[international medical journal published in UK]
Volume 357, Number 9259, 17 March 2001
In August, 1999, three-quarters of East Timorese adults voted to end more than two decades of an Indonesian administration never recognised by the United Nations. The ensuing spree of violence and destruction by militia backed by the Indonesian military meant the birth of the fledgling nation became a complex humanitarian disaster. 1 year on, progress was heartening: a transitional government, a judiciary, and tax systems were in place, and East Timor was a proud competitor in the Sydney Olympic games. Rebuilding a country from ground level has brought a golden opportunity for fresh approaches. However, reconstruction is also a slow, complex, and sometimes controversial process at the mercy of multiple agendas. The health sector has seen basic care restored, establishment of a much-needed public-health service, and planning for the future health system. An innovative partnership between WHO/Roll Back Malaria and Merlin for post-conflict research has provided data to guide malaria control. The story of progress from humanitarian emergency to national health plan epitomises the triumphs and challenges of this newest nations' first 18 months.
"Let us not be tempted to build and develop modern hospitals that are costly and in which only half a dozen people benefit from good treatment. Let us concentrate above all on planning intensive campaigns of sanitation, prevention, and the treatment of epidemics and endemics for the whole population." Xanana Gusmão, de-facto President of East Timor
At night, Dili, capital of East Timor, is beautiful. Homely light shines from pastel-coloured bungalows and street hawkers' fires along sleepy, palm-lined streets. The town centre houses the colonial splendour of old government buildings that overlook the sea and the sparkle of passing craft. Daylight brings a different story. Gardens that sport wondrous subtropical plants are attached to roofless, blackened shells of bricks and mortar. A look through the broken windows of schools and hospitals reveals the almost complete destruction of public systems and resources. Street children stare wide-eyed at the heavy traffic full of foreigners and local entrepreneurs. And the government buildings, the focus for frequent demonstrations over jobs and prices, now house the United Nations Transitional Administration in East Timor (UNTAET).1
Photo: Dili remains heavily damaged more than a year after the conflagration
The devastation owes entirely to "the conflagration":
revenge wrought for the independence vote in August, 1999, by departing
militia backed by a regime never recognised by the UN.2-4 With
the immediate departure of the international community, ongoing violence,
destruction, and human-rights abuses spread unchecked. A month of freedom
found many dead, at least half the homes in western areas destroyed, and
virtually the whole population displaced. Much of the mainly Indonesian
civil service had fled, taking with them essential technical skills and
knowledge. Widespread looting and damage was especially targeted at agriculture
and food stocks, leaving this mostly rural people to consume livestock
and seeds. The consequences for future food production were graphically
highlighted by the militia graffiti "Timor eat stone".5 When
the international community returned with humanitarian assistance, it was
clear that this half an island would need to start from scratch.
East Timor was illegally annexed in 1976, and public expenditure, including the bloated civil service, was heavily subsidised by the Jakarta-based regime. However, as the World Bank noted in September, 1999, "development outcomes do not appear to have reflected the relatively high level of recorded expenditure",6 a polite way of saying that little money trickled down to the majority East Timorese underclass. Before 1998, a third of households lived in poverty, less than a third had drinkable water, life expectancy was around 55 years, and under-5 mortality was 124 per 1000.7,8
State health care was centred around community health centres, some with inpatient beds, which provided primary care for the widely spread villages, and coordinated "outreach" care by health subcentres, mobile clinics, and village midwives. Tertiary care was eight small district hospitals, the main Dili hospital with the country's 11 specialist doctors, and the Central Health Laboratory. Few people seem willing to talk about the Indonesian system, perhaps reflecting the relative lack of access to a system designed, run, and staffed at senior level by outsiders.9 One nurse told me that a visit to the doctor was usually a last resort. Drugs would be given solely on the basis of a clinical diagnosis; available tests would not be ordered for East Timorese. Many locals relied on traditional medicine involving specific herbal and heat treatments to drive out the particular horok, or evil spirit, troubling the patient.
Photo: The main Dili hospital is currently run by the International Red Cross
During the conflagration, health care was deliberately disrupted2 and facilities specifically targeted: a third were severely or completely destroyed, and less than 9% escaped damage. An assessment by the joint working group on health services in January, 2000, found that two-thirds still had no mains electricity, almost half had no mains water, and 67% lacked vital equipment. In the eastern Lautem district, all ten health posts were destroyed, Los Palos hospital was looted and damaged, and two nurses and one pharmacist were killed. I found one particularly petty reminder of the militia's vindictiveness in the radiology room: an X-ray machine left for the rats to chew any available flex, because the exposure button was deliberately cut off and destroyed. A replacement button is unlikely to be found.
