Maluk Timor

July and August were tough, and September was a frantic time of transition. On 8th September we walked away from Bairo Pite Clinic, dismayed but not defeated. What followed was a disorientating few weeks of no-man’s-land. Theoretically I no longer had a job, which was odd, because I was busier than ever: there were all kinds of meetings and negotiations and evening Skype calls to Australia finalise the matters at Bairo Pite Clinic, and to try to quickly throw down a foundation for the new entity. We felt a tremendous sense of urgency: we desperately needed to get our new plan up and running so we could retain key staff, and to maintain momentum with the donors and supporters whom we hoped would stay with us.

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Meanwhile, Bethany hosted a CWA (Country Women’s Association) working group which included her parents and some friends from her home town of Badgingarra. They had made plans for doing some work at the clinic, but of course that was no longer an option. Bethany arranged a busy schedule of projects at three other sites, all of which are terrific organisations with whom we share a strong connection. In her inimitable style, Bethany planned three weeks’ worth of projects for a one week visit, and possibly failed to appreciate that some of the group were the wrong side of seventy… even the wrong side of eighty! In spite of their… ummm… vast life experience… they weathered the heat and produced some fantastic playground equipment, an enormous painted mural, a rain shelter, and a new concrete floor.

They managed all that in under week, and still found time for a number of life-threatening motorbike and motor vehicle accidents.

Bethany worked the week as a labourer: shovelling and concreting in tropical heat proved to be among the less favoured tasks for the group. Our kids also got a chance to get their hands… and heads… dirty.

Our planning and scheming for life after Bairo Pite Clinic continued, and culminated in a three day talk-fest in early October. The Australian Board of the organisation come to Dili twice a year for regular meetings, but this time the meetings were to be different. It was now the time to decide whether the organisation could continue on, and if so, in what direction, and with what funding? Naturally, we thoroughly ambushed them with an array of irresistible plans for the future, and won them all over.

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Channelling Winston Churchill to inspire the battered troops

Well, that’s how I like to think of it anyway. The reality of course was that most of these people have given far more, and have been committed far longer, than either of us. The  fact that they continue to give up four or five days and pay their own expenses to Dili twice a year is a clear indication of their willingness to carry on. Even so, it was pleasing how well the weekend went, and that by the end of it we had the framework for a revitalised organisation, to be called Maluk Timor.

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The word maluk (pronounced MAH-look… yes, I want you to say it out loud right now. Especially if you’re Australian, which means you’re linguistically-challenged. Your brain is going to prefer every other conceivable pronunciation aside from the actual correct one, so c’mon now, say it… MAH-look… emphasis on the first syllable) means something like family, kin, close friends, or ‘our people’. More importantly, it’s unique enough that if someone Googles us we should appear in the top ten hits. Apparently that’s all that matters.

I won’t spend the rest of the blog telling you what Maluk Timor is – you can check it out for yourself: www.maluktimor.org . Basically, it is carrying forward many of the strengths of Bairo Pite Clinic (programs for tuberculosis, HIV, malnutrition, rheumatic heart disease, women’s health and social care, medical education, etc) but refocussing them upon working side-by-side with the Timorese in their own government-run hospitals and clinics. I hate to oversimplify this complex vision, but it is along the lines of the overused cliche: “give a man a fish, you feed him for a day – teach a man to fish, and you feed him for a lifetime.” Except that our goal is more like ‘teaching a man how to teach other men to fish’, or better yet, teaching the women how to teach other women… Men just use fishing as excuse to drink beer and get away from their families for a few hours. If women went fishing they would actually bring home food.

I’m being a bit facetious. I really believe in the vision of what we’re doing. I had the opportunity a week or so back to fully explain it too, as the Ministry of Health asked us for a Five Year Strategic Plan for Maluk Timor. Our organisation was about three days old at that point… five years felt like a long way off. But, Bethany locked me away in an office for the best part of two days and when I stumbled out, dazed and disorientated by exhaustion and the blinding natural light, I was holding a 14,000 word document that ran into 52 pages. They won’t ask me for another one of them, I’m pretty sure.

