Health in Timor-Leste

"…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 Gusmao 

Message for Opening of Melbourne Strategic Development Planning for ET Conference 5 April 1999

Speeches, interviews, published papers and other documentation relevant to Timor Leste health. Click on the title below. In chronological order.

INDEX

Aussie docs let the sun shine again Herald Sun ( Melbourne , Australia ) July 2, 2005  

Taking the family to East Timor Carolyn L Beckett MJA 2004; 181 (11/12): 603-604

Doctors in the Pacific David A K Watters and David F Scott MJA 2004; 181 (11/12): 597-601

Australian surgeons to treat Timorese in need of eye surgery UNMISET November 2004

"We thought it was Oil. But it was Blood. A Nigerian Perspective Learning from Nigeria 's Experience La'o Hamutuk Bulletin Volume 5, No. 3-4. October 2004 

Expert to help WHO in Dili, East Timor with tropical diseases 10 June 2004  

Girl, 12, chokes to death on worms   May 8, 2004

WHO warns betel and areca-nut chewing even without tobacco causes cancer   7 August 2003

UNMISET air ambulances 'the difference between life and death to Timorese women and children' UNMISET Press release August 2003

Probable Dengue Virus Infection Among Italian Troops, East Timor, 1999–2000Center for Disease Control and Prevention   CDC Emerging Infectious Diseases Vol. 9, No. 7 July 2003

Fighting poverty and deprivation crucial to ensuring peace and security . Kofi Anna July 2003

Health care, education out of reach for East Timorese, says activist Feb-11-2003 

Social and Economic Conditions in East Timor Editors: Jon Pedersen and Marie Arneberg 2002

Child Mortality rate is 124 per thousand Mariza Costa-Cabral December 2002 Healing A Nation's Wounds Dr Alan Saunder Surgeon in Dili December 2002 

ICEVI East Timor Project - June/July 2002 Frances Gentle

UNDP interview with Dr. Rui Maria de Araujo, Minister of Health on the issue of HIV/AIDS in East Timor June 29 2002  

Health Policy Framework June 2002 (Opens a Word document, 553 KB) 

International Council for the Education of People with Visual Impairment . Project: East Timor 22nd June to 6th July 2002 (To web site) 

Report of the Rapid Assessment on Salt Situation in the Democratic Republic of Timor-Leste , 18-25 June 2002 UNICEF 

Practical Assistance to Build East Timor's Health System Media release from the Prime Minister of Australia 19 May 2002  

UNICEF East Timor Donor Update May 2002 (Opens Adobe Acrobat file, 266 KB) 

East Timor at Glance World Bank statistics for East Timor   (Opens Adobe Acrobat file, 27KB) 

Health Ministry Enters a New Phase in Health Care Plan 1 March 2002  

Central Lab upgrades to combat  disease outbreak UNTAET Daily Briefing 14 Feb 2002

UNTAET Fact Sheet 16: Health February 2002

Growing pains of East Timor: health of an infant nation Kelly Morris Lancet 2001    

United Nations Development Programme in East Timor National Human Development Report for 2002   (Opens Adobe Acrobat file, 1002KB) 

Oecussi Integrated development strategy UNDP Jun2 2001 (Adobe Acrobat file, 217KB) 

Poverty and Social Indicators 2001 World Bank  (Opens Adobe Acrobat file, 11KB) 

Role and Function of WHO in East Timor 2001 (Adobe Acrobat file, 119KB) 

Report of the First Cases of Cutaneous Leishmaniasis in East Timor Clinical Infectious Diseases 2000.   

Healthcare in East Timor stepping out from the emergency phase . East Timor Observatory 2001

Building a National Health System for East Timor The La'o Hulamatuk Bulletin Vol. 1, No. 3. 17 November 2000 (Opens Adobe Acrobat file, 89kB) 

East Timor Health Sector Situation Report   WHO Jan-Jun 2000

East Timorese get a taste of Western food by rummaging through trash Kyodo News Service TIBAR, East Timor , Jan. 24 2000  

Health and human rights of the East Timorese Derrick Silove. Lancet 1999

Dengue Fever in ET Charles Henderson. Blood Weekly 1998

See also HIV , Tuberculosis , Mental health , Child health and Women's issues .

Aussie docs let the sun shine again 

Herald Sun ( Melbourne , Australia )
July 2, 2005 Saturday

For a small band of Australian eye doctors, reward comes when peeling back the bandages to restore the joy of lost sight, as ELLEN WHINNETT writes. The old man is crawling on his hands and knees towards the gate when Australian doctor David McKnight spots him. He has a bandage over his eye, is painfully thin, and can't see clearly enough to walk. His feet are dusty and misshapen in his rubber thongs and he has carefully hitched up his traditional teis-cloth skirt. He is planning to crawl home -- more than 3km -- when McKnight intercepts him and steers him back inside the hospital. Like many who have come to this clinic in a remote region of East Timor , he simply doesn't have the 10c bus fare to get home. He also has no money for food. There are no taxis here and no residential telephones to contact his family, if he has one.

Dr McKnight, a Ballarat eye surgeon, is upset that he hasn't seen the man before he began crawling across the sharp gravel driveway of the Oecussi hospital. Earlier, he had operated on the elderly patient, removing a cataract from his eye. Now he helps him up and leads him back inside where a team of volunteer Australian doctors, nurses and optometrists have set up a specialist eye clinic. The staff find him a bed ,  an old, striped mattress on a rusty frame,  and promise a plate of food. The next day, doctors will remove his bandage, clean his eye and he will walk out of the hospital able to see clearly for the first time in years. 

"It's the difference really between life and death when they are profoundly blind," McKnight says. "He can fend for himself and that makes a big difference to the family because they don't have to fend for him. That's one of the things in East Timor , the extended families have been destroyed over the years because people have been killed."

Dr McKnight, 46, runs the Ballarat Eye Clinic, but takes regular time away from his practice to work in developing Pacific nations. He said the attraction was being able to provide immediate help for some of the most needy people in our region. A cataract removal takes little more than 20 minutes, but profoundly changes the life of the person who has been afflicted.

"We're not talking here about people being able to read their stock reports, we're talking about them being able to walk to the market and get some food," Dr McKnight says.

The violence which accompanied East Timor 's decision to declare its independence from Indonesia in 1999 left the world's newest nation in ruins. Rampaging militia violence saw buildings and infrastructure destroyed, while health services crumbled and withdrew back into neighbouring Indonesia . The Australian volunteers have been working since 2000 to provide specialist eye services to East Timor , treating cataract blindness, trauma injuries, cancers and Vitamin A deficiency. A program run by the International Centre for Eye Care Education sees optometrists work in remote areas and provide glasses.

"We see all the diseases we see in Australia but we see them at a much younger age and in a much more advanced state than we see them in Australia ," Dr McKnight says. "And we see infections like tuberculosis we don't see in Australia ."

The elderly man from Oecussi is one of 1200 people who have undergone cataract operations since the East Timor Eye Program began. The volunteer doctors, nurses and optometrists have examined more than 20,000 people in the past four years and prescribed 17,000 pairs of glasses, working in remote areas across the country. The Federal Government's AusAID program and the Royal Australasian College of Surgeons provide substantial financial backing and extra funds are raised by supporters mainly in Victoria , Tasmania and Queensland . The surgeons work in the capital Dili and the second-largest town of Baucau , and have expanded at the request of East Timorese President Xanana Gusmao into the remote outpost of Oecussi. A tiny area of land populated by 60,000 East Timorese people, Oecussi is surrounded on three sides by West Timor and bore the brunt of military-backed violence in 1999. 

Melbourne surgeon Mark Ellis is removing a cataract in the Oecussi hospital when the generator and power go off. Two colleagues come to his aid and stand over him with torches while he finishes the delicate procedure by torchlight. The ophthalmologist from the Hawthorn Eye Clinic, 49, has volunteered twice in Oecussi and says he has formed a lasting bond with the place. Ellis says he had wanted to do mission work in the developing world and collared the co-ordinator of the East Timor Eye Program, Tasmanian eye surgeon Nitin Verma, at a conference.

"I said, 'How do I do it? I'll pay my own way'."

Dr Verma took him up on his offer and sent him to Oecussi. A giant Russian helicopter delivers the eye team to Oecussi, dropping them and their medical supplies off at the airstrip just outside regional capital Pante Macassar. The local hospital is poor and rundown, but clean and staffed by dedicated, hard-working people who make a little go a long way. The heat is so intense the optometrists work barefoot, preferring the cool tiles as they set about examining the hundreds of people who have come to the clinic. The doctors and nurses set up a makeshift operating room nearby. There is no door to the operating theatre because termites have eaten away the door frame. The drip is attached to a rusty pole, cemented into an old food can. Ellis works with the optometrists in their clinic before donning a sterile gown and joining McKnight in the theatre. 

"We're talking about people who can't see the food on their plates, who can't see their way out the door," Dr Ellis says. "The care that's needed can be given in an extended family but in East Timor so many people have been killed off." 

Dr Ellis says the highlight for him is taking the bandage off the eye of a person who has been blinded by cataracts and helping them to see.

"It's highly emotional, the smiles when that bandage comes off," he says. "We had one guy who had his cataract out and he could see again. He was so happy he came back every day and led the patients in."

While the East Timor Eye Program does have sponsors, it is run on a tight budget. In Oecussi, that means rudimentary accommodation and food and regular bouts of gastric upsets. An optometrist loses his watch when a rat steals it in the night. It is found days later in a corner, the leather band gnawed away. Another wakes to find a goat has eaten his toothbrush.

"I sweat over there just thinking how good it would be to be home," Dr Ellis says. "On returning to Australia it is only a matter of time that I want to be back. Their need is greater."

The International Centre for Eye Care Education has seven local eye nurses in training, while the doctors are training Marcellino Correa as the first East Timorese-born eye surgeon. They dream of one day having two doctors and are directing their fundraising efforts towards training and equipping local doctors.

"We turned our backs on East Timor in the '70s when they needed us and this almost feels like a way of saying sorry," Dr Ellis says. "These people are desperately in need of any good care. What's more, they are very appreciative of our efforts. I am conscious of our turning a blind eye during their struggles for independence. This is a way of giving back to those who helped us in World War II."

East Timor President Xanana Gusmao will visit Australia to raise funds for the East Timor Eye Program. He will attend a fundraising cocktail function at the Royal Australasian College of Surgeons, Spring St, on Friday. To make a donation or to attend the function, call toll-free 1800 051 333.

President Gusmao to promote sight-saving efforts

The Courier Mail ( Queensland , Australia ) 
July 2, 2005 Saturday

EAST Timorese president Xanana Gusmao will arrive in Australia on Sunday for a week-long official tour that coincides with efforts to raise $200,000 to help treat curable blindness in his country. Up to 10,000 East Timorese have lost their sight because of cataracts which could be removed with basic surgery. President Gusmao, will use part of his visit to promote work by Australia 's East Timor Eye Program. The program's founder, eye surgeon Nitin Verma, has regularly travelled to East Timor with a team of doctors drawn from across Australia to save the sight of 2200 Timorese. Dr Verma said the monies would help purchase supplies and continue the training of East Timor 's first local eye surgeon. 

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Taking the family to East Timor

Carolyn L Beckett 
MJA 2004; 181 (11/12): 603-604

How did I come to be in East Timor ? That is the exact question I asked myself upon arriving in Dili, the national capital, with my husband Ben, our 2-year-old son Oscar and 6-month-old daughter Chloe in tow. It was very hot and humid and there was a real threat of a looming dengue epidemic from Indonesia . My anxiety for the health of our children was in no way eased when, a few days after our arrival, an Australian expatriate asked, “What sort of a place is this to bring kids?”.

I had been aware of a program coordinated by Eugene Athan, an infectious diseases physician, whereby Australian physicians could work at the Dili National Hospital . As an infectious diseases physician with an interest in medicine in developing countries, and having been assured of the political stability of the country, I put up my hand to go. Ben was able to take time off work to care for our children. After many months of planning, multiple vaccinations, and reassuring family and friends of our safety and wellbeing, we arrived in Dili in late January 2004.

The Dili National Hospital is run by the East Timor Ministry of Health. The hospital medical staff consists of overseas visiting specialists, Indonesian emergency department doctors, and Timorese resident doctors working on the wards and in the outpatient department. There are no locally trained specialists — a major limitation to the long-term goal of having an autonomous Timorese hospital.

I worked on the women's medical ward for 2 months. While not arduous, the work was emotionally draining. In my first week, there were three postpartum deaths due to presumed sepsis. Like anyone, I found this difficult to deal with, but being there with my family, and still breastfeeding Chloe, made it even harder. My emotions were fuelled by the thought that one family now consisted of a husband without a wife, and four kids without a mum. The harsh reality of the estimated maternal mortality in Timor (around 800 per 100 000 live births) is that this family circumstance is not uncommon.

Despite Portuguese being the official language, the majority of Timorese people speak either Tetum, Indonesian, or one of 16 indigenous languages. As my Tetum capabilities were limited to pleasantries, I relied heavily on certain hospital staff to interpret for me. Needless to say, taking an adequate history and communicating with the patients and hospital staff proved to be a challenge — like a combination of charades and Pictionary. The language barrier became even more difficult towards the end of my stint, when a Chinese medical team arrived that included doctors, a nurse and a translator. They had spent 6 months learning Portuguese, which, despite the best of intentions, was of no practical use to the majority of people at the hospital.

One of the beaches within an hour's drive of Dili. These were a favourite place for expatriates and United Nations staff to gather on Sunday afternoons.

The hospital was serviced by hospital and national laboratories that performed basic testing, which was intermittently available and of variable standard. Malaria films were regularly performed, with frequent positive results. Biochemical tests, including tests for urea and creatinine, were not available during my stay. Minimal microbiological investigations (including tuberculosis smears, and serology for HIV, hepatitis B, hepatitis C and syphilis) were available. Pathology specimens were sent to Australia , with a 6–8-week turnaround time. The major medical problems I encountered at the hospital included tuberculosis, malaria, renal failure, heart failure, thyroid disease and hypertension. As all patients had varying degrees of malnutrition, I kept them in hospital for as long as possible, knowing that the hospital would provide nutritious meals.

Of concern was the lack of a single positive sputum smear test for acid-fast bacilli during my stay. For whatever reason (be it deficiencies in collection, transport, processing, laboratory technique or reporting), all sputum smears were negative. Aware that this could not be accurate, I introduced antituberculosis therapies in patients for whom there was a high suspicion of tuberculosis based on clinical features and x-ray results. Of greater public health concern was the lack of mycobacterial culture and sensitivity testing facilities. A national tuberculosis control program has been established to monitor patients during treatment, but some patients did not complete their therapy and it is unclear whether drug resistance is a problem.

It was hard to believe we were only a 1-hour flight away from Australia . Drug therapy options were limited to an essential drug list; however, even these, at times, were unavailable. Although we had previously worked in Africa , we found it difficult to comprehend that the national hospital of one of Australia 's close neighbours could have such limited resources.

Despite their many hardships and difficulties, I was touched by the loving nature and strong sense of family among the Timorese people. They were very receptive to us as a family, but we certainly raised some eyebrows. For starters, I was working while Ben stayed at home with the kids, which many locals found amusing! Ben spent most of the time fighting off malaria and dengue-carrying mosquitoes and keeping the kids and himself cool by whatever means, including a staple diet of ice-cream for the kids and beer for himself. During weekends off, we were able to hire a car and explore many beautiful parts of the country.

Having spent only a short period of time at the Dili hospital, I was grateful for the welcome I received and the warmth of the hospital staff. Upon leaving, I felt I had contributed to the health of my patients, and yet had a deep sense of sadness because it seemed that the healthcare system may worsen before it improves.

So, were we foolish to take our kids to Timor ? On the contrary — we believe that we took them to a place full of caring, loving and welcoming people who deserve the chance to live a better life. 

Carolyn L Beckett, MB BS(Hons), FRACP, Infectious Diseases Physician
Infectious Diseases Department, Box Hill Hospital , Box Hill, VIC.

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Doctors in the Pacific

David A K Watters and David F Scott 
MJA 2004; 181 (11/12): 597-601

East Timorese doctors have been trained in Indonesian medical schools. After the vote for independence in 2000, the country's infrastructure was destroyed by the departing Indonesians, although the hospitals were not damaged. There are currently 46 qualified East Timorese doctors, but only 23 are working for the government, with just 17 in clinical work. There are no practising local specialists. Non-government organisations staff some of the hospitals and health facilities in the provinces. Specialist care in East Timor is provided by a few doctors whose positions are funded by the Department of Health or by aid projects, such as those managed by the Royal Australasian College of Surgeons (RACS) and HealthNet (a Dutch non-government organisation, formerly CORDAid). The service provided is supplemented by visiting specialist teams

Specialist surgical aid program in East Timor

East Timor , a small country with a population of 850 000, is among the 10 poorest nations in the world (Box 1). It receives considerable support from donor countries such as the United States , Japan , Australia and Portugal . East Timor had an organised health service similar to that of the rest of Indonesia before the independence vote in 2000. After independence, East Timor had to rebuild its health service after almost all health infrastructure and records had been destroyed and experienced doctors had departed.

Hospital services were reactivated in 2000 in the capital, Dili, by the International Committee of the Red Cross and in Bacau by Médecins Sans Frontières. These programs ended in mid-2001. Since then, the running of the national referral hospital in Dili has been assisted by Healthnet (formerly CORDAid), a non-government organisation. Specialist staff in the major disciplines of surgery, anaesthesia, obstetrics, paediatrics and internal medicine have been recruited by the East Timor Department of Health, Healthnet and an AusAid program managed by the Royal Australasian College of Surgeons (RACS). The RACS program is based primarily in Dili and provides a resident surgeon and anaesthetist and visiting specialty teams. Each month, a specialist surgical team comes to undertake procedures not normally performed by the resident general surgeon. Cases are selected on the basis of requiring specialist skills and having a chance of success in a situation of limited postoperative care and follow-up. Such cases include cataract removal by ophthalmology teams and repairs of cleft lip and palate by plastic surgery teams. Paediatric surgery teams have repaired imperforate anus in a number of children who previously had only a colostomy performed at birth. Visiting cardiac surgery teams have, to date, undertaken patent ductus repairs but not open heart surgery, even though rheumatic fever, with subsequent rheumatic heart disease and congenital heart disease, is common.

Common procedures performed by visiting urologists are removal of bladder stones, prostatectomy, and repair of urethral strictures. Orthopaedic teams are involved in managing congenital disease (eg, club foot) and malunion or non-union of fractures in trauma victims. Patients with cancer usually present late, staging is based on clinical assessment and plain x-rays, and surgical treatment is limited.

There are currently no East Timorese surgical specialists. The future specialist workforce in East Timor will be made up of a hotch-potch of graduates from training programs in a variety of countries. Part of the RACS program is to assist in developing specialist skills in-country. To obtain recognition of their specialist training, three East Timorese doctors are starting surgical training in the UPNG program (two in general surgery and one in ophthalmology). Other East Timorese doctors have gone to other countries, including the Philippines and Portugal , for postgraduate training.

