Childhood Illnesses

INDEX

Infant Mortality Compels Aussie Doctor To Support Timor Sea TV Ads 

Inheriting the World: an atlas of Children's Health and the Environment

Miracle workers of East Timor The story of OSSAA work to repair cleft palates in Timor Leste. From an article by Rochelle Mutton NT News October 9 2004

Management of the Child with a Serious Infection or Severe Malnutrition

UN and Japan support national immunisation campaign UNMISET Dili, 21 October 2003 .

Eleven thousand Children in East Timor are Malnourished . UNMISET  Dili, 14 October 2003 .

Government Leads Community Consultation In Rollout Of Poverty And Child Welfare Data . January 15, 2003 .

Childhood in East Timor: Mortality rate is 124 per thousand JSD Lusa/End Lusa Agency. 11 December 2002 .

A Household Level Analysis   A study looking at use of trad ional treatment of child illness by Angela Rogers, MPH Yale University August 2001.

Infant Mortality Compels Aussie Doctor To Support Timor Sea TV Ads 

Thursday 21 April 2005

www.timorseajustice.org

Emeritus consultant gynaecologist, Barry Mendelawitz, who spent time working in East Timor, has felt compelled by the abysmal state of East Timor's health system to urge the Australian Government to give our neighbours a fair go in the Timor Sea. 

Featuring in the next phase of Ian Melrose's television ads, Dr Mendelawitz said the appalling conditions in East Timor could be significantly assisted by increased revenue while the country struggles to establish a viable economy and believes a fair share of the gas and oil in the Timor Sea is the most obvious source. 

"During my time in East Timor at the National hospital, it was almost a daily occurrence for a dead baby to be delivered," Dr Mendelawitz said. 

Dr Mendelawitz, who has forty years of experience in health service delivery, said twelve out of every 100 East Timorese children will die before the age of five and East Timor has the highest maternal mortality rate in the region. 

"In 2003, almost one in five babies born in the national hospital was born dead and there's every reason to expect that conditions are even worse in areas outside of Dili. The vast majority of births are not attended by professional health workers, in the regional districts it's just a case of relatives assisting with births," Dr Mendelawitz said. 

Dr Mendelawitz believes the revenue from gas and oil in the Timor Sea would have a major impact in allowing East Timor to address overwhelming levels of poverty, illiteracy, preventable disease and widespread hunger. 

"The business of negotiating maritime boundaries should have been mediated a long time ago, because in the meanwhile East Timor is in desperate need of funds for basic services such as health and education," Dr Mendalawitz said. 

He also strongly supports the Timor Sea Justice Campaign's calls for the Australian Government to put contested gas and oil revenues into a trust fund until the dispute is resolved. 

"It's the only way to ensure money that East Timor is legally entitled to, isn't spent by the Australian Government," Dr Mendalawitz said. The ads will screen nationally from tomorrow night on channels Seven, Nine and SBS. 

Protest rallies for 'A Fair Go For East Timor' are taking place at 12noon in both Sydney and Melbourne next Tuesday when maritime boundary negotiations resume in Dili. 

For more information, please contact: Tom Clarke, co-ordinator, Timor Sea Justice Campaign, Melbourne, 0422 545 763.

www.timorseajustice.org

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Inheriting the World: an atlas of Children's Health ant he Environment

Gordon B Mackay R Rehfuess. WHO Geneva 2004

A review of this recent publication by Mark Raines

This book contains many coloured maps and snippets of data. Unfortunately, data from East Timor is lacking for a many areas. In some cases the data is from neighbouring Indonesia .

Illness

10 million children under the age of five years die prematurely every year. 98% of these deaths occur in developing countries. 

2002 Main causes of child mortality

Death associated with malnutrition 54%.

In 1998 North American and Europeans spent $17 billion US dollars on pet food. In 2001 the cost of scaling up vaccinations, malaria prevention and essential treatment to reach every child in the developing world was projected to cost less than half of that; 7.5 billion US dollars. In Timor Leste the under 5-year old mortality is 126 per live births (2000 data) which is worse than neighbouring Indonesia at 50 per live births and Australia with 6 per live births. Timor Leste's child mortality rate is half of Nigeria 's despite that countries oil resources. 

Cooking

Every year smoke from solid fuels in the home kills one million children under the age of five years worldwide. Particulates in smoke lead to pneumonia and other respiratory illnesses. In many East Timorese homes wood is used to fuel cooking fires. Most houses in Dili have a separate kitchen, often outside under cover which reduces exposure to smoke. East Timor gas is a promise that is still far away.  

Water 

Intestinal diseases caused by unsafe drinking water include diarrhoea, cholera, dysentery and typhoid. Access to water is essential for simple hygiene measures such as washing hands after defaecation. Uncovered water sources may be breeding grounds for mosquito borne illnesses such as malaria, dengue and Japanese encephalitis. Inadequate sanitation and lack of clean drinking water tend to go hand in hand. One gram of faeces may contain 10 million viruses, 1 million bacterial, a thousand parasite cysts and a hundred worm eggs. In many remote villages time much time is spent in just carrying water from wells to homes. This is the work of women and children. Water contaminated by toxins such as lead, mercury and arsenic, all of which conspire to stunt a young mind and body.

Wash Your Hands - Hygiene promotion posters published by the Ministry of Health in East Timor (By Mark Raines 2004)	This young East Timorese girl enjoys fresh clean water because of the work of an NGO, Kids Ark , in the village of Sidara near Hera, a short drive from Dili. (By Mark Raines 2004)

Ninety percent of the worldwide deaths due to malaria occur in Africa , even so almost 60,000 under 5-year-old children died in South East Asia in 2002. Malaria affects a child's education through illness, neurological insult from repeated infection and anaemia. Drug treatment is only one weapon in the battle against malaria. Any standing water provides a breeding ground for the mosquito. Insecticide-treated mosquito are another important measure. 