So now we’re three weeks into it. We’ve got our great new headquarters, we’ve hired about 25 staff, and three of our seven major programs are running, with the others due to start in the coming months.

I’m apparently now the CEO. I’ll have to Google what a CEO is actually supposed to do. In my mind it means that I get to go to a lot of long lunches, employ an attractive secretary, and that I’ll eventually get sacked when the share price falls (and get paid out an enormous undisclosed sum).

Actually one of the early troubles has been financial – a cash flow issues. The separation from Bairo Pite Clinic was extremely costly, because we wanted to ensure that we fully honoured the staff’s redundancies and entitlements. The clinic barely survived on a. month-to-month basis as it was, as we spent every dollar we could on medicines and expanding our services. So the coffers were well and truly emptied – and then some – in finalising the financial obligations of the clinic. Maluk Timor was starting from zero.

However, our supporters have been extraordinarily faithful. I think they recognise that we are the same team that achieved so much over the last six years at Bairo Pite Clinic, and that the new trajectory offers possibilities of having an even wider impact in a country that remains very much in need.

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One key donation we were waiting on, to balance the books for our first quarter, was a tentative $30,000 pledge from a guy I had met just once. It was many months ago: I was asked to come in to the clinic on a hot Saturday afternoon to show a group of visitors around, and tell them about what we do. They were late. I was sitting in the heat, waiting for them, feeling well and truly irritated. But the group turned out to be very interested in our work, and we spent an hour or so in discussion about the health needs of Timor, and the many challenges facing the clinic. When I had finished, one of the group stayed back to chat, and introduced himself. I was looking forward to heading home, but we talked a short while. He told me that he donated $30,000 each year to a particular United Nations fund. I nodded. “But I hate those b*stards,” he said. I cocked my head and looked at him – now he had my attention! He went on to indicate that he might be willing to send that money our way. That was as good as a promise to me.

But I didn’t got the chance to follow him up. He was traveling and uncontactable for several weeks, and by the time he was back, things at Bairo Pite were so uncertain I didn’t feel that I could ask anyone for anything. But now, with Maluk Timor, it was time to try to make my pitch.

I gave it my best shot. I sent him a warm and enthusiastic email, an introduction about Maluk Timor, and even my 52 page plan. I wanted him to know we were serious and legitimate. A week went past and there was no response. I thought back to the Board meetings earlier in the month, and how the finances for our first three months pretty much depended on whether or not this $30,000 donation (that I’d told them about) would come through. Failing that, we would run out of money.

Then, trawling through my junkmail, I found his response! He had read my plan, he’d looked over all of it. But he wasn’t that impressed. He explained that it didn’t really address the key clinical areas that he was really passionate about.

He said he’d give the money anyway! A most remarkable fellow…

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Some of our Family Medicine trainees, deep in thought

And so we have the office, the staff, the Strategic Plan and now the money… the last missing piece is the approval of the Ministry of Health. So my attention is sharply focussed on winning exactly that. In one sense, it shouldn’t be difficult. They know who we are, they know our track record, and they know we have a lot of offer. If anything, our new vision is much more closely aligned with their own priorities than our former one. We just need to get an MoU (Memorandum of Understanding) signed and we’re in business. But there’s good news and bad news…

Bad news: It took us 5 years to get an MoU with Bairo Pite Clinic.

Good news: The new Minister of Health, former Prime Minister Dr Rui de Araujo, is a man of action who has been signing MoUs with other NGOs almost every day. We think it could happen very quickly for us this time around.

Bad news: He may not be Minister of Health for very much longer.

The Timorese Parliament is teetering on the brink of collapse. It’s a long story, but in short, the minority government elected in July has been unable to win support for its major program. This went very close to triggering a collapse of the government a week ago, but the Parliament has held it together and will carry on into November or December, and try to pass the program again. If it fails again, the President will most likely call for new elections, which won’t be until next year. There could be civil unrest, and there could be violence: last Friday people started leaving Dili in droves, and the price of rice in some places more than doubled in anticipation of possible conflict, but the resumption of Parliament has seemingly settled everything for now. Most people think it won’t be violent, but a dissolution of Parliament would certainly get in the way of  us getting an MoU signed. So again, we feel a tremendous sense of urgency…

However, the faster you try to work the more irritated you are by interruptions and setbacks. And they come in all shapes and sizes. One of the many from last week was at least an interesting one.

