Planes and Drains

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Dr Bethany, in our minor operating theatre (kitchen)

 

 

 

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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Maluk Timor Christmas Party

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Order & Chaos

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

“Can you use 1% lignocaine for eyes?”

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

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

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

“Can you use coconut cream for pasta sauce?”

“Can you use household bleach for pool chlorine?”

“Can you use superglue for wounds?”

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Yin and the Yang.

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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Yes, it was that cold…

 

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

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

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

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

Running

You know you’re living in Timor when…

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

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

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

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

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

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

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

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

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

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The whole gang, after the climb up to Cristo Rei

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

A life less ordinary

Basic bodily functions become an adventure in Timor-Leste. Even aside from the gastrointestinal lottery enjoyed by most inhabitants of tropical countries, there are amusements to be had with the various bathroom amenities. Although squat toilets are the preference of many locals, I’m mostly able to find conventional western toilets for my purposes, but the challenge doesn’t end there. Last week I was sampling the ablutions at the National Hospital, just prior to an important meeting. I recklessly took care of my morning business without first conducting a thorough survey of the options on hand.

Of course one hopes to find a fully loaded one of these…

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…but one is often disappointed. With no spare roll to be found, I looked around: at least there was the bucket and scoop on hand.

IMG_8986Whilst very useful for flushing and washing hands when the mains water is out (a very frequent occurrence), it isn’t a lot of use for the particular service I required. On to option three: the spray. If you’ve never experienced the satisfaction of the spray, I can only commend it to you. Sure, you end up with wet undergarments at the end, but it’s more than worth it.

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I found the spray and thought my troubles were over… but I knew better than to celebrate: I’ve been deceived by the spray before. Often it isn’t connected to any running water and merely teases you by its presence. Knowing this, I pulled the trigger to test it: nothing. Following the hose back with my hand, I found a tap just above the ground on the wall behind me. I couldn’t see it, but I could feel it. There was still hope of satisfaction. I gently turned the tap, and water sprayed out from the gun in all directions (except the one intended), even with the trigger off. Narrowly avoiding soaking my bag and shoes, I quickly turned the tap off again. Hmmm… I love the thrill of problem solving. I surmised that if I held the trigger down while turning on the tap, the likely outcome would be that most of the water would spray through the gun as God had intended it. I tested my theory, pointing the gun at the toilet floor and pulling the trigger… it spurted powerfully from the nozzle, again very nearly soaking my leather bag. So, I lowered the gun into position, and aimed more or less at the target. Carefully balancing myself on the seat, with one arm committed to a steady aim, the other arm reached behind me to manipulate the tap. I turned it to full and was rewarded with sweet relief, without soaking myself before the meeting. Success! It doesn’t always end so happily. Ahhhh, what challenges will tomorrow bring?

 

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Thankfully not our motorbike. Nor our truck. 

A little more than a week ago we arrived back in Dili after a few weeks in Australia. Twice each year we head back to Australia – earn some money, keep our medical registration up, and reconnect with friends and family – and so far we’ve found that this straddling of two worlds seems to work for us.

For the kids, Australia is truly a wonderland. It is the land of perpetual holiday, as they never go to school when they’re there. But it’s the little things too: as Levi finished a long draught of the overpriced bottled water on the Jetstar flight, he exhaled with a satisfied ‘ahhhh’, and declared it to be ‘glorious water’. As we drove from Perth airport, Micah asked why there were still ‘Christmas lights’ up everywhere. We explained that these are called street lights. The next morning he exclaimed with all the exuberance he could muster: “Dad!! Nanny has WEETBIX!” Yes, she certainly does. And after a four-month outage of Weetbix in Dili, this was good news indeed.

We took the chance to go on our very first proper camping trip as a family.

We also had the chance to briefly reconnect with some of the people that made all this possible: some of them are the influences in our life that helped lead us to this point; others are financial supporters, or people who keep us encouraged enough to carry on, through their prayer and correspondence. It means a lot to us to have this support crew behind us. And now we’re back, and things carry on. With fewer rabbits (some casualties while we were away), more kittens (arrghh!), and our first banana harvest!

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Saturday morning was a great little snapshot of a typical day for us in Dili, so I thought I would walk you through it.

The day begins: I mostly don’t work on Saturdays now, but we are running a training workshop at Maluk Timor so I want to be there to make sure it all goes off ok. The kids are playing in the lounge room, so I enjoy a peaceful breakfast alone with my thoughts and a filtered Timorese coffee. If you don’t already know, Timorese coffee is among the finest in the world – keep an eye out for it.

fullsizeoutput_92e2Our front gate – made from steel angle iron, painted green – rattles loudly as I slide it aside, and reverse out into our street. It’s a bright sunny morning, and the kids from the local school are clustered up and down the street in their blue and red uniforms, wandering this way and that. As I drive to Maluk Timor, less than ten minutes away, I’m starting to practise a welcome speech in Tetun. It’s a clumsy start, I’m struggling to find basic words of greeting. I’m well out of practice, and my Tetun generally hasn’t much improved over the last 12 months due to lack of diligence on my part, and a few significant distractions. I remind myself of how I badly need to make more effort on my language study between now and Christmas, and revisit my plan to hire a language teacher for Maluk Timor next week. I’m almost at Maluk Timor, and only the first few words of the speech are rehearsed.