Passive smoking

Many men and some women smoke cigarettes in East Timor . Children are exposed to carcinogens and particulates in cigarette smoke. Middle ear infection, respiratory illness such as asthma and pneumonia and cancers are linked to passive smoking. Mothers who smoke increase risk of small babies, premature delivery and other problems in pregnancy. Children see their parents smoke and may well take up the habit.

Injuries

In East Timor as other countries around the world, children face the prospect of injury. Thankfully there are no mine fields and few guns to maim an adventurous child but there are still hazards aplenty. The road is a major hazard. Children play in the street as there are few open parks, they are often balanced onto a motorcycle with Mum and Dad, wandering pigs and dogs are another hazard, falling from trees and falling into open drains may also await them. Poor health care can then compound their injury. I met a young boy who fell from a tree, broke his arm but never received proper medical attention, that arm is now uselessly deformed form an incorrectly applied plaster cast. 

Child labour

Every year 25,000 young lives are lost in work place accidents throughout the world. It is perhaps fortunate that East Timor has few employment opportunities for young children. Yes, some children do have to labour in the field for their family instead of gain an education. But there are no mines or multinational run sweatshops that are suited to exploitation of children. 

Gangs of idle young men can be seen standing around Dili. I wonder what these young minds will turn to if the government cannot provide job. Although many young people have access to schools, some parents cannot afford the fees. 

Children do work in prostitution in East Timor . BPC treats young women with sexual transmitted infections that are an occupational hazard in a culture that doesn't believe in condoms. Infertility or an early death due to HIV is their prospect.

Statistics

Timor Leste 739,000 people of which 48% are under the age of 18 years. The gross national income in 2002 was USD $520 per capita. As a comparison 24 % of Australia 's population is less than 18 year and its GNP was USD $19,740. 

Good economic management of oil resources, access to improved education, sanitation, water and food, immunisation, disease treatment are all key issues in improving the future for the children of Timor Leste. 

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Miracle workers of East Timor

From an article by Rochelle Mutton (NT News October 9 2004 )

The plight of thousands of East Timorese is in safe hands of a hard-working group of Aussie volunteers. The Overseas Surgical Specialists Association of Australia (OSSAA) includes a core of the group's volunteers, an Adelaide surgeon, a Sydney plastic and reconstructive surgeon, South Australian theatre nurse and a Darwin organiser-translator. 

The group was formed after Adelaide plastic surgeon Dr Mark Moore joined retired surgeon Dr John Hargrave in East Timor in June 2000. He saw first-hand children sentences to lives of cruel prejudice discrimination and physical disability and pain by deformities he could fix in hours. Dr. Hargrave, a respected leprosy specialist, hand and burn surgeon, based in the Northern Territory from 1956 to 1995, recognised the need for a reconstructive and rehabilitation surgical service in Eastern Indonesia and East Timor in the early 1990s. Many people in the region suffer from physical deformities and disabilities arising from leprosy, burns, trauma, poliomyelitis and congenital defects. There is no surgical service available in the rural hospitals and the majority of the rural population cannot afford to pay for the service. 

In the early 1990s, Dr. Hargrave led small teams of specialist doctors to West Timor under Northmed, to develop reconstructive and surgical programmes. In 1995, when Northmed no longer functioned, Dr. Hargrave registered the organisation under ASEA Rehab (Australia-South East Asia Rehabilitation Foundation), a Northern Territory based organisation, limiting participants of the surgical teams to Northern Territory residents. Due to limited specialist personnel from the Northern Territory , most of the specialists undertaking the surgical visits under the auspices of ASEA Rehab are based in Adelaide . In addition, much of the support and interest of the programme was generated from South Australian organisations, hence OSSAA was founded with the committee of management based in Adelaide to allow the main participants of the surgical teams to contribute towards its operation. Dr. Hargrave retired in the year 2000, and has nominated surgeons, Dr. Peter Riddell and Dr. Mark Moore to continue the specialist surgical programme in East Timor , West Timor , Flores and Papua. 

Outside a medical clinic in the East Timor highlands waits a 15-year-old girl whose youthful beauty and trendy street wear makes her standout among the villagers in the queue. Bertha de Costa Meskuita is here to show off the best gift she ever had, a normal face! It has taken her more than a day's walk from her bamboo village along rugged mountain path to get here and despite arriving early she is last in line.

Behind the open windows of the Aileu Clinic two hours south of Dili, plastic surgeon Mark Moor listens to a variety of tales. Eleven-year-old Marcelina's toes were burnt off in a fireplace accident a decade ago and the skin remains badly calloused. Maria, 9 years of age, has a mysterious dark lesion on her thigh and one-month Fatima has a cleft lip that without surgery will become a life-long stigma, hindering eating, speech and possibly destroying her prospects for marriage. 

The warmth of Dr Moore's smile melts the children's fears and belies the seriousness of his work. For each patient's problem he considered sophisticated surgery that is nothing short of a miracle to there highland people. Finally local Maryknoll Sister Susan Gubbins announces the patient list is complete – except for a little surprise. The clinic's nuns watch expectantly as Dr Moore walks to the door where the best has been saved for last.

Among the core of the group's volunteers is Sydney plastic and reconstructive surgeon Antonio Fernandes who has made six trips with the team. Equipped with little more than instruments and sutures he has performed dozens of operations that dramatically improves lives of many East Timorese children. He says he was “shell shocked” by his first visit in 2002 when the team stayed in a hospital room with a squat toilet and every night down the corridors a child died from a preventable disease. Since then the surgeon had not only adjusted but come to deeply values the life lessons he has leant from East Timorese as he shared his surgical skills.

“There are some cases that really wrench your heart and we think how lucky we are”, he said “But poverty doesn't their pride. They've taught me a lot about life”.

The elite plastic surgery team also includes a specialist anaesthetist, Steve Kinnear of Adelaide and Peter Malcolm of Sydney , Adelaide theatre nurses Liz Mazzel and Penny Craig and trip organiser-translator Ruth Boveington. 

