pasta, rice and flour probably don’t do you any harm, and resort to only scooping out the dark-coloured adults.
  • Driving becomes the ultimate multi-tasking activity, including texting, trying to clap mosquitoes between your hands, and occasionally watching the road.
  • Your internet-based phone-calls consist mostly of both parties repeatedly exchanging distorted and delayed enquiries of “Hello? Hello?”
  • Your alarm clock is the neighbour who pumps out ‘Despacito‘ (Timor’s surrogate national anthem) on his subwoofers every morning.
  • You see motorcyclists routinely cruising the pitch-dark streets without headlights, apparently ‘saving fuel’.IMG_9160
  • The closest thing you can get to a circus is your own backyard, and the best cricket ground you can find is a 10m stretch of beach…IMG_9065

Timor-Leste is hard to visualise without being here. We’ve lived here two years and have still seen so little of it. Last week we had a public holiday and attempted a rare road-trip into the mountains. Our goal was Aileu, only 20km away as the crow flies. The trip there took 90 minutes, on the good road. The return trip on the old road took more than two hours. Even at that speed, Annika got car-sick enough to bring up lunch.

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Annika’s face says it best. Awesome road-trip.  

We are so used to Timor now that we have stopped noticing how the people around us live. Well, almost. But when you try to see it again with fresh eyes, you realise how different our worlds really are.

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It’s hard to imagine the challenges of living up in these remote parts of Timor, as most of the population do. Below is a map of the country with the profiles of the new Family Medicine doctors we’re training. As you can see they literally come from all over the country:

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Some of them work in the larger Community Health Centres (CHCs), while others are based in Health Posts. Your average CHC in the districts might have four or five doctors and a cohort of nurses and midwives. They can do some very basic tests and have a very limited list of available medications. They may be 1-2 hours by road from a larger centre, or up to five hours from one of Timor’s few hospitals. If a woman needs a Caesarean section or someone needs emergency surgery, that’s how far they may need to go… on those same painful roads that claimed Annika’s stomach contents.

As for Health Posts, they are equipped with much less. One of our trainees works as a doctor in a Health Post with no nurse, no midwife… just him. He has no diagnostic tests nor even basic medical equipment. There is no oxygen. Quite often there is no power nor running water. He has a handful of medicines at his disposal. During the dry season, the nearest CHC is 60 minutes away, but during the wet season he can’t get patients out at all. So he has to deal with whatever arises in his community of around 800 people on his own. Geographically speaking he is 60km from Dili, but he might as well be on another planet.

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This is why we want to help train Timorese doctors, help support them in their isolation, and help supply them with basic equipment. You might remember our Doctor’s Bag project: setting up Timorese doctors with basic equipment and diagnostics that they need to practice independently. It’s something we hope to expand into the future. And, as always, we continue to partner with the Ministry of Health, who year-by-year are lifting the standards of the facilities and services being provided.

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The whole gang, after the climb up to Cristo Rei

If you’ve ever seen greyhound racing then you’ll know that those svelte, wiry hounds chase a mechanical rabbit around the track, luring them forward. The bait is always close but never quite within reach. It’s a fairly accurate metaphor for my life here in Timor-Leste these past 12 months. Except for the part about being svelte.

This time last year we were facing the shocking reality of having to leave Bairo Pite Clinic behind and start out with something new. It was overwhelming, and the first time that such a course of action was suggested to me it seemed genuinely impossible and not even worth attempting. But as our options narrowed and it became the only reasonable way forward we had to earnestly examine what such a process would ask of us.

The advice we received was complex but it gave us assurance that within a few months we could have everything back up and running, with all our registrations and licences back in place. We would then have the ability to rebuild a team and carry on. It gave us enough hope to put one foot in front of the other, and push through those really tough months at the end of 2017. But what we’d been told simply wasn’t true. Those months passed and the same registrations and licences we needed remained out of reach.

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I’m a regular-yet-conspicuous feature at Ministry of Health meetings…

At the beginning of the year we were filled with new hope that our processes were almost complete, and that our all-important Memorandum of Understanding (MoU) with the Ministry of Health was imminent. There always just seemed to be one final step we were waiting on, and then it would be complete. Somehow that one last step always had three other steps built into it, and then another last step would appear after that one. Followed by another final hurdle. Followed by one more little thing. Which would need one other document, which we almost had. We could get it if we could just get a particular meeting with a particular person. But then… uh oh… that person is no longer the Minister. But there’ll be a new Minister soon, right? Maybe. Well, not yet. Soon. Just one more step…

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Today: Talking with Dr Rui Maria de Araujo – former Prime Minister and Health Minister – a meeting I’ve been hoping for since 2016

And so it carries on, nearing the end of August. We’re so close, but that mechanical rabbit is always a few steps out in front of us, and it just never quite comes within our grasp. So we run harder. It’s been infuriating and I’m learning to draw from a deep well of patience that I didn’t know I had.

But when I think about it, that’s the only way it could have been. If I had known, 12 months ago, that the mechanical rabbit was this damn fast I would never have set out to catch it in the first place. I don’t think we would have had the strength of conviction to launch Maluk Timor if we’d know it would be this hard. We needed the bait right in front of us at all times, to keep our hopes up when our strength was failing.

A journey of a thousand miles begins with a single step, they say, and the God I pursue often only allows me to see the next step in front of me just as my foot falls on the ground ahead. Looking back, I’m not sure it could have been any other way.

What if I had known, 12 months ago, that it would take this long? We might well have packed up and gone home, thinking it was all futile. What becomes of the nine programs we now run as Maluk Timor? What would it have meant for the Timorese doctors we graduated in Family Medicine in June of this year, or the ones we’re training now? What would have become of the 100 children with rheumatic heart disease who get their monthly penicillin through us, keeping their hearts from destruction? And that’s just two of the programs.

What would it have meant for our 40 staff, who are now growing as leaders in health in this country, and many of whom take an income home to their whole extended families? They have 30 or 40 years of their working life ahead of them – how much impact will they have in this country over that time?

I’m grateful for the mechanical rabbit – the MoU that has been dangled in front of us for 12 months and has kept us running hard. After all, the greyhound is never meant to catch the rabbit. He’s meant to run. It’s the pursuit that is actually the good, not the achievement of the goal itself. So we keep running, and it’s not been in vain. While chasing that MoU we’ve still managed to assemble a great team, get our programs running, and impact a lot of lives.

Today Bethany attended a major ceremony for of a friend of ours being ordained as a priest. It was a colourful mixture of Catholic worship and Timorese tradition.

Young and old, the people of Timor face enormous difficulties. We’re glad we’re here with them, running. I wonder what we’ll do if we ever actually catch that mechanical rabbit?