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Our street in Bebonuk

I’m early, as I like to be, but as usual my anxiety turns out to be well-founded. There is no-one there. There is supposed to be a gate-man, who watches over the place when we’re not there. He’s nowhere to be seen and all three gates are locked. I beep the horn a few times, trying not to upset the neighbours (upon whose ongoing goodwill we depend), but hoping to rouse the absent gate-man. It’s getting embarrassing as some of the participants for the training event – doctors and nurses from the Ministry of Health – are already assembled at the gate, waiting to come in. They watch me in amusement as I pace up and down, dialling one of my managers for an explanation. He says he’ll make some phonecalls. Time passes – I’m not early anymore. I call him again, and he tells me he didn’t reach anyone with his calls.

I was hoping it wouldn’t come to this. Shaking my head, I walk up to the gate where the crowd is gathering, smile at them ruefully and say in Tetun, “Don’t tell anyone!”, and then I climb over our security fence. I am supposed to be attending this event as the illustrious Director who will open proceedings. Now I’m hitching up my trousers and climbing the fence. Workmen from the street stop what they’re doing to watch in amusement. A white guy breaking into a Timorese property. ‘Don’t see that everyday…’

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View from the inside. There’s no way those Americans were getting out. 

Thankfully, whoever built this fence did so the wrong way around: the top of the fence angles inward, rather than outward. This property used to accommodate staff from the American Embassy – perhaps they had a habit of trying to escape? Whatever the reason, it’s easier to break in than out. So pretty soon I was in, and was somewhat annoyed to discover the gate wasn’t locked, and could be easily opened from the inside – another lapse in security, but a convenient one for my purposes. I opened the gate and smiled at the participants.

Hurrying to unlock the building, I was pleased to find that the training room had been elegantly laid out by staff the previous day. Maybe everything would run smoothly after all. I wrestle with a coffee thermos to try to get that ready, and then some of my staff arrive. They seem relaxed and confident, and pretty soon it seems that everything is in order.

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Our office in the early morning

There are no water bottles though, and this is a significant oversight. There is a formula for Ministry of Health training events and everyone knows it: there should be plastic waterbottles. Our credibility is at stake. I drive down the street to the local Chinese-run general store. These are scattered all over Dili and also seem to have a formula, but today I am caught out as they have reconfigured the store and I can’t find the boxes of water bottles. Waiting my turn at the counter, I ask the Chinese owner for a ‘caixa’, or ‘box’. He sends a man out back who return carrying a case of “Bocks”, a carton of beer. After a moment’s consideration I decide that that probably won’t do and restate my order in as many languages as I know. I doubt the Russian helps, but who knows? This time they return with a box of water bottles, and soon I’m loading it into my car, cursing the thought that I am almost certainly responsible for another 24 plastic bottles in the ocean.

Minutes later, the bottles are laid out and all looks to be as it should be. Except for my speech, which is still a clutter of nonsense rattling around in my head. One of my brilliant Timorese staff invites the 20 or so participants in and opens the day with a prayer, as is custom here. Then he introduces the great Director.

Every training event I’ve ever attended in Timor begins with a series a dull orations by various dignitaries who seem mostly concerned with demonstrating their inestimable importance to the gathered audience. I guess it’s the same the world over, and I’m probably no different, as Director. Except it’s pretty hard to convince anyone of your importance when they’ve just seen you break into your own facility, dash out to buy water bottles, and then fumble through a hopelessly inane introduction in a language you barely know. I reckon I nailed it.

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I was also interrupted by a phone call from a Timorese man who was supposed to be receiving a large sum of money from an Australian patron, having sent that money through me. Bad timing, but it was my fault. I’d put this man off the day before and told him to come back to today. He had arrived at Maluk Timor, which was fine, except I’d left the money at home.

So after my rousing introductory speech, delivered in halted, stuttering Tetun, I rush out again. Back on the road, a bus slows down in front of me, so I attempt to overtake. He’s slowed down, now stopped, because a utility vehicle in front of him has lost its cargo of steel frames on to the road. I’m just able to weave through the debris on the road and the passers-by trying to move it, and then I’m away, dodging the schoolkids in bright uniforms, the scrawny dogs scavenging the roadside, and the swerving gawdy minibuses (microlets), painted and pimped up to advertise their trade. No such luck for the bus.


The drive itself is always of interest. I go past Woolworths…

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…past the David Jones store…

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…past the airport roundabout, featuring the late great Nicolau Lobato…

fullsizeoutput_92d9…and then I’m back on my street, almost home.

