Parasites & Superheroes

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Bethany’s birthday

Bairo Pite Clinic only exists because of the generosity of strangers. Almost all of the funding for the clinic – approximately a million Australian dollars per year – comes from private donations from individuals and families who live outside of Timor Leste. Many of these people have visited the clinic, or volunteered in some way, but just as many have never even met a Timorese person and yet give anyway.

It’s humbling, working in such a place, knowing that the money we are spending has come to us from the pockets of willing private donors, rather than oblivious tax payers (though we’d happily accept their money too!). It adds to the sense of responsibility we feel in making sure that our money is being used well, as we really want the spending of it to reflect the spirit in which it was donated.

In recent months we’ve had some great new donated equipment arrive. In each case the equipment was new, and was specifically chosen with our particular needs in mind.

We’ve received a microscopy camera, which allows us to take high quality digital images of what we’re seeing through the lens. The pictures can be used in teaching and training, but also can be sent to specialists overseas for an immediate opinion. In a country with no practising haematologist, it’s a great thing to be able to send images of a possible leukaemia or an unusual anaemia and get a response from a consultant haematologist within hours. Free of charge.

We’ve also received a neonatal pulse oximeter for measuring oxygen levels in our newborns. This is an expensive, highly-specialised instrument that enables us to detect subtle changes in oxygenation that can help reveal congenital heart disease, and perhaps more importantly, early sepsis and respiratory infection. Early detection means early antibiotic treatment, and as I’ve seen in my own experience here, potentially a life saved.

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And we’ve received a brand new ultrasound machine. This is a state-of-the-art, portable model that we can use to image almost every part of the body. Performing an ultrasound costs us almost nothing, is non-invasive and harmless to the patient, and is therefore the perfect imaging tool for underdeveloped nations like Timor Leste.

Some of these donations were actually purchases we’ve been able to make with donated money. Last year one of these blog entries generated an enormous response (to the tune of about AUD$32,000). I’ve been holding off my announcement of exactly how that money is being spent, because I’m waiting for some of the building works to be completed (they’re happening now), but I’m very much looking forward to revealing the results. We’ve been able to make that money stretch a very long way. Thank you.

Sometimes the help we get comes in other forms. Through this blog we met a great family who have come to Timor from Western Australia, and they’ve helped us with a lot of practical things at the Clinic. A few weeks ago, when we were clearing a storeroom to make way for building works we’re doing, we had some forklift trouble. It was quite comical: the young operator of the rented forklift navigated it very carefully through a tight passageway at the clinic – a very busy thoroughfare – but when it came down to the fine maneuvering our assistant manager at the clinic (an experienced forklift operator himself) offered to take over. No sooner had he taken his seat at the controls when the engine over-revved dramatically and then conked out with a bang and a big plume of black smoke. Our Timorese assistant manager tried to look innocent, but we’d all seen it, and were laughing heartily at his obvious discomfort (not that he’d actually done anything wrong). The forklift was now stuck, completely obstructing a very busy passageway, mid-morning on a typically busy day.

Thankfully, our friends from WA were on hand and within minutes one of them had the forklift purring nicely, and the work resumed. I don’t know how long we would have been stuck there without him. Thanks Brian.

When we’re not clearing storerooms and fixing forklifts, we occasionally look after sick people. And when you come to somewhere like Timor you brace yourself for the full range of tropical diseases that might present themselves. What we hadn’t expected was an expat girl who came to us for help after honeymooning in the jungles of Central America. She had something living in her leg.

Sure enough, in a hole in near her shin there lived a nasty little flesh-eating maggot.

images-6These are not native to Timor, and she was suitably concerned that this maggot might indeed grow into a fly and introduce a new tropical disease (Timor is not really in need of any new ones). Plus, she didn’t like the feeling of it wriggling around under her skin. With some help from Google and YouTube, we worked out together that this was the larva of a botfly, and that to remove it we needed to first suffocate it with Vasoline under an occlusive dressing, and then try to remove it in one piece.

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Ever the eager surgeon, Bethany performed the honours with a pair of tweezers on our back verandah at home, and with a satsifying pop the suffocated larva was removed.

The other interesting creature we encountered recently was a little guy called Strongyloides. Strongyloides stercoralis is a roundworm that lives in the soil, penetrates the skin and finds its way to your small intestine. There it lays its eggs, which hatch into larvae, which are either excreted or burrow back into you again and reproduce further. They can ultimately migrate to other parts of your body, and really make a mess of things.

We had young man admitted to Bairo Pite Clinic with what looked like encephalitis. He was essentially comatose, and didn’t seem to improve with IV antibiotics, antivirals, nor anything else we tried. One of our doctors spotted an unusual, distinctive, migratory rash on the young man’s trunk. I don’t have the actual photo of our Timorese patient but this one is close enough.

This is called cutaneous larva currens, an inflammatory reaction to Strongyloides larvae moving through the skin. With this new information, the man was treated for Strongyloides hyper-infection – the worms must have been wandering around his brain – and then he steadily recovered. I say it again: have you dewormed yourself lately?

Not all the diseases we deal with are so exotic. Common things are common, they say, and we see things like asthma in Timor Leste too. That might not sound very frightening.

A man in his late twenties was brought in to Clinic early in the day, and was seen in our Treatment Room. Several of our doctors assessed him and commenced the usual salbutamol (Ventolin) nebulisers. I happened to walk into the Treatment Room looking for someone, and my eyes met his. And his eyes were scary.

They were wide-open, seemingly getting wider at the end of each one of his gasping breaths. He was sitting upright, his hands clutching the bed down near his thighs, and his arms were braced in rigid tension. He was using them to help him breathe. His whole body trembled with exertion as he fought the battle for each breath against the tightly constricted airways that simply wouldn’t allow the air in nor out. Soon my eyes were almost as wide as his.

I’ve seen a bit of asthma, but it’s been a while since I was the senior doctor in Emergency making the decisions about managing an acute asthma attack. I felt uncertain, and was getting anxious. We had done the basics, and he wasn’t responding. In fact, he seemed to be tiring. I was relieved when one of my colleagues with more recent Emergency experience in Australia came in to join me. I was very happy for him to take the lead. Together we discussed our options. We had given him most of the standard treatments – should we just wait and see if he can fight through it? Usually I’d be looking to transfer a critical patient like this to the National Hospital. Admittedly, their treatment of such a case wouldn’t necessarily be better than ours, but if such a patient dies on your hands it leaves you wondering whether they – the major hospital in the country – might not have been able to do something more.

But we knew this man from a previous asthma episode, and he had refused then to be transferred to the National Hospital under any circumstances. His brother had died there in the recent past, and there was no way he would agree to us sending him. He was our problem.

So, we added a magnesium sulfate infusion. That sometimes helps, as it relaxes your muscles a little, and we needed those tiny muscles that were squeezing his airways to relax their grip. The effect of the magnesium was visible, but not necessarily good. His muscles did relax, but that meant he was less able to fight for each breath with his chest and arms. After some minutes of this, with his respiratory effort dropping, he slumped back on the bed and his eyes rolled back. He stopped responding to us. When you see this happen, you know his carbon dioxide levels are climbing to almost fatal levels. High carbon dioxide levels act almost like a drug of sedation, which is bad news in someone who needs to be awake and fighting.