Anaesthetics in East Timor are mostly given by nurse anaesthetists. Australian anaesthetists have developed an appropriate 1-year program for nurses that includes a 3-month rotation to an anaesthetic teaching department in Indonesia . Perioperative theatre nurse education has been incorporated into this program, and two primary trauma-care courses using Indonesian-speaking doctors have been successfully conducted.

The challenge in training the workforce in East Timor is to develop skills appropriate for the facilities available, the local disease mix, and health budgets for the foreseeable future. It has been an important policy direction for Ministry of Health planners to design a health service that is sustainable in the medium to long term with the level of expenditure likely to be available from their own resources and firm donor country commitment.

These good intentions can be overwhelmed from time to time when some overseas aid teams arrive without the necessary language skills or interpreters and with minimal financial resources to provide the technical supplies they consume in the hospitals.

The concept of specialist surgical aid programs providing tertiary care has been questioned as an appropriate priority in countries with underdeveloped health services. The conventional argument is that money would be better spent on clean water, vaccination programs and village-based health centres that deliver simple, effective services.

We agree that supporting primary health services is important. Nevertheless, the community also gains from access to acute hospital care for common problems such as trauma, acute infections and obstructed labour. Relatively simple surgery requiring short hospital stays can restore patients to normal health and prevent much disability. Beyond this, tertiary surgical services — again with simple surgery and short stay for conditions such as cleft lip and palate in the young and blindness due to cataract in the elderly — can restore large numbers of patients to active and economic participation in their communities. The statistics from our visiting teams support this view.

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Australian surgeons to treat Timorese in need of eye surgery

http://www.unmiset.org/

26 November 2004

A team of doctors from Australia will be arriving in Dili this weekend to treat patients in need of vital eye surgery. The Royal Australian College of Eye Surgeons medical team, which is headed by Dr Nitin Virma and Dr John Kennedy, will be treating patients and performing operations in the capital Dili and the second largest city Baucau from 27 November to 3 December. 

Doctors Virma and Kennedy visited Timor-Leste in 2000, when they established the country's first ever eye clinic. Earlier this year, the two surgeons opened another temporary clinic in the Oecussi enclave following a request made by the President of the Democratic Republic of Timor-Leste, Mr Xanana Gusmão. President Gusmão made the request because many patients in need of surgery were unable to travel the long distance to the capital Dili. 

Since their first visit to Timor-Leste in 2000, the medical team has consulted more than 29,000 patients and carried out nearly 4,000 eye operations, namely to treat patients with cataract disease. In addition, an estimated 24,000 pairs of spectacles have been provided to people.

To ensure that as many people as possible receive treatment during the six-day visit, the Military component of the United Nations Mission of Support in East Timor (UNMISET) will be providing transport, helping to move one tonne of equipment to Baucau from Dili, as well as making available a back-up generator for the operating theatre in Baucau. 

The Lions Club, a charity organization working worldwide to treat people with vision impairments, has contributed to funding the trip to Timor-Leste at the end of this week and has assisted with the cost of all necessary equipment. The Lions Club will also pay for the cost of additional equipment, which will be used to train Timorese eye doctors. 

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"We thought it was Oil. But it was Blood. 

East Timor Exchange Visit: A Nigerian Perspective Learning from Nigeria 's Experience 

La'o Hamutuk Bulletin Volume 5, No. 3-4. October 2004
Justice and the Resource Curse: Part two of three.

www.etan.org/lh/ bulletins /2004/bulletinv5n3.html

East Timor is rich in oil and natural gas resources. The people of East Timor are hoping that income from the oil and gas in the Timor Sea can be used to build roads, schools, hospitals and funding the development of the country. This much was what the people of Nigeria , West Africa also thought. Nigeria , with some of the most plentiful oil and natural gas reserves in the world, is still one of the poorest countries.

As part of a South-South exchange, seven Timorese activists representing organizations focused on environmental issues, human rights, development, labor rights, women's rights and other areas, travelled to Nigeria between January 16 and 28, 2004 to observe and learn about the effects of petroleum activities and development and how communities and local people respond to them. The group visited Lagos , Port Harcourt and several Niger Delta communities and petroleum facilities and met with local activists, environmental experts, government officials, community leaders and journalists. 

The exchange had three main objectives: 

1. To understand how the exploration and exploitation of natural resources had impacted on environmental and social issues as well as its effects on the grass roots communities. 
2. To learn more about the links between oil companies and the Nigerian government and military. 
3. To develop relationships and solidarity between East Timor and Nigerian people. 

A quick review of the health differences between Nigeria and East Timor .

Source for most figures: 2004 UNDP Human Development Report

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Expert to help WHO in Dili, East Timor with tropical diseases

Thursday, 10-Jun-2004 , by News-Medical

A JCU public health expert is off to Dili, Timor Leste (formerly East Timor ) to help the World Health Organisation address three serious tropical diseases: lymphatic filariasis, intestinal worms and yaws. Reverend Dr Wayne Melrose, JCU Associate Lecturer in the School of Public Health and Tropical Medicine and Deputy Director of the World Health Organization (WHO) Collaborating Center for Control of Lymphatic Filariasis will spend the next several weeks in the WHO office helping Timorese health professionals draw up control plans for these diseases and trial them in two districts. Dr Melrose said if the district trials proved successful, the program would be extended to the whole country in the next few years.   The WHO chose Dr Melrose to do this work because the filariasis centre at JCU has been involved in lymphatic filariasis research and control for over a decade, and is currently supporting successful control programs in Papua New Guinea and the Pacific Islands . It will also be Dr Melrose's fifth trip to Timor-Leste, where he has been involved in health assessment and teaching since 2002. His said while his work assisted Timor Leste people it also helped safeguard Australia from disease in neighbouring countries.

"There is more to this than being a good neighbour," Dr Melrose said. "There are human and animal diseases in nearby countries that we must keep out of Australia . Helping countries in our region improve their disease control also helps to safeguard Australia 's interests."

T Supali, H Wibowo, P Ruckert, K Fischer, IS Ismid, Purnomo, Y Djuardi, and P Fischer. High prevalence of Brugia timori infection in the highland of Alor Island , Indonesia . American Journal of Tropical Medicine and Hygiene, Vol 66, Issue 5, 560-565.

To identify areas endemic for Brugia timori infection, a field survey was carried out in 2001 on Alor, East Nusa Tenggara Timor, Indonesia . Elephantiasis was reported on this island by villagers as a major health problem. 

Bancroftian filariasis was detected in four villages in the coastal area, whereas B. timori was identified in four rice-farming villages. No mixed infections with both species were found. In the highland village Mainang (elevation = 880 m), 586 individuals were examined for B. timori infection and 157 (27%) microfilaria carriers were detected. The prevalence of microfilaremic individuals standardized by sex and age was 25%. The geometric mean microfilarial density of microfilaremic individuals was 138 microfilariae/ml. Among teenagers and adults, males tended to have a higher microfilarial prevalence than females. Microfilaria prevalence increased with age and a maximum was observed in the fifth decade of life. In infected individuals, the microfilarial density increased rapidly and high levels were observed in those individuals 11-20 years old. The highest microfilaria density was found in a 27-year-old woman (6,028 microfilariae/ml). Brugia timori on Alor was nocturnally periodic, but in patients with high parasite loads, a small number of microfilariae was also detected in the day blood. 

The disease rate was high and many persons reported a history of acute filarial attacks. Seventy-seven (13%) individuals showed lymphedema of the leg that occasionally presented severe elephantiasis. No hydrocele or genital lymphedema were observed. This study showed that B. timori infection is not restricted to the lowland and indicated that it might have a wider distribution in the lesser Sunda archipelago than previously assumed. 

WHO site on Filarial illnesss

http://www.who.int/mediacentre/factsheets/fs102/en/

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Girl, 12, chokes to death on worms

By Rochelle Mutton, May 8, 2004 The Age Newspaper

The worm-ridden body of a 12-year-old girl, who was suffocated by hundreds of the parasites, has alerted authorities to the spectre of worm infestations in East Timor . Like thousands of other East Timorese children, the girl could have escaped death with the help of a 10-cent tablet. The girl was asphyxiated when hundreds of 20 to 30-centimetre roundworms clogged her oesophagus.    It was the worst worm infestation UN forensic pathologist Dr Muhammad Nurul Islam had seen in 16 years. He said her death was an alert for a massive incidence of worm infestations in a poverty-stricken nation with a cultural reluctance towards autopsies. Autopsies were never conducted under Indonesian rule but have begun under the United Nations Mission of Support in East Timor .   The girl died last October but the autopsy details have not previously been released. She had not eaten for two days. The worms, seeking food, crawled from her small intestine to her stomach, up her oesophagus and into her mouth, then blocked her trachea.  

"Even I can't imagine this," Dr Nurul said. "But the autopsy findings prove that this is the reality. "In this 21st century, we have some responsibilities towards any citizen of this world suffering from hundreds and thousands of worm infestation leading to death." 

In a report to the East Timorese Health Minister, Riu de Araujo, Dr Nurul said thousands of children were likely to be suffering from chronic health problems from infections of several worm species, including malnutrition, anaemia, mental dullness and stunted growth. He said the girl's death exposed the need for an immediate nationwide program for worm prevention and cures. Mr Araujo said tablets and instruction manuals for de-worming had been allocated to East Timor but there were no staff to run a nationwide health education program. Foreign help to run a national worming program in primary schools would be welcomed by the East Timorese Government and non-government organisations. A pilot program launched east of Dili, in Baucau, involved less than a dozen primary schools.

"The problem is we need more financial resources to mobilise the de-worming program in all primary schools," Health Minister Mr Araujo said.

The Department of Pathology and Microbiology University of South Carolina has a useful page on worms including Ascaris lumbricoides (roundworm) if you would like more information, click on the link below....

http://www.med.sc.edu85/contents.htm

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WHO WARNS BETEL AND ARECA-NUT CHEWING EVEN WITHOUT TOBACCO CAUSES CANCER

World Health Organization,  New York , 7 August  2003

Betel-quid and areca-nut chewing, a traditional habit widely practiced in many parts of Asia (including East Timor), causes oral cancer even when not chewed in combination with tobacco, according to new findings released by the United Nations World Health Organization today.

A new cause for concern is aggressive advertising, targeted at the middle class and at children, that has enhanced sales and use of mass-produced, pre-packaged areca-nut products now available in many countries around the world, WHO said in a news release in Geneva . In some parts of India , almost one out of three children and teenagers regularly or occasionally chew these products.

A previous evaluation in 1985 had found only that chewing betel quid with tobacco was carcinogenic to humans. The habit is popular not only in Asia but among immigrants resident in the United Kingdom , other parts of Europe , North America and Australia . 

The new findings are the work of an international group of scientific experts convened by the Monographs Programme of the International Agency for Research on Cancer (IARC), part of WHO.  The experts determined that betel quid with tobacco causes oral cancer, cancer of the pharynx, and cancer of the oesophagus in humans. Betel quid without tobacco is now known to cause oral cancer. Areca nut, a common component of all betel quid preparations, has been observed to cause oral submucous fibrosis, a pre-cancerous condition that can progress to malignant oral cancer, leading to the determination that areca nut itself is carcinogenic to humans.

Studies among Asian migrant communities have demonstrated a significantly higher risk for oral cancer compared with natives of countries where they have settled. Oral cancers are more common in parts of the world where betel quid is chewed. Of  the 390,000 oral and oro-pharyngeal cancers estimated to occur annually in the world, 228,000 - or 58 per cent - occur in South and Southeast Asia .

In some parts of India , oral cancer is the most common cancer. Striking evidence has emerged from Taiwan Province of China, where the incidence of oral cancer in men has tripled since the early 1980s, coinciding with a steep rise since the early 1970s and predominantly among men, in the practice of chewing betel quid, WHO said. Tobacco generally is not added to the betel quid in that region.

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UNMISET air ambulances 'the difference between life and death to Timorese women and children'

UNMISET PRESS RELEASE Dili, 1 August

The Head of UNMISET's Aero Medical Evacuation (AME) Unit, Colonel Jeff Brock, today said that more than two thirds of AMEs are for Timorese patients in remote locations who would most likely die without the air ambulance service. "These days, for every UN person we evacuate, we evacuate 2 or 3 Timorese. The vast majority are women suffering from pregnancy complications, and seriously sick or injured children", says Col. Brock. Just a few days ago [29th July], the District Medical Officer in Oecussi requested an urgent AME for a young Timorese woman who was 39 weeks pregnant. Her blood pressure was dropping rapidly, and he was certain that she had a ruptured womb.

UNMISET launched an AME helicopter with a medical team on board and, before they got there, a second woman about to give birth was also taken to the Oecussi Medical Centre with severe bleeding and abdominal pain. The women and their babies were considered to be at risk of death. During the return flight to Dili, the medical team helped the second woman deliver a baby girl. When they arrived at Dili National Hospital , the first woman was taken to the operating theatre immediately for an emergency caesarean section. Regrettably, her baby could not be saved and she remains seriously ill but is in a stable condition. 

Col. Brock also tells the case a couple of months ago of a one-month old baby from Ataúro Island . The baby had difficulties breathing, and an UNPOL officer requested an urgent AME. At the time the medical team arrived, the baby was not breathing and had turned blue. They brought the baby and her mother back to Dili National Hospital . The baby received emergency treatment for pneumonia, and has now fully recovered.

The AME Unit is made up of PKF Australian personnel: 2 doctors, 2 nurses and 1 medic who work in 2 teams to provide an emergency service at any time of the day or night, 7 days per week. Col. Brock is concerned that when UNMISET leaves Timor-Leste in May next year, there may not be any AME capacity in the country.

"The reality is that aeromedical evacuations are a luxury, they are very expensive", says Col. Brock. In rich countries such as Australia , the United Kingdom or the United States , AME teams are very much part of the service available to the community and often taken for granted. But developing countries cannot always afford it. Col. Brock, who is also a general practitioner, recognises that "as a doctor, I'd say that here in Timor-Leste, if the money is there, a bigger priority would be to get all clinics to have vaccination programmes, and to have better maternal and child healthcare, that'll do more good in the long term".

But at the same time, the nature of the terrain in Timor-Leste, the lack of infrastructure and of resources all make AMEs a necessity. Residents in more isolated areas such as Ataúro, Same and Oecussi are particularly vulnerable. "People usually live in remote villages, access to these places is difficult. Even when they get to the clinics, there's no reliable communication network between the clinics and hospitals, doctors can't talk to obstetricians to seek advice. In the districts, there are few telephones. They also lack trained personnel and basic equipment, things like blood and oxygen which are the essentials of resuscitation".

This is where UNMISET comes in. Usually someone will contact an UNPOL officer or UNMO [UN Military Observer] and they in turn will get in touch with the AME Unit. Once a call is received, Col. Brock will decide whether an evacuation is really necessary and, if it is, he gets approval to deploy the AME team, all within ten minutes of the call being received. The AME team aims to get to the patient within 30 minutes of launch.

This quick reaction is very important, says Col. Brock: "by the time someone reaches someone able to call us, the patient is very, very ill. In the case of women suffering from pregnancy complications, the speed of the response can literally make the difference between life and death minutes can count!"

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

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Probable Dengue Virus Infection Among Italian Troops, East Timor , 1999–2000Center for Disease Control and Prevention

CDC Emerging Infectious Diseases

Vol. 9, No. 7 July 2003

http://www.cdc.gov/ncidod/eid/vol9no7/02-0496.htm

Mario Stefano Peragallo,* Loredana Nicoletti,† Florigio Lista,* and ‡Raffaele D'Amelio for The East Timor Dengue Study Group1 *Centro Studi e Ricerche Sanità e Veterinaria Esercito, Rome , Italy ; †Istituto Superiore di Sanità, Rome , Italy ; and ‡Stato Maggiore della Difesa and Università “La Sapienza,” Seconda Facoltà di Medicina, Rome , Italy

To investigate the attack rate and risk factors for probable dengue fever, a cross-sectional study was conducted of an Italian military unit after its deployment to East Timor . Probable dengue was contracted by 16 (6.6%) of 241 army troops and caused half of all medical evacuations (12/24); no cases were detected among navy and air force personnel.

Dengue fever (DF), caused by dengue virus (DENV) serotypes 1 to 4, is an emerging public health problem in many tropical countries (1). Dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS), the severe manifestations of DENV infection, were first recognized in the 1950s in Southeast Asia and are today a leading cause of childhood illness and death in many tropical countries. More recently, DHF and DSS have emerged in Central and South America and in the Pacific region (2,3). DF is also recognized as an emerging health problem for international travelers (4,5) and for troops deployed to tropical countries (6,7). In 1999, following a United Nations Security Council recommendation, the International Force for East Timor (interfet) was formed to restore peace on the island. In November 1999, Interfet troops totaled 11,000 from 17 countries. The Italian Armed Forces contributed 640 soldiers.

DF is endemic in East Timor . The peak transmission periods for DF are July–August and December –January, corresponding to the rainy months (8). In 1998, at least 11% of hospital inpatient deaths in East Timor were attributed to DHF (9). In October 1999, a localized outbreak of DF in a western district was attributed to serotype 3 (9) and serotype 2 was isolated in December 1999 (10). Serotypes 2 and 3 were also responsible for DF cases among Australian troops returning from East Timor in January–February 2000 (11).

During deployment, a high attack rate of febrile illness consistent with DF was reported among Italian troops. A seroepidemiologic survey was therefore conducted in February 2000 among soldiers returning home, in an attempt to determine the cause of this outbreak and to define infection rates and risk factors for infection. The Study

All Italian troops eligible for deployment are routinely vaccinated against diphtheria/tetanus, tetravalent meningococcal meningitis, measles/mumps/rubella, hepatitis A and B, polio (with inactivated virus), typhoid fever (orally), and yellow fever (YF). In this situation, troops were also vaccinated against Japanese encephalitis (JE) (Nakajama strain, 3 doses on days 0, 7, and 14) just before landing in East Timor .

DF prevention consisted of the use of personal protection measures against mosquitoes (repellents applied to the skin; permethrin-treated bed nets and uniforms) along with environmental mosquito control. Adulticide spraying was conducted weekly by pesticide-dispersal units but only within the campsite and in its nearest surroundings, which were also inspected daily to reduce or eliminate breeding sites of vectors.

Italian troops were deployed in East Timor from late September 1999 to mid-February 2000, and all 640 participating military personnel were eligible for inclusion in the study. Army soldiers were permanently based on the ground and operated in Dili and surrounding areas, while air force and navy personnel had only logistical tasks and their presence in Dili was episodic, since they were mainly aboard ship or based in Darwin (Australia).

A seroepidemiologic survey was conducted February 15–28, 2000 , among troops returning to Italy after their 3-month period of duty in East Timor . After informed consent was obtained, peripheral blood specimens were drawn and a written questionnaire administered. The questionnaire asked for personal health data, including all symptoms experienced during deployment and information about compliance with personal protection measures. Immunization status and clinical data concerning febrile illness cases consistent with DF were obtained from standardized records kept by medical personnel. Soldiers and navy/air force personnel were studied according to their serologic status and disease status during deployment.