IMG_8994Driving up my street I see Bethany ahead of me, walking home in the same direction, carrying a black plastic bag in one hand. That will be a purchase of 10c frozen ice pops from the local Chinese store – she’s throwing together an impromptu pancake breakfast to celebrate Alico’s birthday, and must have needed something extra to brighten it up. She doesn’t know I’m driving up behind her, and I see her high-five a local school boy (who looks about six, but could easily be ten). He leaps as he slaps her hand, smile beaming on his face, but there is a problem. His friend protests that he has missed out, so Bethany doubles back to give not only a high-five but a low-five. She’s upping the stakes, I think, wondering if it will escalate the cycle of jealousy. But it’s smiles all round and she carries on down the road, and I cruise past her, reaching the front gate at almost the same moment.

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Pancake breakfast

I dash inside, noting that the pancake breakfast is almost underway, and count out the money I left behind earlier. Back in the car, and then back to Maluk Timor. When I arrive, I almost give the money to a man who is waiting around outside the office, but he explains he’s there because his wife is one of the doctors inside. Wrong guy. I call the right guy back, he comes back to the office, and the money is handed over.

I check in on the training room, and all is going well. Our team is working their way through the teaching program, teaching the staff of one of the Community Health Centres in Dili about penicillin treatment for rheumatic heart disease. I take a few photos and then excuse myself, hiding at my desk back in the empty office to battle through an overloaded inbox.

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Soon it’s lunch time, and spirits are up. The participants are really engaged in the training, and we’re all feeling good. I’m particularly feeling good, as I’ve finally written up a program budget that has been long overdue. It’s been a good morning. I decide to head home, so I leave my office key with them and depart.

Later in the afternoon, one of my colleagues drops the key back to my house and reports back on the day. It has been a great success, but there are two worthy stories to tell before he rushes out the door.

The first was about one of the Timorese doctors from the health centre, whom I knew from previous years. She was one of our bright volunteers back at Bairo Pite Clinic, and we had put her through almost six months of supervised training there. She was also one of our Doctors’ Bags recipients, and kept up contact with us. During the teaching today there had been a session on echocardiography (heart ultrasound), demonstrating the damage that occurs to heart valves in rheumatic heart disease. This particular Timorese doctor had asked whether she could bring her young nephew in as a practice model for the teaching, as he was suffering with 4 days of fever and joint pain. Our expert trainer had then examined the boy and found that yes, he was suffering acute rheumatic fever, and needed to begin penicillin treatment immediately. Such is the prevalence of this condition here.

The second story was about what happened shortly after that, when one of our Rheumatic Heart Disease Program nurses also volunteered as a practice model for scanning. He is supposed to be healthy, but when being scanned even he showed signs of mitral regurgitation, a sign of rheumatic heart disease from his youth. Aged 30, he is probably out of the danger period, but it goes to show just how widespread the problem is.

And so, another day is done. This kind of day feels utterly normal now, and had I not written about it, it would simply blur into the mass of indistinct memories we have of our time in Timor. In years to come I’ll relive these memories with nostalgia and wonder.

Today was another memorable day. The Australian Foreign Minister, Ms Julie Bishop, was in Dili today. I went along to two functions, and ended up with two handshakes and two very brief conversations with her. It’s pleasing to see a thawing in the relationship between the two countries I live in.

Among other things, she was here to announce a new three year project called ‘STRONG TL’, led by a close friend (and Maluk Timor Board member), Dr Joshua Francis. If you zoom right into the photo of the banner you’ll see that this is a collaboration between the Australian government, the Timorese Ministry of Health, Menzies School of Research and, among others, Maluk Timor. We’re the in-country implementing partner, working on this project to help improve laboratory and disease surveillance capability in Timor. It’s very ambitious, but we’re excited to be a part of it. It will have a direct effect on the detection and treatment of lethal infectious diseases that still ravage the families of this country. Anything that can give these kids a better chance is worth fighting for.

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Don’t believe the labelling. That’s not Levi. 

This remarkable place

Timor-Leste is a simply remarkable place. When you compile the odd collection of other-worldly experiences we have here in any given month, you realise how fortunate we are to be living this extraordinary life.

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Annika holding court with our Timorese friends

When I last wrote, it was days before the election and there was an uneasy tension across the country. The final days of political rallies were colourful and disruptive. I got caught in a Fretilin motorcade at one point, which was quite good fun.

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One of my work colleagues did too, and managed to snap these photos:

Yes, that is a live rooster stuck to the top of a taxi, painted in Fretilin colours.

Up until the results began being reported on election night, both major sides were seemingly very confident of a comprehensive win. Ultimately it was Xanana’s coalition, the Change for Progress Alliance (AMP), that prevailed with an outright majority. That latter point was important, because it was the troubles of a minority government that had crippled Fretilin’s 10 month term, and precipitated the early election. Whether you support the AMP or not, at least a majority means the government can govern.