Bethany has been ordering a lot of medical equipment to help furnish the Timorese doctors with a basic medical kit. After all, it’s only so much use training them to be good doctors when they can’t access the simplest things, be it thermometers, blood glucose tests, or pulse oximetry. The pulse oximeter is that little peg that goes on your finger and measures the oxygen level in your blood. It’s a pretty useful piece of kit. But, as we found out, it is replaceable:

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We were not entirely pleased to hear that we were being sent $252 worth of snake repellers, as useful as they may prove to be.

Thankfully it turned out to be some kind of technical error, and the oximeters arrived after all… but no snake repellers, so we’ll have to be more vigilant than ever.

 

 

 

 

 

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Upstream causes

I wrote this some time ago, after seeing a very sad case at Bairo Pite Clinic. Some of the patient details have been changed to preserve confidentiality.

I was working in our Treatment Room when a three-month-old boy was brought in looking very unwell. He was panting for breath, but otherwise floppy, and his open eyes stared unblinkingly at the ceiling above. His lips were dry and cracked, like someone who had staggered through a desert for days, and his tongue was like sandpaper. Unsurprisingly the first clinical information that surfaced was a recent history of fever and diarrhoea.  

Diarrhoeal disease is still the second highest cause of death under the age of five in the world, and yet these deaths are almost completely preventable. Access to clean drinking water is a big part of it, but even without that, diarrhoea shouldn’t kill children. ORS (oral rehydration solution), which can be easily made up in the home using boiled water, sugar and salt, is a cheap and life-saving treatment. Even cholera can be managed very effectively using ORS.

Obviously not everyone knows about ORS, and so we continue to see children in this condition. We have so much more to do.

This child was severely dehydrated, and close to death. Our nurses and Timorese doctors worked busily to record vital signs and to establish IV access. Getting an IV cannula into a 3-month-old infant is never easy, and this becomes all the more difficult when the veins are flat from dehydration. After two failed attempts in the first few minutes, we moved on to intraosseous access, a strong needle that can be pushed into the bone. Through this needle we were able to give fluids and glucose. The glucose was needed because the blood sugar was 0.7mmol/L. Anyone familiar with normal blood sugar levels (usually above 3.5mmol) will recognise that this number is frightening low, and often associated with seizures, coma or worse. 

We were getting more history from the family while this was going on. The baby had been born at home, and hadn’t been brought in for his immunisations. 

Being born at home in a country like Timor-Leste is not a good start to life. Very few Timorese homes are fit for safe and clean delivery, and most delivering mothers will not be supported by anyone who could be described as a skilled birth attendant. It is thought that as many as two thirds of neonatal deaths could be prevented by delivering babies in health facilities with a skilled birth attendant present.

Why would this mother choose to deliver at home? It’s easy for us to criticise her in this decision, but there are many reasons why this could be so, and most of them are out of her hands. Perhaps her husband or another respected family member opposed any plan to attend a health facility. Sometimes those beliefs are based on tradition or superstition, but in other instances they are grounded in the experiences of friends or family. She might have had a family member die or lose a baby in the nearest clinic, and now be fearful of the dreaded Pontiana, an evil spirit who steals the babies away from pregnant women. Or perhaps a friend or family member was treated very badly there: it’s not uncommon for women to be slapped or berated while birthing in Timor-Leste.

Perhaps she had no means: no transport, no money, no one to care for her other children? Women in this country are largely at the mercy of their circumstances, and often not in control of the resources and decisions that so greatly affect their lives. Or perhaps, like my own wife, she simply didn’t make it to the hospital in time! We don’t know, but part of our mission here has to be to improve access for women who want to deliver in a health facility.

Immunisations save lives, and by missing immunisations this baby was going to be more vulnerable to life-threatening infection. Why was the baby not immunised? In our context we would look squarely at the mother, who (usually in discussion with her partner) tends to make the decision. In Timor-Leste, things couldn’t be more different. A mother has little say in such decisions: it will often be her partner, or their own parents – even their grandparents – who will have their say in this. Any number of fears, traditions or superstitions about this mysterious medicine could have swayed one of the family to oppose the immunisations – we have enough trouble with that in our own countries.