All specimens were screened for antibodies to dengue virus serotype 2 (DEN-2), yellow fever virus (YVF), and West Nile virus (WNV) by hemagglutination-inhibition test (HI). All serum specimens positive for DEN-2 were tested by neutralization test (NT) for DEN-2. Additionally, serum samples from participants who had experienced an acute clinical syndrome suggestive of DF were directly tested by NT for antibodies to DEN-2. Serum specimens negative for DEN-2 were then tested for neutralizing antibodies to dengue virus serotypes 1, 3, and 4 (DEN-1, DEN-3 and DEN-4).

The HI test was performed by the method of Clarke and Casals (12) and NT as 90% plaque reduction neutralization test (PRNT) on Vero cells. Briefly, serum specimens (twofold dilutions) and virus (102 PFU) were incubated overnight at 4°C, injected onto monolayers of Vero cells, and overlaid with 1% Tragacanth gum (Sigma-Aldrich S.r.I., Milan , Italy ). Seven days postinfection, cells were washed with saline and stained with 1% crystal violet in 20% ethanol (DEN-2 and DEN-3) or by immunodetection assay (DEN-1 and DEN-4) as described (13). Vero cells were propagated in minimum essential medium with Earle's salts (EMEM), supplemented with nonessential amino acids, 10% fetal calf serum, 100 IE/mL of penicillin G, and 100 IE/mL of streptomycin.

The following viruses were used in the study: DEN-1 ( Hawaii ), DEN-2 (NGB), DEN-3 (H87), DEN-4 (H241), YF (Asibi), and WN ( Bratislava ). Viruses were injected into suckling mice by the intracerebral route. For NT, viral stocks were prepared as 10% brain suspension in Hank's saline+7.5% bovine serum albumin (Sigma-Aldrich). For HI, test antigens were prepared by sucrose-acetone extraction from mouse infected brains (12). Monoclonal antibodies specific for DEN-1 or broadly reactive with flaviviruses were purchased from ATCC (ATCC HB112, ATCC HB47) and used as mouse ascitic fluid after injection into adult BALB/c mice.

Undetermined febrile illness was defined as an acute clinical syndrome with temperature >38.5°C, unrelated to diarrhoea, malaria, or other identified infections. Suspected dengue (14) was defined as an undetermined febrile illness of 2–7 days' duration, associated with two or more of the following manifestations: headache, retroorbital pain, myalgia, arthralgia, cutaneous rash.

Antibody levels >1:1,280 dilutions by HI (1,15) for DEN-2 and > 1:20 dilutions by NT to at least one of the four DENV serotypes were considered supportive serologic evidence of a recent dengue infection. Probable dengue (1,14) was defined as a case compatible with the clinical description of suspected DF and serologic findings supportive of a recent dengue infection.

The prevalence of undetermined febrile illness, suspected dengue, and probable dengue was compared by chi-square test among army and navy/air force personnel. Since navy and air force personnel had a limited exposure to the environment of East Timor , risk factors for probable dengue were studied only in the army contingent. A univariate analysis was first performed by Fisher exact test; each risk variable was crossed with the prevalence of probable dengue. Significance was tested at a level of =0.05.

A multiple logistic regression model was used to determine the relationship between the outcome of probable dengue and a set of explanatory variables, and test the significance of each variable while simultaneously accounting for demographic and risk factors. The following variables were included in the model: age, rank, previous deployments in dengue-endemic areas, YF/JE vaccination, night guards, skin repellents/permethrin-treated uniforms/bed nets use, and operational versus logistic tasks. To identify a subset of variables significantly related to probable DF, the stepwise procedure was performed with the likelihood ratio test, by using at each step the p value of 0.05 as entry criterion and the p value of 0.10 as removal criterion. Univariate statistical analysis was performed with EpiInfo 6.04d software (Centers for Diseases Control and Prevention, Atlanta, GA, January, 2001)] and multivariate analysis by SPSS 11.0 software (SPSS Inc., Chicago, IL). Conclusions

Of 640 eligible participants (280 army, 93 air force, and 267 navy), 595 (93%) were included in the study: 241 army, 88 air force, and 266 navy personnel (Table 1). Serum specimens and questionnaires were obtained within 2 weeks after the troops' return, in late February 2000.

Some (14.5%) of the troops had previously been deployed to DF-endemic areas, primarily Somalia and Mozambique in 1992–1994. According to their immunization status versus YF and JE viruses, 100 (41.5%) of the 241 army soldiers had received vaccinations against YFV and JEV, 119 (49.4%) had been vaccinated against JEV only, 2 (0.8%) against YF only, and 20 (8.3%) had not been vaccinated.

Undetermined febrile illness was more frequently reported (p<0.01) among army soldiers than among navy and air force personnel: 85 (35.3%) of /241 versus 13 (3.7%) of 354 , respectively. All participants with suspected dengue (n=30), with serologic results supportive of a recent dengue infection (n=27), and with a probable case of dengue n=16), belonged to the army group.

The 16 participants with probable dengue showed also a significant increase (p<0.01) in HI antibody titers to YFV (>1:1,280 in 15/16 infected soldiers vs. 14/225 uninfected soldiers) and WNV (>1:1,280 in 10/16 vs. 6/225). The average interval between the onset of clinical manifestations suggestive of DF and the date when blood samples were taken was 36±25 days. All 16 case-patients with probable DF had a fever >38.5°C; a saddle-back fever pattern was recorded for 5 (31.3%). Other reported symptoms included myalgia and rash in 13 (81.3%); headache in 11 (68.8%); retroorbital pain in 9 (56.3%), and adenopathy in 3 (18.8%). No patients had DHF/DSS.

The mean duration of probable DF cases was 7±3 days. Moreover, 12 of the 16 patients with probable DF were evacuated because of their clinical status. Univariate analysis of risk factors for probable DF suggested a possible protective effect of JEV vaccination and personal protection measures (Table 3). However, logistic regression analysis identified only a subset of variables significantly related to probable dengue, whose risk was higher among soldiers on duty in operational rather than logistic units, and lower among participants with regular use of bed nets (Table 4).

Since most of soldiers had been previously vaccinated with a flavivirus vaccine (YFV, JEV, or both), their immune response to an eventual dengue infection was expected to be a secondary (anamnestic) response, with high-titer antibodies cross-reacting with several DENV serotypes, as well as other flaviviruses (15). Thus, in spite of the lack of paired serum specimens, high antibody titers to DEN-2 by HI (>1:1,280) (1,16) and to any of the four dengue virus serotypes by NT (>1:20), after an average of 36 days from the onset of clinical manifestations compatible with dengue infection, may be considered supportive serology of a recent flavivirus infection, likely acquired during deployment.

Overall, 6.6% of army soldiers contracted probable dengue. No cases of probable DF were detected in the low-exposure group of navy and air force personnel. The high attack rate of probable dengue among the army contingent may be due to several reasons. First, DF and DHF/DSS are epidemic throughout Southeast Asia (3), including Indonesia (17); in particular, the incidence of DF markedly increased in East Timor in 1998–1999 (18). Secondly, the multinational deployment to East Timor took place during the rainy season (December–January), when the risk of infection is high.

Approximately 60% of troops with supportive serologic evidence of a recent dengue infection showed the clinical manifestations of classic DF, 20% had milder symptoms, and 20% were asymptomatic. This finding agrees with the U.S. troops' experience in Somalia in 1993, where >85% of all DENV infections were symptomatic (6). In contrast, the overall ratio of inapparent to clinical DENV infections is quite high in persons living in disease-endemic areas, as in Indonesia, where it has been reported to be as high as 9.3 (17).

Performing duties outside the camp was associated with a significantly higher risk of infection, probably because vector control activities were regularly carried out within the compound. Regular use of bed nets was the only personal protection measure that significantly decreased the risk of contracting probable dengue. This finding is not new (6) and may have been because some of the troops were frequently on duty at night and thus slept during the day when the biting activity of dengue vectors is highest. Otherwise, the regular use of repellents (applied to the skin) and permethrin-treated uniforms seemed to decrease the risk for dengue infection, but the differences between those who did not follow these practices and those who did were not significant statistically.

DF is therefore an emerging problem for troops deployed to dengue-endemic areas, mainly because of the lack of effective preventive measures, the high attack rate, the high symptomatic/inapparent infection ratio, and the long period of being unfit for duty after the acute phase of the disease. DF may thus seriously disrupt the readiness of a military unit. Moreover, previously infected soldiers redeployed to disease-endemic areas may be at increased risk for DHF/DSS complications. Persons previously infected by a DENV serotype may be at higher risk of developing DHF/DSS, if they are subsequently infected by a different serotype. Such risks should be taken into account while planning international peace-keeping operations, and the risk of DHF among previously dengue-infected military personnel should be evaluated. 

Cross-reaction by antiflavivirus antibodies induced by JEV vaccine may otherwise afford some cross-protection against DF. JEV vaccine (Nakajama strain) seems to decrease the attack rate of DHF and reduce the severity of cases for a short time (19). More recently, researchers have noted that prior vaccination of hamsters with a live, attenuated JEV vaccine strain (not licensed for human use) and a St. Louis encephalitis virus wild strain seems to reduce the severity of a subsequent WNV infection (20). Our data suggest that prior vaccination with the commercially available JEV inactivated vaccine for human use (Nakajama strain) may have some protective effect against subsequent probable DF. The decrease was, however, not significant, according to the multiple logistic regression model we used.  

Our data suggest that effectiveness of routine protective measures against vector mosquitoes is far from satisfactory. A tetravalent dengue vaccine is needed to effectively reduce the risk for DF and DHF/DSS among troops deployed to tropical areas as well as to protect long-term international travelers to dengue-endemic countries. 

Acknowledgements : We thank David Vaughn, Ashley Croft, and Tom Jefferson for critical review of the manuscript and Antonino Bella and Fortunato “Paolo” D'Ancona for statistical analysis. Dr. Peragallo is a researcher at the Centro Studi e Ricerche di Sanità e Veterinaria of the Italian Army. His main research topics are the epidemiology and control of infectious diseases, particularly in tropical settings.

References

•  Gibbons RV, Vaughn DW. Dengue: an escalating problem. BMJ 2002;324:1563–6.

•  Gubler DJ and Clark GG. Dengue/dengue hemorragic fever: the emergence of a global health problem. Emerg Infect Dis 1995; 1:55 –7.

•  World Health Organization. Dengue/dengue haemorragic fever: situation in 2000. Wkly Epidemiol Rec 2000;75:193–200.

•  Potasman I, Srugo I, Schwartz E. Dengue seroconversion among Israeli travelers to tropical countries. Emerg Infect Dis 1999;5:824–7.

•  Jelinek T. Dengue fever in international travelers. Clin Infect Dis 2000;31:144–7.

•  Sharp TW, Wallace MR, Hayes CG, Sanchez JL, DeFraites RF, Arthur RR, et al. Dengue fever in U.S. troops during operation Restore Hope, Somalia, 1992–1993. Am J Trop Med Hyg 1995;53:89–94.

•  Trofa AF, DeFraites RF, Smoak BL, Kanesa-thasan N, King AD, Burrous JM, et al. Dengue fever in US military personnel in Haiti. JAMA 1997; 277:1546–8.

•  World Health Organization, Dili Office, East Timor . East Timor health sector situation report: January-June 2000. Available from: URL: http://www.who.int/eha/emergenc/etimor/14082000.htm

•  World Health Organization, Dili Office, East Timor . Weekly Report 45. 1999. Available from: URL: http://www.who.int/eha/emergenc/etimor/191199.htm

•  World Health Organization, Dili Office, East Timor . Weekly Report 50–52 1999 & 01 2000. Available from: URL: http://www.who.int/eha/emergenc/etimor/141200.htm

•  Hills S, Piispanen J, Foley P, Smith G, Humphreys J, Simpson J, et al. Public health implications of dengue in personnel returning from East Timor . Communicable Disease Intelligence [serial online] 2000;24:365–8. Available from: URL: http://www.health.gov.au/pubhlth/cdi/cdi2000.htm#december

•  Clarke DH, Casals J. Techniques for the hemagglutination and hemagglutination-inhibition with arthropod-borne viruses. Am J Trop Med Hyg 1958;7:561–77.

•  Desprès P, Frenkiel MP and Deubel V. Differences between cell membrane fusion activities of two Dengue type-1 isolates reflect modification of viral structure. Virology 1993;196:209–19.

•  World Health Organization. Recommended surveillance standards. 2nd edition. Geneva : The Organization; 1999. p. 39.

•  World Health Organization. Laboratory diagnosis. In: Dengue haemorragic fever. Diagnosis, treatment, prevention and control. 2nd edition. Geneva : The Organization, 1997. p. 34–47.

•  Gubler DJ. Dengue and dengue hemorrhagic fever. Clin Microbiol Rev 1998;11:480–96.

•  Corwin AL, Larasati RP, Bangs MJ, Wuryadi S, Arjoso S, Sukri N, et al. Epidemic dengue transmission in southern Sumatra, Indonesia. Trans R Soc Trop Med Hyg 2001;95:257–65.

•  Krause V. Increase in dengue fever notifications in visitors to East Timor . Northern Territory Disease Control Bulletin [serial online] 2000;7:6-7. Available from: URL: http://www.nt.gov.au/health/cdc/bulletin/june_2000.pdf

•  Hoke CH, Nisalak A, Sangawhipa N, Jatanasen S, Laorakapongse T, Innis BL, et al. Protection against Japanese encephalitis by inactivated vaccine. N Engl J Med 1988;319:608–14.

•  Tesh RB, Travassos da Rosa APA, Guzman H, Araujo TP, Xiao SY. Immunization with heterologous Flaviviruses protective against fatal West Nile encephalitis. Emerg Infect Dis 2002;8:245–51.

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FIGHTING POVERTY AND DEPRIVATION CRUCIAL TO ENSURING PEACE AND SECURITY

KOFI ANNAN New York , Jul 30 2003  

Ensuring cheap generic drugs and free and fair agricultural trade for poor and developing countries in the face of subsidies, tariffs and quotas from rich nations is crucial to countering the more conventional threats to peace and security from wars and unrest, United Nations Secretary-General Kofi Annan said today. Fresh from two days of talks with leaders of some 20 of the world's regional organizations, Mr. Annan told his semi-annual news conference

"Indeed, one of the points most strongly made at our meeting was that our success in countering the more conventional threats may depend in large part on the progress we make in overcoming poverty and deprivation. These cannot be thought of as lesser priorities."

"History will not forgive us if we neglect them," he said in introductory remarks, explaining that was why he attached so much importance to the current round of trade talks that will reach "a crunch point" with the ministerial meeting at Cancun, Mexico, in September.

"Decisions taken there will tell us whether this is to be a real 'development round' - in other words, whether poor countries will or will not, at last, be given a real chance to trade their way out of poverty," he added.

Dividing the challenge into two parts, he said one - the issue of intellectual property as it affects public health in developing countries - was relatively narrow. 

"We must reach an agreement allowing those developing countries that cannot produce cheap generic drugs themselves to import them from other countries that can," he declared.

The other was very broad and potentially decisive for the economic prospects of many developing countries - the issue of trade in agricultural products. 

"We must reach an agreement that allows farmers in poor countries a fair chance to compete, both in world markets and at home," Mr. Annan said. "They should no longer face exclusion from rich countries' markets by protective tariffs and quotas. Nor should they have to face unfair competition from heavily subsidized producers in those same rich countries at home."

Another non-conventional threat that "we cannot afford to ignore" was HIV/AIDS, Mr. Annan said in announcing that he had just written to all Heads of State and Government urging them to attend a one-day session in September that the UN General Assembly will hold on the issue on the day before the general debate begins.

"I believe all these crises can be solved, if the peoples and states of the world are really determined to work on them together, making good use of the United Nations and other multilateral institutions such as those whose leaders are here this week," he said. "But we must not underestimate the gravity or the urgency of the task. We have real opportunities to make the world safer and fairer for all its inhabitants."  

For more details go to UN News Centre at http://www.un.org/news

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Health care, education out of reach for East Timorese, says activist

Stephen Steele Catholic News Service

Feb-11-2003

More than three years after East Timor voted for independence, access to adequate health care, education and basic human rights remains out of reach for most people in the country, said an East Timorese human rights worker.

Jose Luis de Oliveira, director of the Association for Law, Human Rights and Justice, known by the Indonesian acronym HAK, said East Timorese institutions are unable to serve citizens due to a myriad of economic and social problems. At the root of the problems is the absence of justice for the perpetrators of the violence that followed a 1999 U.N.-sponsored referendum, when East Timorese overwhelmingly rejected Indonesian rule. More than 1,000 people were killed and most of East Timor 's infrastructure was destroyed by militias and retreating Indonesian troops following the vote. An ad hoc human rights trial conducted in Jakarta , Indonesia , acquitted senior-level Indonesian military officials, while convicted militia leaders received minor sentences. Those acquitted were being tried for ordering the September 1999 massacre at a church in Suai, East Timor . At least 151 people were killed at Suai, although human rights activists say as many as 400 were massacred.

"This was really painful for the East Timorese to hear, that people directly involved in the massacre at the Suai church were set free. This is like saying that what happened to us didn't really happen," he said. East Timor 's fledgling judicial system is ill-equipped to handle such cases, he added. Many militia members and others involved in the 1999 violence have returned to East Timor and remain free. "The new government has no clear steps toward pushing for a justice process for crimes that happened in the past," he said. "We have a situation where people aren't feeling any sense of justice, as if independence is just a formality," he said. De Oliveira attributed the inefficiency of the new government, which took power in May 2002, to the U.N. transitional government that administered East Timor for the three years after Indonesian rule ended.

"We feel the current situation is in large respect the consequence of a lack of thorough foundation building during the transition," de Oliveira told Catholic News Service in Washington in early February while in the midst of a one-month U.S. speaking tour sponsored by the East Timor Action Network.

De Oliveira said many East Timorese were excluded from participating in the transitional government because of education and language requirements that discriminated against them. "East Timorese who cooperated with Indonesia and gained higher education are now in higher positions with the new government," he said.  Those who resisted Indonesian rule often lacked higher education, leaving them on the outside looking in with regard to the new government, said de Oliveira. Additionally, impoverished communities under Indonesian rule have remained poor, leading to rising tensions between young East Timorese and their government. "We are told that in independence we need people with skills and with higher education and so the people who gave so much for independence cannot contribute in this new structure. Those who suffered the most in the past have the most burdens placed upon them now," de Oliveira said. "As a result, what would normally be a small incident turned into a huge demonstration and unrest that led to a lot of violence," he said referring to the early December riots in Dili, East Timor's capital, following the arrest of a student protester.

De Oliveira also criticized the East Timorese government for modeling its judicial system on a Portuguese system. East Timor is a former Portuguese colony. "Less than 7 percent of East Timorese can speak Portuguese, but our judges are coming from Portuguese-speaking countries. This combination of very few East Timorese speaking Portuguese and the imposition of a foreign system has led to unequal justice," he said. "Most people don't understand their basic rights," he said.

Constancio Pinto, charge d'affairs for the East Timorese Embassy in Washington , said the new government was struggling in providing basic services to its citizens because of lack of funding. "We are a new and very poor country. More funding from the international community would help," he told Catholic News Service.