“A lot don't go to school. They're seen as inferior, some struggle to talk and others are hidden away”, Dr Moore said. “By making them normal you can produce a dramatic transformation and quality of life”.

This is what makes plastic surgery in East Timor so different. Dr Fernandes performs reconstructive microsurgery on facial fractures and congenital disorders but 30% of his work is of purely aesthetic value. But across the Timor Sea , the OSSAA team changes lives in totality, correcting many horribly disfiguring burn scars and more than 200 cleft lips and palates. The clefts, a grotesque splits of the lip and open roof in the mouth occur in every 1000 East Timorese baby. Congenital deformities are more common in East Timor than Australia , as genetics conspire with other factors such as poor nutrition, smoking and parents having children well into their later years.

Along the coast three hours east of Dili is one the plastic surgeons regular rendezvous, Baucau. The once serviced municipality has been bereft of electricity for six months and abundant fresh water supply dried up undoubtedly diverted from upstream. The average income flounders at the international poverty line of $1 a day. Most people can't afford to eat more than twice a day and even then they only eat rice an vegetables with meats a luxury once a month.

In the last few years, East Timor hospitals have received vital information donated by the Australian government and strengthened by hard working local staff who help the plastic surgeons scrub, anaesthetise and scout for equipment during operations. The local medicos use schools and the Catholic Church as a village telegraph to announce the plastic surgery team's arrival. Inevitably a long queue gathers the morning the Australian roll up and everyone is guaranteed an assessment. 

While high priority cases will be operated on within days, there is always too much work to do. Dr Fernandes laments that many children will have to wait for when the surgical group returns later in the year. 

“What hurts me is when we leave other 50 we can't operate on, they're as important as the 20 we did” he said.

Nothing seems to happen easily or quickly in this part of the world, which makes the efficiency of the Australian plastic surgery team, breathtaking. Here the total health budget for 800,000 people is just $8 million a year or $10 per person per year. The work of OSSAA is not only changing individual lives but leaving a legacy that helps build public trust in hospitals and redefines health care. 

“It shows a health system starting to work, starting to care for its people”, Dr Moore explained. “Hospitals in Indonesian times from 1975 to 1999 were places were you went to die. People weren't well looked after.”

The lapse in good post operative care during that period meant that some children who had surgery on there cleft palates were not correctly monitored and bled starved the brain of oxygen and causing permanent brain damage or even death. One of the more rewarding part of the Australian team's work has been establishing trusts the East Timorese through word of mouth. Dr Kinnear, a specialist anaesthetist with OSSAA, says it is amazing the East Timorese children have faith in their team. "

I think they're terrified, some of them, and fearful of what's going to happen”, he said. “But in Baucau and Dili where we've been before there is a degree of trust. They hand themselves over to the nursing staff and jump on the bed and let me give them an anaesthetic. You wouldn't find kids in Australia willing to do that, they'd be crying and screaming, understandably.” 

One of the major long-term goals of the plastic surgery team is to fix every cleft lip and cleft palate in East Timor until they are only operating on new deformities as they appear in new-borns, as happens in Australia . The sums have been done and at the current rate of 40 cleft operations per visit, clearing the back log is achievable in five to six years. That is based on there being about 800 clefts and taking into account the some require multiple operations. The expense of each trip comes to about $15,000 to $20,000 which is pretty cheap plastic surgery considering treating a burns patient in Australia costs $100,000. Trip expenses have so far been met by the Royal Australasian College of Surgeons form its AusAid allocation, Rotary , Lions and other service clubs. “Certainly any fund raising we get is invaluable because that is what we rely upon”, Dr Moore said. “The dedication of the plastic surgery team is certain, even if the future funding is not”. 

“It's personally fulfilling”, says Dr Kinnear, who has been to East Timor four times as part of the OSAA team. “Seeing a child's face put back tother in a space of a couple of short hours, it is impressive”. The reaction of parents is fantastic. I've seen mothers crying for joy. Its an expression you don't see too often in parents especially East Timorese who are used to putting up with a lot”

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Management of the Child with a Serious Infection or Severe Malnutrition

WHO website

This manual is for use by doctors, senior nurses and other senior health workers who are responsible for the care of young children at the first referral level in developing countries. It presents up-to-date clinical guidelines, prepared by experts, for both inpatient and outpatient care in small hospitals where basic laboratory facilities and essential drugs and inexpensive medicines are available. In some settings, the manual can be used in large health centres where a small number of sick children can be admitted for inpatient care.

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UN and Japan support national immunisation campaign

UNMISET PRESS RELEASE Dili, 21 October 2003

A national campaign to immunise Timorese children against measles kicks off in Dili tomorrow when First Lady Kirsty Sword Gusmão takes her 2 children to receive their immunisation and vitamin A supplements. The campaign will last until the 29th of October and aims to vaccinate some 130,000 children through 738 health posts across the country. 

UNICEF and the World Health Organization (WHO) are supporting the government's initiative, and Japan has provided U$ 1.5 million to finance the procurement of vaccines, syringes, needles and boxes for safe disposal of used needles, among other things. 

All children aged between 6 months and 5 years old [59 months] will be vaccinated and receive vitamin A supplements.

Mobile teams will cover isolated locations one week after the national campaign to ensure no child is left out. Remote villages will receive information on the dates the mobile teams will visit them.  PKF, Pastoral da Criança, Café Timor and other NGOs are actively involved in helping disseminate information on the campaign and in reaching remote areas. 

For further information contact: Marcia Poole Spokesperson/UNMISET Mobile: + 670 723 0793 Telephone: + 61 8 8946 3900   Ext. 6059

From: East Timor Action Network

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Eleven thousand Children in East Timor are Malnourished

UNMISET  Dili, 14 October 2003

The Deputy Minister of Health Luis Lobato told Timor Post on Monday that according to information collected by the health clinics around the country, 11,000 Timorese children under the age of five are malnourished. Lobato said the Health Department is taken the issue very seriously and 20 per cent of these children have already received food through the malnourished program. He added that several children had to be admitted to the national hospital and their condition are under medical supervision .