The blood sugar improved, and the IV fluid was steadily syringed in through the bone in the baby’s lower leg. The child didn’t look noticeably better. A first dose of IV antibiotic was given, as overwhelming infection is often present in a child with fever and severe dehydration. Having given initial resuscitation, we then prepared the ambulance for transfer to the National Hospital, just ten minutes away. Tears rolled down his mother’s face as she told us more: the baby was not breastfed, instead receiving baby formula. 

Breastfeeding is the best nutritional start to life, as we all know, and offers some protection against early childhood infections. It also helps prevent diarrhoea, because the child is not drinking water, which may be contaminated. Why wasn’t this baby breastfed? In the rush of the transfer, we never found out. In any case, in that moment we didn’t want to seem like we were interrogating or blaming the mother for something that was very likely not her fault. Sometimes formula feeding is a status symbol (it denotes affluence), but I doubt very much that was the reason in this case. More likely there was simply a difficulty with attachment, sucking or her milk supply, and at some point she had to resort to formula feeding. Whatever it was, in this baby it was a devastating setback.

In the days following the baby’s transfer we heard back from our colleague at the National Hospital: the baby was alive but doing very poorly. He was exhibiting signs of serious neurological injury, with spasticity of his limbs. He was not expected to make a full recovery. This brain injury was probably due to the combination of severe dehydration, profound hypoglycaemia, and perhaps most importantly, a high serum sodium level of 179mmol/L (normal is under 150mmol/L).

Why such a high sodium level? The mother – perhaps unable to read the Indonesian instructions – had misunderstood the formula mixing: instead of adding 1 scoop of formula to 30ml of water, she had been using 4 scoops with 40ml. The sodium load was much too high, and when combined with a diarrhoeal illness, the baby’s sodium levels went through the roof.

This is a devastating story of gender disadvantage. In our home countries, a mother with this kind of story would be heavily criticised for such an outcome, but such a criticism can only be levelled in place where mothers are empowered to make decisions for the care of their children. In Timor-Leste that cannot be assumed. We will make every effort to build the health system here, but until women are respected and empowered enough to access that healthcare on behalf of their families, our progress will be slow.

Thankfully this dynamic is well-recognised, and there is a lot of energy and funding going toward the empowerment of women in the village communities of this country. The fifth Sustainable Development Goal (SDG) is gender equality, including an end to violence against women (domestic violence rates in Timor Leste are approximately 70%), and we will do all that we can to move toward that goal.

IMG_7092One of our key programs – back at Bairo Pite Clinic, and carrying on with Maluk Timor – is our Women’s Health and Social Care program. Led by dynamic young Timorese women, this includes community education and empowerment, crisis care for gender-based violence, and postnatal care and home visits for vulnerable women. They are taking this work out to the districts of Timor-Leste, meeting with groups of women who are hearing about their rights and opportunities for the very first time, as well as gaining information about and access to health services they’ve never had before.

So many of the medical problems we see here have complex upstream causes, and medical answers alone are not enough.

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Our team visiting a group of women on Atauro Island

Endings and Beginnings

 

Shall we begin with the elephant in the room? There’s no getting away from the fact that the turmoil at Bairo Pite Clinic has dominated every aspect of our life these past couple of months. The calm before the storm – my last post – was my cryptic reference to what we knew would be difficult times.

 

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HOWZAT?!  Timor’s first President (and occasional cricket umpire), Francisco Xavier do Amaral, gives his decision on the Bairo Pite Clinic situation. 

If you’ve not heard, the Australian organisation that has provided the funding and governance for Bairo Pite Clinic these past six years has chosen to withdraw that support from the clinic, and I am now in my final week as Medical Director. This blog is obviously not the appropriate forum to go into the details of that, but I think there are a couple things I can say fairly safely:

The first is that this withdrawal is the absolute last resort in a protracted process that has unfolded over the past five months, involving extensive consultation, exploration of alternative solutions, attempts at mediation with key parties and more handwringing and soul-searching than you would believe. You will have to read between the lines and draw your own conclusions as to why we felt we could go no further, but please understand that it was a heartbreaking decision that was reached for lack of other viable alternatives.