My colleagues and I looked anxiously at each other. As one of them said at the time, it was hard to tell if he was straining less because his airways were now relaxing, or whether he was just slipping away from us. We talked about the next step. Would we intubate him? We didn’t have the drugs we needed to make that effective. And in any case, once intubated there was nowhere we could send him that was able to adequately care for him. It wasn’t an option. We would have to wait it out.

And so we stood there, running serial nebulisers, and hoping that the various steroids and other medicines we’d given him would begin to take effect and turn things around. It wasn’t looking good. I continued praying silently. There was little else to be done. His family turned their eyes to us with pleading looks. They knew we had done all we could, but their eyes silently begged of us, “isn’t there something else you can do?”

And then, there was the hint of a change. He began to exert a little more energy in his breathing. Imperceptibly at first, but then more obviously, his respiratory effort began to improve. Over the minutes that followed, the heaving of his chest intensified, and soon he lifted his head from the upright bed and began to fix his gaze on his surroundings. Moments later he was murmuring some gasped responses to our questions. He was back. I’ve never seen an asthma case go so close to the brink, and yet even in Australia around 400 people a year die of acute asthma, many of them young adults who never saw it coming. I don’t know how many die in Timor Leste, but this is country where most can’t afford to buy “Ventolin” inhalers, and the type of inhaler we rely on in Australia to control severe asthma (“preventers”) are not available at all.

Meanwhile, on the home front, Bethany has been juggling car repairs, visiting tradesmen (to repair a series of household setbacks), and the usual bevy of sick children. The average young child suffers 6-10 viral illnesses per year. When you have four children, that’s about 30 viral illnesses per year, and with some of those lingering for up to two weeks, that means that most weeks of the year you’ve got at least one sick child. And that’s if you’re in Australia. I think we’ve used up quite a number of those thirty illnesses these past few months, as it seems like we’ve rolled from one into the next, and Bethany and I have often been dragged down with them. Micah has taken it a step further by developing a moderate pneumonia, though thankfully he’s now on the mend.

Somehow, amidst all that, Bethany has managed to kick off an exciting new training programme at the Clinic. Westmead Children’s Hospital (Sydney) runs an outstanding 12-month diploma of paediatrics for GPs and other non-specialists, and they have had the vision to invite doctors from countries such as Timor-Leste to enrol in the same course at around 2% of the price! Bethany has managed to get three of our Timorese doctors enrolled into this world-class diploma, and others in the Clinic are benefitting from the lectures as well.

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Bethany with five Timorese doctors (and two British medical students) gathered around my laptop, watching a lecture during lunch break

People who follow along with what we’re up to in Timor sometimes tell us that what we’re doing is “amazing”. Whilst we appreciate their encouragement, I can tell you it doesn’t often feel like that. If we ever run the risk of getting carried away with our own achievements there is plenty to bring us crashing back to earth again.

A couple of months ago I proudly launched my pilot for a new ‘patient-held medical record’ I designed. This little booklet, which I got printed in bulk in India and shipped over, has the potential to transform our primary care service.

Screen Shot 2017-05-07 at 3.47.57 PMWe have hopes it will be taken up (in some form or other) right across the nation. As I handed around the first shiny copies of the booklet, there were murmurings of approval, until someone politely pointed out a spelling mistake… in the main title… on the front cover.

I couldn’t believe it. I had asked several people to proofread it and no one had spotted it. Any sense of pride had been immediately replaced by fury and humiliation. Thankfully it’s only a pilot, and we only printed 500. When we eventually print tens of thousands I’ll make sure we get that straightened out!

Learning a foreign language is generally an experience of recurrent humiliation. A week or so ago I was attending an important function at the National Institute of Health, and as I strode purposefully from my car toward the entrance I felt confident. I am getting used to these kind of events, I thought, and I was well dressed, switched on, and ready to put my best foot forward. As I arrived near the entrance, a dignified Timorese man who I later discovered to be the Director of Cooperation smiled at me. I greeted him with an assertive “Botarde”, which means ‘Good afternoon’. It was 9 o’clock in the morning. I realised immediately but it was too late, I’d walked past him. My aura of confidence evaporated in an instant and I once again felt like a scared little boy on his first day at ‘the big school’. Yep, it keeps you humble.

Last week Bethany asked our three-year-old son, Micah, whether he would be ok to ‘look after’ Estela and Annika while she went out to the Clinic. He protested plaintively, “No! I can’t! I’m not a superhero! I can’t fly, and I don’t even have a cape. I’m not super!”

I think that’s how all of us feel, really. A lot is asked of us in this place, and most days we just don’t feel very super at all. Thankfully we’re not here on our own: we have so many others sharing this journey with us. Some of them live and work by our side here in Dili, but many others support us from a distance. We don’t feel like we’re doing this alone at all. And if you’ve read this far, then you must be one of those who has chosen to walk this road with us. Thank you – it means a lot.

 

 

 

 

The Telstra Lament

 

If you’ve followed this blog for a while you’ll know that Telstra and I don’t really get along. I needed a cathartic outlet to vent this frustration.
Enjoy ‘The Telstra Lament’ … a true story…
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Communication coverage in the country aint much fun.
By moving up to Geraldton the choice was down to one.
“Signing up to Telstra?” I asked in doubtful voice.
Their plans were bad, their fees were high… there was no other choice.
First there was the landline, the rates not of this earth.
For half a dozen local calls and two short calls to Perth,
Sixty bucks for every month the scoundrels made me pay.
We joined the hipster urbanites and gave that phone away.
Their internet was hopeless, in our distant country town.
Even checking email was enough to get you down.
Forget about your YouTube, and your streaming live TV,
We were back to playing checkers, sipping quiet cups of tea.
I once went on a holiday with wife and kids to France,
I switched off all the data, tucked the phone inside my pants.
I’d heard about this ‘Roaming’ and of all those giant fees
Incurred by foolish tourists using phones just as they please.
But travelling is littered with all kinds of sneaky traps
And I confess that once or twice I switched on Google Maps,
Then quickly switched it off again, just as I always planned.
We got back home to Geraldton: the phone bill was two grand!
And then last year I thought that Telstra lost its grip on me.
We moved up to East Timor, then we knew that we were free!
How foolish was that thought, though? It was such a simple blunder:
Forgetting that I need to keep my old Australian number.
And so I pay them every month, I know I can’t refuse –
More than thirty dollars for a phone that I don’t use.
But as we left for East Timor they gave us a farewell:
Five hundred dollars overcharged! Not happy, can you tell?!
With many calls and online chats I finally set it straight,
But then they did the same again, the problem won’t abate.
Looking through the FAQs I knew that I was stuck:
I couldn’t find my question there – there was no “What the flip?!”
My spirit now is broken and my head in hands is laid,
My phone-rage now abated, they say “Change it to pre-paid.”
But even that has not been quite as simple as you’d think –
Especially internationally – it’s driving me to drink.
Last week I spent two hours engaged with Telstra’s ‘Online Chat’.
I thought we’d almost got there but then things went very flat:
“I’m sorry sir…” the agent said (I felt my tension mount),
The next words almost killed me: “…but we can’t find your account.”
Two hours of painful wastage and yet all that I achieved
Was getting that much closer to an aneurysmal bleed.
And so I am defeated, nothing left to cry nor shout –
If only Timor Telecom would buy the mongrels out.