The Indonesian system, after centuries
of Portuguese rule, left other legacies. Jim Tulloch, international co-head
of health, notes that the previous centralised and uniform service "was
based on a standard that was not relevant to local population needs, situation,
or their capacity to maintain it". Timorese co-head of health Sergio Lobo,
who is widely tipped to be the first Health Minister, points out that "under
both the Portuguese and Indonesian systems, Timorese had nothing to do
with planning or managing the system". And if doctors were in short supply
before, they are now like gold dust. In 1998, the country had 133; now,
there are 18 local doctors and five medical students studying abroad who
will graduate by 2001. The situation is similarly dire for other health-care
workers, and a "brain drain" of the most talented individuals is already
making matters worse.
As international agencies poured in, local health-care workers returned to what remained of their workplaces and restarted work without remuneration or often even the basic tools. For 6 months, the priority was humanitarian relief. 18 months on, health is further along in development than many other sectors. The Interim Health Authority (IHA) formed in February, 2000, when international experts from the UNTAET office of health paired with local counterparts to specifically enhance East Timorese sovereignty over their prospective health system. Health-care development has accelerated with the June, 2000, announcement of a US$12·7 million grant from World Bank and UNTAET trust funds, and the designation of the Health Program Management Unit.9
With humanitarian relief hailed as mostly
successful,10 those working within the expanded IHA structure
are mindful that their decisions are laying the foundations for the new
health service. The trick, says Tulloch, has been to use international
resources to provide a breathing space to design the system and develop
policy. To further draw on international expertise, the coordinating non-governmental
organisation for each district was asked in June, 2000, to propose, with
local consultation, a strategy for future district health care. District
health plans have now been implemented. But he and Lobo are keen to emphasise
that overall strategy will not be driven by these post-emergency plans,
which were instead useful to generate valuable data and innovative ideas
Despite huge efforts, services are far from ideal. Of 150 health facilities functioning in June, 2000, most still needed repair, and only 23 had inpatient beds. Of the 592 beds in the country, half of them are in Dili. And even there, drug shortages are evident. Elsewhere, when roads are cut off, lack of fuel for generators means power rationing. When I visited, Los Palos hospital had no bed or window netting, rudimentary toilet and kitchen facilities, and no incinerator--clinical waste was burnt at the back of the hospital grounds. Head nurse Julio Pereira told me that before the destruction, the hospital usually had 30 patients in the 54 beds. Now, the 44 remaining beds are full and sometimes more patients sleep on the floor.
The involvement of several, mainly international, players generates many of the key difficulties, locally and nationally. Suboptimal coordination and communication has led to frustrating gaps or overlaps in services. Most importantly, consultation with the East Timorese has not been adequate, according to La'o Hamutuk, a Dili-based non-governmental organisation that monitors international activity.10 Although great efforts have been made in the health sector, conflicts of culture and clashes of interest have arisen. Some examples are: offers of "high-tech" equipment; co-opting of health-care workers as translators; adoption of international standards of clinical care; and provision of surgical services by peacekeeping forces, all of which can seem reasonable policies in the short-term, but may not be appropriate, affordable, or sustainable in the longer-term.
Local health-care staff face personal difficulties.
A substantial minority still work without remuneration, and the majority
employed by UNTAET face the insecurity of 3-month contracts, irregular
salary payments, and the possibility of unemployment in the new health
structure. Yet, local staff are expected to take on roles and skills they
may never have had, and international organisations usually expect longer
working hours than the standard Indonesian day of 0700-1100 h. These challenges
and the rising cost of living, undoubtedly inflated by the international
presence, seem the main factors involved in generating labour disputes,
ranging from strikes to repeated informal requests for wage increases.
Currently, the IHA national plan divides services into basic, specialist (eg, mental health), and health promotion (including public health). Although the prominence of public health has been criticised as too low, Tulloch counters that basic-service priorities--immunisation, health promotion, tuberculosis control, and nutrition--are key public-health issues. And, he adds, "future health policy is likely to be strongly oriented towards prevention and health promotion". Infectious diseases are the main public-health threat, with high rates of malaria, dengue, diarrhoeal diseases, tuberculosis, and acute respiratory infections. In addition, new data suggest that Japanese encephalitis may be endemic, and cutaneous leishmaniasis has also been newly reported.11
So far, the public-health system consists of vertical programmes for tuberculosis, malaria control, and disease surveillance. Tuberculosis control was readily revitalised as a public programme from the private Catholic diagnostic and treatment programme, with assistance from Caritas--an international confederation of Catholic organisations--and WHO. Meanwhile, the WHO/Roll Back Malaria initiative has taken the unique step of partnering with a non-governmental organisation--UK-based Merlin--that would research and implement a national malaria-control strategy in the field.12
When Merlin arrived in January, 2000, emergency health services were treating record numbers of people with fever, particularly children. However, incidence and prevalence surveys suggested that although Plasmodium falciparum and P vivax are almost equally prevalent in East Timor, malaria transmission is not intense. Moreover, the data suggested that parasitaemia was not well associated with fever, making dengue the most likely diagnosis in patients presenting with fever. In this situation, diagnostic services are essential to reduce inappropriate treatment, and Merlin has now retrained technicians and ensured that each affected district has a basic malaria diagnostic laboratory. Because development can only build on what is left, one future issue is the reconciliation of tuberculosis and malaria diagnostics within district-level laboratory facilities.