The second is that every effort is being made to ensure the patients and programs of the clinic are being transitioned safely and appropriately, and that the clinic staff are being taken care of.

The third is that the clinic itself will carry on in some form without us, with Dr Daniel Murphy (the clinic founder, with whom the Australian Board has fallen out) determined to continue his practice. And the fourth (and final) is that we intend to carry on ourselves – Bethany and I, but also the organisation behind Bairo Pite Clinic – in a new project which is rapidly taking shape. This project will carry on many of the strongest areas of our work at Bairo Pite Clinic, with even greater focus upon developing Timorese leaders within their respective fields in health so they can train and develop their colleagues around them.

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Tuberculosis of the spine in a 10yo boy (it’s a side-on Xray, with his spine on the left, and his chin up the top right). There’s more work to do here in Timor-Leste. 

So it’s been a torrid couple of months. The action began an hour or so after landing back in Dili in mid-July, with the first of many critical meetings with Dr Dan, and it hasn’t really let up since.

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What to make of this? Coming back to my desk to find a model skull, split open with brains spilled out… what was I to think?

It’s been an uninterrupted flurry of meetings – in person and on Skype – and it’s been with us every minute of every day. I’ve been waking in the early hours of the morning, unable to get back to sleep, running the different strategies and plans through my mind searching for a clear path through the troubles. We’ve had media invasions of the clinic, and I’ve had to give TV and radio interviews in Tetun (with help). We’ve had confrontations and conflict – the details of which are best left off this blog – and at times concerns for our own safety. Ultimately we have come to the final stages of this turmoil with a sense that we’ve done all that we could have done to resolve this, that we’ve managed to diffuse a volatile situation, and lay a foundation for a bright future. But we’re not quite out of the woods yet.

While things at work have been tough, we’ve had plenty of sideshow events in our life to keep us occupied. In fact, more so than our usual diet of car problems, scrambling for visas, and fending off childhood illnesses (we’ve had all of those too, just as usual).

One notable event was a cunning move by our youngest, Annika, who recently turned two. I’m blaming it on the breakfast cereal famine. We have ongoing problems here in Dili finding edible breakfast cereal, as the Indonesian sugar puffs that masquerade under all kinds of different brands just don’t cut it. The only good cereals have to be brought in from Australia, and we’ve been stocked out.

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Don’t let the smiles deceive you – the breakfast cereal famine is taking its toll

Sensing that an international shopping expedition was overdue, Annika climbed on to our kitchen bench, got the child-safe lid off a large bottle of paracetamol syrup, and took a long draught. Or so we thought – hard to know for sure. She admitted to having drunk some, and the bottle was mostly empty, so what were we to think? Bethany assaulted her in all kinds of unspeakable ways to induce vomiting, with mixed success. I phoned a couple of paediatrician friends to make sure we weren’t overreacting, and then we began booking flights.

The trouble with paracetamol is that it can kill you. Silently at first, and then slowly, over a few days or a week, through fulminant liver failure. In Australia, as long as the overdose is recognised it can be easily assessed and treated: a serum paracetamol level, and if the result is dangerously high, then an intravenous antidote that protects the liver from harm. Not so in Dili, where neither the test nor the treatment are available. So, we booked Annika and Bethany on a little overnighter to Darwin.

As we stood at Check In an hour or so later, relieved to have found a flight at very short notice, I looked at Annika: she was perky and cheeky, looking completely well.

“I hope she doesn’t vomit on you on the plane,” I remarked to Bethany. Not five seconds later she put that doubt to rest by vomiting all over the airport floor. Never mind: Dili Airport is the kind of place in which you just wander through a few forbidden doors as though you’re entitled to be there, find your own mop out near the baggage handlers, and then walk back in and clean it up yourself. No harm done, and no vomiting on the subsequent flight.

Annika and Bethany, waiting to board at Dili Airport. Both looking forward to restocking on Cheerios. 