Terrapins of Timor

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Sometimes in life you reach a confronting threshold at which a sudden realisation casts into doubt everything you’ve ever believed about yourself: perhaps you’re a musician, but it suddenly dawns on you that you’re not that into music. Maybe you’re a pilot, but you discover that you’ don’t really love flying.

Or maybe you’re a doctor and you finally confront a longstanding, niggling doubt that you’re not really that captivated by… well… doctoring. Where would that leave you?

I guess the warning signs had been there all along. As a 17-year-old I chose Medicine without a clear purpose, mostly because it seemed like the sort of thing a high achieving private school student ought to do. At least it opened up a lot of possibilities, I thought. Then, three years into the degree, I was really unsure whether I wanted to carry on, so took a year off and ended up in self-imposed exile in Siberia for almost 6 months, trying to figure it all out.

Eventually finishing the degree but without complete conviction, I chose the rapid route to what I thought would give me maximum freedom and flexibility: procedural general practice. On that point at least, I was right – it enabled me to travel and to develop many interests outside of medicine. But I always suspected that somehow I just didn’t love medicine like my colleagues around me. For some of my colleagues, it’s all they live and breathe, and they just can’t get enough of it. In such company I always feel like a pretender.

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Dili – apologies to Isabel Nolasco (follow her at @nolasco_isabel)

 

And then I find myself here: running a hospital in Timor Leste. And, I love it. It captivates me in a way that clinical medicine never has. It challenges every part of me, and it draws out everything within me that I have to offer. It occupies my mind, day and night, such that I have to consciously turn my brain off to make sure I’m still in the moment with the people around me. For many doctors who come to Timor, it is the fascination of the clinical work that they find so compelling. But I’ve discovered that’s not me. Instead, I’m realising that what I love to do is to look for solutions to big picture problems. Treating a patient is all well and good for me, but I want to get further upstream.

There’s a fable about two men standing by a flowing river who hear screams coming from the waters. They look across and see a child, waving her arms frantically in desperation. The men dive in and swim after her and manage to pull her safely to shore, but moments later more screaming is heard. There are two more children bobbing along in the foaming current, and the men dive in again. Having saved them too, the men see more, and then more children being dragged along by the river’s flow. Going in a fourth and fifth time, the men drag as many to safety as they can, but one of the men eventually pulls himself up the riverbank and appears to run away from the scene. The remaining man, thinking he is being abandoned, calls out in anger, “Where are you going!?” The running man answers over his shoulder, “I’m going to go find out who or what is throwing all these kids into the river!”

I don’t share this story to suggest that what I’m setting out to do is more clever, or more important than providing medical care for the sick. I tell it to explain what I’m feeling, that I’ve found a sense of purpose in my work that appeals to my particular personality and temperament. It turns out I’m an ordinary clinician, but I have found a role that I seem to be able to do very well. Running a hospital, yes, but also chasing after the kinds of things that lead to people ending up in hospital in the first place.

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Dr Mat (UK) observing a scenario teaching session with three of our Timorese doctors

Even so, it is a strange feeling to discover that you’re a doctor who isn’t much into doctoring, in the conventional sense. Thankfully that realisation hasn’t left me empty, but rather has only come to light because of how full I feel now. Things are busy – very busy. We’re busy because, for a combination of reasons, the doors are opening up. Not just the doors actually: it feels like the whole ceiling and roof have lifted off and the daylight has come pouring in. We’re almost overwhelmed with the new opportunities being presented to us for constructive change. New partnerships with DFAT, the Royal Australian College of Surgeons, the Ministry of Health, the National Hospital, the Medical Association of Timor Leste, the Ministry of Social Solidarity, Global Fund… it goes on and on. New building projects, new volunteers, new possibilities, and faster than we could have dreamed. We’re having meetings and creating MoUs and developing plans and programs and policies… it’s a frenzy of activity. It might sound like death-by-bureaucracy, but these are actually long-awaiting strategic partnerships with very significant benefits for all involved.

In fact, it’s been a bit of a relief to escape for a week to Australia. I was getting a bit too much of a good thing. However, we packed up the family and were all set to fly to Darwin when our plans collapsed. We made it to the airport in plenty of time on the Saturday morning, relaxed and positive about the week ahead. The kids were absolutely pumped with the promise of a waterpark and a family dinner to celebrate my birthday, some shopping and other indulgences to look forward to. While queuing we were directed to another line at Check In. “Ahhh,” I thought, “they’ve taken sympathy on the family with the four little kids.” Except that the line we ended up in didn’t move. The line we had been in was moving nicely, people checking in and heading off through Immigration. We waited. No problem, we were relaxed enough. That is, until the medical students from our clinic who were lined up in front of us were split up, with one girl told, “You’re on standby. The flight is overbooked.” I felt bad for her, poor girl. Imagine getting bumped from the flight! I wondered if there was something I could do to help. Then the power in the airport went out, and all the Check In computers reset themselves, and then wouldn’t reconnect to the internet. The Boarding Time came and went, and we were still lined up at Check In. Fifteen minutes passed, with the clerk shrugging his shoulders. Nothing moved. I was starting to get concerned. The scheduled departure time had arrived, and we were still at Check In.

I’ll skip ahead over another 25 minutes of delay, confusion, negotiation, more confusion, a visit to the QANTAS office, and the eventual realisation that we were being bumped. The plane hadn’t taken off yet, but we were told, “There is no seat available.” I wondered why my full-fare purchase of our tickets two months earlier was now being considered more of a tentative expression of interest. I couldn’t even shrug it off as ‘a Timor thing’, because this was Airnorth, an Australian airline, who had overbooked the flight and were kicking us off. Bethany was furious. The kids were sobbing in disappointment. I put up a token argument, rightly suspecting that it would all be in vain. We had been bumped. At least the medical student made it on, as a result of us missing out.

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Me being dragged from the overbooked Airnorth flight

A good friend came to pick us up, and kindly took us back to her place to commiserate. So, having to now wait a day and half for the next flight, we decided to salvage the weekend as best we could. We did what any family in the midst of disappointment would do: we went tortoise hunting.

Micah calls them tortoises, and I would have done so too except I’ve since been educated to call them terrapins. They’re a kind of aquatic tortoise, having apparently come in from Japan during World War II. They live in the ponds and drains of Dili, but until now we hadn’t been able to find any. We had put the word out on Facebook, we had offered money to small children to find them for us, but we still had our custom-built terrapin enclosure with no terrapins. That was about to change.

Estela, our home help, had come up with a promising lead. We drove around Dili with Estela and our excited kids, picking up different members from Estela’s extended family and friends, who helped us locate a boy who knew a boy who knew about terrapins. With ten of us in the Pajero, we were led by the young boy to a low-lying part of Dili where farmers grow vegetable greens in shallow ponds, like rice paddies.

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With buckets in hand, Levi and then Bethany and Miriam carefully traversed the slippery dirt ridges between paddies to reach the family who knew about terrapins. I stayed back with Micah and Annika, watching as Levi fell in to the paddies several times, soaking himself in muddy water up to his chest. Undeterred, they carried on and made it to the other side. A long discussion ensued with the Timorese family, and yes, there were terrapins: many of them, living in the paddies, but evidently one can only find them at night. And so, after a long discourse, Bethany left the buckets and agreed on a plan for me to return at 8pm for the terrapins.