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Social and Economic Conditions in East Timor

Editors: Jon Pedersen and Marie Arneberg

This report on Social and Economic Conditions in East Timor is the product of a year-long collaboration between Columbia University 's International Conflict Resolution Program ( New York , USA ) and Fafo, the Institute for Applied Social Science ( Oslo , Norway ). Under the overall direction of David L. Phillips, Executive Director of the International Conflict Resolution Program at Columbia University , the project sought to establish a reliable base-line data set of socio-economic conditions in East Timor at the time of the UN-sponsored referendum on autonomy within Indonesia .

Jon Pedersen and Marie Arneberg of Fafo's Centre for International Studies oversaw the technical aspects of the study with help from Rick Hooper, Senior Advisor to the Programme for International Cooperation and Conflict Resolution at Fafo. Shepard Forman, Director of the Center on International Cooperation at New York University and Terje Røed-Larsen, Honourary Chair of Fafo's Programme for International Cooperation and Conflict Resolution, served as senior advisors to the project.

The project's full report provides detailed coverage of the demography, environment, agriculture, health, economy, education, and governance sectors in East Timor , and includes an assessment of development assistance. The report considers available data, identifies information gaps, and makes preliminary recommendations for program and policy development. Sectoral analyses were written by a team of international experts and included contributions from professionals from the World Bank. The overview of development assistance was prepared by the Center on International Cooperation at NYU. Part I presents project findings and recommendations. Part II contains more detailed statistics and an extensive bibliography. An executive summary is also available. 

Click here to open the complete report as a pdf file.

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Child Mortality rate is 124 per thousand

Mariza Costa-Cabral < cabral@gkss.de >

from the ETAN website

Lisbon , 11 December 2002 (Lusa) - 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. Entitled "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, data is 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.

Copyright Lusa Agency. All rights reserved.

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Healing A Nation's Wounds 

By Alan Saunder as reported in the The Age ( Melbourne ) December 21, 2002 Saturday

from the ETAN website

Melbourne surgeon Alan Saunder discovers the realities of third-world medicine in Dili. Cock-a-doodle-doo - another delightful Dili dawn, another wake-up call from the local poultry. As the sun emerges from behind the rim of hills encircling East Timor 's capital, the air is already warm, the sky clear and the city stirring. It's 6.30am , time for a morning walk to the beach before beginning the day's duties at the hospital.

On the streets, those roosters are now frantically picking at the dusty road for invisible morsels. Pigs forage along the side of the street. Dogs scuffle, as if to get any disagreements out of the way before the heat of the day. People emerge, similarly keen to go about their business before the temperature rises.

At the bowserless petrol station, diesel is decanted, ready for sale, into 25-litre plastic containers. Next door, the coffin maker displays a magnificent array of timber boxes in various states of readiness for the inevitable. Beyond, surveying the harbour, stands Jesus, 27 metres high, arms outstretched, looking down on the fishermen as they check their nets for the day's outing.

As I stride down the dusty road, I am greeted regularly with the friendly Tetun morning call, bondia, to which I happily reply the same. What a way to start the day - with such friendliness from such outwardly happy and desperately poor people.  

As a surgeon at the Dili National Hospital , part of a program run through Ausaid and organised by the Royal Australian College of Surgeons. Already I find myself settling into a routine far removed from my Melbourne existence. At home I am a vascular and transplant surgeon, a skill that invites wry amusement in Dili, given the absence of anything remotely like a transplant program. Here I am, surgery's equivalent of the jack-of-all-trades, and learning all the time.  

At 7.45am , I meet my colleague, Dr Taco Walbeehm, an experienced Dutch surgeon, outside the hospital bungalows we call home, and the daily surgical routine begins. We make our way to the intensive care unit. This is not intensive care as we know it in Australia - there are no machines for ventilating patients, cardiac monitoring, dialysis or the like. The "intensive care" comes in the form of a nursing ratio of two patients to one nurse. Today the unit has three patients to review.

The first is eight-year-old Moses. We operated on him yesterday to repair a tear in his small bowel - the result of a fall from a coconut tree. The injury had been straightforward to repair, and this morning he is surprisingly well and essentially pain free. Much of the credit must go to our anaesthetic colleague, Dr Dave Sandford, from Sydney .  

We move on to Carlos, 34, who severely injured his spine weeks ago in a road accident. He shows few signs that he will recover the use of his arms and legs. He is in ICU because there is nowhere else for him to go. His prognosis is poor.  

Our next patient is even more of a worry. Ely, 11, has tetanus - something rare in first-world medicine. The only other case I have seen was in Kenya as a medical student 20 years back. Ely is from Atauro, an island about 20 kilometres north of Dili, and his family travelled overnight in an open boat to bring him to hospital. His spasms were difficult to control initially, and as he deteriorated he showed some of the classic features of tetanus: the sardonic smile that is associated with lockjaw, and extreme arching of the back with each spasm. His contortions are so violent he appears to have fractured his lower spine.  

Dave, the anaesthetist, has got his hands on some midazolam, a short-acting sedative and anti-spasmodic. It has worked like a dream for the past 24 hours, but we know that by afternoon there will be no midazolam left in the hospital or, as it turns out, in the country. It is awful to watch this previously healthy boy in excruciating agony. Knowing it can be avoided by immunisation just makes it more painful. Anyone who has read this far and is overdue for their tetanus booster should visit their GP today!

A ward round follows. This morning we concentrate on the female and paediatric ward. The majority of patients are stable and recovering as expected. This is one of the great attractions of surgery - most patients do get better. However, there is one 10-year-old boy who has been here for months with extensive osteomyelitis (inflammation of the bone) in his left leg. Both our clinical assessment and the X-ray results are not encouraging.  

By 9am , it is time to go to theatre. As Dave prepares the first patient, Taco and I take a moment to support East Timor 's struggling economy by buying a cup of coffee - the new nation's only agricultural export product. Salvadore - our major case for the day - is prepared and on the table. Taco and I will work on him together. He has benign prostate disease, common in East Timor in older men, but here they seek medical attention much later than in Australia . The prostates are therefore enormous and, because of a lack of suitable telescopic equipment in Dili, most are removed by open surgery, cutting through the lower abdomen and the bladder. Taco acts as my surgical mentor, instructing me in this unfamiliar procedure. It's all over in less than an hour.  

Taco and I tackle the remainder of the day's list separately. There's the removal of a benign breast lump; a burns dressing that needs changing; a fracture to be placed and set; a sigmoidoscopy (inspection of the rectum and colon); and a circumcision on an adult man. Day surgery in Dili is simple. The patients turn up to the operating theatre at 8am , await their turn and walk into theatre. They remove the appropriate garment once they are on the operating table, are anaesthetised and then operated on. The circumcision is under local anaesthetic, and at the end of it the man pulls up his shorts and walks out of theatre and home. Even day-case patients receiving a general anaesthetic will spend only 20 minutes or so in the recovery room before going home.  

The last case of the morning is Jose, who has stripped the flesh from his lower leg down to the bone in a motorbike accident. This is his fourth journey to theatre to clean the exposed wound and prepare it for a graft.  

We emerge from the air-conditioned theatre just after noon . Walking back to my bungalow I hug the shaded walkway where I can. The sun burns as if concentrated through a magnifying glass. Lunch is a sandwich, a litre of ice-cold water and a 30-minute siesta in the blessedly cool bedroom.  

By 2pm we're due back at the hospital for the outpatient clinic. Conducted in a covered open air area with one shared consulting room, this is what you might call a very public health system. The only privacy is provided by a screen around a couch and an adjoining room with a bunk for examinations.  

Maria and Fatima, who run the clinic, advise that this afternoon we have 45 patients to see. Many are here to have their dressings reviewed or to show us X-rays of broken bones, which are all mending well. A 12-year-old girl hops in, unable to put her right foot on the ground. Her forefoot is grossly swollen and an examination of the sole reveals a grubby closed wound under the tough plantar skin that is testament to her barefoot existence. She needs to be admitted to hospital so her foot abscess can be drained and then X-rayed to see if there is something buried in there.  

Another patient has a chain of enlarged lymph glands down her neck - a typical manifestation of tuberculosis in East Timor . She will need to be treated by the hospital's sole physician. One of the last patients I see is six-year-old Maria. She had a biopsy of her right leg six weeks ago after complaining of a slightly painful lump just below the knee. The pathology has taken all this time to come back, and reveals she has a bone tumour. 

In Australia , chemotherapy and limb salvage surgery would give her about a 70 per cent shot at a cure. But here, no appropriate chemo is available. The only treatment option for her is an above-knee amputation, which has a cure rate of about 10 per cent. We discuss the possibility of her having treatment in Australia , if we could find a way to finance it. As it turned out, this was impossible to organise. At last report, Maria was in the care of a local medicine man. 

After the clinic, we check the emergency room for any new arrivals and find Armino, a patient who had an emergency abdominal procedure some weeks back and has returned vomiting, emaciated, dehydrated and with a palpable mass on his upper abdomen. It feels like a tumour, probably obstructing his stomach, but we have no medical notes to guide us on his history. Armino, 20, needs immediate intravenous rehydration. It turns out the earlier surgery removed part of a tumour in his small bowel. As with Maria, it has taken six weeks to get the pathology back from Melbourne and it reveals he has Burkitt's lymphoma. The drugs he needs will have to be imported - but will they arrive in time?  

The care of such patients, many of them malnourished, in a tropical environment and with limited resources, is a real challenge. It makes me reflect on the extravagance of some of our own treatments and how much we take for granted in our hospital system.  

I head for the small office where I have access to the world, my Melbourne practice, my surgical colleagues and my family via the Internet. Glancing outside, I watch some local boys play soccer in part of an old coconut grove. Their bare-foot skills are astounding, and I wonder whether the next Pele or Maradona is lurking here among the coconuts in Dili.  

Despite the heat, I need supplies - especially more fluids - so I make my way downtown to the Hello Mister supermarket. The landscape is notable for two things - the dust and the shipping containers. They are everywhere. The containers serve as offices. Stacked on top of one another, they are apartments. The neighbourhood is riddled with the burnt shells of what were once houses. I find myself wondering what atrocities have been witnessed in these streets. Back at the bungalow complex, Taco and I talk shop and politics over Tiger beer before our thoughts turn to dinner. Taco is a veritable Age Good Food Guide for Dili. The influx of United Nations personnel has created a thriving restaurant scene. He recommends a local waring and, along with Dave, we indulge in some of East Timor 's fabulous fare. Back in my bungalow afterwards, I call home, check the air-conditioner and light the mosquito coil. I read up on the nuances of an unfamiliar procedure I will be tackling in the morning, and dip into a phrase book to try to master a few more snippets of Tetun.  

Drifting into sleep, I can't get past my good fortune: at being Australian; at being an Australian- trained surgeon with the capacity to contribute to this Ausaid project; at having a part to play in helping this poor, fledgling neighbour; at having supportive colleagues and a loving family back in Melbourne who have given me the chance to be here.   My mind turns to the roosters. How long till they crow again?

The Ausaid hospital program is organised by the Royal Australasian College of Surgeons, and provides a consultant anaesthetist and a general surgeon for Dili National Hospital for an initial period of three years. The program has just completed its first year.

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ICEVI* East Timor Project - June/July 2002 

Frances Gentle 

Email: vision@stedmunds.nsw.edu.au

From the September 2002 edition of the Australian Braille Authority News Letter

(*International Council for Education of People with Visual Impairment http://www.icevi.org/ )

This is a report on my recent visit to East Timor for a two-week period, on behalf of the International Council for the Education of People with Visual Impairment (ICEVI). The purpose of the trip was to investigate current educational services for people who are blind or vision impaired and to determine ways the international community can provide support. ICEVI is a professional non-government organization that promotes educational opportunities for children and adults with vision impairment throughout the world.

Due to issues of safety, I accompanied the East Timor Eye Care Program (ETEP) team, a group of Australian eye specialists who visit East Timor biannually, to provide much needed eye care services. The ETEP team assessed approximately 1200 people with vision problems, 400 from the district of Aileu and 800 from the district of Dili. Approximately half of the people assessed had near and distance vision problems, and were prescribed spectacles, free of cost. Another group had more serious eye conditions, including cataract and glaucoma, and received eye surgery. A third group were blind as a result of eye trauma, congenital eye conditions and Vitamin A deficiencies associated with disease and nutrition. 

During my travels in the districts of Aileu, Maunfahe and Dili, I discussed the needs of people with vision impairment with government officials, village chiefs, church leaders, school principals and teachers, aid workers, people with vision impairment and their families. The issues facing East Timor are significant and pressing. With an average life expectancy of 57 years of age and illiteracy rates of 50% (United Nations Poverty Assessment, February 2002), support from the international community is vital. Villages often lack the basic services of health care, electricity, and clean water supply. Schools have reopened, and are all in need of reading and writing materials in Portuguese, Indonesian, Tetun and English.

In general, children who are blind do not attend school and are illiterate. They are cared for by their families, but are not expected to assume positions of leadership within families or communities.

The recommendations that I have put forward for consideration by the ICEVI Council include the following:

• Establishment of an Association of blind citizens of East Timor .
• Establishment of community-based educational services for people with vision impairment.
• The promotion of capacity through the provision of "train the trainer" programs, including the areas of braille literacy, dual literacy media, orientation and mobility, optical and non-optical aids, curriculum modification and teaching strategies.
• Provision of reading material in alternate formats in the languages of Tetun, Portuguese and Indonesian. The Portuguese Braille code (Grade 1) is recommended for the production of material in Tetun and Portuguese, as it accommodates the linguistic features of both official national languages.

Overall, my experiences in East Timor were very positive. I met many hard working, dedicated people representing Australian and international organizations working in East Timor . I was humbled by the dignity and sincerity of the East Timorese people I met. The playfulness and open curiosity of all the children I encountered gives me hope that they will recover from the trauma of past violence and move forward into brighter futures as free and independent people.

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Transcript of the Interview with Dr. Rui Maria de Araujo,

 Minister of Health, East Timor Dili, 28 of June 2002

Introduction

East Timor at present can count itself fortunate: so far it appears to have avoided the kind of HIV/AIDS problem that has ravaged many other developing nations. This means it has a rare opportunity to prevent an HIV/AIDS epidemic, learning from the lessons of other less fortunate nations to build a healthier future for its people. UNDP is supporting the East Timorese government in their efforts to create a programme that will bring about that future, by facilitating the drafting and discussion of a National Strategic Plan, and by sending the new Minister for Health, Dr Rui Maria de Araujo to Barcelona, so that East Timor can for the first time as a nation join the international dialogue on responding to the HIV/AIDS issue. But Timor is a small and very poor nation with many, many other problems - is it really in a position to seize the opportunity it now has? In this exclusive interview, Dr. Rui Maria de Araujo tells UNDP why and how East Timor can handle the HIV/ AIDS issue.

How important is it to East Timor to deal with the issue of AIDS/HIV?

"I think for East Timor it's very important, because we do realize that the AIDS epidemic is going to be a real challenge, the biggest trap for the economic development of this country. We understand that looking at the examples we have – in Papua New Guinea for example, the most recent outcry, the spread of the disease has affected the whole country, particularly the workforce. That's why we do realize that HIV/AIDS is very important, it's one of our highest priorities and we are doing all that we can to get the involvement of everyone in the country – civil society, the church, parliament and right up to the president himself because we realize it's very important to get people at the top involved."

At present, East Timor has a very low recorded prevalence of HIV/AIDS and that means that you have the opportunity here to prevent that kind of epidemic. Are you confident that that can be achieved?

"Let me start a little bit back from that. Yes prevalence is low but the vulnerability is there. All the necessary ingredients for a tragedy are there. Poverty, drug use is on the increase although we don't have the exact figures, we have street children out there, we have prostitution out there, we have jobless people and at the other side of the coin, we have a huge presence of expatriate people here with a great capacity of buying things, including buying sex, and that is a great risk. Obviously because the prevalence is low, according to the testing up to now, even though on that side I'm a little bit pessimistic because the cases that we've found indicated that contact with the disease happened already during the Indonesian times. We had an AIDS case who died two months ago and just doing the counting, simple math's, that means that guy was exposed five or ten years ago, which means he was exposed during Indonesian times. Now, to what extent has that exposure affected East Timor ? I think the low prevalence that we're talking about is just the tip of the iceberg. Obviously that does not discount the focus that we need to give to the prevention side, and particularly on the health promotion. Spreading the information to all communities in order to make them aware. We've been doing this for the last one, one and a half years – direct intervention with at risk groups to raise the sensitivity, the awareness about the prevention of the disease, and the response has been quite good. Now, to what extent that kind of information is going to change people's behaviour, that remains to be answered, but although this might seem a very optimistic view I think we can do something on that. 

"It is very difficult to know what the incidence rate is in Timor . Are there any plans for a systematic research programme?

" Well, not systematic research, but the start of the Strategy plan, one of the activities that is first going to be activated is to set up a testing and counselling unit, and to set up a surveillance system for HIV/AIDS in the main hospitals, in the blood transfusion unit, to get the real picture. From now onwards we are planning to establish that as part of the national HIV/AIDS programme, and possibly it's going to be at the national hospital – they are now doing the proposal for the implementation of that. And with the voluntary testing and counselling unit and the surveillance system we will be able to get more data about the incidence rate. In the past we have also based on screening of blood for transfusion and based on some screening samples for people going to the police force and army, we came up with a prevalence rate we are now using of 0.64. The plan for the voluntary testing and counselling unit is to have pre-test counselling, and then post-test counselling in case we find out people are positive and we need to have the network to follow up once people are positive. So these are the principles that led to the founding of this centre, but it will take another few months. We need psychologists, blood technicians and social workers in order to make that centre functional. Obviously that is from the supply side. From the demand side, we may end up with people not coming for testing because it's something scary for people, even if they know that they've had a risky life in the past it is scary for them. Once they are fully aware of the connotations that are attached to that disease, on the demand side, we may face this problem. But we are doing our best on the supply side to make it an appropriate centre.

" You are of course well aware that in East Timor, any HIV/AIDS campaign has to work with the Church, who are enormously influential here and whose views on approaches to HIV/AIDS are very different to those of many HIV/AIDS experts. How are you going to tackle that difference in viewpoint?

"Well, on the prevention side, one thing that's becoming a huge challenge is the possible tension between government prevention in terms of providing or making available condoms to people that want them, and the views of the Catholic Church. That is a very real potential tension that might jeopardize our prevention activities. We are now on the ground working with the Catholic Church, having a dialogue with the Church, and we have come to the conclusion that the government has the responsibility to provide all the information available about the effectiveness of prevention to people, and the people will have to make their own choice based on their religious beliefs. Let's make the choice available and let them make the choice – that is more or less the informal agreement we have with the church.

" Are you confident that that relationship can work in the context of the church out in the districts, as opposed to with the religious leadership in Dili?

"At the moment, I'm not very confident of this. But I believe that as long as the government is frank in its discussions and as long as the risks of not embarking on that policy are made clear to the Church, not only to the hierarchy but at the community level, I think they will be aware. Because the main concern of the Church is of the risk of increasing promiscuity with the campaign of using condoms. Obviously we can produce scientific evidence showing that that's not the case, but in moral terms, there is a huge reluctance to openly advocate the use of condoms. But they do realize that the use of condoms is one way to prevent AIDS. It's not the only way, it's one way. And the dialogue that we are having revolves around the three main effective ways of prevention, ABC – A, Abstinence, B, Be Faithful and C, use a condom. Now A and B fit perfect with the Church's views. Obviously we are all human beings and there have to be choices, when the moral method doesn't work any more, then you have to provide information to people. Condoms should be last call. For people with the catholic faith, A and B are very important.