Thanks to our friends in Darwin, it was all relatively painless. Annika took the two IV cannulations in good spirit, seeming to appreciate that she had brought this disaster upon herself. The serum level was, of course, undetectable, so she was cleared for a return home. She got her way: the breakfast cereal supplies were replenished.

A few nights later, we were visiting friends to discuss our new plans for transition. In the inky darkness of the Dili streetscape, we slowly pulled into their ‘street’: a pretty generous description of the rocky track winding its way up a steep hill. Suddenly a young guy on a motorbike came hurtling out of the night and ploughed into the front of our almost stationary Pajero. He went flying into the gutter, lacerating his face, and almost destroying his motorbike. Shocked, we got out to face the gathering crowd of neighbours.

IMG_6597There’s a simple system for sorting out these matters in Dili: the foreigner is always at fault. I’m not sure that’s how the actual legislation reads, and I’m also inclined to think that some responsibility should be borne by an intoxicated rider running into an almost stationary car the size of a Timorese house, but nonetheless the rule on the street seems pretty clear: it was on us. Our friend – a nurse with fluent Tetun – helped patch him up, and we later made arrangements for the bike to be repaired. Even that is quite a process of negotiation which is best handled between the Timorese rather than by us, so our friend Alico took over as our delegate. Our Pajero took the blow manfully and needs only a tiny touch up. We’re just very relieved that he didn’t sustain serious injuries.

These events served as pleasant distractions during our troubles at the clinic: things have a way of sorting themselves out for the best in this place. Let me give you another example: a week or so back, we had the opportunity to buy another car (being offloaded at a very good price by a friend leaving the country), but the downside was not having any more space in our driveway in which to park it. I didn’t really want to leave it out on the street. This problem sorted itself out too: on the same day we were taking possession of the car, there was a communication breakdown at the petrol station and the attendant filled my RAV4 with diesel. Not realising she had done so, I duly started the car, and put it out of action for the foreseeable future and getting it towed to the mechanic for a complete flush out. Our parking congestion problems were solved!

In reality, with relentless stress and poor sleep, and with some of these additional nuisances to add to our pain, I would have to admit it’s been one of the most difficult times in our lives. And made worse by the revelation, in the same week as many of these other dramas, of a cancer diagnosis in a very close relative.

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Parenting strategies often get pretty draconian during times of acute stress

Meanwhile, Bethany has had to come to grips with the fact that her work with the midwives at Bairo Pite Clinic is over, and she has been at sea in terms of knowing what to do next. We’re working through this, and I think we’ve found the answer, but it’s been a very unsettling time for her, losing some of her sense of purpose for being here.

When I look back on it all, I’m surprised we’re holding up as well as we are, and that there hasn’t been more talk of packing up and going home. But neither of us have really entertained that thought as we both feel that our work here has really just begun. I think the fact that we are being presented with many new opportunities for what to do next means we can remain optimistic about the future here, even through some very challenging times. We’ve also been well supported by family, friends and colleagues, who continue encouraging us to press forward.

Apart from anything else, we know there’s so much more to do. We’ve now got ourselves settled here and are beginning to understand what is most needed to make an effective difference. We’ve done our apprenticeship and now we’re ready for the next challenge. So we’re busily formulating and developing the new project, and assembling the team around us – in Timor and back in Australia – who are absolutely essential if this is going to succeed.

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Measuring mid-upper arm circumference: a recent survey by visiting students revealed that of the children aged 2-5 years visiting Bairo Pite Clinic outpatients, a shocking 46% qualify as either moderately or severely malnourished! Our work here is most certainly not done.

We hope you’ll continue to follow our journey and partner with us. By mid-October we’ll have some real clarity about the detail of this new project, and a new name for our organisation, so we’ll be eager to tell you more. Watch this space…

 

 

 

The calm before the storm

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This Saturday is the Parliamentary election in Timor-Leste. 21 parties are vying for seats, and the city of Dili is alive with flags and banners supporting the major players. Will the longstanding left wing powerhouse party of Fretilin sweep the day, as they did the Presidential elections, or will Xanana Gusmao’s CNRT win power?