We had almost made it back to our home when Estela’s phone rang. The terrapin man had caught six of them in the twilight. I headed back and sure enough, by the time I arrived there were seven on offer. I paid them the agreed price of $20 for the four smallest ones, and triumphantly returned home. Levi declared it the best day ever, the highlight having been his falls into the rice paddies. A demoralising day had been salvaged.

The next morning, I was out the back of our house near the pool, and I saw something surprising. One of the terrapins was standing proudly on the stony path, looking right at me. He was understandably proud of himself: he had escaped the terrapin enclosure and he wanted me to know it. I raised the alarm, and used all my agility and cunning to recapture him. It turns out that turtles on land are not as evasive as TMNT would have us believe. A quick headcount back at the enclosure revealed that in fact all of the terrapins had escaped. At least that answered the question of how we would spend the morning. An additional level of timber was added to reinforce the enclosure, and three of the four terrapins were eventually recovered, one of them having made it part the way up a palm tree. The fourth reappeared in the enclosure a week or so later!

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Annika observing a small terrapin, before the Great Escape

And so, later that afternoon we tried our luck again with Airnorth, who this time graciously agreed to honour our booking. We arrived in Darwin. I was only staying momentarily, continuing on through to Melbourne for the World Congress of Public Health. Meanwhile, Bethany had a full week of appointments and shopping. Levi was due to have some more dental work, which turned into three appointments and another extraction, in the chair. We’re very proud of his resilience, especially as he knew what was coming this time and still bravely faced up to it. Micah, having recently developed a stutter like his old man, had a couple of speech therapy appointments.

And Bethany wrangled the kids through the wonders of several epic shopping trips (Kmart is almost like DisneyLand to our kids, given the lack of shopping in Timor), while at the other end of the country I tackled the big questions of global health.

Did you know that many of our superannuation and insurance funds invest our money in international shares, which very often include major tobacco companies? Yep, you too might be helping to finance some of the most malignant and predatory companies in the world, without even realising it. Tobacco will kill 1 billion people this century, and many of us are unwitting shareholders – collaborators if you will – in this horrific and deliberate destruction of human life. Check with your fund manager: is your portfolio tobacco-free?

Tobacco is infuriating. There is no one in the world who is helped by consuming tobacco products. This entire industry exists to profit from people destroying themselves. In Australia we’ve done well in getting smoking rates down, but smoking continues to rise in the majority world. More than half of Timorese adult males smoke. The tragic thing about this is we already know what is needed to reduce smoking and save lives – we know what works – and yet in many countries we’re almost powerless to enact those policies because Big Tobacco is way ahead of us, and has those governments all stitched up.

Such was the World Congress on Public Health: two thousand delegates from around the world pitting themselves against transnational companies and the vested interests of corrupt governments to promote equity and health. The irony for me personally, fighting off some serious man-flu, was that while I was sitting in my seat at this conference about the health of humankind my upper respiratory tract was producing enough highly infectious fluid to wipe out a whole refugee camp. I hope I’m not personally responsible for having propagated the next pandemic.

And so we are back to Dili to resume our work. Levi, as our eldest, has the most awareness of the contrast between life in Timor and life in Australia. Of course this contrast is very much exaggerated by the fact that when we get to Australia it’s usually Christmas, or holiday time, or catching up with family, or a chance to enjoy some shopping and some real playgrounds. I think he’s forgotten that people in Australia have to work, go to school, and do household chores as well. He sometimes remarks, “I sometimes wish I had an easy life.” Hah! We try to correct him on this ‘grass is greener’ moment of self-pity, but there’s no denying that life is different in Timor. After all, how many Australian kids get to fall into rice paddies in pursuit of a pet terrapin? One day he’ll romanticise his memory of magical childhood adventures in Dili… as he reclines on the psychotherapist’s couch, reflecting on his traumatic and deprived upbringing.

It’s always good to end with a bunny update: our first litter of rabbit kittens. I’m not much into pets, but when God was creating animals and he decided to go for something super-cute, He went with bunnies. He even decided to make their poo cute. I mean, if you were the artist for an animated kid’s TV show and you had to include a scene in featuring your adorable character taking a poop, you would draw their poop like bunny poop. Perfectly round, uniform, inoffensive little marbles. There it is – I’ve said it – the bunnies have won me over.

Plagues, Progress & Partnerships

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From a mountain top in Timor. Doesn’t look like much, especially after viewing my friend’s blog from the Himalayas… but it was very picturesque

You may have noticed in my previous blog a reference to “mysterious febrile illnesses” afflicting a number of our family at the time of writing. How little I knew…

 

You would think that as a couple of doctors we would be red-hot on diagnosing ourselves and our children accurately. Sadly, as with many doctors’ and nurses’ families, the reverse is often true. It took until Day 6 or 7, when the unmistakeable rash broke out, that we finally conceded. It was dengue.

It was ironic that we failed to recognised it, given the attention I paid to dengue in the last blog. However, we all got sick at once (one way or another) and it just didn’t make sense that we all had dengue simultaneously. We considered it often enough, but surely it was something else. We were hearing stories of ‘flu doing the rounds in Dili, but the symptoms never quite matched up with that. After 6 days of consecutive fevers, headaches, eye pain, general exhaustion and finally, the telltale rash… there was little doubt. Bethany phoned through to Paul the Embassy Doctor, very experienced in Asia, and as she described what each of us had been suffering he advised not to bother getting blood tests: we all had dengue, plain as day.

Bethany was the only one who really got sick with it. She was really laid low, and had the petechiae (from a falling platelet count) to prove it. I had fevers, headache and fatigue (and eventually the rash), but wasn’t nearly as unwell. The kids were even less afflicted, but it really affected our whole household profoundly. The fatigue was something extraordinary: we were pushing the kids into bed as early as we could so we could get to bed ourselves! And that was often after having slept during the day as well. I found myself even emotionally off balance. I was having difficulty describing to Bethany how I was feeling, and she took over and said she felt like she was pregnant (in an emotional sense only, thankfully), that is, tearful, unpredictably volatile, and vulnerable. That was as good a description as I could grasp: I felt like I was pregnant too. It was, as Enid Blyton’s The Faraway Tree series would say (which we’re reading with for the kids at the moment), most peculiar.

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Most peculiar: finding two pigs under your car after a day of work

It was a struggle to get through each day, and our evenings were wiped out with exhaustion. Slowly the fog cleared, but it took weeks. When the plague of dengue abated, it was quickly followed by the plague of croup, something our children have always been susceptible to. Ever since we missed a flight from New Zealand due to the 8-month-old Levi needing an ambulance in Christchurch, we have always kept steroid syrup on hand for such occasions, and on consecutive nights it was required for three of our children. And then there was the plague of gastroenteritis, which miserably coincided with the plague of failing household appliances, most notably our washing machine. A family bout of gastro and a broken washing machine is a truly hellish combination. Perhaps my greatest achievement of the last month was the urgent purchase of a new one: the old one can be repaired and sold later. This was no time for waiting on unreliable repairmen.

At last it seems that the plagues have cleared, though I’m hesitant to claim too much of a victory yet.

It has been a very busy and productive time for us, in spite of all of that. Bethany and I both undertook language intensives, which was pretty taxing given than they occurred during the dengue plague. My lessons involved a classroom of a single student, with 3-4 hour sessions of direct exchange with the language teacher. It just about killed me, but the payoff has been worth it. Bethany’s was a more sociable group, and although she’s the first to concede her difficulties as a language learner, she has taken some solid steps forward.