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Government Leads Community Consultation In Rollout Of Poverty And Child Welfare Data

January 15, 2003

The government of Timor-Leste is hosting a series of information and discussion forums based on the Poverty Assessment Report and the UNICEF Mother and Child Welfare Survey Report (also known as the Multiple Indicator Cluster Survey – MICS). The Poverty Assessment was supported by the World Bank, the Asian Development Bank (ADB), the United Nations Development Program (UNDP), and the Japan International Cooperation Agency (JICA). It comprised the 2001 Suco Survey, the Participatory Potential Assessment (PPA) and the Household Expenditure Survey. The findings of the Suco Survey and the PPA were finalized and presented in October 2001 and March 2002 respectively. The results from the full analysis of the Household Survey and MICS are being disseminated through forums being held in Dili this week with additional regional forums in Baucau, Ainaro and Maliana next week.

The Household Survey findings will be discussed by forum groups in the context of the national priorities already set by the government in their National Development Plan (NDP), and can be used to assist the government and local communities to develop practical interventions to reduce poverty and enhance the economic and social welfare of the people. The consultations will involve government officials, civil society including the Church, womens', students' and youth groups, NGOs, Chefe de Sucos and development partners.

Some of the key findings include:

Timor-Leste is not only a new nation, but a very young nation with approximately half of the population under 15 years and many moving into reproductive age in the next decade

The trend is for women, on average, to have seven children each. This is one of the highest rates in the world - putting pressure on the health of women and children, as well as squeezing social services and dramatically increasing the needs for job creation as this population reaches working age.

Education is a key factor in the reduction of poverty and while the government has done an excellent job in boosting school enrolments, especially amongst the poorest in the community (a quarter of the national budget is spent on education), there are still several key challenges: non- attendance is still at around 10%; many children do not start school until they are 8 or 9, making them 13 or 14 by the time they finish elementary schooling; the age discrepancies in classes makes teaching more difficult as children in a classroom are at different stages of social development; dropout rates are much higher for children 14 and over.

Literacy is a significant issue with 3 out of every 5 adults not having attended school and are therefore illiterate

Infant and child mortality rates are high with around 8 – 9% children dying before the age of 1, and another 3- 4% before the age of 5. The government has done a commendable job in boosting immunisation rates, especially in urban areas, but rates are still low with only about 5% of children aged 12 – 23 months having received their full cycle of immunisations at the time of the survey.

Malnutrition – defined as not just too little food, but too little access to a wide range of necessary nutrients – is high in children in Timor-Leste with about 43% of children under five deemed to be moderately or severely underweight.

Food insecurity is a substantive issue for more than two-thirds of the population who stated they had inadequate food in the months between the rice and maize harvest (November to February).

This round of community forums and consultations will be followed by the dissemination of a composite report that incorporates the findings of the three components of the poverty assessment – the Suco Survey, PPA and the Household Survey. This will be done at the national level as well as with Chefe de Sucos across the country so the information gets to the grass-roots communities and local village-based solutions to issues can be developed.

World Bank Group Dev News Media Centre

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Childhood in East Timor : Mortality rate is 124 per thousand  

JSD Lusa/End Lusa Agency. 11 December 2002

East Timor has a mortality rate for children less than 5 years old of 124 for every 1,000 births, which ranks it in 36th place in the list of countries with the highest mortality rates, states a UNICEF report released today. ntitled "Situacao Mundial da Infancia/2003" [TN: possibly: "State of World Childhood/2003 "], the document analyses a series of data on East Timor and 192 other developing nations. 

The mortality rate for children under one year of age is 85 in a thousand.

Although the study provides health data for most developing countries, such as data on HIV/Aids, nutrition and education, in the case of East Timor it reports no such data because they are not available. The study states that the East Timorese population under 18 years old (375 thousand people) corresponds to one-half of the population (750 thousand people), and that there are 90 thousand children under 5 years of age.

The annual population growth rate between 1979 and 1990 was one percent and has dropped 0.1 percent in the last decade. The percentage of urban population was 8.0% in 2001. In the 1970s, the raw mortality rate was 24 per thousand and dropped to 14 per thousand in 2001. The birth rate also dropped from 45 per thousand in the 1970s to 25 per thousand in 2001. Life expectancy in East Timor rose from 39 to 49 years of age in the last three decades.  

Concerning women [fertility], data as scarce, but point to the prevalence of contraceptive use by 27%, coverage of pre-natal care by 71% and to 26% of births being assisted by technical qualified people. 

For East Timor , only one economic indicator is mentioned, that of the entry fluxes of the "Official Assistance to Development", which were about 233 million dollars (about the same in Euros) in year 2000.

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A Household Level Analysis -  Preliminary Report of Findings

Primary Investigator: Angela Rogers, MPH Yale University

  In cooperation with Bairo Pite Clinic Dili, East Timor  August 2001

Note: This is a preliminary report offindings with basic analysis. For a copyof the completed report when finished, including a more comprehensive analysisof the data, please contact Angela Rogers ( email ).

BACKGROUND

East Timor is currently in a transitional reconstruction phase, recovering from a total collapse of the country's health infrastructure which was virtually demolished following the August 1999 referendum for independence from Indonesia. During the rampage of violence and destruction, the Indonesian militia damaged 77% of health facilities, and looted or destroyed 67% of the medical equipment. [1] Indonesian doctors and health workers left East Timor just prior to the elections, leaving only 35 East Timorese doctors in the entire country. In addition to a severe shortage of trained health workers, the country faced the aftermath of massive displacement of the majority of the population (75%), which occurred after the independence referendum. [2] Conflict, displacement, and gross human rights violations have only exacerbated the already poor health status of the East Timorese.