IMG_6405Xanana still looms as a huge figure in this country. Then there are many smaller parties, such as the PLP, fronted by the recent President Taur Matan Ruak, that hope to make an impact. Or perhaps none of that matters because they’ll all band together for a unity government anyway?

It’s hard for me to judge just how important policy is in this election. In my opinion it’s largely irrelevant in the elections of most other countries, so I expect it’s similarly peripheral here. As far as I can tell, political campaigning involves loading up dump trucks with Timorese youth adorned in party colours, and driving them up and down the main streets honking horns and waving flags. IMG_6401

Historically speaking, elections in Timor-Leste can be times of significant unrest. A few days ago we were in Australia, still wondering at the wisdom of reentering the country on the eve of such on event, but thankfully all seems relatively quiet, for now at least.  Perhaps it’s just the calm before the storm.

It feels like the calm before the storm at the clinic too. The few weeks I had in Australia were dramatically interrupted by a series of teleconferences relating to the critical financial strain being faced by the clinic at this particular time. Over the last 12 months we’ve been able to expand some of our services through projects which attract designated funding, but the everyday running costs of the clinic remain very difficult to meet each month. It’s very hard to attract funding for staff salaries, and even harder to cover electricity, printing costs, medicines and consumables, clinic maintenance, fuel and other less attractive budget items. So, unfortunately, it’s time for the razor gang. Yet trimming the fat from a lean machine like Bairo Pite Clinic is no easy thing.  The salaries of international staff (meagre as they are) are the first thing to be cut: at least patient care is relatively unaffected, and it means we don’t have to cut Timorese staff who would lose their entire livelihood, and put their families at risk. Many of them exist on the poverty line already. The reality is that we can’t run a clinic with money we don’t have, so there could be some very hard choices with very serious consequences for our most vulnerable patients. We are going to do everything we can to stand in the way of having to cut back our services. But all though I feel there is probably a storm coming, the rest of the clinic staff are getting about their business with their usual energy and courage.

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I’ve been pretty quiet on this blog for a while. Part of that was family illness – again. In May we had a horrible run of respiratory infections through the household, with fevers stretching out to beyond a week in some instances. It’s an eerie feeling, caring for your own children at home. We have the pulse oximeter on at times: Micah’s saturations were sitting around 92% (should be above 97%), with a respiratory rate of almost fifty breaths per minute while he slept… he ended up with a chest X-ray. I wondered if he might have developed TB (consumption), but given that he weighs more than some Timorese adults at the age of four I’d have to concede that’s unlikely. However, the concern is always that one of the kids might get a little worse than what we can handle at home, and then you have to start thinking about medical evacuation to Darwin. Thankfully that was not required this time.

Meanwhile, Bethany was busy putting our house and yard back together. We had a string of maintenance issues with house and car that needed addressing, and then we were hit by a tremendous storm at the hands of tree-loppers from the national electricity company. Our landlords commissioned them to take down some of our big shady trees (which admittedly threaten the house with their enormous branches), but what followed was almost apocalyptic. The cool and verdant refuge that was our home became a internationally-recognised disaster zone, with colossal branches carelessly crashed down upon all quarters of the yard, destroying almost everything underneath.

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Hmmm… where’s my backyard gone?

Those of you who know of Bethany’s love of gardening and outdoor aesthetics will understand that this was a knife through her heart: 12 months of creative nurturing destroyed in an afternoon’s chaos. Our Timorese landlords were left in no doubt as to our feelings on the matter, as Bethany lambasted them in a style to which they were clearly not accustomed (something of a cultural faux pas, perhaps). This is a country that mostly prefers a concreted courtyard to a tropical oasis, so they didn’t quite appreciate why we were so aggrieved to lose these troublesome trees and plants that had so seriously infested their property.

Back at the clinic, I have been busy kickstarting the Family Medicine Program. The Royal Australian College of Surgeons administers this course, but we’re now responsible for the content and clinical supervision. We’re the only trainers of family medicine in the whole country, so it’s both a great opportunity and a heavy responsibility. IMG_6395

We hope not just to teach them how to treat sore throats but how to be a doctor how to make people wait for an hour, then charge them $75 for telling them their problem is all in their head.– how to build trust and develop the doctor-patient relationship, how to pursue the upstream causes of the diseases they’re seeing in their clinics, how to advocate for people and the difficulties they face beyond their presenting illness, and how to lead them into making better health choices in their own lives and for their families. We are in the midst of this great pioneering moment in time in which we can lay down a template for how family medicine is practiced in this country into the future.