" The ministry has now adopted a National Strategic Plan. Can you explain what that plan involves and what your first steps will be to implement it?

"The main view here is that we are at the right time to prevent an epidemic in this country, and the emphasis of the strategy is to enable the whole community to adopt preventative measures and that is going to be implemented through different activities, such as education campaign, such as increasing the awareness particularly of the youth, and also having civic programmes focusing on the risk population: drug users, street children, prostitutes – they will be the main focus. We have adopted that strategic document, we are now in the process of forming a National Advisory council. The next step will be to finalize the whole document and then bring it up to the council of ministers for formal approval, and then start to break it down. Who is going to manage the whole process and who will be the partners? For the sake of co-ordination, the ministry of health has taken the role of national coordinator. The implementation will come with NGOS who are working in that area, both national and international NGOS. We have international NGOs, a number of Timorese NGOs and of course the UN agencies. They will be the main players in the implementation of this Plan.

" What's the composition of the Advisory Council and how will it function?

"The members of the National Council will be nominated by NGOs who are part of the National Conference of HIV and AIDS where we discussed the programme, and obviously that will involve people who are concerned about the issue, who have the right networking capabilities and I think we are foreseeing between ten to fifteen people, and the main role is going to be advising the national management team, particularly on policy issues. And when you talk about policy issues that will involve issues like condom use, they will have to come through that advisory council before we adopt anything officially. That's only one example.

" What are you hoping for from the Barcelona conference?

"Well, if you are going to name them one by one it'll be a long list of hopes. But I think the main thing I'm hoping is to get in touch with a variety of people coming from all over the world and using that chance as a way of improving our networking, and also using that chance to learn from experiences in other places, particularly experiences that are relevant to our socio-economic experiences here in Timor, and I'm very interested in finding out in other places how the relationship between the government and the catholic church was developed on HIV/AIDS. Apart from that my hope is also to meet people like the head of UN AIDS and to meet NGOS, development agencies that are working throughout the world with HIV/AIDS to explore the possibility of establishing partnerships or future activities in this country. And also one other hope is to meet people that have been successful in their application to the Global Fund, the Fund that the UN is now making available to develo ping countries to tackle the three main diseases affecting people in the world now – HIV, malaria and tuberculosis.

" Is there a stigma attached to HIV/AIDS in this country or do you think people still understand so little about the illness there is no stigma?

"The problem is we haven't had any experience of people coming out and saying look, I am HIV positive or I'm suffering from AIDS. I think the reason is the level of education and awareness here is very low and probably people are still thinking oh, HIV AIDS, it's so far away. In Indonesia they say the enemy is still miles away so hey, we can know about it but so what? Once we put it in their faces that OK, we have cases here in East Timor now, people might wake up – at least among the educated ones.

" A lot of people here blame the international presence for bringing AIDS and HIV to this country. Do you think there is any validity to that, or do you think it's unhelpful and that East Timorese people need to take responsibility for themselves?

"Well, to start with, we don't have enough evidence to blame either the period of Indonesian station here or to blame the international presence at the moment. And we cannot blame the East Timorese themselves because of the conditions here, because we have prostitution, drug users, because we are poor. So it is not an issue of blame, of who is wrong, it's a question of what we can do now. And look to the facts, to the evidence: HIV/AIDS is a reality now in this country and we are exposed. Who is going to be blamed for the exposure, well, I don't think personally, as a medical community and as an East Timorese, that we should blame the internationals. But obviously we also need to increase the awareness of the internationals about their behaviour in this country. If you are coming from a developed country or a place where HIV AIDS is a reality and you are aware of the risks of unsafe sexual behaviours, then at least as a human being you should practice that. There is no need to say because you are coming from Europe , you don't give a damn about the way you behave in East Timor .

" East Timor is not a rich country and this is an ambitious programme –do you believe you have adequate resources to run it?

From the Ministry of Health point of view, due to the fact we are small country, we have less than one million people living here and most importantly due to our limited resources, we are committed to implementing this programme in a very co-ordinated way in order not to waste resources. That does not mean the Ministry and the government want to control everything and not give others space to work in this area, but it's very important to have coordination. In order to be sustainable and bring good effects to the people, we need to make the best use of the resources we have.

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PRACTICAL ASSISTANCE TO BUILD EAST TIMOR 'S HEALTH SYSTEM

Media release from the Prime Minister of Australia 19 May 2002

"I am pleased to announce three new Australian aid projects to provide practical assistance in the reconstruction of East Timor 's health system. Since late 1999 Australia has been working in partnership with the East Timorese to improve basic health services and build the capacity of the Ministry of Health. Through our overseas aid agency, AusAID, we will build on these efforts in three significant areas. 

The $3 million Specialist Medical Services Project will run for four years and provide specialist medical services. At present, there are no practising East Timorese surgeons or specialists and the Ministry of Health has limited resources to maintain essential minimum surgical capability. The project will provide a general surgeon and anaesthetist to the Hospital Nacional Dili for three years and involve approximately 13 visits per year for three years by visiting specialist teams, including plastic and reconstructive surgery, eye surgery, ear, nose and throat surgery and paediatric surgery. This Specialist Medical Services Project will be managed by the Royal Australasian College of Surgeons and will also offer training in surgical and anaesthetic services to East Timorese medical personnel. This Project will build upon the successful interim surgical support that has been provided to East Timor by Australia since mid-2001.

The second project is the provision of 10 four-wheel drive ambulances, worth approximately $900,000 for an East Timor District Ambulance Service. A $430,000 training package will also be delivered to ambulance personnel such as drivers and nurses. At present, the Ministry of Health has just four ambulances based in Dili, Baucau, Viqueque and Same. The additional vehicles will assist in establishing a simple, sustainable and low cost district ambulance service in East Timor . 

The third project deals with mental health. Over the next three years, starting around September 2002, support will be given to the Ministry of Health to implement a mental health program in all 13 districts of East Timor . It will train 15 specialist mental health workers and generalist health workers in the recognition, diagnosis and treatment of people with severe mental illness. It is anticipated that by the end of three years this project will have set in place measures to sustain a National Mental Health Program that has broad community support and involvement and is aligned with World Heath Organisation policies and strategies for mental health services. This Project will build upon the successful PRADET (Psychosocial Recovery and Development for East Timor ) activity that has been providing mental health services in East Timor since 2000.

I am confident that these programs will play an important part in creating the foundations of a new health service in East Timor . They will build upon a significant aid programme already in place to build health services in East Timor , including assistance to combat HIV/AIDS and a $5 million oral health project."

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HEALTH MINISTRY ENTERS NEW PHASE IN 

HEALTH CARE PLAN

Dili, 1 March 2002

The Ministry of Health's Project Management Unit is entering a new phase in the restoration of the nation's health care system building on the basic health services and infrastructure that have been put in place since the violence of 1999, Vice Minister of Health João Soares Martins said in a briefing today.  

The second phase of the rehabilitation and development program focuses on strengthening the health care referral system, meeting the needs of inpatients and improving surgical facilities – particularly emergency care for mothers and their children. 

The Ministry of Health is in the process of recruiting 21 international doctors. Thirteen of them are already working, and eight more will be recruited in March. Additionally, health promotion training was conducted for all District Public Health Officers in February. 

Other health-related developments include:  

• The construction of the first Community Health Centre (CHC) in Comoro is on schedule to be completed this month; 
• A national HIV/AIDS situation assessment is being carried out by the HIV/AIDS Working Group;
• The Vector Borne Disease Control Group has produced a malaria situation analysis. A protocol treatment for malaria was recently produced and approved, and it will soon be distributed to the districts. 

Martins said that East Timor 's Second Transitional Government has confidence in the rehabilitation and development program and believes the next two years of implementation will bring markedly increased health benefits to the people of the nation.

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UNTAET FACT SHEET 16: Health. 

February 2002

On 20 September 2001 , Dr. Rui Maria de Araújo was sworn-in as the first Health Minister of East Timor and João Martins as the Vice-Minister . De Araújo was among the first 17 East Timorese Senior Civil Servants of the Division of Health Services of the East Timor Transitional Administration (ETTA) to be sworn-in by the Special Representative of the Secretary-General Sergio Vieira de Mello in June 2001.

An additional 64 senior-level East Timorese have been recruited to senior management and clinical positions in the health services, including as Heads of District Health Services (DHS) in each of the districts. As of December 2001, East Timor 's Health Division has more than 700 Timorese staff out of 1,457 posts.  Recruitment is expected to be completed by March 2002.

Since the formation of the Second Transitional Government, the Ministry of Health has largely taken over the implementation of district health care in all districts. These plans include services to be provided through a network of 64 community health centres, 88 health posts and 117 mobile clinics. Not all of the health posts and mobile clinics are yet functioning. Recruitment of doctors is ongoing. Plans call for 21 doctors to be distributed throughout the districts. Working groups involving both ministry staff and other stakeholders are active in health policy, health promotion, vector-borne disease control, reproductive health and STD/HIV/AIDS.

In June 2001, the second Trust Fund for East Timor-funded health sector rehabilitation and development project was signed, totalling US$12.6 million. This will overlap with the first, ongoing US$12.7 million project. With an additional US$8.8 million anticipated from the European Commission, the project will finance the reconstruction or rehabilitation of hospitals, as well as other activities.

The construction of the first Community Health Centre (CHS) at Comoro, Dili, is expected to be completed at the end of February. Construction of 21 more will start soon. The construction of the National Medical Store at Kampung Alor, Dili – a key element in the establishment of an autonomous medical supply system – was completed in late December. Most drugs used in the health system are procured through the DHS Central Pharmacy, which opened in Dili in April 2000.

The International Committee of the Red Cross (ICRC) handed over the management of the Dili National Hospital to ETTA in June 2001. The DHS is assisted in this task by Cordaid, a Dutch NGO. When ICRC undertook the management of the hospital in September 1999 much of the equipment and medical supplies were missing or damaged. Since then the hospital has been rehabilitated and now operates at near full capacity. Significant efforts have been dedicated to the training and capacity building of Timorese medical staff, whom the ICRC credits with saving hundreds of lives. 

UNITED NATIONS TRANSITIONAL ADMINISTRATION IN EAST TIMOR (UNTAET) OFFICE OF COMMUNICATION AND PUBLIC INFORMATION (OCPI)

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Growing pains of East Timor : health of an infant nation

Kelly Morris Lancet 2001; 357: 873-77

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

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.

Under Indonesian administration

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

During the conflagration, health care was deliberately disrupted 2 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.

Progress

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 locally.

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.

Public health

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 bed net treatment and distribution. 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

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".

Post-conflict research: malaria resistance

Public health was never a priority for the Indonesian regime, and with the increasing groundswell of support for independence, many initiatives, such as insecticide spraying, were stopped in 1998. The post-conflagration situation comprised almost all of the factors that increase malaria risk: a long rainy season, a displaced population, crowded housing, problems with water supply and sanitation, reduced food supply, no surveillance, poor clinical facilities and drug shortages, lack of bed nets and insecticide, and, potentially, drug resistance. Unsurprisingly then, a massive rise in acute febrile illnesses was seen. Around 10000 suspected cases of malaria were diagnosed in 1998, but between September, 1999, and mid-January, 2000, more than 30000 clinical cases were seen.

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 .

The future

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.

References

1 UN security council resolution 1272 of Oct 25, 1999 . www.un.org/Docs/scres/1999/99sc1272.htm (accessed March 5, 2001 ).

2 Stein D, Ayotte B. East Timor: extreme deprivation of health and human rights.   Lancet  1999;  354:  2075-77. [ Text ]

3 UN security council resolution 384 of Dec 22, 1975 . www.un.org/documents/sc/res/1975/75r384e.pdf (accessed March 5, 2001 ).

4 UN security council resolution 389 of Apr 22, 1976 . www.un.org/documents/sc/res/1976/76r389e.pdf (accessed March 5, 2001 ).

5 Clausen L. Under clearing skies. Time 2000; 24: 44-53.

6 World Bank East Asia and Pacific region. Background paper prepared for the information meeting on East Timor . Washington DC : World Bank, 1999.

7 East Timor Joint Assessment Mission . Report of the Joint Assessment Mission to East Timor . Washington DC : World Bank, 1999. (accessed March 5, 2001 ).

8 East Timor Joint Assessment Mission . Health and education background paper . Washington DC : World Bank, 1999. (accessed March 5, 2001 ).

9 World Bank East Asia and Pacific region. East Timor Health Sector Rehabilitation and Development Project. Washington DC : World Bank, 2000.

10 Anon. Evaluation of humanitarian relief process released by UNTAET . La'o Hamutuk Bulletin 2000; 1: 4-6. http://etan.org/1h/bulletin02.html#_04 (accessed March 5, 2001 ).

11 Carrette P, Petit D, De Mauleon P, Pourriere M, Martinie C, Didier C. Report of the first cases of cutaneous leishmaniasis in East Timor. Clin Infect Dis 2000; 30: 840.

12 Morris K. Malaria-control partnerships key to combat disaster deaths. Lancet 2000; 356:144 .

13 Ezard N. Research in complex emergencies. Lancet 2001; 357: 149 .

14 Pribadi W. In vitro sensitivity of Plasmodium falciparum to chloroquine and other antimalarials in east Timor and east Kalimantan , Indonesia . Southeast Asian J Trop Med Public Health 1992; 23 (suppl 4): 143-48.

15 Fryauff DJ, Soekartano, Tuti S, et al. Survey of resistance in vivo to chloroquine of Plasmodium falciparum and P vivax in North Sulawesi, Indonesia.   Trans R Soc Trop Med Hyg  1998;  92:  82-83. [ PubMed ]

16 UN Development Programme. Conceptual framework for reconstruction, recovery and development of East Timor (draft). New York : UNDP, 1999. www.undp.org/erd/archives/concept_paper_east_timor.pdf (accessed March 5. 2001).

17 Soeprapto W, Ertono S, Hudoyo H, et al. HIV and peacekeeping operations in Cambodia.   Lancet  1995;  346:  1304-05. [ PubMed ]

18 Morris K. email KellyMorris@Dili. The Guardian July 10, 2000 .

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Report of the First Cases of Cutaneous Leishmaniasis in East Timor  

B. Chevalier,  Th. Carmoi, E. Sagui, Ph. Carrette, D. Petit, P. De Mauleon, M. Pourriere, C. Martinie, and C. Didier.

Clinical Infectious Diseases 2000;30:840

SIR: According to the World Health Organization's division of control of tropical diseases statistics, leishmaniasis currently affects 12 million people in 88 countries, and it is estimated that 350 million people are exposed to the risk of infection by the different species of Leishmania parasites. The French military medicosurgical group, part of the International Force for East Timor (INTERFET), is deployed in Dili (the capital of East Timor ) in the context of a humanitarian mission for medical support of the local population. Here we report 46 cases of cutaneous leishmaniasis detected in November 1999 during daily free clinic consultations for people in that area.

The detected cutaneous lesions had been developing for 13 months, and all the clinical criteria were consistent with cutaneous leishmaniasis. Diagnosis was confirmed by direct microscopic examination of lesion specimens stained with May-Grünwald-Giemsa reagent, showing typical intracellular parasites.

The patients were treated with metronidazole and local dressing. Clinical follow-up was not possible because of their refugee status and permanent mobility. These cases are, we believe, the first to occur in this territory and in all of Indonesia . Species -identification procedures are being pursued.

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East Timor Health Sector Situation Report Jan-Jun 2000

World Health Organization (WHO) 18 August 2000

OVERVIEW

During the two weeks of violence that followed the 30 August 1999 population consultation in East Timor , more than 75% of the population was displaced. A large proportion of private and public buildings, including health centers, hospitals and other health facilities, were heavily damaged or destroyed.

In addition to the physical destruction of health facilities, there was a loss of senior health staff from the central, district and sub-district levels. Many doctors and other core health professionals were Indonesian nationals, and returned to Indonesia during the lead-up to the referendum. This loss of expertise further contributed to the total collapse of the East Timorese health system, and left only 35 East Timorese doctors in the country.

East Timor needed urgent assistance from the international community. Within a few days of the deployment of INTERFET (the International Force for East Timor ), OCHA, UNHCR, ICRC and WHO's Department of Emergency and Humanitarian Action (EHA) had established a presence in East Timor . WHO/EHA role was to immediately coordinate the public health interventions and ensure timely and appropriate information sharing among all partners involved. ICRC and fifteen international NGOs, together with military medical teams from INTERFET, began to provide curative services to the general population. By 30 June 2000 , almost half a million consultations have been provided - more than one half of the current population of East Timor .

WHO has participated in the review of health services of East Timor and technically supported the establishment, in February 2000, of the Interim Health Authority. WHO will continue to support the Interim Health Authority in the formulation of national health policy, and in strengthening of national capacity in public health and curative health services. Special emphasis will be given to the reconstruction and delivery of basic services, prevention and control of communicable diseases (especially malaria and tuberculosis), and child, adolescent and women's health. For this purpose, WHO has prepared a detailed Plan of Action.

WHO will also continue to play a technical coordination role in the field of health service and sustainable public health development and fully supports the Sector Wide Approach being adopted in East Timor . The support provided by WHO has been, from the early phase of the crisis, coordinated by the Department of Emergency and Humanitarian Action (EHA).

Currently, most curative health services to the general population are provided by international NGOs. From September 2000 until September 2001, each district will have a nominated lead NGO that will be responsible to the IHA for planning, coordination, implementation and delivery of clinical and basic public health services.

During this time, the national health capacity will be gradually established through timely and appropriate training programmes and the involvement of East Timorese partners in health work force and service delivery planning processes. WHO, in collaboration with HealthNet International, took the lead in supporting UNTAET and the Interim Health Authority in addressing this issue through provision of technical support to develop capacity in all aspects of human resources development, as part of health systems reconstruction. Activities include HRD policy development, short and long term workforce planning, national educational planning and human resources management. A computerized HRD database will be completed by July 2000. Specific target areas will be development of management skills, redefinition of the roles and functions of health workers and redesign of health worker training programmes.

In order to encourage the timely recognition of and response to epidemic diseases, WHO established a communicable disease surveillance system early in its presence in East Timor . The original system was subsequently modified in January 2000. The surveillance system is based on regular reports submitted by NGO lead agencies providing primary health care in the field, using WHO case definitions. Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin .

Based on the data from the surveillance system, it has been possible to coordinate and guide the work of the NGOs involved in providing clinical and public health services in East Timor . The work of WHO in the field of disease surveillance will subsequently form the foundation for a national disease surveillance system.

The communicable disease surveillance network also has the ability to detect other conditions of potential public health importance but not subject to formal surveillance. For example, the system identified, for the first time in East Timor , cases of Japanese Encephalitis and Cutaneous Leishmaniasis.