Currently East Timor faces a multitude of major health challenges, including acute respiratory infections, diarrhoeal diseases, malaria, dengue fever, malnutrition, and tuberculosis. WHO has identified treatment of common childhood diseases (diarrhoea, malaria, and acute respiratory infections) as among the highest priority of current health issues for East Timor . [3] Reconstructing the health infrastructure in East Timor is an immense endeavour. At present each of the thirteen districts in the country has a non-governmental organization (NGO) appointed as the lead health service provider, although there are plans to transition the provision of these services to the Division of Health Services. To date, there is no country-wide standardized provision of services and training among the many health NGOs. This has major implications for attempting to assess health at the national level, and no systematic assessment of the health and nutritional status of the East Timorese population has been performed. WHO states, “Although health statistics are available from prior to the referendum, the environmental, economic and personal health conditional are now very different than they were in the past.” [4]

There is a great need to ensure that international NGOs and health professionals have a good understanding of cultural concepts surrounding health and disease, home treatment of illness, use of traditional medicine, and the factors influencing utilization of health care services. This is especially relevant in light of a history which includes cases of mistrust of foreign (Indonesian) medical personnel, as well as human rights violations committed by Indonesian medical personnel (e.g. forced sterilization's, etc.).

It is recognized that traditional medicine is part of Timorese culture, and has been in existence since before the Portuguese colonization. [5] However, despite the widespread use of traditional medicine, virtually no research exists on the subject. It is difficult to estimate either the positive or negative impacts traditional medicine might have in East Timor , because of the sparse knowledge of the relationship between traditional and western medicine. Parents and caregivers are faced with many choices in treating a child's illness – whom to ask for advice, what treatments to use at home, whether to use traditional or Western medicine, and when to take their child to see a doctor/nurse or to a traditional healer. The specific aim of this research project was to examine the treatment of child illness in Dili through informal interviews as well as a household questionnaire designed to gather information on home treatment and care practices, use of traditional medicine, use of clinics and traditional healers, and factors influencing seeking care from health providers. This research project was conducted in Dili, East Timor during June-August 2001 in coordination with Bairo Pite Clinic. Funding for this project came from the Down's International Travel Fellowship at Yale University , and the Office of Student Research at Yale University School of Medicine.

METHODS

Instrument

The questionnaire used for this study was compiled from questions used in previous questionnaires in developing countries, as well as original questions. The questionnaire was translated into both Tetum and Bahasa Indonesia by native speakers, back-translated into English, and field tested. Six East Timorese workers from Bairo Pite Clinic were trained to administer the questionnaire. The questionnaire was administered in Dili between July 11, 2001 – July 16, 2001 . Informed consent was received from all participants. In addition to data collected from the questionnaire, informal interviews were conducted with traditional healers, health workers, and the lay public to gather more qualitative data. The questionnaire was approved by the Human Subjects Research Review Committee at Yale University School of Nursing (protocol #01-34). In addition, this research project was approved by Dr. Dan Murphy of Bairo Pite Clinic.

Sampling

A sample size of 360 households was originally selected to estimate a population proportion with specified absolute precision (within 5% on either side) at a confidence level of 95%, and taking into consideration the design effect of cluster sampling. Thirty clusters were selected among eligible clusters (sukos in urban Dili), and 12 households from each cluster were interviewed. Cluster selection was based on the Probability-Proportional-to-Size (PPS) method. Households within clusters were selected using the Random-Walk Method (as used in EPI surveys). Only eligible households were interviewed. Eligibility consisted of having a child in the household under five years old who was sick in the previous 30 days. Eight surveys were excluded from the study due to ineligibility (children were five years-old), leaving a final sample count of 352.

RESULTS & DISCUSSION

Informant and household demographic information

Participants were given the option to have the questionnaire conducted in either Tetum or Bahasa Indonesia. In total, 86.4% of questionnaires were conducted in Tetum, and 13.6% in Bahasa Indonesia. The majority of informants interviewed were female (83.5%). The mean age of informants was 30.7 years, with ages ranging from 17 years old to 78 years old. The highest level of education completed for informants varied substantially: 16.2% of informants never attended school, 10.3% completed up through Primary School (SD), 21.4% completed Middle School (SMP), 47.6% of informants completed secondary school (SMA), and 4.5% completed university. Most of the informants (77.8%) were the mother of the child in question; the remaining informants include: father of child (15.0%), other relative (6.9%), and non-relative (0.3%). Households interviewed had a mean number of 2.1 (median 2.0) children under five-years-old living in the household.

Child information

Information was gathered on 352 children under five years-old who were either sick at the time of interview, or sick within the previous 30 days. If multiple children in the household were ill in the previous 30 days, the child who was most recently ill was selected. The age distribution of children is included in Figure 1 below.

Figure 1 - Age of children

Of the children included in the questionnaire, there was a higher percentage of males (53.4%) than females (46.6%) who were reportedly ill. Statistical significance of this difference has not yet been determined.

Child symptoms/ Health problems

Informants were asked to describe the child's illness, and to list up to three symptoms/ health problems. The average number of symptoms reported was 2.8. The five most common symptoms reported include: cough (69.0% of children), runny nose (47.2%), fever (44.9%), diarrhoea (21.3%), and fever with chills (15.3%).

Advice sought before taking child to provider

Informants were asked whether they sought advice or consulted anyone else about the child's illness before taking their child to see a provider. Interviewers recorded up to three people from whom advice was sought. A majority (63.9%) of informants responded that they did seek advice or consult with at least one other person, while 36.1% replied that they did not seek advice or consult with anyone. Those who did consult with someone else consulted with on average 1.58 people. Those consulted most frequently were the informant's spouse (66.2% of cases where advice was sought from at least one person), informant's mother (40.4%), other female relative (22.2%), and friend/neighbour (21.8%). Refer to Figure 3 below for a complete listing. Although not surprising, it is important to recognize that most caregivers are not acting alone in making decisions regarding their child's health. This should be a consideration in health education efforts.