As for agencies throughout the country, the key challenge for Merlin has been to fit in with other players and their work, thus avoiding duplication or omissions while ensuring uniform standards, explains Nadine Ezard, project coordinator. Merlin's priority therefore has been liaison with numerous agencies, like the IHA, peacekeeping forces, and diverse non-governmental organisations--at district level and in national programmes (eg, International Rescue Committee for bednet treatment and distribution, Oxfam for health promotion, Aide Medicale Internationale for nursing education). As a small non-governmental organisation implementing a national programme, Merlin initially faced resistance. One senior WHO official privately admitted to me that he was "critical in the early stages", because he did not believe that a non-governmental organisation would offer the same quality as a UN institution. In turn, at a Roll Back Malaria conference in June, 2000, Ezard indicated that future partnerships would benefit from improved information, communication, and technical support from WHO.12,13
One of the most touching stories of health-care reconstruction is that of the Central Health Laboratory, which reopened as a reference facility in June, 2000. Head of the laboratory Vicente da Conceiçâo Reis told me how staff hid laboratory stock, including 22 microscopes, in their houses, away from destruction by militia. After resuming work at the end of September, 1999, staff were not paid until May, 2000, yet all of them subsequently contributed money towards reconnecting water supplies and tending the gardens--a prized feature of all Timorese health-care facilities. Reis also managed to organise an outbreak investigation in late 1999, on a shoestring budget with volunteer staff. The laboratory now offers standard pathology testing, although reagents are lacking for pregnancy and HIV tests, and a telephone and car are unaffordable. Reis's main wish, however, is for easier access to international experts. "We have many, many problems, and we have no money, but we want to see and learn more."
Photo: Sparse facilities at the Central Health Laboratory, Dili
Diagnostics represent a major advance for
the WHO-run surveillance system, and will hopefully soon resolve the major
question of how many suspected malaria cases are due to dengue viruses
and other pathogens. Rob Condon, head of the WHO Infectious Disease Surveillance
and Epidemic Preparedness Unit in Dili, believes that efforts should now
be focused on vector-borne disease control to ensure that all aspects are
in place before a serious epidemic emerges. To this end, Condon has started
an advocacy group of interested parties, but his major concern is lack
of human resources. When I visited in July, 2000, he was cheered to discover
a qualified epidemiologist and two individuals training in public health,
although none is medically qualified. The public-health system might need
to be run by an epidemiologist and a nurse practitioner, he suggests, "and
there will probably be a need for technical support from outside East Timor
for some time".
During the initial emergency, WHO drew up an interim treatment protocol. Chloroquine resistance was reported in Indonesia as early as 1974, and high rates were found in East Timor in 1992 and on nearby Sembeh island in 1998.14,15 So for clinics with no diagnostic facilities or for proven falciparum malaria, the protocol recommended chloroquine with Fansidar (sulphadoxine/pyrimethamine) as first-line treatment for mild-to-moderate disease. Merlin's first job was to disseminate the protocol throughout the country. But, notes Ezard, the proposed treatment of mild-to-moderate malaria was controversial, and many non-governmental organisations decided not to implement the recommendation, "partly because they did not feel the [previous] data were 100% solid and partly because they were not seeing treatment failures with chloroquine alone".
Photo: Recruitment for post-conflict malaria research - Joãzinho da Cruz--an East Timorese nurse employed by Merlin--recruits volunteers to study clinical chloroquine resistance
As usual, more data were needed, but research in an emergency situation, despite becoming Merlin's forte, is not easy. The drug-resistance studies were affected by the common enemies of researchers everywhere: financial constraints and bureaucracy. Meanwhile, in-country logistical difficulties, such as strikes and the lack of housing, meant that the four-way study proposal became a single-drug efficacy study in one site, Los Palos, where Merlin's data indicated 40% parasitaemia, with splenomegaly in 72% of children aged 2-9 years and in 43% of adults.