Xanana Gusmao was buoyant: a big election victory on the back of having recently returned to Timor after concluding the long-running maritime boundary negotiations with Australia. We saw this exuberance first hand at an art exhibition a few nights ago: he was in everything, jumping from keynote speaker to interpreter, to percussionist, and then to impromptu-artist – a man basking confidently in the adoration of his people. In high spirits, he even took Bethany’s hand and graced it with a gentleman’s kiss. I missed out and had to settle for an enthusiastic handshake and a pat on the chest. Maybe next time.

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The art exhibition was commemorating the signing of the maritime agreement, and thus there were many paintings of crocodiles (the Timorese totem) and kangaroos, either sparring or embracing, set on backgrounds of open seas or flags. There were many notable patrons present: Bethany was excited to get an opportunity for a chat and a photo with Timor-Leste’s preeminent singer-songwriter:

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Except it wasn’t him… a case of mistaken identity. Nevertheless, we found out later it was a man they call Maun Iliwatu, the founder and director of Timor’s leading art school. Still worth a photo.

The exhibition was held at the Timorese Resistance Museum, so we took the chance to wander those displays too. When you follow the story from 1975, and see that Xanana has been the mastermind and people’s champion for more than forty years, it’s not hard to see why he is so revered.

Unfortunately, a kiss from the people’s champion does not equate to legal recognition of Maluk Timor by the Ministry of Justice. I’ve made some reference to this on my blog before: we have been labouring to get our registration as a rebranded NGO approved, some eight months after separating from Bairo Pite Clinic. Sequential legal obstacles have delayed our progress, so we were pleased to finally win an audience with the Minister of Justice to plead our case. This was no small matter, and I was nervous. There are many conventions as to how one is to conduct oneself in these high-level meetings, and sadly I’m oblivious to most of them. I’m pretty sure there isn’t one that says you should stumble into the glass coffee table in the foyer. I knocked the thing off its legs, and spent the next few minutes trying hopelessly to reassemble it, apologising all the while to the stunned reception staff who were trying to find out who I was and why I was demolishing their furniture. A flying start.

Thankfully the Minister (in blue) was delightful. I assume that news of the coffee table’s demise was yet to reach her. A friend (pictured) introduced me to the Vice-Minister as well. Why not? The outcome of all this was that the Minister advised us to resubmit a key document to her department, offering to try to help.

I asked our lawyers for the key document… Ahhh yes. That one. Yes, the one we have spent months getting approved by the Notary. The original has been submitted for publishing, and there aren’t any copies. Hmmm. That’s not ideal. Oh, and the publisher says they don’t have it, nor any record of having received it. OK. Right. Good.

AARRRRGHHHH!!!!

And so began a couple of weeks of to-and-fro. Had the Notary delivered it? Yes, confirmed. signature to prove it. Had it been received? Allegedly not. How could that be? Disaster loomed.

On Tuesday I sat, downcast, in a government strategic planning meeting, representing Maluk Timor and watching all the other key players – Timorese and international – laughing and backslapping together. And yet we still sat as outsiders, without formal registration, despite 8 months of trying. I felt entirely demoralised. Unhitching the safety mechanism on my weapon of choice – my smartphone – I fired a volley of frustrated messages as I sat in self-pity and disappointment. It triggered some action: that same afternoon, two of our representatives returned to the publisher and uncovered that they had in fact received the document, and better yet, they had already published our legal recognition in the national journal. It was already done, and we hadn’t even known it. A badly needed victory, and cause for celebration. Yes, it’s just one step of many, but an essential one, one that justified the ruining of a badly-designed Indonesian coffee table. Acceptable collateral damage. I was vindicated.

 

 

 

This is the Timor we’re slowly coming to know and understand – where things rarely go as planned. A couple of weeks ago, Miriam was overwhelmingly excited about her class going on a school excursion to the beach to fly their homemade kites. She was counting down the days. Bethany was going to go along as support, but a late change in plans meant it would be me instead. I met the bus down at the beach as they arrived. It was picturesque as always:

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Ugh. The tide was up, the waves were bigger than usual, and all that was left of the beach was a scatter of muddy puddles under the placenta tree.

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(The placenta tree, on the very right of the photo above, has placentas in plastic bags hanging from it. There are several such trees in Dili. I’ve never quite grasped the traditional reasons for why people hang placentas from certain trees, but it’s probably not the ideal landmark for a Year 2 school excursion.)

The excursion was abandoned, and the devastated kids were returned to school. It broke my heart to see their grieving faces poking out the bus windows, gazing longingly at the filthy sludge and puddles  they’d been so cruelly denied.

A week or so later, we attended the farewell party of some good friends, and part of the entertainment was a joyride in a Timorese outrigger. Levi signed up, as any 8-year-old should. The pictures tell the story:

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Hmmm, this boat looks a little less than seaworthy…

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Uhhh, that’s a lot of water to have onboard at the beginning of a boat-trip…

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Are you sure this is a good idea?

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Putting more kids in should help…

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Riding kinda low in the water, aren’t we?

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What do you mean the motor won’t start?

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I’ll take my chances with the crocodiles

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Another great adventure!