It’s been a time of great progress in our partnerships too. Finally, in the culmination of a five year process, I had the privilege of signing an MoU (Memorandum of Understanding) with the Ministry of Health, on behalf of Bairo Pite Clinic.

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Signing the MoU with the Vice-Minister. Taking credit for Fi’s work (seated next to me)

This is the realisation of an enormous amount of work – very little of it mine – and it opens the door for new cooperation with the government and other NGO’s.

In the same week we received a visit to the clinic from Jose Ramos Horta. You probably know the name: he is the guy who was sent out from Timor Leste in 1975 when the Indonesians invaded to be the voice of an abandoned people. He worked tirelessly in New York, Washington, and all over the world to raise the profile of Timor Leste and make known to the world what was happening under the Indonesians. He eventually returned in triumph, served as President, was shot in an assassination attempt and went within minutes of dying from blood loss before being resuscitated and transferred to Darwin ICU, after which he returned and declared his forgiveness of his assailants, and he ultimately won a Nobel Peace Prize. Not a bad CV, I guess. We only spent a short time with him at the clinic, but then he invited some of us to his home (and insisted I bring Bethany and the kids).

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Jose Ramos Horta, Fi Oakes (Clinic Manager) and the rest of us. Kids chose their own hats for the occasion.

We spent an extraordinary evening with him, some of his family and his pet deer, Bambi. It was a really special time and we felt so privileged to be there. He was particularly tender with the kids, who thankfully seemed to grasp the gravitas of the occasion and behaved even better than we could have hoped. Micah barely offered a yelp when he was bowled over and pawed at by the sizeable Bambi – it wouldn’t be polite to cry out at such a dignified occasion.

The very next day we had a breakthrough meeting with DFAT (Department of Foreign Affaris & Trade), and we seem to have crossed a bridge with some of the departments at the National Hospital too, opening up new possibilities for our work at the clinic. It’s felt like everything has started to click at once.

Meanwhile the kids have bounced back from illness and are loving school life. Levi and Miriam, Grade 2 & 1 respectively, have been learning about life cycles. Their teachers have been keen to introduce real examples of life cycles in action, and had no further to look that our own home, which is fast becoming Dili’s best attempt at a zoo. Our rabbit had ‘kits’, or kittens (yes, rabbits have kittens) last week, which has delighted all of our children but is also very timely for the school.

Our kids have worked with Bethany to create a habitat for a terrapin (something between a turtle & a tortoise), with a well-stocked fishpond included. Disappointingly we haven’t been able to locate a terrapin yet, in spite of offering to pay numerous groups of Timorese youngsters to find some for us (they live in some of the local drains… the terrapins, not the youngsters). Perhaps it’s a seasonal thing, but even the most confident of them came up empty. Hopefully we’ll have something to report back for the next blog.

Micah has joined the big class at his preprimary/playgroup. He developed a stutter quite suddenly some weeks back (before the move of class, if you’re wondering), which is not terribly surprising given the strong family history. I could barely get a word out as a Year 1. We’ll need to get on to it quickly. Still, it doesn’t stop him owning the house with his particular combination of affectionate charm, “I really missed you, Dad – I’m so glad to meet you!”, and belligerent tantrums, “That’s really naughty, Dad! You do that again I put you to your bedroom!”

Annika has been… how to say this knowing she might read it some day…  she’s been persistently curious in her exploration of other people’s personal items, and very expressive in the communication of her displeasure. In other words, she’s been a complete pain in the… well, you get the idea. IMG_5501Still, as much as we’ve found her more than a little wearing of late, that’s nothing compared to what our pets experience. She insists on picking them up and carrying them everywhere, often getting kicked or scratched during the process (she’s not yet developed optimal animal handling techniques). She’s relentless. We had to expedite the gifting of one poor kitten to our friends just to get her out of Annika’s clutches.

Impressively, and somewhat to our surprise, our kids don’t seem to be resenting being here in Timor, even though they know they miss out on a lot. They don’t beg us to go back to Australia, and they seem to be understanding why it is that we’re here. At evening prayers the other night Levi did not pray that we could all go back to Australia, but rather that more people would come from Australia to help the Timorese. It’s quite touching for us to hear.

I’ve at last had the opportunity to see a little more of what’s outside Dili. I went along on one of our project visits delivering penicillin injections to children with rheumatic heart disease (to prevent them from getting worse). I was just getting over dengue so didn’t mind the eight hours in the car – it was nice to just sit – even though the road was potted and muddy, and at times almost impassable. We went up to Letefoho (which translates approximately as ‘mountaintop’) the origin of some of the finest coffee in Timor. It is beautiful country as you might expect, with steep mountain slopes carpeted in thick greenery.

Most surprising was the response of the children receiving monthly injections (and these injections are known to be about as painful as any injections can be). There was not a tear, not a complaint, and plenty of mirth and playfulness on display. We hope this program will prevent these children – who already have severe valvular heart disease that threatens their journey to adulthood – from progressing into heart failure and a very premature death.

This condition, almost forgotten in Australia (though still commonly seen in remote areas and indigenous communities) is closely linked with poor living conditions, scabies and skin and throat infections. It is preventable, as the modern world has demonstrated, and yet in this country approximately 2% of children suffer from have severe disease. That’s around 10,000 kids, most of whom will never receive treatment and will die too soon. It’s an enormous problem.

A number of doctors closely connected with our clinic are trying to meet this challenge head on. One of them in particular, Dr Josh Francis, would probably achieve even more in the fight against rheumatic heart disease if he wasn’t kept busy working as our mule between Darwin and Dili.

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Dr Josh Francis – launching the Antibiotic Guidelines for Timor-Leste this week. Occasionally useful as a doctor when he’s not working as our courier. 

Many of the medical supplies we can’t access here in Dili are purchased online (often funded by donors – thank you, you know who you are) and shipped to the Francis’ address in Darwin. On our behalf they receive boxes of medical records, boxes of urine pots, as well as birthday presents for our kids, and all manner of other items. Then Josh and his wife Laura carry them in their luggage when they next visit Timor, which is thankfully pretty often. But even they hesitated when one of Bethany’s recent purchases arrived at their home last week, in a box labelled “Female Pelvis”. It was a perfectly innocent teaching tool, but quite possibly not the kind of thing you wanted to have to explain at Customs. Bethany is feeling like the decision not to purchase the model vulva was probably a good one.

IMG_5665Tomorrow is the Presidential Election here in Timor Leste, so most people have returned to their home districts to vote. Having fought hard for the right to vote for their own government, they take voting pretty seriously. I’m not sure how important actual policies are here – it seems to be more about your affiliation with a particular party – but it doesn’t seem that policy matters very much in any other election around the world either. So, we’ve had very visible campaigning going on in recent weeks, manifested in convoys of dump-trucks filled with flag-waving enthusiasts, and the roar of packs of motorbikes with reconfigured mufflers assaulting our ears. It seems the police got a bit fed up with these mobs, impounding 370 or so motorbikes last week on the grounds of their illegal mufflers. We’re very grateful for their intervention.

We’re also thankful that things have been comparatively peaceful. Peaceful elections are a fairly new concept in this nation, so we take nothing for granted, but there have been only minor skirmishes thus far. We hope it stays that way tomorrow.