Home treatments given

One specific aim of this study was to identify possible areas of concern and potential areas of education in regards to home treatment of illness. In order to do this, informants were asked to identify up to three home treatments given to the child before the child was taken to see a doctor/nurse or traditional healer. A majority (66.5%) of informants gave the child at least one treatment before seeking additional care from a health provider. Of those who first gave a home treatment before seeking further care, an average of 2.13 treatments per child were used. Of those children who received at least one home treatment, the most common home treatments given include rubbing coconut oil on the child's body (38.5%), rubbing a mixture of coconut oil and onions on the child's body (28.6%), compress (25.2%), medicine bought from the market/store (20.9%), and Oral Rehydration Salts (ORS) - including both store bought and homemade (15.4%).  

It is of interest that 13.9% of all respondents (20.9% of respondents who used at least one home treatment) gave their child medicine which had been purchased from the market or store. Informants were not asked what medicine was given, but a full range of medicines from aspirin to antibiotics and analgesics are sold in the market. There are no regulations on the medicines sold – some medicines are expired, others may be unsafe for children. There certainly are no provisions to ensure that the appropriate medicine or dosage is given to the child, or that the seller of the medicine has adequate knowledge of the drugs he/she is selling.  

While the majority of traditional home treatments (use of leaves for tea, coconut oil, etc.) appear to be safe, one potentially dangerous traditional home remedy is the treatment informants reported using for worms – smelling a mixture of petrol and onions, and rubbing it on the belly of the child. Of the 31 children with worms that were given a home treatment, 11 (35.5%) were given the petrol-onion mixture. While the efficacy of this treatment is unknown, there are safer alternatives available to treat worms. 

A total of 14.7% of all children (22.2% of children who were given at least one home treatment) were given traditional medicine that consisted of using the leaves/bark/milk of trees or plants. Informal interviews support the theory that there is, on the whole, a broad level of knowledge of traditional medicine and its uses within the general population. This is not surprising given the long history of traditional medicine in the country, as well as the history of forced displacement of the population and periods in which health care has been inaccessible or unavailable.

Providers seen

Another primary area of interest in this study was to determine which providers caregivers take their child to when ill, the reasons why, and the sequence of providers if multiple providers were seen during the course of the child's illness. This study included anyone the caregiver took to see outside of the home as a provider. Informants were asked who they took their child to see first: ema hatene aimoruk timor (a person who knows about traditional medicine/traditional healer), matan dok (literal translation “eye far” – a matan dok is similar to a shaman – they predict the future, treat spiritual problems as well as health problems, and use traditional medicine), doctor/nurse, a person who sells medicine in the market/store, or someone else. Nearly all informants (95.7%) reported that the first provider they took their child to see was a doctor/nurse. Only one informant (0.3%) responded that they first took their child to see a traditional healer, and one informant (0.3%) took their child to see a person selling medicine at the market/store. Two informants reported taking their child to someone other than a doctor/nurse, traditional healers, or person selling medicine at the market. Eleven respondents (3.1%) did not take their child to see a provider. No one reported taking their child to see a matan dok .

To gain better insight into health seeking behaviour, informants who took their child to see a doctor/nurse as first provider were asked the open-ended question of why they took their child to see a doctor/nurse first instead of someone else. Common responses include:

·        The doctor knows all about medicine, illness and how to treat sick children

·        The doctor is good/best; we believe in the doctor

·        We always go to the doctor

·        To get medicine; the doctor gives good medicine

·        The doctor gives good treatment and can cure people

For those who did not take their child to see a provider, the reasons given include:

·        Our family knows about medicine and can treat illness at home

·        We believe in traditional medicine/traditional medicine is good

·        The child was not very sick

Twenty-eight informants (8%) who took their child to see a first provider also took their child to see a second provider. Of those who took their child to see a second provider, 89.7% went to a traditional healer. Only 2 informants (7.1%) reported taking their child to see a doctor/nurse as a second provider. One informant (3.6%) took their child to see a person selling medicine at the market after going to a first provider. Although the numbers of respondents who took their child to see a second provider are small, it is relevant that people were more likely to take their child to see a traditional healer than a doctor/nurse as a second provider. This has particular implications for health clinics wanting to provide follow-up care, especially when the diagnosis may be uncertain due to vague symptoms or lack of investigation. It may be of concern to clinics if clinic health workers are advising their patients to return if their condition either does not improve or worsens, and the patients are instead going to see a traditional healer.

The general popular consensus that many people take their child to see traditional healers and shamans was supported by informal interviews with East Timorese, but not by the data collected in the questionnaire. The data do, however, suggest that a general pattern of health seeking behaviours is to first treat at home, then go to the doctor/nurse if the child's health does not improve, and if the child still does not improve after seeing a doctor/nurse, then take the child to a traditional healer. Even so, the figure of people reporting taking their child to see a doctor/nurse first (95.7%) seems very high, especially when there is concern that health services in the country are under-utilised. It is possible that informants over reported seeking care from a doctor/nurse, and underreported seeking care from a traditional healer. Several reasons could contribute to this. Interviewers identified themselves as being from Bairo Pite Clinic, and it is possible that informants were reluctant to admit to someone from the Clinic that they took their child to see anyone other than a doctor/nurse, and simply gave the answer they thought the interviewers would want to hear. There also appears to be some stigma associated with certain types of traditional healers and shamans. Informants may have been embarrassed to admit going to see a healer or shaman.

A subset of households were asked the more broad question, “Why do you think some people go to traditional healers and shamans, and for what health problems?” in an attempt to try and discern if there are certain situations or health problems that people are more likely to see a traditional healer or shaman for rather than a doctor/nurse. Some people replied that they did not know because they do not go to traditional healers or shamans. Of those who did respond, however, common answers emerged. The primary reasons given for why people go to see a traditional healer or shaman include:

•  If a person does not improve after seeing a doctor, then they go to a healer/shaman

•  People go because they believe in traditional medicine and healers/shamans

•  People go if they believe that they (or their child) became sick because someone (intentionally) made them sick, because of a devil, or because of an angry ghost

Only one informant replied that people go to healers/shamans if they live far from a health clinic. However, in informal interviews, people agree that the use of traditional healers/shamans is much greater in the mountains and rural areas than in Dili, both because of cultural history and because health clinics are less accessible.