Our kids are racking up all kinds of life experiences, good and bad. Last week one of our Timorese friends cut some coconuts from the palm in our front yard, and we supped on fresh coconut milk.

IMG_8440The same day we were invited by the neighbours, who live in the laneway running alongside our house, to come and see their pet. Who knew we had a pet deer living next door?

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Then they showed us their other pet.

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You think I’m joking. I’m not. That is a nine-foot saltwater crocodile living in their backyard. His name is Apeu. Apparently they’ve had him for nine years. I asked who cleans the enclosure: they said they just hose it from the outside. He gets chicken and fish once a week. I was absolutely dumbfounded.

How can we have lived in our house for two years and not known that we had an 150kg man-eater living in the laneway next door?

You see what I mean? This is an extraordinary place, and just when you think there won’t be too many more surprises, a nine-foot salty appears in your life.

 

 

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The rollerblading craze has hit Dili, and they’re rollin’ like it’s 1995. Just when we thought the streets of Dili couldn’t be any more perilous…

Sometimes it’s new things taking us by surprise, and sometimes it’s old things hitting us afresh. This week I was asked by a Timorese gentleman at the strategic planning workshop if I could help his daughter, currently admitted in the National Hospital with rheumatic fever. He knew of our connection with East Timor Hearts Fund and others, and he wondered if we could help arrange the emergency heart surgery she needed to survive. I said I’d make some enquiries about her case. He visited me at Maluk Timor two days later, and I was able to fill him on the grim outlook. Her condition was so poor that she almost certainly would never be well enough for a flight to Australia, even if it was thought that surgery could help her at such a late stage. There was a chance, but it was very slim. He understood, having heard a similar explanation already. He was gentle, and gracious, but his grief was palpable. He described to me how she was too breathless to eat, and that she couldn’t lie down to sleep. He told me that the previous day had been her birthday, which she had spent in a hospital bed, gasping for breath. Her twelfth birthday. Something in me broke. As I farewelled him, and Bethany asked me about the conversation, I couldn’t answer her. Tears rolled down my cheeks. What is there to say? As a father of four children I could barely comprehend what it would feel like, watching one of my own children die, acknowledging a birthday in the midst of it. She is one of so many, dying unnecessarily.

She is not lost yet, and we will do what we can to save her. But if nothing else, I set my jaw again, with renewed purpose, throwing my shoulder to the wheel. There is work to be done, and there is an urgency to do it.

067aa907-d194-47c2-8d86-fa5aabe89d1dThankfully we have many reasons to be optimistic. There are so many little wins. This is a photo of one of our Timorese doctors, whom we’ve been supervising for 11 months. She wears the black garb of mourning, having lost a dear family member herself just months ago. She is pictured here with one of our volunteer doctors from the UK, and together they are on a community home-visit in a remote village west of Dili. They are providing a home medical assessment for a man with a physical disability – the first such medical assessment he’s probably ever had. It’s a new frontier for Maluk Timor, started less than a fortnight ago. Sure, their car got a flat tire and they spent the whole day stuck out there waiting to be rescued, but that’s all part of the experience!

That’s just part of living in this remarkable place.

 

 

 

 

Hearts and minds

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Courtesy of Naychi Lwin

April was a breakthrough month in Timor-Leste with respect to one of her most crippling conditions: rheumatic heart disease. Rheumatic fever is something you might read about in a Victorian romance novel, but in Timor (and northern Australia) it is a devastating disease that still kills many young people. To refresh your memory, rheumatic heart disease is an autoimmune condition in which the immune system attacks the heart valves, triggered by recurrent streptococcal infections. It usually takes hold during the primary school years, tends to progress (often fatally) through adolescence and early adulthood.

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Until April, very little was being in done in Timor-Leste about this condition even though it’s long been suspected that Timor-Leste has among the highest rates in the world.  Though we were seeing many of these kids firsthand the problem wasn’t attracting wider attention. Well, no one can claim that now. On the 16th April, the Medical Journal of Australia published the results of a study undertaken in 2017 by my colleagues (at Bairo Pite Clinic, East Timor Hearts Fund, and others), which puts this issue right into the spotlight. It showed that rates of rheumatic heart disease (RHD) among school kids in Timor-Leste were probably around 3.5%, or one in every classroom. As high as anywhere, perhaps higher. The story was picked up widely in Australian media, which was great to see.

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Kids lining up for screening for RHD

Imagine that for a moment: looking at a primary school classroom full of kids and knowing that one of them is sitting on a timebomb that could very likely kill them before they reach full maturity.

On the same day, another study was launched here (led my many of the same people, and spearheaded by Menzies School of Health Research in Darwin) to conduct two weeks of further echocardiography screening for RHD, and to evaluate the reliability of Timorese doctors, nurses and healthworkers who were newly trained as echo scanners. After all, it’s great when Australian teams of cardiologists come to Timor to screen for RHD, but how much better would it be if we could train Timorese clinicians to do the screening themselves? There are something like 300,000 school kids out there…

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Maluk Timor sent along ten of our own staff, some of whom have been trained as scanners. The team worked tirelessly to perform two echo scans on each of 2,600 children in two weeks. I don’t have the final numbers, but I’m told at least 55 confirmed cases have been identified. Each of those kids will now be enrolled in our penicillin program, and our staff will counsel and educate their families and communities, and visit them monthly for penicillin treatment for at least the next ten years, probably longer. This prevents the progression of the disease, and probably saves their lives.

