REPORT TO THE YALE SCHOOL OF MEDICINE ON HEALTH CARE IN EAST TIMOR
Fredric O. Finkelstein,
Susan H. Finkelstein, MSW.
We visited East Timor as members of the Yale delegation to East Timor in March 2001. We are members of the Departments of Medicine and Psychiatry at the Medical School and were looking at health care delivery in East Timor to see how the Medical School could provide assistance to the country in terms of health care delivery or educational support. During our stay, we visited several health care facilities and discussed at length the problems of health care delivery with the current United Nations personnel in charge of health care in East Timor, some of the East Timorese who will be assuming leadership roles as the UN withdraws, and various physicians, administrators and other personnel currently involved in health care delivery in East Timor. The following summarizes our impressions and recommendations for future opportunities for Yale to provide assistance.
BASIC FACTS ON EAST TIMOR HEALTH CARE - 1
Under the Indonesian Administration, Health Care in East Timor was poorly run
a) East Timorese were, to a large extent,
denied active participation in the Health Care System
b) Life expectancy in East Timor was 48 years (compared to 66 in Indonesia)
c) Infant mortality rates were 135 per 1000 live births
d) Overall health care planning was poorly organized
BASIC FACTS ON EAST TIMOR HEALTH CARE - 2
1. During the struggle for independence, 35% of health care centers were totally destroyed or severely damaged; the remaining 65% had various degrees of damage, but were potentially reparable
2. 67% of the medical equipment was destroyed or looted during the Indonesian withdrawal
HUMAN RESOURCES FOR HEALTH CARE DELIVERY
1. There are about 22 East Timorese doctors -- 6 are out of the country at present receiving additional training in Australia or New Zealand
2. There are about 60 medical students who completed some training in Indonesia. Two are now at Griffin Hospital in Derby, Connecticut, completing their training. The official policy of the UN Health Care Agency is that the partially trained students should return to Indonesia to complete their training, despite threats issued to these students.
3. There are about 400 East Timorese nurses; 11 of these had completed a 3-year diploma course; the remainder, a 3-year high school program
4. In terms of international health professionals, there are currently about 40 doctors and 50 nurses working in East Timor
5. The Interim Health Authority is currently trying to coordinate health care in East Timor
6. Educational resources: The educational system is East Timor is completely disrupted. The University in Dili is just starting to function; there is no medical, nursing, or public health school.
CURRENT ORGANIZATION OF THE INTERIM HEALTH AUTHORITY (IHA)
1. The IHA is composed of 16 Timorese and 9 International health professionals
2. The goals
are to work with the various NGOs, UN agencies and East Timorese to:
a) rebuild and rehabilitate health care facilities
b) train and support East Timorese health personnel
c) ensure an adequate supply of drugs via a central pharmacy for the country
d) maintain a communicable disease surveillance system
e) develop a well-coordinated health care system
3. Current head of the IHA is a WHO official—the aim is to transfer leadership to the East Timorese by the end of the year 2001
GOALS OF THE IHA FOR THE FUTURE
To develop a health care system based on
levels of service. These include:
a) Level 1: mobile clinic and village health post—staffed by nurses and mid-wives
b) Level 2: community health center—no in-patient beds—focus on out-patient care—located in each of 64 health care districts
c) Level 3: community health center with 5-10 in-patient beds; located in each of 8 district capitals
d) Level 4: tertiary hospital -- 5 hospitals (down from the current 8) to be staffed with physicians provided by NGOs working with East Timorese doctors. Specialty services to be provided by teams of foreign health care providers (e.g. ophthalmology and plastic surgery teams to fly in from Australia at fixed intervals)
FOCUS OF HEALTH CARE INITIATIVES
1. Child health—immunizations, basic care
2. Reproductive health—issues of family planning present problems with the Catholic Church
a) malaria: over 100,000 cases diagnosed per year (according to UNTAET), one of the leading causes of death
b) tuberculosis: estimates are that between 15-25,000 East Timorese are infected with TB; less than 1,000 people are being treated
c) Dengue fever: is endemic in East Timor; hemorrhagic dengue fever is not common but present
d) Japanese encephalitis: endemic in East Timor; high mortality rate for those with active infection
e) HIV: no estimates of prevalence; Dr. Ramin Ahmadi is proposing a study to look at this question this summer
EXAMPLES OF NGO INITIATIVES
1. Dr. Dan Murphy: runs a remarkable clinic in downtown Dili; receives no government or UN support; has a small in-patient facility; refers patients requiring hospitalization to the ICRC Hospital; sees 100-200 patients per day
2. ICRC Hospital: 210 beds, 7000 admissions/year, 3000 surgical cases; internal medical service is currently run by two Columbia/Cornell doctors who just completed their residency; they are leaving in the fall and will be replaced by Dutch physicians provided by CORDAID
du Monde: runs primarily out-patient facilities in Dili and Suai; are actively
training village health care workers with a
well-coordinated curriculum; bring the village workers to their facilities for brief stays and intensive training
4. New Zealand Army Base at Suai: provides the most sophisticated level of health care (that we observed) in East Timor out of a field hospital (excellent in-hospital facilities, operating room, lab support); e.g. surgery for ruptured appendix, C-section; 2 children with TB meningitis
5. Fokupers and ETWave, run by East Timorese and supported by NGO funding, provide support, counseling, and shelters for victims of trauma and domestic violence; Fokupers focuses on the empowerment and support of women; one of the ETWave shelters is called Kofi-1, and was a gift of Kofi Annan
MENTAL HEALTH ISSUES AND SERVICES
Mental health issues are of major importance given the recent traumas that the East Timorese have sustained. However, the issues are not being addressed in a systematic way.
1. There is no existing plan to provide mental health care.
2. A recent study of Ramin Ahmadi (JAMA, in press) documents a high incidence of PTSD and depressive symptomatology in East Timorese.
3. There is widespread domestic violence, especially spousal abuse. Women are particularly vulnerable in this society—they marry young, the husband’s family pays a dowry, and thus she is considered the “property” of the husband.
4. There are few reproductive health services—this reflects in part the influence of the Catholic Church.
5. Men, who
have fought for years for independence, have not been adequately educated
with learning or technical skills for work. Their history in the struggle
for independence makes violent behavior more likely.
SUMMARY AND CONCLUSIONS
The development of an effective health
care system in East Timor requires that the following issues be addressed:
a) coordination of various health care programs—the NGOs, Department of Health, United Nations—via a strong central Department of Health
b) complete the basic training of the East Timorese medical students who have completed some training
c) develop longterm educational goals for the country, in terms of strategies to train physicians, nurses, para-medical personnel
d) development of programs to train village health care workers
e) development of basic strategies to provide immunizations; treat endemic diseases, such as TB, malaria, etc.
f) maintain channels of communication with tertiary care centers and academic institutions outside of East Timor
g) organize and provide the health care in the context of
1) the recent traumas of the East Timorese
2) understanding the local, traditional channels of authority—village leaders, shamans, etc.
3) recognizing the economic constraints placed on the country by the lack of basic industry, business, etc.
We think that the areas cited above that require planning and attention represent possible opportunities for Yale to provide assistance to East Timor.
Fredric O. Finkelstein, M.D.
Clinical Professor of Medicine
Susan H. Finkelstein, MSW
Assistant Professor of Social Work in Psychiatry
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