Joãzinho da Cruz, an emergency-room
nurse, and Edmundo Vieira, a paediatric nurse, were paid a standard R30000
(US$0·30) per day for additional study work. They recruited children
with fever within 24 h--almost no one refused. One participant, 5-year-old
Julieta, had had fever for 30 months, but was brought to the hospital when
she developed chills, cough, abdominal pain, diarrhoea, and vomiting. After
da Cruz checked inclusion criteria and obtained verbal consent from her
parents, Vieira found she had hepatomegaly, severe anaemia, scars from
heat traditionally applied to an enlarged spleen, and a positive rapid
malaria assay. Merlin vector biologist Matthew Burns was not surprised
to find positive thick and thin films with a P falciparum count
of 26667 per µL. Julieta was given chloroquine treatment alone, then
followed up for treatment failure five times in the next month. Follow-up
was virtually 100% because a driver was sent to pick up absentees. This
meant the nurses worked long hours, such as the occasion when I visited:
8-year-old Justina had a rising parasite count at follow-up, but the driver
looked around her village in vain for hours. It was gone 1700 h after a
night shift, and the research nurses remained wholly enthusiastic about
the need for the study. They were looking forward to moving offices because
it meant an end to the leaky roof and research by torchlight in the blackouts.
After 3 months of slow recruitment, partly due to heavy rains when no one could get to the hospital for weeks, Merlin have analysable data from 48 patients. 32 had treatment failure (66·7%); in 31, treatment failed after day 3, and in many, anaemia persisted to 28 days. Genotyping is awaited to determine whether failure was due to reinfection, or as is more likely, recrudescence of disease due to drug resistance. Meanwhile, Merlin has recommended to the IHA that chloroquine is inappropriate for first-line therapy in a setting of such high resistance, a situation likely to be found throughout East Timor.
With first elections proposed as early as August, 2001, the future for the fledgling nation seems hopeful. However, the Jakarta-based government's already loose grip may be weakening on militia active in West Timor. In September, 2000, insecurity necessitated withdrawal of international staff from Oecussi--the vulnerable East Timorese enclave situated well into West Timor. The fate of some 100000 East Timorese refugees in the enclave looks increasingly bleak. And despite the urgent need for the international community to plan its withdrawal as soon as possible to avoid further economic and social distortion,10,16 an ongoing UN presence is likely to be felt for years.
In the health sector, as in the nation, the challenge is to minimise international impact and maintain motivation of the populace in the face of the inherent difficulties of reconstruction--what Lobo describes as "our new national realities". Not all expectations will be realised easily, if at all--a fact that is already leading to discontent and political fractionation. "People fought for and are full of hope for full independence and all that goes with that", observes Tulloch, yet the persisting need for international support "inevitably has postponed their ability to take the situation into their own hands".
Quick, high-profile results, such as childhood immunisation, are a priority for improving not only health but also public opinion, although the concern is that less visible, more complex issues such as human and gender rights, could languish longer on agendas. Full East Timorese participation is the only way to appreciate the complexity of certain issues. For example, condom promotion for HIV prevention might be unacceptable in a Catholic country that harbours not unreasonable historical fears about birth control as a tool of the state. This message would be even less palatable if the country's greatest HIV risk were found to be from international staff, as in Cambodia.17 And although careers will be made for all those who pioneer future systems, these individuals will have to remain sensitive to public perceptions, given the history of occupation and inequity.18 Public notices to conserve water are difficult to swallow alongside the litres of daily mineral water in the UN staff allowance.
Perhaps the greatest test will be long-term health financing. In September, 1999, the UN Development Programme suggested that "conflict for other social resources such as public investment in education suggests that a significant subsidy on the local health system can not be sustainably institutionalised".16 The World Bank has promised a review of health funding, but is clear that "options for medium-term financing include fee for services, private co-payment, and a long-term social insurance scheme".8 The concern is that, post- transition, substantial state funding for health will not sit easily with the focus on economic growth preferred by the Bank and donors. However, clear indications have come from de-facto president Xanana Gusmão for the need for "free health assistance" and from the IHA, which in its minimum standards document calls for services that are "universally accessible to all citizens".
So far, the independence movement's clear
vision for their nation has held true, perhaps because as the stoical leader
of an enduring people put it at the 1999 World Bank Information Meeting,
"we have had a long time to think about it". Freedom is just the start.
I thank WHO/Roll Back Malaria for financial assistance with air travel; to Merlin and their in-country team, especially Nadine Ezard, for facilitating my trip and for supporting and accommodating me in my work; and to everyone, named and un-named, who took time out from reconstruction work to comment.