Despite the destruction of health facilities and limited accessibility to rural areas in East Timor, a timely and rapid laboratory and epidemiological investigation of Japanese Encephalitis was successfully undertaken by WHO and the Interim Health Authority, in close collaboration with, MSF (France), ICRC, IRC, Medical Relief International (Merlin) and the Institute of Clinical Pathology and Medical Research (ICPMR) Sydney, Australia. This joint action provides an excellent example of how international and national institutions can work together in the spirit of partnership advocated by the WHO Director-General, Dr Gro Harlem Brundtland.

Jointly with Merlin and the International Rescue Committee, WHO is implementing a Roll Back Malaria strategy in East Timor .

Significant progress has been made in the establishment of a National Tuberculosis Programme, based on the WHO DOTS strategy, in East Timor . Caritas Norway, together with Caritas East Timor, the Menzies School of Health Research in Darwin, Australia, and WHO have actively supported the establishment of the programme. More than 1 300 TB patients are currently receiving treatment through the programme, which is active in 9 clinics and three hospitals in six districts of East Timor . By the end of the year, it is anticipated that the programme will have progressively extended to cover the whole country.

With WHO participation, other key public health functions such as routine childhood immunization have been reestablished. However, areas such as water and food testing, have been delayed by slow progress in re-establishing appropriate legislation, while still others such as health information systems and improving laboratory services have been hampered by the complexities of donor support.

Although there are still emergency needs in health and other sectors, it is clear that East Timor generally is no longer in a state of emergency. The current phase could be classified as a transitional / developmental phase, in which international support will need to be adjusted and re-focused. As we move into this stage, it is imperative that support be provided for the establishment of a sustainable and independent health system in East Timor .

The World Bank has acknowledged this by allocating a grant of US$12.7 million from the Emergency Trust Fund for a Health Sector Rehabilitation and Development Project, reflecting the timely changes that are taking place in East Timor .

DEMOGRAPHICS AND HEALTH STATUS

Demographics

Provisional estimates by the UNTAET Bureau of Statistics, Research and Census (May 2000) put the population of East Timor at 780 000.

Over 280 000 individuals were displaced during the East Timor crisis of 1999; of those, 165 000 have now returned to their usual place of abode. Within East Timor , more than 80% of the remaining population was internally displaced due to destruction of their homes and ongoing violence. UNHCR estimates that about 105 000 East Timorese remain in West Timor , but most of these are eventually expected to return to East Timor . In addition, 12,000 to 16,000 East Timorese are currently resident in Australia ; there is no indication of when they may return to East Timor .

Just over 50% of the population is under 20 years of age; children under 5 years of age make up 13.5% of the population.

The birth rate is high, but an accurate post-crisis estimation is difficult to make.

The true crude mortality rate during and after the crisis is difficult to estimate; few deaths have been reported through the WHO communicable diseases surveillance system or other avenues. A formal death surveillance system has not yet been established.

It is thought that over 95% of the population is ethically East Timorese. Ethnic minority groups include a small Chinese community; there is also a small population of Indonesian Muslims who chose to remain in the country after the crisis.

Approximately 9,000 foreign nationals are presently in East Timor , working on reconstruction, aid and development and security related activities.

Unemployment among East Timorese nationals is estimated at 70%. Per capita income is now estimated around US$210 per year, approximately 50% below its 1996 level (Source: Project Appraisal Document on a Proposed Grant in the amount of US$12,7 Million Equivalent to East Timor for a Health Sector Rehabilitation and Development Project, May 24 2000 ; World Bank Document). Health status

Pre-crisis estimates suggest an infant mortality rate (IMR) of between 70 and 90 per 1 000 live births; the most common causes were infections, prematurity and birth trauma.

Only one in five births is attended by appropriately skilled personnel; prior to the crisis, this figure was approximately 40%.

The maternal mortality ratio (MMR) has been estimated at 450-500 per 1000 live births; however, due to the large proportion of births taking place without skilled birth attendants, the MMR may be as high as 850 per 100 000 live births. This is unacceptably high; for example, in Indonesia , the mortality ratio is estimated to be only 390 per 100 000 life births. The most common cause of maternal death is severe bleeding, generally occurring in postpartum period.

The under 5 mortality rate (U5MR) was reportedly 124 per 1 000 live births (UNICEF and Government of Indonesia estimates, 1997; World Bank Joint Assessment Mission, 1999), but this may be an underestimate.

The most common childhood illnesses are acute respiratory and diarrhoeal diseases, followed by malaria and dengue infection. An estimated 80% of children have intestinal parasitic infection.

Cross sectional nutritional surveys have been conducted in selected districts, and suggest that 3-4% of children aged 6 months to five years are acutely malnourished, while one in five are chronically malnourished. WHO, WFP and the IHA propose to conduct a national nutritional survey for the identification of nutritional problems for targeted intervention.

Malaria is highly endemic in all districts, with the highest morbidity and mortality rates reported in children. The peak transmission periods are July/August and December/January, although a longer transmission season exists in the east of the country (Lautem district), owing to the prolonged wet season. Based on historical and recent data, P falciparum and P vivax malaria are equally represented. Four districts, including the capital, are high transmission areas and chloroquine resistant strains have been reported. Since 1 January 2000 , almost 62 000 suspected malaria cases (with 40 deaths) have been reported to the national communicable diseases surveillance system. - Kalra NL: "REVIEW OF INTEGRATED EMERGENCY MALARIA CONTROL PROGRAMME IN EAST TIMOR "; data from WHO communicable diseases surveillance system

East Timor is endemic for leprosy; prior to the crisis, the registered leprosy case prevalence rate is 1.8 per 10 000 - Indonesian MOH data

East Timor is highly endemic for lymphatic filariasis; three species are present ( Brugia timori, Bruga malayi and Wuchereria bancrofti ), and patients with clinical manifestations of chronic lymphatic obstruction have been well documented.

Tuberculosis is a major public health problem, with an estimated 8000 active TB cases nationally (over 1% of the total population). More than 1 300 patients are currently under treatment; of these, 31% are under 15 years of age.

Sexually transmitted infections (STI) are common in sexually active age groups. The existing curative institutions reported a total of about 35 STI cases per week (not confirmed)

Routine childhood immunization recommenced in early March. To prevent an expected outbreak of measles, more then 45 000 children were immunized during a special campaign; this immunization programme has limited the number of cases of measles reported in East Timor (634 reported cases between 1 January and 30 June 2000, representing a crude attack rate of 13.6 cases per 100 000 per month). - data from WHO communicable diseases surveillance system

The level of knowledge on health matters in the general population is poor, and health promotion has been identified as a key component of the basic package of health services to be introduced.

Between 20 September 1999 and 30 June 2000 , the curative institutions (international NGOs and the military medical team from INTERFET) provided 480 000 consultations and curative interventions to the population. - data from WHO communicable diseases surveillance system

Communicable diseases account for the majority of deaths (approximately 60%, particularly in children) followed by the non-communicable diseases, chronic diseases, road traffic accidents and other conditions.

INTERIM HEALTH AUTHORITY, HEALTH POLICY AND PLANNING, AND HEALTH REGULATIONS

Interim Health Authority

The future direction of Health development in East Timor has been discussed in two workshops involving health workers, UN agencies and health service providers.

After the first workshop (held in mid-December 1999), a Joint Working Group on Health Services was formed. This group was composed of representatives from WHO, UNICEF, UNFPA, international NGOs and the East Timorese Health Professionals' Working Group. It undertook a review of health service provision throughout the country, and drafted a document defining minimum standards for health care service provision.

The second workshop, chaired by WHO, took place in mid-February 2000 and, once again, involved health workers, UN agencies and health service providers. At this workshop a consensus was reached on the minimum standards document, and the formation of the Interim Health Authority was formally announced.

The Interim Health Authority is composed of 16 senior East Timorese health professionals. It is supported by the UNTAET Office of Health, which contributes seven international UNTAET staff. A provisional organogram for the IHA has been agreed, and regulatory planning work is expected to begin in July 2000.

Although no formal head has been appointed, nor other specific positions assigned, IHA is seen as the embryonic "Ministry of Heath", with overall responsibility for defining health policy, and for the planning, implementation and coordination of health services for the country.

Health Policy and Health Regulations

The Interim Health Authority, together with WHO, is in process of formulating health policy guidelines for East Timor , and a draft for the reform of health services in the country is being prepared. The reform is based on an integrated approach to health care delivery.

Health services are proposed to be free at the point of delivery, but economic constraints, both now and in future, mean that the main policy makers are starting to consider options for contributory financing (including health insurance schemes and patient co-payments).

District Health Plans

Health services in East Timor are currently provided by a large number of different entities. Coverage of the population is uneven, both in terms of physical access and the services provided. This situation has arisen from the necessary involvement of NGOs in health service provision during the emergency and early developmental phases. A strategy is being developed and implemented to guide the transition from the current situation to the future national health system. This strategy must:

• be rapidly implementable;
• ensure delivery of basic services to the greatest possible population;
• build capacity among East Timorese health staff;
• ensure efficient use of available resources;
• not interfere with the future development of the health system; and
• take into account the principles developed by the East Timorese Health Professionals' Working Group (technically supported by WHO), including sensitivity to culture, religion and traditions of the East Timorese people.

To ensure more equitable coverage, more efficient use of resources, and clear division of responsibilities, along with greater accountability, the Interim Health Authority has proposed that one key entity be identified in each district to plan, organize and manage the provision of health services. Other health agencies working in the district will need to collaborate and coordinate their activities with the lead agency.

This IHA initiative will make for easier coordination, monitoring and evaluation of health sector.

The Interim Health Authority has requested proposals from lead NGOs for the provision and management of health services for each district, in the form of a District Health Plan.

To facilitate a development of the District Health Plans, WHO organised a workshop, held on 10 June 2000 . The workshop provided the opportunity to WHO and IHA to give detailed information and recommendations to the NGOs regarding the important components of health planning at the district level, focusing specifically on the 12-18 month transitional period from NGO leadership to a national health authority.

All NGOs involved in health sector leadership are expected to submit their proposals to the IHA for review not later than 5 July 2000 ; these documents will form the basis of Memoranda of Understanding between the IHA and each of the district service providers.

HEALTH SERVICE DELIVERY

Health Services Coordination

At this stage, many NGOs, national and international institutions, UN agencies and donors wish to be involved in the process of restoration of health services in East Timor . To harmonize and coordinate these efforts, the Interim Health Authority has begun coordinating the work in public health and curative services.

Before the formation of the Interim Health Authority, WHO had responsibility for this overall coordination. At present, WHO provides mostly technical and some operational support to the Interim Health Authority, other UN agencies, and national and international NGOs involved in health.

On WHO's recommendation, the Interim Health Authority has elected to refrain from strongly vertical (ie single disease) programmes that may potentially damage or retard the integrated health care approach.

Primary Health Care

The review of health service provision undertaken by the Joint Working Group between the December and February workshops identified 15 international NGOs, 6 local NGOs, 23 church organisations, four military contingents, and two private or business agencies providing health care services.

These bodies are mostly running small clinics, many with rural extension services via mobile clinics. At least one clinic per district has simple facilities for in-patient care. The levels of coverage and access vary widely across the country, depending on the policies (and resources) of the different implementing agencies.

The Expanded Programme of Immunization has re-commenced this year, with the support of UNICEF, technical input from WHO and various NGOs. The standard antigens for childhood immunization (DTP, OPV and measles) are in use, and tetanus toxoid for pregnant women has also commenced.

Hospitals

There are currently two civilian hospitals in Dili offering at least some specialist surgical and medical services. The principal hospital, Toko Baru, is run by ICRC, while the Portuguese Government Mission has a small inpatient facility in the former Dr Antonio Carvalho Hospital. It is intended that these will, in future, both be administered as a single hospital, but divided into two campuses. No sub-specialty care is available in the country.

In Baucau, the former Indonesian hospital is running with the support of MSF Belgium. It provides a basic surgical service for the eastern districts. MDM Portugal is supporting the small hospital in Los Palos in the east of the country.

Human resources

The East Timorese Health Professionals Working Group identified approximately 2,000 health workers as present in the country and available for work. This is considerably lower than the estimated 3,500 health workers during the former system. Most of the senior level health service managers and doctors were Indonesian and they have now left the country. Only approximately 35 East Timorese doctors remain, one at specialist level. There is a serious lack of capacity at senior and middle management levels.

Projections for the future health workforce are much lower than previous staffing levels. UNTAET proposed 1,480 staff, however the NCC and CNRT, concerned at the problems of sustaining the civil service after the withdrawal of UNTAET, have proposed 1,087. There is concern as to the difficulties of sustaining a health service with such a small workforce.

Virtually all of the Timorese health workers were previously employed by international or national NGOs. Currently, a number are paid by UNTAET. It is intended that civil service recruitment will commence within the next two months, once district health plans are accepted and the final size of the health workforce is established.

The recovery of the personnel records of all former health staff provides valuable information to support the civil service recruitment process. WHO and HealthNet International have collaborated to transfer the records into a computerized database, which is linked with the civil service databases. This database is expected to be completed in mid July 2000 and will be a useful tool to support both long- and short-term workforce and training planning processes.

Due to the reduction in the workforce and the shortage of doctors, health workers of all categories will have to take on extra roles and responsibilities, in both clinical and administrative areas. It is crucial that these health workers are given appropriate training for their new functions. A short term national training plan will be developed and implemented for the future appointed health workers, this will be funded through the UNTAET and World Bank administered Trust Funds.

Currently training of health workers is carried out by NGO's on an ad hoc basis much is on the job training and only a very few training courses are competency based. Future training will be competency based and standardized to ensure accreditation processes. This will be based on the national job descriptions, which are currently being developed by the IHA prior to the civil service recruitment process.

HRD is an important component of the District Health Plans. A HRD planning framework has been developed to assist districts in planning the human resources required to implement the planned health services.

A HRD Task Group was formed within the IHA. A WHO/HealthNet specialist is working closely with the Group. The work of this taskforce was disrupted by the attendance of members at a 6-week intensive English course. The Task Group has now been reformed with new members and will recommence working at the beginning of July.

Pharmaceuticals and Drug Supply

During the emergency phase immediately after the crisis, WHO took a leading role in the management of drug supplies, via the SUMA programme.

To date, the major source of medications and other consumables for the health service has been the various NGOs, which have each provided for their own programmes. Smaller amounts of specific drugs have come through other programmes, such as the national TB programme (supported by Caritas and WHO), and the Merlin project on malaria.

The Irish NGO, Goal, also supported the original SUMA team which was set up by WHO/EHA. The WHO/Goal team has gone on to be the nucleus of the Central Pharmacy within the UNTAET/Interim Health Authority. The Central Pharmacy has also received substantial donations from JICA and from UNICEF, and has begun to support health services throughout the country. The official opening of the central pharmaceutical warehouse took place on 4 April 2000 .

To support the future development of a national drug policy, WHO has provided the services of a technical consultant. He has developed a list of essential drugs for East Timor , based on an assessment of the current health status of the general population, available data on morbidity, mortality and prevalence of communicable and non-communicable diseases, and the experience of available staff at various levels of the health service.

• Since a large number of doctors have left the country, it will be mainly nurses and midwives who run the level 2 and level 3 clinics. This fact was kept in mind while developing the list of essential drugs.
• The draft list of essential drugs was discussed at a meeting of an expert group of East Timorese doctors, who provided advice and suggestions for the inclusion of various drugs at different levels of the health service.
• Vaccines used by UNICEF and contraceptives used in the programme were included.
• The National Tuberculosis Programme provided the list of anti-tuberculosis drugs.

For establishment of a comprehensive national essential drug programme for East Timor necessary steps and systems have been identified. The initial systems at the national level can be effective only when the national government is formed. Right now, at best, a plan and structure can be formulated that will have to be implemented in phases. The systems and related activities will have to be planned in a away that their operation starts in the interim period and continues after the national government comes into existence. The necessary steps to establish a comprehensive national essential drug programme for East Timor will be formulated under the following headings:

1. National Drug Policy
2. Legislation, regulations and guidelines
3. Selection of drugs
4. Supply
5. Quality assurance
6. Rational drug use
7. Monitoring and evaluation
8. Human resources development
9. Technical cooperation among countries

The implementation of these systems could be materialized using resources proposed in the World Bank project. The timely provided WHO technical support was an important and crucial step for starting establishment of essential drug programme in East Timor . The major thrust from WHO will be towards capacity building and training national staff in the development of pharmaceutical component of the health care facility. WHO has prepared a plan of action that acts synergistic to the proposed IHA activities supported by the World Bank.

PUBLIC HEALTH

Communicable disease surveillance

In order to encourage the timely recognition of and response to epidemic diseases, WHO/EHA established a communicable disease surveillance system early in its presence in East Timor . The original system was subsequently modified in January 2000. Based on the data from the surveillance system, it has been possible to coordinate and provide guidance to the NGOs involved in providing clinical and public health services in East Timor . The work done by the WHO in the field of disease surveillance will be a foundation for the subsequent establishment of a national disease surveillance system.

All laboratory services in East Timor were destroyed in the wake of the post-referendum violence. The surveillance system is therefore based on regular clinical reports submitted by NGO lead agencies providing primary health care in the field, using WHO case definitions. Diseases currently subject to surveillance include: simple and bloody diarrhoea, suspected cholera, suspected malaria, other (non-malaria) febrile illness, suspected measles, suspected meningitis/encephalitis upper and lower respiratory tract infection, acute jaundice syndrome, acute flaccid paralysis (suspected poliomyelitis) and neonatal tetanus.

Weekly analysis of the surveillance database is summarized in a Weekly Epidemiological Bulletin . The WHO Bulletin is disseminated to all institutions involved in health in East Timor , and to many international collaborators. In addition to the English language version, it is proposed that the Bulletin will soon be produced in a second official language of East Timor . Starting in June 2000, an electronic version of the Bulletin is available via the Timor Today internet site.

Major communicable disease problems recorded by the surveillance system since 1 January 2000 include:

• more than 61 000 cases of malaria,
• almost 23 000 cases of lower respiratory tract infection,
• 13 700 and 2 600 cases of simple and bloody diarrhoea respectively,
• 634 cases of suspected measles, and
• over 300 cases of suspected meningitis.

Currently the basic microbiological and some serological tests can be done at the central laboratory but work is needed to establish a reliable integrated laboratory system in the country providing services to Public health and curative institutions alike.

Restoration of the integrated laboratory services is planned including equipment and training. As diagnostic facilities become re-established and diagnostic criteria agreed upon, a laboratory component to the surveillance system will begin to monitor incident cases of malaria by species, Restoration of the integrated laboratory services is planned including equipment and training. As diagnostic facilities become re-established and diagnostic criteria agreed upon, a laboratory component to the surveillance system will begin to monitor incident cases of malaria by species, newly diagnosed cases of tuberculosis, and bacterial isolates from sterile sites.

The communicable disease surveillance network also identified, for the first time in East Timor , cases of Japanese encephalitis (JE) and cutaneous leishmaniasis. On the basis of this investigation and sero-epidemiological studies, JE infection has been identified as an emerging public health problem in East Timor . The immunization of children against JE should be considered an appropriate intervention, and an immunization schedule will be developed using the serological findings from this study. The intervention will require the allocation of adequate resources and an understanding by donor and other agencies of the importance of the elimination of JE as a public health problem in East Timor .

