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Last updated: 19 October 2002
Dr James B Hudson
This activity was undertaken in Bairo Pite Clinic, Dili during the month of June 2001. This work was done on a voluntary basis. An opportunity was available to refresh skills required for the effective diagnosis, treatment and prevention of many of the commonly encountered tropical diseases. Due to the limited pathology and backup facilities available in Dili, this clinical experience also provided for an intense review of clinical self reliance, and bedside diagnosis, together with on overview of public health measures available in such a setting. A unique opportunity was therefore provided to me to reflect upon current practice in Australia.
Location: Bairo Pite Clinic, Dili, East Timor.
Dates: 1 June 2001 - 3 July 2001
THE CLINICAL EXPERIENCE
This activity was conducted in a full-time working clinic. Bairo Pite Clinic offers a wide range of services to the local population including the following;
1. General Outpatients.
2. Inpatient facilities comprising of TB, General medical and maternity wards.
3. TB control and treatment programme.
4. Dental clinic.
6. Outlying TB facility.
7. Limited pathology laboratory facilities.
All the above were supplied at no cost to the patient, including drug supplies.
Limited backup only was available
at the Dili Hospital, which also suffered from a severe lack of facilities
and funding. Pathology facilities were limited to FBC, smears for malaria,
TB and leprosy, and urine microscopy. No support was available from the
medical facilities maintained by the personnel of the various UN forces in
Dili (cf discussion of TB control programme below). A high degree of self
reliance was thus required by the clinic as a whole, and the medical staff
Twelve general nurses
Four pharmacy staff
Four medical students
Eight ancillary and clerical staff
1. General Outpatients.
The bulk of my time was spent in the consulting with general outpatients. Language difficulties were surmounted with the aid of four former Timorese medical students who worked on a roster system as translators, until such times as I was able to consult without their assistance. (These students are employed full-time at the clinic and perform such valuable work as overseeing the TB programme, and assisting in the onsite laboratory).
Much of the work consisted of simple management of many of the conditions commonly encountered in Australian General Practice. Respiratory and renal tract infections, skin rashes and simple musculoskeletal problems were particularly common, and whilst in many cases the management was simple and straightforward, with the high prevalence of both TB and malaria, constant vigilance had to be maintained to avoid diagnostic pitfalls.
Unexplained fever in a child was by necessity treated with caution, as malaria was always a likely diagnosis. Similarly a simple rash could be lepromatous, or the child with meningeal signs could have tuberculous, rather than bacterial or viral meningitis.
Gastric upsets in both adults and children were common, presumably due to a lack of clean drinking water. I believe that a large proportion of those patients presenting with vague abdominal symptoms had parasitic involvement, again as a result of lack of clean water and basic hygiene. The adequate supply of oral rehydration solutions was essential to the survival of many young children, and thankfully this was one item the onsite pharmacy was able to supply in abundance.
The relative absence of conditions such obesity, cardiovascular disease and the other so called "first world conditions" so commonly encountered in Australia can, without doubt be ascribed to lifestyle factors. Psychiatric conditions similarly, made only rare (if dramatic) appearances, and whilst the challenge of presenting such problems through an interpreter may have had a bearing on this, I feel strongly that cultural factors were also at play here. There can be no doubt that a significant percentage of the population suffers Post Traumatic Stress Disorder, given the events of recent years. The low incidence of presentation with this condition is likely to be due to a number of factors, not least of which is the paucity of time and facilities available for management, and the awareness of the local population of this. Given the pressure of work due to infectious disease, there was little opportunity for the clinician to actively screen for this condition.
2. Inpatient Facilities.
TB; Up to eight beds were available for the treatment of TB patients. Diagnosis was usually made on clinical grounds only, although some patients were proven to be smear positive by the clinic laboratory. X-rays were not available. Confirmation of diagnosis was often simply a response to treatment. Patients with TB were admitted if they were smear positive (and thus presumably most infectious), too weak to be cared for in the home, or lived in a distant part of Timor and could not therefore be initiated on the programme as outpatients. These eight beds were usually full.
General Inpatients; Up to seven general medical patients were cared for on a regular basis, although this number was often exceeded in spite of the lack of beds! Common conditions included pneumonia, malaria (both vivax and falciparum in abundance) and dehydration as a result of GI infection.
Maternity; Approximately ninety deliveries occurred at the clinic during my stay of one month. These were mainly attended by the clinic midwives who were thoroughly competent. During the month of June, there were no deaths, and only two maternity patients required transfer to Dili Hospital. These patients were as follows, amniotic fluid embolus in the presence of anaemia secondary to malaria, and a severe post partum haemorrhage. Whilst I ascribe the low incidence of referral to the competence of the midwives, and to the large percentage of multips at this clinic, I wonder if the lack of sophisticated monitoring devices may have played a role. This situation contrasts sharply with current practice in Australia.
3. TB control and treatment programme.This was one of the busiest parts of the clinic. Perhaps the single most important aspect of this programme was the education of the population regarding TB. Also vital was the overseeing of medication regimes, and ensuring compliance amongst those infected. Screening of family members of affected patients was also undertaken, although this was not always possible, as in some instances patients had come from distant parts of Timor. Every effort was made to ensure compliance with treatment regimes, and indeed in the early stages of treatment, many patients were admitted, or had their medication directly observed.
This programme was primarily run by nursing staff, and two of the Timorese medical students. It is a tribute to the efforts of these people that the UN in Dili referred suspected TB cases amongst their staff to this clinic, and to this TB programme.
Working with, and observing this part of the clinic, I was able to gain good insights into the problems (and solutions) involved in controlling a serious disease, with a high prevalence, in a community which is at this time struggling to maintain basic hygiene and nutrition.
4. Dental clinic.
This part of the clinic was fortunate to have a fulltime dentist who had volunteered his services. Again, however, much of the work was performed by nursing staff who had been trained on-site. Work was primarily limited to extractions.
Drugs required to treat the major, and the common diseases were in good supply, and available from central Dili pharmacy at no cost. Thus treatment of TB, leprosy, malaria, scabies, fungi etc presented no therapeutic dilemmas. There was however, little choice of drugs for the treatment of many other conditions.
Asthma, for example was not so straightforward to treat, partly due to the very limited choice of drugs. The question "should I use steroids to terminate this asthma attack?" was, for example complicated by the risk of provoking TB in a previously asymptomatic patient, and by the fact that the drug options consisted of salbutamol, prednisolone and hydrocortisone only. This situation once again contrasts starkly with that in Australia, with our plethora of drug options, treatment plans and options.
6. Outlying TB facility.
This part of the clinic was situated on the other side of
Dili, and was the analogue of the old style sanatorium. This facility was
visited on a twice weekly basis, and had twenty four beds. Whilst all the
patients here had active TB, most were inpatients simply due to social
1. The practitioners knowledge of conditions rarely seen or treated in General Practice in Australia, is to some degree dormant only. Hands on experience leads to a rapid acquisition of new skills and knowledge, and a rapid reactivation of old skills and rarely used knowledge.
2. The absence of backup accelerated the process described in point 1.
3. The standard of care provided at this facility, given the severe constraints, was absolutely first class.
4. Whilst limitations in pharmaceuticals, pathology services etc. do, to some degree impact on the approach of the clinician, this does not necessarily need to significantly affect the efficiency of the facility to provide good health care.
Dr James B Hudson BSc MBChB FACRRM July 2001
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