Lastly, I want to pass on something shared with me by a friend (who worked most of last year with me at the clinic). She’s not usually one for warm fuzzes, and even apologised for the positivity of the message, but she couldn’t resist sending me this. IMG_5610

I didn’t know what Ikigai was – I had to Google it. I imagined it was a really great teppanyaki restaurant, but apparently it means something close to the French raison d’être (reason for living). I’m not going to get all philosophical about this – as a Christian I’ve got my own thoughts on how my life is centred – but it made me appreciate how fortunate I am to be right where I am, right now. Life for me right now pretty much ticks all the boxes. Spend a minute or two thinking about it. Have you found your ikigai? Want to come to Timor and find it?

 

 

 

Deflation & Expectation

img_8299As many of you know, we spent some weeks in Australia over the summer period. In theory this was at least partly for rest and recovery, but in reality we both worked a lot and didn’t take many days to rest at all. Even so, it was a recharge in many ways – catching up with family and enjoying the fine food that Australian supermarkets have to offer, and being relieved of the various demands that Timorese life exerts upon us.

Many of our friends and colleagues wanted to hear about what we had been doing, but we weren’t expecting people to act so surprised to hear we were going back. “You’re going back?! I thought you’d finished!”

For us to feel so surprised by that response probably shows something of where this journey has taken us. We see before us an enormous challenge and feel like we’ve barely begun. We don’t know how long this chapter of our lives will be, but I doubt the work will ever be ‘finished’.

To our surprise the kids were happy enough to be heading back to Dili, though the flights themselves are always a challenge. img_8166The youngest ones steadfastly resisted sleep, with Micah at one point reaching a point of drunken exhaustion. Late in the evening he resolutely sat bolt upright, refusing to rest back into his chair. Fed up with my insistence that he go to sleep, his bleary eyes stared me down and he pointed at me and bellowed like a man in the midst of spilling his final drink for the night, “YOU MUST… NOT… DO…. SILLY THINGS TO ME!” An instant later his eyelids collapsed under their own weight and he fell asleep where he was, still sitting up defiantly.

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Even Lego men have a tough time on their flights with low cost carriers

 

In hindsight we could have planned things better. One of my final appointments before leaving Australia was a delicate family-planning procedure, which all went splendidly until Day 4. It’s probable that hauling four kids and 175kg of luggage through three airports and enduring an overtired toddler bouncing on my lap during the flight wasn’t exactly in keeping with the doctor’s advice for rest and convalescence. After having my loins pulverised by my hefty youngest daughter I acquired a new appreciation for the value of postoperative icepacks. As they say when it rains during a cricket match, there were some unexpected delays in the resumption of play.

Having been gone five weeks, we found that the degenerative changes to Timor life were readily apparent. That’s the thing about Timor: new things only stay new for a few months, before they’re broken or looking much like everything else. The new traffic lights on the road to Bairo Pite Clinic, freshly installed late in 2016, now just flash orange incessantly, like the demented mind of a man who has lost all hope of a future. The tarpaulin I had covered our pool with is torn, and the new mosquito mesh we installed on some of the windows is already ripped. Levi’s rabbit has died inexplicably. Two of Levi’s best friends have had to suddenly leave the country suddenly. The emergency trolley I has set up in the Treatment Room at work in November already has many of its vital instruments missing. It is the deterioration of order that we see everywhere, but the Timorese version of it is very much accelerated.

img_5444Unfortunately Levi was subject to some deterioration of his own. Despite having had a good friend perform an informal dental check only days before we left Australia, on arrival back in Dili Levi was struck down with toothache and a surprising amount of bleeding that seemed to be coming from the tooth itself (actually from a hole in the tooth, as it turned out). It’s a long story, but Levi has been afflicted by a very unusual dental condition called internal resorption, which as the name suggests, results in one or more teeth mysteriously being reabsorbed from within. One of his premolars had become virtually a translucent eggshell, the pulp within eroding the dentine and through the enamel. He bravely endured the necessary dental extraction in the chair in a dental clinic in Dili, though I’m not sure he’ll be quite so agreeable when he realises that there’s a second one affected that also needs to come out!

We were also welcomed back to Dili by our arch nemesis, the Aedes mosquito. My Tropical Medicine training in Liverpool taught me how to recognise different mosquitos, which is critically important as they carry different diseases. Until now I’d only been catching Culex mosquitos in our house (which rarely spread Japanese encephalitis but are mostly just nuisance biters), but we have now begun to find a few Aedes, notable for their bright black and white markings.

Aedes potentially carry

  • Zika (which we think has arrived here, though no proof yet),
  • chikungunya (a virus similar to Ross River Virus)
  • DENGUE !

Dengue is a particular concern to us, especially having heard that the Ministry of Health has recorded seven times as many dengue cases in January 2017 compared with January 2016, with the hotspot recognised as our subdistrict within Dili. So we’ve redoubled our efforts in the mosquito wars, at least for the next few months until the peak season passes. As I write, three of our household have mysterious febrile illnesses, and sleep has been hard to find. For me, to pleasantly recall distant memories of what eight hours of uninterrupted sleep feels like is akin to remembering an historic town you visited in your early childhood: you imagine it must have felt great to have been there but you just can’t quite recall what that feeling was like.

These challenges were not the only cause for deflation on our return to Dili. My first task from a work point of view was to dial in for a crisis teleconference about how, to remain viable, we urgently needed to cut 10% of our operating expenses at the clinic. Such is the predicament of a donor-funded hospital: we treat as many as we can but that leaves us sailing very close to annihilation, on a month by month basis. At least I was able to bring some good news: the extraordinary generosity of our friends from home (and other readers of this blog!) has gone quite some way to alleviating the immediate threat, and has allowed us to plan some other expansions, repairs and purchases that would have otherwise been impossible. Thank you.

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First Aid Kits from Exmouth, WA

And so the work continues. A couple of weeks ago I saw a woman brought in to the clinic by worried friends. She had delivered a very underweight baby at home a week or so earlier, but the baby was feeding poorly and seemingly losing weight. When we saw the child he was around 1.5kg. Tragically this same woman had lost three previous children, all in early childhood, to what were probably very preventable conditions, such as diarrhoea. We held grave fears for this newest child, but almost more concern for the mother. She was emaciated, with paper-thin skin stretched over her cheek bones. She stared past me, with a glazed, wide-eyed expression of untold trauma that suggested she had almost no awareness of her predicament. We transferred her to the National Hospital, where her baby’s feeding could be better assisted, and as we suspected in our referral, she was diagnosed with tuberculosis. At least that is something we can treat, and perhaps she can make some kind of recovery.

I saw another man stagger into our treatment room, looking dreadfully unwell. Comparatively tall for a Timorese man, at his age of 24 he should have been fit and strong, with a smile from ear to ear. Instead he was pale and gaunt, his muscles wasted, and his belly swollen. He winced as he walked, each step appearing more painful than the last, and he struggled to ascend the examination bed. I held little hope for him, after four months of worsening abdominal pain, vomiting and weight loss. His abdomen was full of firm masses, and excess fluid. Whatever was killing him was well on track for success.

I saw him in our TB ward a week later. He was sitting up, smiling, and he’d been eating. We had treated him presumptively for abdominal tuberculosis, and been rewarded not only by his rapid improvement with medication, but also by a positive microbacterial result from 800ml of fluid we drained from his chest. He was confirmed as TB, and he was responding to treatment. The TB masses in his abdomen are melting away, and in time he will likely make a complete recovery.