Their road ahead, with years of penicillin injections, is not easy, but that’s 55 families – perhaps 55 communities – that shouldn’t have to face the grief of another premature death.

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This is Ainary, or Januario if you prefer. He is the leader of Maluk Timor’s and East Timor Hearts Fund’s shared penicillin program, and he is the one doing the face-to-face work with the kids and families. He’s like a rockstar: he goes into the schools and communities and the kids mob him. He always gets them laughing and playing, even in the midst of another round of painful penicillin injections. This is what makes the program work: building trust in the community.

So April was big for RHD here. It’s now attracting the attention of the Ministry of Health, who say they are working on an action plan. This has been our hope for some years: we’ve been leading a pilot RHD program that we hope they will adopt and expand to cover the nation. Let’s hope we can break through and hit the driving cause of this condition – the unchecked streptococcal infections in the throats and on the skin of the Timorese children – and see this disease eradicated as it is in so many other parts of the world.

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Reaching the remote communities of Timor with our health messages

With all this activity going on around us, Bethany and I did the right thing and fled back to Atauro Island for a long weekend with some friends. This is clearly going to become a regular habit.

We were at the marina early – the wrong place as it turned out, but no harm done – and we loaded the kids and luggage into the boat. As a naturally-anxious person it’s always an uneasy time for me, waiting for the voyage to start. Over-excited toddlers exploring every corner of the vessel, putting their hands into things they shouldn’t be, and me wondering what the seas will be like once we’re out of the shelter of the bay. I looked at the crew of our boat, a moderately-sized powerboat, nothing more, but owned by an Australian company, so surely seaworthy enough?

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What could possibly go wrong? OK, this wasn’t the actual boat, just the tender. 

The crew on this occasion were all Timorese. They looked like they knew what they were doing. At least I thought so until we heard an enormous splash from alongside the boat, and realised one of them had slipped off a ledge and fallen in, fully clothed, with a phone in his pocket and all… while the boat was still moored in the placid pond that was the marina that morning. It didn’t do a lot for my confidence.

But I needn’t have worried, the voyage went off uneventfully, and the Timorese crew were indeed proficient and very watchful of our children. We had another delightful time on the beach at Atauro, with fewer near-death experiences than last time.

This time we made it to the Saturday market, though Levi didn’t entirely appreciate the overpowering fishy odour of the dried seafood on offer.

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If the voyage over was uneventful, the one home was anything but. We knew the weather had blown up appreciably since we’d arrived, and expected some trouble. Actually we hoped they would send their larger boat: they didn’t. The journey is similar to the English Channel in distance, so not to be taken lightly. We pre-loaded the kids with travel-sickness medicine, which must have included the wondrous side-effect of drowsiness, as they all slept peacefully through the heaving seas. Not so the adults, whose faces collectively spanned the full palette of known shades of grey and green. I was well placed: sitting on the floor, facing the side of boat that was copping most of the battering, and nursing a sleeping Annika. I wasn’t moving for anyone. Once you’ve got your rhythm in those seas, you stay put. All it takes is a change of position and you can lose your lunch very quickly, as some of the others found out. I was hearing calls of “dolphins!”, “oh, look! there’s heaps of them!”. I couldn’t see them from where I was on the floor, and I couldn’t have cared less. I was focused. I held my ground, and stared straight ahead. It was a great relief to make it back into the marina after a very long couple of hours.

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There are boats, and then there are Timorese boats. A while back I posted this photo of Annika in our new sandpit, made from a genuine Timorese outrigger boat. The real story of this photo however, is yet to be told: I need to introduce the man in this photo. This is Alico.

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Alico is our Mr Fixit. His family live at the end of the laneway alongside our house, and since he was a teenager Alico has been helping at our house as a gatekeeper and groundsman. That’s not his fulltime job – he is completing his agriculture studies and loves growing flowers… not that there’s much of a market for that here yet, so he’ll probably be stuck growing cashcrops like everyone else. Hopefully he’ll at least be the boss.

Some of the fruit growing in our backyard, papaya and banana.

Alico has progressively increased in value to us over the past two years. We’ve gradually learnt that he is a man who knows how to get things done. When we crashed into a motorcyclist, it was Alico who did the negotiating and all the running around to get the guy’s bike fixed. Every time our car breaks down now (yes, twice again last week), it’s Alico who gets it sorted. If you want a truckload of rocks or soil for the garden – Alico. Getting a vehicle registered? Alico. The waterpump breaks down? You get the idea.

 

 

 

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The pile of receipts Alico brings home after a day of running around getting my car fixed. Nothing here is achieved in a single visit to a single store.