Informants replied that people consult healers/shamans for a wide range of health problems including: tuberculosis, kidney stones, broken bones, cough, virus, severe illness, itching, fever, diarrhea, bloody diarrhoea, persistent illness, wounds, vomiting with blood, jaundice, and swelling.

Traditional healers are especially known for their ability to heal broken bones quickly. Even though the sample size of children with broken bones in the questionnaire is small (n=3), all three children with a broken bone were (at some point) taken to see a traditional healer for treatment. In an informal interview with one traditional healer, the healer reported that many people come to see her for broken bones because she heals them faster than going to a clinic.

Health problems seen by traditional healers & traditional healer treatments

Although the sample size of children who were taken to see a traditional healer is small (n=28), it is nonetheless worthwhile to examine both the health problems of children taken to see a healer, and the treatment they received. Table 1 below lists the frequencies of symptoms/health problems of the children that were taken to see a traditional healer.

Table 1 – Health problems of children taken to traditional healers

*Up to three health problems were included per child

Informants who took their child to see a traditional healer were asked to list up to three treatments the healer gave to the child. Healers gave an average of 2 treatments per child. Healer treatments predominately consist of traditional medicine (various uses of tree leaves/ bark), massage, and coconut oil. A list of treatments and frequency used is included in Table 2 below.

Table 2 – Treatments used by traditional healers

* Up to three treatments per child were included

Interviews with traditional healers

Knowledge about traditional healers in East Timor is scarce – how many there are, who comes to them for treatment, what problems they treat, what kinds of treatments they use, their background and training. For this reason, informal interviews were conducted with six traditional healers in Dili as well as the assistant of one other healer. The exact number of traditional healers in Dili is unknown, although at least ten were identified through asking Dili residents. The healers that were interviewed had much in common, although there is a significant range in their ideology and practice. Some only treated health problems with traditional medicine, others also treated problems believed to be caused by ghosts or someone else's ill will. Several said that they could also predict the future. For simplicity, despite the variation in practice, this report will refer to all of them as traditional healers. There is a significant range in the age of healers (34 years old – 85 years old) and number of years working as a healer (2 years – 53 years) and number of patients seen on average per day (a few people a day – 40 people per day). Both male and female healers were interviewed.

The healers interviewed had various kinds of training, and some none at all. One healer had attended a traditional medicine training program in Indonesia ; one received informal training from his father who also was a healer. One healer worked as a nurse for over thirty years until his wife (who was a traditional healer) died, in which he quit working as a nurse, and started seeing people in the capacity of a healer. Another healer, who herself received no training, previously worked for the government training midwives in the 1970s. All of the healers are religious (Catholic and Protestant), and most began practicing traditional medicine after having some sort of a spiritual experience. Three of the healers said they originally prayed to God (or Santa Maria ) to know about traditional medicine and how to be able to heal people, and that all of their knowledge comes from God (or Santa Maria ). Another healer said that he was 11 years old when he was led away from his village by a spirit and taught about traditional medicine. One healer starting practicing after his father appeared to him in a dream teaching him about traditional medicine. All healers reported that they pray before treating each patient who comes to them for treatment.

There is significant variation in the problems that the healers treat. Some healers only treat health problems, while others give treatment for almost any problem or situation imaginable. One healer had a posted list of his treatments, which included among other things: “medicine to make the ghosts go away”, “medicine if your husband/wife left you and you want them to come back”, and “medicine if you are stupid and want to be clever.” The healers said that people come to them with every kind of health problem, including broken bones. All of the healers treat both adults and children except for one, who only treats adults. Each of the healers said that most of the people who come to see them for health problems have first gone to see a doctor/nurse, but their condition did not improve, so they then sought treatment from a traditional healer. Healer treatments generally include use of prayer, candles, traditional medicine (bark, leaves, roots, etc.), coconut oil, and massage. One healer also instructs people who come to see him to return with certain objects which he examines to help him determine the problem and treatment, then returns the objects. Another healer said that he has a special tool given to him by a spirit which allows him to be able to know any problem a person has. Two of the healers interviewed have set prices for the services they provide. The other healers said that they don't charge for their treatment, and that it is up to the people to give what they want.

The healers were asked if people come to see them because they felt that someone had intentionally made them ill (generally through the use of ghosts or “bad medicine”), and all of the healers except for two replied that they did treat these people. They also said that people come to see them for this reason because a doctor does not know how to treat this problem. One of the healers said that she does not believe that people can intentionally make others sick, so people who feel they are sick for this reason will go to see someone else, not her. Another healer said that the only people who come to see him are those who feel their illness or problem is a result of someone else's ill will or ghosts. He does not give medicine for the individual to drink, but rather his treatment consists of prayer and giving a special mixture of water and medicine for patients to take home and sprinkle around their house.

All of the healers said that sometimes people come to see them with serious health problems. One healer said that people will come to see him because they are about to die, and want to see if there is anything he can do for them. The healers were asked if they have ever referred someone to a doctor or hospital because they felt that the problem was too serious for them to treat. Only two healers replied that they had ever referred anyone to a doctor or the hospital. The remaining healers said that they can always treat people themselves, and will pray if they need help.

Perceived cause of child's illness

In order to gain a better understanding of caregivers perceived cause of their child's illness, the open-ended question was asked, “Why do you think your child became sick?” and up to two responses included. It is likely that the question was misunderstood or not clarified properly, as some informants instead answered reasons how they could tell their child was sick (child cries, is lethargic, and listing of symptoms). However, a variety of other answers were also given, and are included below in Table 3. The most common reason informants gave as to why their child became ill what that the child plays in the water, dirt, or dirty water. Interestingly, a small number of informants (4.7%) believed their child became ill because they had worried that the child might get ill.