It’s good for me to write such paragraphs to keep myself on track. When you arrive back in country to find the washing machine is broken, the gas has run out, the water mains pipe has been trodden on and broken, and then the power goes off in the middle of the night, it can be demoralising. That’s to say nothing of the perennially sick children.

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Annika summed up our feelings on arriving home to Dili

If you’re sick of hearing about our sick children, let me say that SO ARE WE! This time it’s Australian germs we’ve come back with, and they don’t seem any more sympathetic to our cause than the Timorese varieties. We’ve never seen Annika so miserable.

I remind myself that were we still living and working as doctors in Geraldton, we’d still be struggling with exhaustion, sick kids, laptop failures (last week), car versus kangaroo incidents (the week before), and worst of all, Telstra. No one is spared such nuisances, the difference is only that we live somewhere that makes it easy to blame everything on the circumstances around you. The reality is that we are so privileged to be doing what we’re doing, with four beautiful kids who are coping well with their varied lifestyle, and we should be (and are) very grateful. We also have a lot of people supporting us in different ways, as is plainly obvious whenever we return to Australia and are blessed by the generosity and kindness of friends and family. We have nothing to complain about, really. Though I wouldn’t turn down an uninterrupted night of sleep.

One great development coming back into the country this time (other than the abolition of departure cards leaving the Australian airport – I’m so sick of writing them out six times over), was that we finally got our work visas! This means we don’t need to renew our tourist visas every month ($$), nor leave the country every three months ($$$). Of course the kids can’t get work visas, so they’ll still have to go to Bali or Darwin every three months, but that should give Bethany and I a nice break.

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In October last year I posted on this blog about malnutrition in Timor-Leste, and suggested people might like to donate toward building an additional consultation room that could be used for extending our antenatal consultations to include education about how to prevent malnutrition (among other things). The response was jaw-dropping, and the final amount raised was A$32,573.40.

 

This was much more than I ever expected to get in response, and we were able to achieve a lot with this money:

  • Refurbishment of an additional consultation room for antenatal care
  • External works around Maternity and Malnutrition units
  • Major office refurbishments and development of a new training room
  • Finalise the purchase of a new ultrasound unit worth around $15,000 (mostly donated by a German colleague, but we needed to pay some costs at our end)
  • Paying enrolment for three of our Timorese doctors in an international paediatric diploma
  • Securing clinic-wide access to an online medical Tetun course for our foreign staff and volunteers
  • Funding English lessons for groups of Timorese staff
  • Repairs to water-damaged floor in the patient toilet block
  • Other minor purchases of equipment and consumables

I’m enormously grateful for the support that came from readers of this blog, to make all this possible. Some of these investments will be career-changing for our Timorese doctors and staff, and life-changing for some of our patients.

And so, I’m back into the thick of the action at Bairo Pite Clinic, and it’s such a relief. My duties over the previous three weeks were as full-time house-husband, during school holidays. I’ve played Barbies, wrestled pony tails, held play-dates with seven children in my care, raced down the driveway on a trike more times than I can count, been peppered by Nerf guns, I’ve set up (and then packed up) the Marble Run two dozen times, played Chuggington, Ninjas. Fireman Sam, been wailed at, screamed at, vomited on, and generally humiliated on X-Box. Going back to work comes as sweet relief. I don’t know how you mothers do it.

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A mother’s skills: Bethany’s painting for ‘Pin the Wand on the Fairy’ for Miri’s birthday

So let’s hope the calm is not followed by a storm. The best predictor of civil unrest and violence in a country is how recent the last coup or outbreak of violence was. Every year of peace that Timor-Leste can add to its history at this time is golden, and means that within a handful of years the majority of the country’s population will never have known war in their life time. May the elections be quiet, fair, and effective in appointing a government that can continue to take this country forward.

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.