In the sandpit photo, it was Alico who sourced the boat and got it to our house. Alico then repaired it (it was in pretty rough condition), painted it, and found us some nice beach sand (I dare not ask from where) to fill it.

I feel like I could ask Alico to get me a fake German passport, a vintage bottle of Cognac, and two live eggs from a nearly-extinct Amazon ground bird, and he’d be back the next morning with precisely that. Everyone needs an Alico in their life.

4a62c97e-cd07-4f4e-807b-5a0c2ca43622Right now this whole country could do with a Mr Fixit. We are less than a week from another round of elections, yet less than a year after the last one. A minority government that was unable to govern has meant the Timorese people are heading back to the polls. Things have been comparatively low-key, with major parties having bled out their campaign purses last around. Fewer rallies, and fewer trucks filled with Timorese partisans.

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I said ‘fewer’, not ‘none’. 

But no one seems any clearer on how it is going to play out. No one is predicting major violence, but then no one seems entirely optimistic as to the end result, either. An uneasy calm hangs over the place. By the end of this coming week Dili will be partially emptied, with tens of thousands returning to their home districts to vote. I am predicting a return to glory for Xanana Gusmao and his majority alliance, the AMP, and a dark day for the traditional favourite, Fretilin. But what do I know? I’ve only been here two years.

And it is exactly two years, as of the 7th May.

Spot the bunnies in the picture on the right. One bunny = 1 point. Top score so far is 3 points.

Some people only stay two years. Some less. It’s hard to imagine going home now, we honestly feel like we’ve only just got going. Part of that feeling is explained by the way the story has unfolded, of course. The baptism of fire in the latter half of last year in withdrawing from Bairo Pite Clinic, followed by the difficult birth of the new entity Maluk Timor: these are events we feel very much connected to personally. They are things that couldn’t or wouldn’t have happened in the same way without us here. And then that was followed by a frenetic start to this year as Maluk Timor got up and going, and the ongoing sense that even now we’re still on a steep upward trajectory. We really feel like this is the beginning of our work.

A beginning it may be, but we don’t feel as fresh on the starting blocks as one should. Now that the tempo and rate of change has eased slightly, we’re permitting ourselves the space to reflect, and allowing ourselves to ‘feel’ a lot of what we probably didn’t have the capacity to deal with before.

WUVFE9946We still feel bruised, tainted, and heavily responsible for some things that we wish had turned out differently. We’re not living with regret: that’s a different thing. That would suggest we feel we shouldn’t have done what we did, and that would not be accurate to say. We feel two conflicting feelings simultaneously: that we did what was right and yet we still grieve some of the consequences that played out, and how it affected other people. I think of the patients, for example, whom we perhaps could have helped had we been somehow able to stay. I worry what becomes of them now, but I guess we can take some solace in knowing that our new model at Maluk Timor offers a far greater reach and a much more significant long-term gain for the people of this country. Still, there are mixed feelings.

But then I look at our bright young staff, changing the lives and futures of the children of Timor-Leste, and I know we are in the midst of building something very special. We are winding the key on something that we hope will run long after we’re gone, if we do our job right. It’s a great privilege to be in such a position, and that fact is not lost on us.   We remind ourselves to savour it, as I doubt we’ll ever know another time like this.

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Lessons from a misspent youth

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I didn’t know it at the time, but it turns out I’ve been preparing for my life in Timor-Leste since I was a young boy. I chose two particularly frustrating pursuits as my childhood hobbies and it’s finally paying off.

One of those was fishing. I was mad about fishing: from staring at nautical charts of the coastline, looking up different fish species, learning different ways to rig up my line, and of course spending countless hours out on the water… yep, I loved nothing more than fruitlessly hurling thawed seafood into the ocean.

So many fishing trips yielding nothing at all, and yet that did not extinguish the desire to want to try again. There were so many variables: the place, time, the tide, the moon, the wind, cloud cover, the type of bait, the type of hook, the casting technique… sometimes I didn’t achieve anything other than painstakingly learning what didn’t work.

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Ducking out to the corner store to get some milk

Living in Timor is a lot like fishing. Whether it’s setting out to the shops to look for a particular item, or trying to achieve some kind of administrative goal, you don’t expect to succeed the first, nor the second time you go. You know it’s gonna take a while. It took almost ten visits to get my medical registration. Some days the office was closed for a snap public holiday, or the key person was away for some reason. Sometimes there was a new form that you didn’t need last week but had suddenly become a mandatory requirement. Several times it was just that they had run out of printer toner and couldn’t print the ID card. Like with fishing, you learn not to expect success, and if you just happen to catch something it comes as a happy surprise. Similarly, it took more than a dozen attempts to get my work visa. It took almost as many to get the kids’ student visas. Eventually you catch something if you’re persistent enough.