Even though some aspects of returning to Dili were deflating, I have never been more buoyed about the task at hand. We’ve come back to a place we are now beginning to understand with a clear sense of what can be achieved, and a fair idea of how we need to go about it. We know the road ahead will be filled with setbacks and roadblocks, but being convinced that we’re at least heading in the right direction is a good place to start.

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Bethany’s crew: the midwives

At the clinic we’re sensing tremendous opportunity. We have alongside us a very good team of expat doctors, and a bright and enthusiastic cohort of Timorese doctors which I sense might include some of the future leaders of Timorese health. They are with us by choice, while they await their fate with the Ministry of Health, to which they are bonded. While they wait to be allocated a clinical placement, probably in an isolated village clinic in a distant district, they are hungry to learn and to grow. We are working as hard as we can to teach and train this group, so that when they leave us they will choose to practice a different brand of medicine.

Every doctor I’ve asked can think of someone who inspired and shaped them during their training: someone who stood out as different, someone who had mastered their craft, who related to patients and colleagues in an exceptional way, and who blazed a trail for something better than anyone else around them thought was possible. Every doctor can think of someone like that, someone who inspired them to want to be more than the doctor they were. I am challenging each of my expat staff at Bairo Pite Clinic to be that inspirational doctor who influences the way others around them will practice. We need to model to our Timorese colleagues what it is to be a doctor: not simply to respond to a symptom with a medication, but to advocate for a patient’s wellbeing – even the wellbeing of a whole community – and to be prepared to fight to see things improve. We don’t just treat the illness in the patient in front of us: we strive to find the cause of that illness to protect others from it, we chase the ones in the community who aren’t seeking our help, and we raise our voice against the injustice and oppression that underpins so much of human disease.

We’ve been joined in this cause by some friends of old: Jonathan & Caroline Morling have moved to Dili from Derby, WA. Caroline is teaching at the international school, and Dr Jonathan is getting involved in the clinic, particularly in the maternity unit, alongside Bethany. There is much to do there, and it’s a great encouragement to have our friends with us.

And so, far from being finished, we launch out on a new year with high hopes. We’re in good spirits too, after a fun weekend. Saturday involved getting a couple of new rabbits from Hera and checking in on the legendary Branca (Brazilian midwife who has been working here about 17 years), and Sunday afternoon we held our own informal sports festival.

Bethany had heard about a grassy area in the backblocks of Dili, and when we found it late on a sunny afternoon there were just a few bored kids sitting on it. Out hop the glowing blonde heads of the Beckett kids, with a few balls, a small beanbag, a kite and one of those whistling throwing-rockets, and Timorese kids started emerging from everywhere. Within minutes we were amidst a great horde of laughing and running children, who delighted in the unexpected arrival of the circus. We played until dusk, with sweat pouring down our faces, and our parting gift was to pump up their old soccer ball which precipitated a lively village game of soccer. I was very proud of our kids, who threw themselves into the maelstrom, and also of the Timorese kids who played with us so enthusiastically and yet respectfully, and who were very careful to return to us all of our balls and toys as we left. We shall return…

Lessons from the Cowardly Lion

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Phase 1 of cubby house development. Phase 3 is now complete.

My last post – on malnutrition – garnered far more attention than I had anticipated, and the swelling tide of enthusiasm has propelled Timor-Leste from 4th hungriest nation (on the Global Hunger Index) up to 9th hungriest nation in the 2016 report. Well done!

 

(Though I suppose some credit should be shared with the Timorese government, dozens of NGO agencies, and the Timorese people themselves).

The financial response outstripped anything that I had even dared hope for, so I now have the job of developing a sound plan for how best to spend that money in accordance with the sentiment in which it was donated. This needs to be worked out in conjunction  with the Bairo Pite Clinic governance structures and the staff themselves, so may take some time, but I’ll be sure to let you know the result when I have something definite to report. Thank you for your generosity.

On to other things…

The dust is now settling on what was a morbidly compelling US Presidential race. Following it closely has been a fascinating journey into the deeper, darker places of the human soul, where the murky forces that drive our behaviours are unmasked. Brilliant commentaries have been written in recent months exploring these things, so I’ll not venture there myself, except to say that it got me thinking about fear and the effect it has upon us.

I don’t think we can distil down the causes of what happened on November 8 to a single concept, but I feel very strongly that – like Brexit – the result was at least somewhat influenced by fear. Australian politics is most definitely not exempt from this, and we’ve seen both sides of politics using fear and scaremongering as potent instruments for driving voter behaviour.

But this is not a political blog, so what’s all this got to do with Timor-Leste? For me, everything, because fear is an everyday reality here.

In this last week we’ve had two violent deaths in our neighbourhood. The first was a casualty caused by something called ‘rama ambon’. Rama ambon is a homemade weapon here in Timor used by street gangs and martial arts thugs. They take a length of rebar (the steel rods used to reinforce concrete), sharpen one end into an arrow tip, and attach something like shredded hessian to the other end.

It is then fired at close range out of a slingshot or crossbow device, usually into the chest of an unsuspecting victim. There have been quite a number of these attacks in our neighbourhood this year, and unfortunately this week there was another fatality. Then the following night there were predictable retaliations and another man was killed in street violence not far from where we live.

Don’t worry too much on our behalf: these attacks are thought to be gang-related, and typically occur in the dark of night (when we are at home, behind our big gate). There have been no reports of attacks against foreigners. But it does play on your mind…

There is fear in the street, and there is fear at work. This same week we had a devastating case in which we lost both mother and baby. I was very closely involved, as was Bethany, and it hit us both very hard, even though we doubt that anything we could have done would have changed the outcome. You still find yourself replaying the events in your mind, imagining all kinds of alternate scenarios that each begin with, “If only I had…” It’s futile, but you do it anyway. I was afraid, as I stood at the head of the bed and led our attempted rescue effort, and it’s a fear that – sadly – I know I’ll taste again.

You can let fear rule your life here, if you don’t resist it. We could avoid the beach for fear of crocodile attacks. We could lather ourselves in 80% DEET every night for fear of mosquito-borne diseases… dengue, malaria, chikungunya, Japanese encephalitis. We could refuse to drive for fear of the crazy traffic. We could bathe in bottled water for fear of diarrhoeal disease. We could run from the Timorese people themselves, for fear of the unknown. And that’s to say nothing of the fear of professional and financial ruin! The truth is, if we choose to live under these kinds of fears, we couldn’t be here. But does being here mean that we’re not afraid?

cowardly-lionMy kids still watch the 1939 version of The Wizard of Oz, on occasion, and you’ll recall a badly costumed character known as the Cowardly Lion. He feels he’s a miserable failure: he’s supposed to be the King but instead he’s wracked by his own fears and inadequacy. He’s hoping the Wizard can give him the gift of courage, and yet as the story unfolds, the Cowardly Lion is brave in many instances, in spite of his almost-paralysing fear.

I think I know the Cowardly Lion pretty well. I’m supposed to be leading my family, and now leading a whole clinic, bravely in the midst of ever-present danger. And yet much of the time I’m afraid, and at times I feel inadequate to handle the task before me. I’ve always had an anxious streak, and it’s never far beneath the surface. However, some years ago I had an epiphany about fear. I’m sure it’s nothing original – if I Google it I’ll no doubt find a million others who arrived at the same conclusion long before I did – but it feels good that I arrived at it before reading it somewhere else. I realised that in my life the decisions I regret the most are the ones that are based upon fear.