Table 3 – Perceived cause of illness

*Other primarily includes: child doesn't sleep well, mosquitoes, child is always running around/doesn't rest, child drinks dirty water, mother is irresponsible/doesn't watch child, and child eats wrong foods.

Obstacles in keeping child healthy

The question “What problems do you have in trying to keep your children healthy?” was included to get a better sense of the obstacles caregivers face in looking after the health of their children. The question was open-ended, and up to three responses were included. While 38.7% of informants replied that they did not have any problems in trying to keep their child healthy, 61.4% of respondents shared at least one obstacle they have encountered. The two biggest problems listed were lack of money, and difficulty in obtaining transportation. The two most common problems, lack of money and difficulty obtaining transportation have potential implications for future utilization rates of health services. Currently, health services provided at clinics and hospitals are free (with the exception of some private clinics), including the medication distributed. If, in the future, the government decides to charge for health services and medication, there could potentially be a drop in utilization of services by those who are already experiencing financial difficulties in trying to keep their children healthy. Those who cannot afford a fee-for-service system might also turn to traditional healers for treatment if traditional healers are cheaper and more accessible than clinics.

Person in household who cares for sick children

Informants were asked who usually cares for sick children in the household. The majority of informants (90.5%) replied that the mother primarily looked after sick children. The remaining informants listed the grandmother (4.3%), father (3.2%), and other relative (2.0%) as being caregivers for sick children.

Age child can be taken out of the home

Two questions were included to gain a better understanding of what age caregivers feel it is safe for infants to leave the house -- “At what age can a healthy baby leave the house?” and “At what age can a sick baby leave the house for treatment at a clinic?” A wide range of ages were given in response to both questions. The mean age given for a healthy baby was 24.6 days (with a standard deviation of 29.6). When asked when a sick child can leave the house for treatment, 8.5% of informants replied, “Whenever the child is sick.” Of those who gave a precise age of when a sick child can leave the house for treatment, the mean age was 14.8 days (with a standard deviation of 21.7).

There is a cultural belief in East Timor that a woman and her newborn baby should not leave the house for forty days after giving birth. During the forty days the women should avoid things that are cold - cold water, cold drinks, fans, air-conditioning, etc. Avoidance of “cold” is extended throughout the duration a woman breastfeeds her child. The belief that a woman and her child should not leave the house for the first forty days after birth as well as the results from the questionnaire in which some informants responded that sick children should not leave the house until after one month of age has the potential to impact adherence to immunization schedules as well as infant mortality rate. A young child's immune system is less mature, and their threshold for treatment is lower, making their treatment needs more urgent.

CONCLUSIONS

The treatment of child illness is a multifaceted issue, parents and caregivers are confronted with many decisions – whom to ask for advice, what treatments to use at home, whether to use traditional or Western medicine, and when to take their child to see a provider outside of the home. This study has attempted, through informal interviews and a questionnaire, to provide a richer understanding of the treatment of child illness at the household level in Dili. The general pattern of treatment over the course of the illness is to first give treatment at home (including traditional medicine, Western medicine, and comfort measures), then take the child to a doctor/nurse if the child does not improve. If the still does not improve after seeing a doctor/nurse, then the child is generally taken to see a traditional healer. Over the course of the child's illness, most caregivers consulted at least one other person (usually their spouse or their mother) about the child's illness.

Informal interviews with traditional healers confirmed that people are utilizing their services for a wide range of health problems, including severe illness as well as sickness believed to be intentionally caused by someone else. Healers have strong religious beliefs and expressed that they are able to get assistance through prayer in order to treat people. From a health planning prospective, there is potential for concern that healers generally do not refer anyone to seek further medical assistance from a doctor or hospital. Healers' general belief that there are no problems that they cannot treat also has implications for any attempts in the future by the government to work with traditional healers.

Informants listed environmental conditions (child plays in dirt/dirty water, mosquitoes, poor conditions in area) both as reasons why they believed their child because ill, and as obstacles they face in trying to keep their child healthy. There could be potential to alter the situation through increased environmental health education and awareness. Lack of money and difficulties in obtaining transportation are the two major problems caregivers reported in trying to keep their child healthy. It is likely that these problems will only be exacerbated if health clinics start charging for services and medicine. As the country rebuilds its health infrastructure, it is critical to consider obstacles caregivers face both in their own sense of control over their child's health as well as access to services.

Although this study only focused on treatment of child illness in Dili, there are many implications for understanding health seeking behaviour in other areas of East Timor . Because there is no data available in East Timor on use of traditional medicine or utilization of traditional healers, it is difficult to predict how variables such as level of education, access to health care, and living in a rural vs. urban area might affect rates of use and utilization. However, it is likely that there is a greater use of traditional medicine and traditional healers in rural areas. Through informal interviews, there is widespread agreement that there is greater use of traditional healers in rural areas, as well as a strong cultural history of belief in healers. Access to health care in rural areas is variable – in some villages the nearest health clinic (staffed by nurses) is a three hour walk. If people encounter difficulties in accessing health clinics, there is the potential that they will instead treat at home or use traditional healers, if healers are more accessible. Gathering baseline data in rural areas will be important in understanding treatment of illness as well as tracking changes in the future.

APPENDIX: List of home treatments/traditional medicines used for common illnesses*

* Note – this list is by no means meant to be comprehensive, but rather a selection of home treatments people use as reported either through informal interviews or the questionnaire.

[1] The La'o Hamutuk Bulletin. Vol.1, No.3: 17 November 2000 . http://etan.org/lh/bulletin03.html

[2] World Health Organization. East Timor health sector situation report: January-June 2000. http://www.who.int/eha/emergenc/etimor/14082000.html

[3] World Health Organization. Role and function of WHO in East Timor : Plan for 2001 (pamphlet). 2000.

[4] World Health Organization. Role and function of WHO in East Timor : Plan for 2001 (pamphlet). 2000.

[5] Martins Joao S. and Rui M de Araujo. Strategic health development planning for East Timor . (undated) http://www.ozemail.com.au/~snrt/papersheal2.html

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