Control of Outbreaks

Between January and June 2000, the following outbreaks or sporadic cases of communicable diseases of public health importance have been investigated:

• acute flaccid paralysis (suspected poliomyelitis) - 3 clusters or sporadic cases, two of which have been confirmed negative by the international reference laboratory in Melbourne, Australia, while results from the third are still pending;
• dengue fever - two outbreaks in urban Dili;
• cutaneous leishmaniasis - one sporadic suspected case;
• Japanese encephalitis - two clinical cases, and associated field investigation; and
• Unknown diseases - two reports requiring field investigation (one each in Liquisa and Manufahi districts).

WHO has worked with the Interim Health Authority and other Agencies in a community education campaign for the control of dengue fever, Japanese encephalitis and malaria.

Malaria Control

WHO Department of Emergency Humanitarian Action (EHA) made a quick assessment of malaria situation early in October 1999. They noted that:

• malaria showed a three-fold increase in incidence due to the break down of surveillance and treatment,
• there was poor access to effective drugs, and
• vector control activities had collapsed.

RBM/HQ identified two International NGOs, Merlin (Medical Emergency Relief International) and IRC (International Rescue Committee) to work in partnership for control of malaria in East Timor . DFID and WHO, in partnership, agreed to support these initiatives with ITNs (175,000) and essential medical supplies.

Merlin with the technical back-up from EHA and RBM was responsible for

• establishing malaria diagnostic facilities
• retraining of microscopists,
• equipping of all 13 district laboratories of the country
• disseminating RBM protocols for case definitions and treatments
• arranging all antimalarial drug supplies,
• undertaking cross sectional malaria prevalence surveys and drug resistance studies, to recommending efficacious insecticides for IRS, and
• promoting net usage.

Merlin, in collaboration with WHO, has trained malaria microscopists for 13 districts, and arranged supply of equipment and reagents. Eight out of 13 district laboratories are now functional, while the rest are expected to become operational by the end of July.

Workshops on the management of severe and complicated malaria were conducted in 7 districts using WHO protocol and guidelines. Adequate provision of essential drugs now exist, and clinicians are familiar with recommended drug regimens and emergency management of malaria.

WHO guidelines for the management of dengue fever and dengue haemorrhagic fever / dengue shock syndrome have been used in the orientation of clinicians for the treatment of this disease.

It is important to note that two cases of quinine resistant malaria have been detected. Currently, MERLIN has made arrangement to conduct further drug resistance studies in East Timor .

IRC was given, under continuous supervision of WHO, responsibilities for protection of pregnant women and children under 5 years of age through an Insecticide Treated Bed Net (ITN) programme, health education and disease awareness.

IRC distributed a total of 115 000 pre treated mosquito nets in all 13 districts, including two nets per family where protection of pregnant mothers and children was necessary. Since they were distributed through different local NGOs, a list, indicating names of head of the family and complete addresses, is being completed to facilitate retreatment and to determine the net usage level. IRC has carried out a KAP study to develop IEC material for disease and prevention awareness.

In summary, the malaria control strategy formulated and carefully monitored by EHA/RBM/HQ has been implemented effectively by two International NGOs, MERLIN and IRC, supported by several local NGOs; this has been achieved under the most difficult field conditions. These efforts have largely helped keep the morbidity and mortality at no higher than the previous year's level, despite extremely adverse conditions.

Based on the current situation, WHO has identified the following areas for consideration in future RBM and integrated vector control activities in East Timor :

With the functioning of district health authority and establishment of district level malaria laboratories, the WHO surveillance Unit should initiate recording malaria morbidity data by species of parasite. These data will help in mapping high-risk areas and forecasting epidemics. Similar mapping is required for drug resistant areas of the country, and the preparation of district health maps.

Emergency stocks of pyrethroid insecticides, as approved by WHO PES, along with dispensing equipments and material, should be kept in reserve as per RBM norms for control of malaria epidemics.

In view of the observed endemicity of dengue in East Timor , these contingency plans should include outbreaks of dengue haemorrhagic fever / dengue shock syndrome.

There is an urgent need to establish a national Entomology and Vector Control Laboratory to undertake micro-stratification in high risk and/or drug resistance areas to develop evidence-based vector control strategies to reduce vector breeding and interrupt transmission, as per RBM guidelines. In the absence of primaquine therapy for malaria cases, and the resultant build up of a reservoir of infection (particularly in foci P falciparum drug resistance), this activity will become crucial. The laboratory will also be responsible for development of integrated vector control strategies for control of other vector borne diseases.

The ITN programme needs further strengthening along the following lines.

• Net coverage in the second phase should be extended to the whole population, with priority given to vulnerable groups (eg people sleeping in field huts to protect their crops, etc.).
• Retreatment of nets should preferably be carried out through the primary health care system, with the total involvement of communities. Retreatment should be done at sub-health centers on predetermined dates, with prior information of the chiefs of the villages. Alternatively, retreatment of nets could be carried out in schools, with the involvement of children, teachers and communities with health staff as facilitators [this method has been employed with great success in Papua New Guinea (PNG)]. As at 26 May 2000 , there are 752 functioning schools in East Timor , with 6 929 teachers and 173 259 children on their rolls. The primary health care route provides a proxy index (on the basis of retreatment of nets) on net usage level over "do it your self kit" route as being contemplated by IRC.
• IRC may undertake "Bed net affordability and willingness to buy" surveys to institutionalize partial subsidy and/or a social marketing system to ensure sustainability

To render urban Dili free of mosquitoes, the drainage system in the watershed areas of the Comoro River (in the east) and the Santana (in the west) needs to be re-designed to take care of surplus irrigation water in rice fields, and storm and waste water from residential areas. Similarly, the practice of growing kang kung (a green, leafy vegetable crop) in city swamps and in specially prepared beds in major drainage canals needs to be stopped. The drainage system needs to be developed with a proper gradient. Major drains require a cunette in the bed to take care of periods of low water flow. The District Health Authority may hire the services of expert civil / public health engineers to prepare a blue print for this work in urban Dili.

For Dengue Heamoraghic Fever control, storage of water in mosquito proof containers/cisterns/mendis indoors and professional management of solid waste disposal are important components of any control strategy.

Development projects, particularly related to water resources development and agriculture sectors, are known to be associated with high build up of vector borne diseases, especially malaria and Japanese Encephalitis (Irrigation) and Dengue Haemorragic fever (harvesting of rain water/domestic storage of water). It is therefore strongly recommended that all development projects should be subjected to an environmental health impact assessment to anticipate adverse health impacts and to recommend mitigating measures for incorporation at the design and planning stage, costed into the project. WHO can provide the necessary guidance.

Pending the establishment of a National Vector Borne Disease Control Programme as part of a coordinated Environmental Health initiative, the Interim Health Authority has requested WHO to coordinate vector control activities in East Timor . WHO has begun conducting regular meetings, with the keen participation of NGOs involved in vector and vector borne disease control: Merlin, IRC and Oxfam.

Tuberculosis

Significant progress has been made in the establishment of a national TB control programme in East Timor . The programme is based on the WHO DOTS strategy. Caritas Norway, together with Caritas East Timor, the Menzies School of Health Research in Darwin, Australia, and WHO have actively supported the establishment of this programme.

The programme is active in 9 clinics and three hospitals in six districts of East Timor .

More than 1,300 TB patients are currently receiving treatment.

Ninety-one percent of all diagnosed TB cases in East Timor attend the three Dili TB clinics (Motael, Bairo Pite and Becora), with each clinic enrolling 25-30 new cases for treatment each week.

By the end of the year, the programme will have progressively extended to cover the whole country.

Expanded Programme of Immunization

Routine immunization services in East Timor were re-established and supported by UNICEF, under the coordination of IHA and with WHO technical support, in early March 2000. The service is implemented by NGOs involved in health service provision in the field. As result of immunization of more than 45 000 children against measles limited cases of this infection occurred. However, after two months of implementation, there were lessons learned and issues to be resolved from both technical and managerial aspects.

The issues included vaccine supply, differing needs between districts, and clarification of roles among all parties involved. Efforts have been made to deal with these issues through the various meetings.

On 16 June 2000, in order to facilitate clarity and consensus among all parties involved regarding the policies and implementation plans of the national immunization services, UNICEF and IHA (with WHO technical support) conducted a National Workshop on immunization services in East Timor.

This workshop resulted in agreement by all participants in the use of a standard immunization schedule (recommended by WHO) and a plan of action for conducting National Immunization Days (September - October, synchronized with sNIDs to be held in Indonesia), and the immunization of primary school children.

Child nutrition

Child nutrition has been a concern since the early crisis days.

An early anthropometric survey suggested that acute malnutrition was not very common among returnees. However as the conditions in the camps in West Timor worsened, more returnees (especially those returning spontaneously) were thin and in poorer general condition, and pockets of childhood malnutrition were identified (eg Atsabe, in Ermera district).

Two main factors have been identified in the majority of those children around the country thin and stunted:

• the vicious cycle of illness and poor appetite, and
• lack of knowledge about appropriate weaning foods for babies and small children.

The food distribution system has been adjusted, from regular general distributions to targeted distributions aimed at vulnerable groups. Special attention has been given to areas like Atsabe.

Integrated Management of Childhood Illness

An important objective of the still to be developed health plan for East Timor will be to reduce the IMR and U5MR from their present high levels.

It is very likely that these rates have increased during the period of instability following the independence referendum.

Data presented in the East Timor Province Health Profile (Ministry of Health, Indonesia, 1998) show that, for children under 5 years of age, diarrhoea, malaria, and acute respiratory infection (ARI, including pneumonia) constitute the majority of reasons for paediatric consultation at health centres and hospitals. These same conditions, plus TB, are the principal causes of death in the same age group.

One of the strategies that may be used to achieve a reduction in IMR and U5MR is the development and implementation of a system of comprehensive care for sick children that visit health facilities, such as the one promoted by IMCI.

The advantages of introducing an IMCI strategy in East Timor would include:

• improved quality of care in situations where a disease specific approach is not appropriate (eg when children present with more than one complaint, or for young infants with non-specific clinical signs);
• a methodical approach where medically trained staff are scarce;
• an emphasis on prevention of childhood illnesses, through immunization and, if necessary, vitamin A supplementation;
• promotion of improved infant feeding, including breast feeding;
• avoidance of duplication of efforts in the fields of training, monitoring, supervision and management; and
• less wastage of resources, because children are treated with the most cost-effective intervention for their condition.

An IMCI approach would also immediately address three essential components of building up a new health system - improving health worker skills, improving the health system and improving family and community practices.

When implemented correctly, IMCI should eventually lead to a lower U5MR.

The generic WHO and UNICEF guidelines and training materials and for IMCI generally need to be adapted to reflect the epidemiological situation, language and national policies of the country in which they are being implemented. Under the former administration, East Timorese health workers were often trained in Bahasa Indonesia. Moreover, the disease pattern has not changed at the macro level since independence. It should therefore be relatively easy to develop a national IMCI approach for East Timor from the current IMCI materials from Indonesia .

IMCI guidelines could then be used as a basis for national policies and guidelines for the management of ARI, CDD and paediatric malaria.

The IMCI Medical Officer from WHO Indonesia visited Dili from 16–23 June 2000. The aims of his visit were:

• to create awareness and knowledge of IMCI among health authorities in East Timor , thereby facilitating informed decisions when a national child health policy is developed; and
• to make a provisional plan for the introduction of IMCI in East Timor .

He also conducted an orientation to IMCI for representatives of NGOs, UNICEF and WHO.

A "classical" 11-day IMCI training course is proposed for September 2000, using the Indonesian IMCI guidelines and training materials. The course would have the following objectives:

• To explain the core of the IMCI approach to participants,
• To train future trainers and supervisors for IMCI
• To adapt the Indonesian IMCI materials for use in East Timor

After the course, it would be useful for those national health officials, who will be involved in IMCI planning and implementation, to visit a neighbouring country with a similar epidemiological and demographic profile that has experience with the IMCI approach.

The next steps would be:

• to develop a comprehensive plan to introduce and implement IMCI in East Timor in a phased manner, first focusing on those health workers who deal with sick children under 5 in outpatient settings (hospitals and clinics); and
• to develop a set of IMCI guidelines and related training materials for East Timor , again focusing on the needs of health workers who deal with sick children under 5 in outpatient settings in hospitals and clinics.

Screening of School Children in East Timor

The UNICEF supported opening of schools in East Timor . During short time of observation, it was found that some proportion of the children and teachers have visual defects. WHO and UNICEF jointly organized screening of school children and teachers in Dili. From 10 schools, 590 children were screened, out of which 16.4% had visual defects and 5% required ophthalmological examination. Among teachers, 69% were found having visual defects and 5.7% require ophthalmological examination. All of them needed glasses, which will be provided free by the Laila Foundation & Territory Health Services, NT Australia and an ophthalmologist will be sent for persons identified who require additional ophthalmological examination. In addition, 105 East Timorese staff working in UN Agencies and CNRT were also examined.

Reproductive Health, HIV/AIDS and Sexually Transmissible Infections

During the initial emergency phase each agency providing health services defined its own approach to reproductive and child health. Most provided only simple antenatal and obstetric services. Obstetric complications were among the commonest reasons for aeromedical evacuation from rural areas to Dili in the early phase. An active reproductive heath group formed by UNFPA and a number of NGOs and other agencies is supporting the Interim Health Authority to develop suitable programmes for the future Timorese national health service.

Contraception has not had a good reputation in the past. It is closely associated in the public mind with a perceived policy of "Javanization" which included attempts to decrease the birth rate of ethnic Timorese. The Catholic Church, which is by far the most important religious group in the country, officially frowns upon it. Recently, Msgr. Carlos Filipe Ximenes Belo, the Titular Bishop of Lorium, Apostolic Administrator of the Diocese of Dili, in a letter dated 22 June 2000 to all health providers and UN agencies involved in family planning and HIV/STI prevention, informed that the promotion of "artificial family planning like distributing condoms and abortion pills etc to our people" was unacceptable to the church. To make future progress in the field family planning and HIV/STI prevention in East Timor will require very careful selection of technical information, educational materials and regular collaboration and close dialog with church. As the Catholic Church of East Timor is very influential, and the strongest messenger and adviser of the healthy life style of the population, WHO is proposing regular meeting with the representatives of church.

HIV incidence is very low, but the virus was already circulating well before the crisis. So far attempts to introduce condom use for control of HIV and other STDs have only been attempted among the expatriate community, via UN Agencies House and "night spots".

During the screening of Police recruits for VDRL Test, 10% positive cases were found. Similarly, during the screening of pregnant women, quite a high number of cases were found VDRL positive (the exact detail would be available at the end of this month). In both the situations, no signs of lesions of primary or secondary Syphilis were detected. It is possible that patients having past experience of Yaws infection may be found positive for VDRL test. It is well known that in Non-treponemal serologic tests for syphilis (e.g. VDRL, RPR) become reactive during the initial stage, remain reactive during the early infection and may continue for many years. Treponemal serologic tests (e.g., FTA-ABS, MHA-TP) usually remain reactive for life.

From data available in literature, cases of Yaws have been detected in some Indonesian Islands . The data for presence of Yaws in East Timor are not available and requires investigation. In case the presence is detected, programme for control and eradication of Yaws in East Timor has to be launched.

Before clarification of the situation and conducting investigation, it is suggested that VDRL positive pregnant women should be treated for Syphilis. The drugs prescribed for treatment of syphilis in pregnant women are Parenteral Penicillin regimen. In case the patient is sensitive to Penicillin, Erythromycin regimen outlined should be prescribed. Also any person found positive for VDRL should be treated accordingly.

Mental Health

Many national and international organizations and institutions have poured into East Timor , offering to help with post conflict emotional and psychological trauma. Proposals to train from 15 to 50 doctors and 45 to 200 nurses in mental health and psychiatry have been received.

While these generous offers and expressions of concern are much appreciated, they must be considered in relation to East Timor 's priority health needs and existing health workforce constraints. Work has already commenced on the analysis of training needs of the health workforce and, within this, priority is being given to the development of community based mental health programmes.

Eleven health workers have undertaken training in mental health in Australia , with special reference to community support programmes.

The WHO HQ technical Department of Mental Health is assisting the Interim Health Authority to establish a National Basic Mental Health System

Other Areas of Need

No progress has been achieved in development of control programmes against intestinal parasitic infection, lymphatic filariasis, and iodine deficiency anemia in children and women, which also are common public health problems.

There is no leprosy control programme. Only intervention which took place when WHO distributed, through the NGOs providing health services, MDT drugs and provided WHO guidelines regarding clinical diagnosis and treatment of leprosy patients. It requires further action and involvement of leprosy technical units for planning and field operations for achieving global target of elimination of leprosy.

WHO ROLE, PLAN OF ACTION, AND COLLABORATION WITH OTHER AGENCIES

WHO Plan of Action for East Timor , 2000-01

In February 2000, the WHO office in East Timor developed a detailed Plan of Action (PoA), where the major thrust is national manpower and capacity development of the public health service in East Timor . EHA/HQ has provided the services of a Public Health expert to adapt the Plan of Action to the UN Cap Appeal

At present, the WHO PoA 2000-2001 for East Timor is under active scrutiny of both regional and HQ technical units. To continue WHO's presence, coordinating function and technical advisory role, Regular Budget needs to be identified while more external funds are sought for continuation of project activities.

The World Bank Health Sector Rehabilitation and Development Program

In light of this situation, in April 2000, World Bank Mission developed a project proposal. The overall goal of this proposal is

I. To address the immediate basic health needs of population of East Timor , and
II. Develop health policies and systems appropriate to the country.

This goal will be achieved through the true specific objectives of:

• Restoring access to basic package of services, and
• Laying the foundation of health policy and system development.

The project document is already approved. The project matrix for the East Timorese Health Sector Development Programme for the transitional period 2000-2002 clearly identifies the important technical role of WHO.

Under the objective 'restoring access to basic package of services', WHO will be involved in accelerating implementation of selected high priority activities e.g.

1. Prevention and control of communicable diseases

2. Health Promotion

3. Further define and elaborate the basic package of health service development and adopt essential drugs list and standard guidelines for prevention and control of communicable/non-communicable diseases

4. Capacity strengthening which includes development of basic package and health administration and management.

Under the objective 'Laying the foundation of health policy and system development', WHO will be involved in:

1. development of an information system, and a monitoring and evaluation system; and

2. Human Resource Strategy Development for health and implementation of a Human Resource Development Programme, including fellowships.

A detailed plan of WHO activities to support Interim Health Authority (UNTAET) under the framework of World Bank Project is currently under preparation.

WHO Profile and Visibility

Between 3 January and 30 June 2000 , the Humanitarian Assistance and Emergency Rehabilitation Pillar of UNTAET produced 67 situation reports. In those reports, the activities of WHO have appeared on 42 occasions.

WHO contributed a substantial portion of the UN Secretary-General's report to the General Assembly, Humanitarian Relief, Rehabilitation and Development for East Timor .

WHO has also participated in (and chaired meetings of) the Common Country Assessment in East Timor , through the Working Group on Access to Basic Services.