That’s not to say that I should always ignore my fear! I am afraid of walking the unlit streets at night here, and so I should be. There is no good reason to confront that fear and head out for a midnight stroll. Fear preserves us at times, and helps us preserve our kids.

But sometimes fear is what stops us doing what we know we should, or what we feel like just maybe we could. In my life, it’s most often been the fear of what other people might think, or perhaps a fear of failure. I am in contempt of myself when this takes hold of me, and have decided to try to live another way. For me, like the Cowardly Lion, courage is not the absence of fear, it’s choosing to act even though I’m afraid. As a Christian I trust in someone bigger than me who knows my fears, and who I believe strengthens me. And yet I stumble each day.

These were things Bethany and I both had to grapple with before we ever planned to come here. It was a plunge into the unknown: we both had to face quitting very good jobs, relocating our family from a great lifestyle in Geraldton and taking new roles that we had to invent as we went along. In a world that seems increasingly ruled by fear, it was a very conscious choice to do something counter-cultural. I’m not trying to make us out as heroes: we were as fearful as anyone. Acting against that fear was a conscious choice, and it’s that kind of choice we hope we can inspire our children to make in their own lives. I don’t want to have regrets at the end of my life, and if it does turn out to be true that the decisions I regret the most are the ones based upon fear, then I need to try to make sure there are as few of those decisions as possible.

To something a little lighter… the kids are going well. They have been ‘helping’ us build a few projects around the house and garden, including my water-tower cubby house (slowly evolving into a three-storey building with tin roof) and Bethany’s rabbit palace. ‘Hutch’ just doesn’t cover it really. Micah has started at what he calls “school” and is very proud of himself, and Annika is now a toddler with attitude.

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Bethany, having at last finished her assignments from her community development unit, now has the time and brain-space to get busy with teaching and training in the Maternity Unit at Bairo Pite Clinic. The Timorese staff are really appreciating having her there, and although she knows there is a huge task ahead, she seems to be really energised by the challenge. We’re looking forward to having a friend of ours – another doctor with obstetric skills – join the team in January. Together I think they’ll do great things.

I think now, after six months, we can really say we’ve landed in the right place. It’s feeling like both of us have a lot to offer here, and that the decision to commit years to the task was the right one. Nothing good happens in a hurry in Timor, and I think it really does take that long to do anything much of lasting value. Thanks for all your encouragement in sharing the journey with us.

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Handy shopping tip: if the car-boot is overflowing and you’ve no room left for your leafy greens, just let them ride on the car roof

 

 

 

Incomprehensible hunger

Whenever we take our well-covered, thick-set children out in public we are reminded anew of the stark contrast around us. “Isin boot!”, the locals remark in wonder, which means “big body”. As one who has spent altogether too much time lugging these hefty parcels of flesh around, I have to agree. But that’s not really what the locals are referring to.

malnut2-1Malnutrition is everywhere here. In fact, Timor-Leste ranks fourth in the world on the Global Hunger Index (2015). It’s easy to breeze past a statistic like that, but stop and think about that for a second. That puts Timor higher (worse) than Ethiopia, Sudan, Niger, Sierra Leone, Afghanistan and just about every other country you can think of.

What I find most troubling about that is not that Timor is only an hour’s flight from Darwin (which ought to be at least a little confronting), but that no one can fully explain why the problem is so bad here. Timor did have a recent war, on the back of decades of oppression, but things have been peaceful in recent years. Timor is mountainous, which makes growing staple foods on a mass scale quite challenging, but it is an extremely fertile country with decent rainfall. There should be no famine here. Timor is also a small nation – less than 1.5 million – so we’re not talking about an insurmountable mass of people to feed. There really should be enough food for this country to eat.

There has been recent research into this, but the answers that come up are many and varied, and so are difficult to address with a single strategy. If you’re interested, I’ve listed some of them in the box below.

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Some of the recent research points to Timor Leste having a rate of 58% stunting among children. Stunting means that because of poor nutrition these children will never reach the height they were genetically destined for. In September when I boarded the plane for Bali en route to Australia, I was surrounded by young Timorese men wearing a uniform. They were smiling a lot, and waving to a mass of onlookers who had gathered at the airport to see them off. I realised these lads must have been the national soccer team, and not one of them would have been up to my chin. Timor Leste currently holds the unenviable title of having the shortest men in the world, at an average of 160cm.timor-leste-football-squad

But stunting’s not so bad right? Good things come in small packages. Maybe. But the trouble is not so much the loss of physical size as the loss of brain function. We know that prolonged malnutrition in early childhood is associated with a significant drop in adult IQ, diminished life-long earning capacity, and probably an increase in antisocial and aggressive behaviour. So the problem is more than meets the eye.

At Bairo Pite Clinic we only see the tip of the iceberg. We know there are thousands of severely malnourished children out there (around 25,000 at any given time, it is thought), of whom perhaps a third to a half will die from the consequences of malnutrition. malnut1-1We only see the ones who are fortunate enough to make it our clinic. Usually they come in because of a concurrent illness, such as pneumonia or prolonged diarrhoea, and we measure their mid-upper-arm-circumference (MUAC).malnut3

Easy enough – if it’s less than 12.5cm (in children aged between 6 months and 5 years) then they have moderate malnutrition. If it’s less than 11.5cm they are severely malnourished. We admit between 15-30 children per month in this latter category – almost one a day – and see many more in the ‘moderate’ category. And we see MUACs down to less than 10.0cm.

The good news is that once they make it to Bairo Pite Clinic they very rarely go wrong. You’ve heard about some of the bad outcomes in my earlier blogs but thankfully they are the rare exceptions. Even though things can be pretty precarious the vast majority respond to our treatment and begin gaining weight rapidly, which is not the case everywhere in the world. We’re extremely proud of our malnutrition unit, managed by a team of Timorese healthcare workers: they are skilled and dedicated, and work closely with the parents of the children to ensure that the lessons learned at Bairo Pite follow the families back to their homes.

It’s one thing treating malnutrition, but we’d prefer to prevent it! We have a busy maternity unit, a big part of which is the bustling antenatal clinic which operates through a single consulting room. The midwives barely have time for the routine things like blood pressure checks and palpating the pregnant bellies, let alone taking time to educate the women on exclusive breastfeeding, when to introduce solids, healthy diets for children, and how to prevent diarrhoeal illnesses. We could be doing so much more.

My current headache is simply finding the space. With Bethany starting work in antenatal clinic, and a dedicated family planning midwife joining the team as well, we are building the human resources to slow the clinic down to spend more time with each woman, with increased education to be a part of that. What we don’t have is a second consulting room to facilitate this. I’ve been pacing around the clinic this week looking for cheap ways of throwing up another makeshift room so I can shift things around and make space for another antenatal room. The possible solutions don’t cost much: a few thousand could buy a converted shipping container (with air-conditioning) that could be placed onsite, or be enough for us to extend an existing structure to find the space we need. Ten thousand (USD) could probably get a couple of basic rooms up and running. But it’s all money that the clinic doesn’t have, and with so many demands on the budget already, my extra consulting room will have to wait. Unless someone out there fancies getting their name on a plaque somewhere?