My other pastime of immeasurable frustration was cricket. I was (and still am) cricket-obsessed. And yet, tragically, I was never very good. That meant expending a lot of effort in preparation and training, and a consuming storm of anticipation leading up to the game itself, and then inevitable desolation as I – once again – failed on the big occasion. Then I would be rewarded with a whole week to lament my failure and prepare myself for another try.

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Living in Timor turns out to be a lot like that too. A couple of weeks ago I had a rare opportunity for a crucial meeting with leading figures in the Ministry of Health. Since our separation from the clinic at Bairo Pite, we’ve been patiently battling away to re-establish a Memorandum of Understanding (MoU) with the Ministry of Health. This might not sound like much, but a great deal of what we plan to do rests on gaining this MoU. After months of waiting, I was called in to discuss Maluk Timor’s situation and future plans. I wrote out a speech. I dusted off the business suit and shiny black shoes. I rallied my team, had everyone prepared, and then set out, arriving five minutes before 9am when the meeting was due to start. Senior ministerial figures filed past us and into the meeting room as we waited in the foyer, nervously waiting for our turn. As the clock struck nine, we took ourselves in to make our introductions.

We were met at the door by a slightly embarrassed-looking gentleman, who apologised that they wouldn’t be able to meet with us. It turned out they were meeting with someone else: Dr Daniel Murphy and his staff from Bairo Pite Clinic!

We were humiliated. Like a girl arriving at a glamorous restaurant only to find her expected dinner companion already seated at a candle-lit table for two, gazing longingly into the eyes of another.

“Come back at 3 o’clock,” they said.

Just like when that red leather ball sends your middle stump cartwheeling behind you, you’ve nothing left to do but walk, head slumped, back to where you came from. And yet somehow you know you’ll be back next week, ready for more punishment. Cricket was great preparation for Timor.

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Rain interrupts play at Dili International School

These setbacks can be pretty deflating, but you do get used to them. Thankfully we have enough to keep us busy: there’s not enough time for melancholic introspection. In March we had one of our twice-yearly meetings, during which many of our Board members and supporters fly into Dili for a long weekend of heavy discussion about our work. The last of these occasions was held in early October, at a time when our organisation was still reeling from the dramatic end to our work at Bairo Pite Clinic, and wondering whether anything could be salvaged from a grim situation. That’s when Maluk Timor was born, though even then it was with a genuine sense of uncertainty as to whether anything much would come of it.

Then, five months on, the same people came back to town to see what had transpired since. They were delighted to find a dynamic team of almost forty staff, with eight distinct health programs either up and running or about to launch. As our Timorese staff each presented their programs, the mood in the room lifted ever higher. The energy and creativity of this group of people is infectious, and their passion to see the health of their people restored left an imprint on us all. We’re not really in the habit of congratulating ourselves, because we look around and see so much left to be done, but there was a genuine air of celebration about the weekend which reached a crescendo on the Saturday evening with some impromptu live performances of energetic Timorese folksongs by the staff… which of course later degenerated into baleful howling: a volley of appalling karaoke performances tore through the still night air of the Dili waterfront.

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One of my favourite parts of the extended weekend was a dinner we had a couple of nights later at a pizzeria. It was relaxed and informal, yet it gathered together a diverse group of people who wanted nothing more than to spend an evening together trying to solve the nation’s tuberculosis tragedy. Timor-Leste has perhaps the highest rates of tuberculosis outside of Africa. It’s hard for people who have never seen the ravages of TB to appreciate how devastating this condition is. To remind you, 1.8 billion people are infected with tuberculosis. It kills around 1.8 million people per year. Yet this is a disease that most of us, in Australia at least, don’t give the slightest thought to.

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Unlike heart disease or cancer, TB is just as likely to kill children and young adults as older people. But what I think is most galling about TB is the fact that we know how to find it, we know how to prevent it, and we know how to treat it. And yet it rages on, as perhaps the biggest killer of humankind in history. In 1850, the leading cause of death in the world was still tuberculosis. Then the western world developed public health and sanitation and, much later, TB medications, all but eradicating the disease. Timor-Leste is still playing catch-up, so unsurprisingly, TB remains the major killer.

I sat with seven other people around a table, eating pasta. I was the oldest person there, and yet among that group was an extraordinary wealth of knowledge, experience and hunger to find real solutions to this epidemic. There was not a hint of ego to be found: none were there to prove anything, nor to further themselves. To be in the company of such brilliance was humbling – to see their eyes sparkling as they spoke animatedly, one after another, of their ideas and strategies for fighting back against this dreaded enemy. This is what I love about this place, about this work.

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Annika & Alico with the latest backyard project

Where do we find such people? Just today three more bright-eyed doctors arrived, fresh from the Liverpool School of Tropical Medicine. I studied there in 2014 and have been recruiting their graduates shamelessly ever since. It’s hard to find a richer pool of talent: it’s a lecture hall filled with idealistic agents for transforming global health. What a privilege I have in leading these people, steering their enthusiasm into making lasting change in such a desperate place. It’s enough to make me want to go fishing, or to strap the pads on and face up to the bowling yet again.

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