WHO Technical Support to the Interim Health Authority and NGOs

During the period 1 January to 30 June 200 , WHO sponsored and presented the following training courses and seminars:

• Seminar on dengue vectors and their control
• Seminar on the clinical management of dengue fever and dengue haemorrhagic fever / dengue shock syndrome
• Seminar on the epidemiology, clinical features and control of Japanese encephalitis
• Seminar on the epidemiology, clinical recognition, management and control of outbreaks of meningitis
• Development of health education materials for the prevention of vector borne diseases
• Seminar on district health planning processes and resources available to NGOs to assist and guide their development

WHO Relationship with Other Agencies and NGOs

WHO and UNICEF collaborated to organize vision screening for school children and teachers in Dili.

WHO, UNICEF and the World Food Programme propose to conduct health assessment of the general population

WHO, Merlin, IRC and Oxfam propose a close collaboration to enhance the control of vector borne diseases.

It is important to mention that mostly all UN agencies already had established offices with regular budget and staff. For example, UNDP office has 10 regular professional staff, 3 consultants and UNICEF has 11 regular professional staff and 9 consultants with 6-11 months contracts.

The relationship of WHO with UNICEF, UNDP, WFP and other UN agencies is very cordial and cooperative, e.g. WFP provided containers, free of charge, for transportation of necessary equipments, such as computers, printers, photocopier machine etc., from Darwin to Dili.

CONCLUSION

Although there are still emergency needs in health and other sectors, it is clear that East Timor has now moved on from the emergency stage. The current phase could be classified as a transitional/development phase, which requires differently focused international support.

From the beginning of the crisis and moving towards a more developmental phase, it is imperative that support be continued to be provided for the establishment of a sustainable and independent health system in East Timor .

WHO has a unique opportunity to utilize its high technical expertise and to work together with other UN agencies, national and international NGOs and donor institutions in the field of development of East Timor, where health been seen as a priority and important component.

While the Interim Health Authority should become responsible for overall coordination with national and international agencies and institutions involved in the development of the health sector in East Timor, WHO will continue its current technical advisory and supportive role to the Interim Health Authority, UN Agencies, national and international NGOs and other institutions involved in health.

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E. Timorese get a taste of Western food by rummaging through trash

Kyodo News Service TIBAR, East Timor , Jan. 24 2000

With a pack of Australian-made apricot jam and some bread she picked up from a heap of thrash, Margarita Pereira, a skinny 8-year-old, and her eight siblings hurry back home. For the first time, Pereira said she and her brothers and sisters will be able to taste the dark-coloured sandwich spread.

"I don't know exactly what this is, but I think it's delicious," she said.

The Pereira 's are among the 100 or so East Timorese who troop daily to a dumpsite to rummage through a huge garbage heap where the U.N. peacekeeping force dump its trash, an Australian peacekeeper told Kyodo News. 

"At least 40 to 50 children clamber onto the (U.N. garbage) truck. It's really dangerous," the soldier said.

The Pereira 's grass hut is a stone's throw away from the dumpsite in the Liquica district village, about 8 kilometers west of East Timor 's seaside capital Dili. Anita Quintaon, a 30-year-old mother, said she comes to the dumpsite to scavenge anything -- jam, Reader's Digest magazines, empty soda cans, empty plastic water bottles, paper plates and even wilted vegetables.

"At least we get to eat delicious food," she said, proudly brandishing five packs of raspberry and apricot jam she had just collected.

It appears the U.N. peacekeepers are providing some East Timorese not only hope for a new life, but also a chance to taste expensive Western food, although unintentionally. While the territory's public markets have resumed normal operations, selling rice, fish, meat, vegetables and canned goods, food supplies remain a problem for many unemployed East Timorese. A kilogram of fish, for instance, used to cost only 1,750 Indonesian rupiah before the September turmoil, residents say. Now, it costs about 3,500 rupiah. Before a kilogram of rice cost 1,800 to 2,000 rupiah, now it costs 3,000 to 3,500 rupiah.

Many residents cannot afford the higher prices of basic commodities. 'People have no money to buy food,' said Chief Inspector Noli Romana, a Filipino civilian police assigned to Baucau, East Timor 's second largest city. Romana said farm produce was also severely affected by the long drought that hit East Timor last year.

"There is also a need to greatly improve the backward farming methods that most of the people here still do," he said.

Dili streets still bear the scars of destruction caused by pro-Indonesian militiamen and soldiers who went on a rampage after East Timorese overwhelmingly voted Aug. 30 last year to become independent of Indonesia . But East Timor is slowly showing signs of pulling out of its violent past. Independence leader Jose Ramos-Horta expressed optimism the food problem now besetting the territory will soon be solved.  

" In another month or two, a lot of public-sector offices and shops will be reopened...economic activity (will again) take place," Ramos-Horta said. " Farmers will start harvesting corn in March. So a lot of the food problem will be alleviated."

Xanana Gusmao, president of the National Council of the Timorese Resistance, said in an interview humanitarian agencies are indeed encountering problems in distributing food supplies, especially to remote villages. 

Relief agency officials said security problems in some areas are hampering the distribution of food supplies to far-flung villages. Assistance programs have also been paralyzed due to poor access, they said. 

"But we are trying to get help from other agencies or solidarity groups to help us close the holes that exist in this distribution,' Gusmao said. " We are asking countries for more emergency (assistance), to help us by sending (farm) tools so the people can start producing more and more and more,'' he said. Gusmao added the East Timorese badly need more tractors and more seeds. 

"Our strategy is to allow our people to stand on their own feet in the food issue in the year 2001."

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East Timor : extreme deprivation of health and human rights

David Stein, Barbara Ayotte.  Lancet 1999; 354 (9195): 11 December 1999

In the run up to the UN-monitored vote on the future status of East Timor in late August, 1999, Physicians for Human Rights (PHR) documented the escalating political tensions and their effects on East Timor 's health-care infrastructure. PHR found chronic intimidation of patients and physicians by militias and Indonesian army troops, militarisation of health facilities, violence toward health-care workers, and an overall severe decline of adequate medical facilities and widespread fear of using these health-care facilities. This climate set the stage for the chaos and carnage that was to stain the weeks following East Timor 's historic 78% majority vote for independence from Indonesia , when virtually all health workers and agencies left East Timor and most facilities were destroyed.

In the report, "Health care on the brink: violations of human rights and medical ethics", PHR provides evidence of gross violations of the Geneva Conventions by both Indonesian armed forces and the irregular militias they supported. As the violence increased immediately before and after the time of the referendum, the Indonesian government blocked willing and able medical providers and non-governmental organisations from working to alleviate the impending health-care shortages and human-rights violations. The blockage of health-care resources is one of the most important contributing factors to the dire health crisis being faced today by the newly independent East Timor . Subsequent massive destruction and intimidation of the population has added to the current threat from epidemics of malaria and tuberculosis.

A PHR physician researcher, David Stein, from The Johns Hopkins University's School of Hygiene and Public Health, arrived in Dili on July 3, 1999 . The next day, the militias attacked a UN humanitarian convoy that carried about 20 severely ill patients and many health-care providers and humanitarian workers. The attack occurred despite the clear UN markings on some of the vehicles in the convoy and notification of government authorities to the humanitarian and medical nature of the convoy. Several in the convoy were injured and one driver was pistol-whipped until he lost consciousness. PHR learned that this driver was later cared for at a non-governmental-organisation clinic for fear of being harassed, interrogated, kidnapped, or "disappearing" if he went to Dili's only functioning civilian hospital, Tokuboro Hospital, for treatment.

Patients from Tokuboro hospital were regularly transferred to the military hospital without their consent, and were often abused by soldiers or interrogated outside of judicial procedure. There were shortages of medicines, supplies, health workers, and providers of health care. The daily census of the hospital was less than half of what it had been historically. Two inspections by PHR's researcher of this hospital in Dili revealed many empty beds and a severe lack of equipment and personnel.

PHR interviews with patients, internally displaced people, human-rights workers, and health workers and providers, including physicians and nurses at various government and non-government facilities, confirmed widespread intimidation of patients and providers through verbal and physical threats. PHR heard reports of the execution of two nurses and the ransacking of another nurse's home by militias. Patients were often prevented from travelling to clinics because of militias near or in their villages. Intimidation and harassment were achieved through blockage of the operations in clinics and hospitals. Food stocks and supplies were often destroyed or stolen by these militias. Such aaction led to widespread malnutrition and increasing threats of disease epidemics of tuberculosis and malaria.

The result for East Timor 's population of over 800 000 just before the referendum had been an extreme shortage of health-care workers and providers, medicines, and access to health care. A patient admitted to hospital with tuberculous meningitis in July was in the most distant hospital ward and no health workers were within or near that particular ward when PHR visited. At times during 1999 there were no surgeons in all of East Timor , during a period when traumatic injury from violence and accidents were occurring on a routine basis. In July there were only four surgeons for this entire population, along with less than 50 physicians in total. Despite this dire situation, the government of Indonesia refused or delayed the entry of teams from non-governmental organisations and attempted to block them from seeing patients if they did enter.

With East Timor completely ravaged to the extent that three out of four domestic buildings are completely razed, the hard, grim task of rebuilding East Timor 's mobile-care facilities and staff will require the long-term commitment of the international medical community. Timely and thorough human-rights investigations of violations that affect medical access and treatment, along with the previously mentioned need for reconstruction, will be essential. A public, intergovernmental forum to apply the rule of law, such as a war crimes tribunal, will be necessary to adequately address these widespread abuses of human rights and humanitarian laws. The violations of medical neutrality documented by PHR should be included as indictable crimes by this tribunal. In addition, the rebuilding of the health system should be on a community basis, allowing access by foot over difficult terrain, and should include human rights and ethics training of all health workers.

David Stein, *Barbara Ayotte *Physicians for Human Rights, 100 Boylston Street, Suite 702, Boston, MA 02116, USA; and The Johns Hopkins School of Medicine and the Johns Hopkins School of Hygiene and Public Health, Baltimore, MD

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Health and human rights of the East Timorese

Derrick Silove. Lancet 1999; 353 (9169): 12 June 1999

East Timor has attracted much attention in the past year, as daily reports of escalating violence continue to emanate from the territory. A confluence of inter-related influences--the lengthy war, widespread human rights violations, and socioeconomic stagnation--have created a humanitarian crisis that has had a direct impact on the health of the East Timorese community.

The history of the current crisis is one of successive occupations by foreign powers--first by the colonial Portuguese, then, during World War II, by the Japanese, and, since 1974­75, by the Indonesians. The human cost of the Indonesian invasion and subsequent war was extensive: a quarter of the population, some 200 000 people, died. The change of leadership in Indonesia in 1998 and the appointment of a caretaker government under Dr B J Habibie opened the way to a United Nations supervised referendum, which is planned for August, 1999, and if it comes about will allow the East Timorese to decide their own political future.

In the interim, there has been an escalation of violence as armed militia groups attack supporters of the independence movements across the territory. Violence is not new to the territory, however, and in the past 24 years, repeated allegations have been made of widespread repression and violations of human rights including extrajudicial killings, arbitrary arrest and detention, kidnapping, and torture. Larger scale atrocities have occurred, such as the massacres in the capital, Dili, in 1991, and, more recently, in Liquisa where at least 18 people were killed by paramilitary groups on April 6, 1999 . There have been reports of violence and intimidation from Dili and several outlying regions. For example, ten people were allegedly abducted by a paramilitary group on April 19, 1999 , in Suai, south of Dili. In the remote district of Sare, 5000 internally displaced people are currently prevented from receiving food, water, or medical assistance.

The combination of war, civil unrest, and socioeconomic under-development has had dire effects on the health of the East Timorese community. Most villages have no sanitary systems and are isolated and impoverished. Preventable diseases such as malnutrition, pneumonia, malaria, diarrhoeal diseases, and tuberculosis are major causes of morbidity and mortality. Conflict-related injuries and disability are also common, but rehabilitation facilities are virtually non-existent. Women have been at particular risk of sexual assault, forced marriages, and resorting to prostitution. Perinatal care is not provided in many areas, and allegations have been made that family planning practices have been coercive.

The extent to which civil instability and repression has disrupted the social and cultural fabric of the community remains to be assessed fully, but East Timorese exiles report that for many years, the prevailing ethos in the territory has been one of fear, dread, and distrust. Few families have remained untouched by violence, human rights violations, and intimidation. Although such concepts as trauma and post-traumatic stress disorder are unknown in the East Timorese culture, health professionals who have worked with the community have seen widespread manifestations of suffering, grief, anger, and depression.

Even before the current crisis, health services in East Timor were rudimentary. In 1999, government facilities consist of 67 community health centres (31 without doctors), eight district hospitals, and one central hospital. Distance, poor transport, and distrust of government institutions all inhibit use of health services. Catholic organisations provide an additional network of health services, but only a basic level of care can be offered. The entire health system is in crisis as a result of shortages at every level. There were about 200 doctors in East Timor before the present crisis, but with the flight of many Indonesian practitioners, only 69 physicians remain in East Timor (16 of whom are indigenous Timorese). There are no surgeons in East Timor (one may return shortly), surgical equipment is rudimentary, and the supply of drugs is unreliable. In May, 1999, an expatriot physician, Dr Dan Murphy, who was pivotal in maintaining health services in Dili, was deported.

East Timorese exiles also continue to face difficult challenges. For several years, more than 1300 East Timorese asylum seekers who fled to Australia have remained locked into a protracted legal battle with the Australian government over the legitimacy of their claims to asylum. Agencies that provide support for these refugees in Australia have noted high levels of stress among this group who live under the constant threat of forced repatriation to a situation of threat and danger. In addition, various untreated disorders have been detected in recently arrived refugees, including hypertension, diabetes, thyrotoxicosis, chronic granulomatous infections, and advanced neoplastic disease. East Timorese refugees commonly express feelings of intense grief, and some show evidence of depression and other stress-related reactions to their situation. Because of their precarious residency status, several exiles have found it difficult to gain access to health care on their arrival in Australia .

The prospect of peace in East Timor is balanced against the risk of a full-scale civil war. Nevertheless, with the expectation of an imminent transition to independence, East Timorese medical professionals have been active in planning for the future health needs of the population. The overall health of the community will clearly benefit from a coordinated strategy of development that builds towards a durable peace, initiates a programme of socioeconomic development, and implements essential public-health measures to prevent communicable diseases and address the disabilities caused by war and conflict. Scarcity of medical skills and resources means that assistance from international experts and aid agencies will be imperative, at least during the early phase of reconstructing an effective health service. That East Timorese health professionals assume the leadership role in this initiative is a matter of paramount importance. Of all the injuries perpetrated on the East Timorese during the period of successive occupations, perhaps the most insulting has been the imputation that the community is incapable of directing its own future.

Derrick Silove Psychiatry Research and Teaching Unit, University of New South Wales, Health Services Building, Liverpool Hospital, Liverpool, New South Wales, 2170 Australia

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Dengue Fever in ET

Dengue Epidemic Adds to Economic Burden: Indonesia Public Health

by Charles Henderson in Blood Weekly 11 May, 1998

Armed with long-barreled sprays, Indonesian health officers are scouring neighborhoods and checking on house drains, with the aim of destroying potential bases for the small, deadly mosquitoes that cause dengue fever. These armies of health officers are part of a national campaign to combat a rash of dengue hemorrhagic fever, which comes as Indonesia is hard-pressed to deal with its worst-ever economic calamity. Already, the economic crisis has led to supply problems with basic medicines and health services, whose prices have also gone up since late in 1997.

The dengue epidemic, caused by the small, black mosquito with white spots called Aedes aegypti, has so far swept through 12 of the country's 27 provinces since February 1998. Some 430 people have died, and more than 20,000 people have been hospitalized, a health ministry official said. The number of affected people is rising by 200 a day. The provinces most affected are Greater Jakarta, South Sumatra , South Sulawesi , North Sulawesi , Jambi, Lampung, Southeast Sulawesi , Central Sulawesi , Maluku and East Timor .  

Medical experts said the spread of dengue fever is due to poor health services, medicine shortage and unsanitary living conditions. The Aedes aegypti mosquito, which carries the virus that causes dengue hemorrhagic fever, lives and breeds in standing water found in tanks, buckets or even in puddles of water dripping from air conditioners onto tiles or cement floors.

The flooding reported in various places in Indonesia , as the weather changes, has also left a lot of idle water that analysts say is feeding the spread of dengue. But these external factors are aggravated by Indonesia 's weak economic condition, which means there are less resources for health care at a time when people are seeing sharp cuts in incomes.

The prices of medicines has soared five or six-fold. The high costs of imports, pushed up by the devaluation of Indonesia's currency, is hurting the health sector because Indonesia imports more than 80 percent of drugs and drug ingredients.

Dr. Rahman Maas, director of the Bandung Hasan Sadikin Public Hospital , said his hospital can hardly get thrombocytes and plasma expanders, which are essential for dengue fever treatment.

The lack of hospital rooms has prompted Jakarta administration officials to build temporary field clinics, as the number of dengue sufferers continues to rise. Many hospitals are now temporarily treating dengue patients in corridors.

Inadequate blood is another hindrance. Red Cross offices are unable to keep up with up the demand for blood, and the government has desperately called on the public to donate blood to be used for transfusions into dengue patients.

City Red Cross chief Uga WIranto said blood supply was very low, and her understaffed office has to toil round the clock to meet the demand.

But some experts are befuddled about the demand for blood, saying too many doctors are liberally prescribing unnecessary transfusions.

"Doctors who hastily recommend blood transfusions for dengue patients are inexperienced," said Zubairi Djoeban, head of the Indonesian Hematology and Blood Transfusion Association. He called the widespread practice of transfusions "misguided."

A. Haryanto Reksodiputro, a medical expert at the University of Indonesia , said blood transfusions are needed only if the patient is already suffering from internal bleeding.

"If there are no red spots on the patients skin, then there is nothing to worry about, even if the number of thrombocytes per microliter of blood is less than 50,000," he said, referring to the levels that show the seriousness of the illness.

As important as prompt treatment of dengue are efforts to make the environment inhospitable for the Aedes aegypti mosquito, experts said. Fumigation is not enough. "What we have to do is to cut the mosquito's life chain by getting rid of idle water," Reksodiputro said.

An increase in dengue fever cases in Indonesia comes in five-year cycles, the last of which came in 1993. Thus, doctors say government health officials should have been better prepared this year.

"They (health officials) are well-informed that the epidemic may come after five years. They should have done enough to anticipate it," one medical expert said.

World Health Organization officials say dengue fever is one of several old diseases recurring in parts of Asia . It is often diagnosed as ordinary flu, as both conditions are characterized by high fever. Other symptoms include runny nose, lower abdominal pain, nosebleeds and skin rashes. If dengue fever is left untreated, it can be fatal. Medical experts said blood tests are still the most effective means of diagnosis. 

The Aedes aegypti mosquito, whose origins have been traced to Egypt , first came to the region through the Philippines . WHO said dengue hemorrhagic fever was detected there in 1953. Dengue fever was reported in Indonesia , through Surabaya in 1968. In the seventies it began showing up in Jakarta and Bandung to the south-east of the capital and other parts of the country.

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