The Naked Doctor

1/4/2008

Three weeks left to the end of my term here in Timor. What I miss most about Singapore hospitals is the glorious abundance of new, inventorized, sterile plastic-wrapped equipment.

Our dinky clinic here is OK for the regular 'flus and diarrhoeas, but the squeeze comes with the small surgeries: abscesses to be poked, cuts to be stitched, wounds to be repaired.

[Do NOT poke me!]

[Post-poking.]

Greatly outgunned by the patients, I returned from the lightning trip to Singapore in Jan with a substantial armoury of dressings, syringes, IV sets... (thanks CM!)

Initially, the only anaesthetic available to me for some procedures was 'brutacaine' - 3 or 4 handy assistants holding down the shrieking patient while I sliced away. Not much more refined than a consultation with our local witch doctor. I've since got my hands on a stash of Ketamine (thanks S!) and Lignocaine (thanks G!), which have greatly decreased the pain and drama of our surgeries.

Dr. Daniel Murphy, a personal hero who's been serving in Timor for 10 years now, responding to an interviewer's question on high-end medical equipment: "You don't need all that stuff. Two hands and a heart, that's all you need. A stethoscope helps, though."

Agreed. But the syringes help too!

-raj

Saving Ballo's Bushes

31/3/2008

Abel Ballo's kids shall no longer abuse the bushes. The CHEs and I built him a toilet this morning. (See 'Penitence', 20/3/2008)
Not a particularly extravagant affair: just a big hole in the ground, overlying planks with a hole, stones for squatting, a bit of zinc fashioned into a cover. But not without its technicalities. Siting needed consideration of relationship to groundwater depth, distance from living quarters, surrounding vegetation and direction of prevailing winds. And digging a 1.5-metre hole was no small task.

'How to build an effective toilet' is a question that's weighing on NGO minds across the globe. A cursory Googling brings up an astounding array of technologies and philosophies, even a World Toilet Organization.

But only half of Timor uses any form of toilet a step above the ad-hoc hole, so we're still pretty proud of our big-hole-with-a-cover.

-raj

Kakrui

13/3/2008

I'm pooped. 3-hour climb to the Kakrui hills south of Vatunau this morning. Visiting homes with our volunteer Community Health Educators, five girls and one guy who've attended weekly health workshops for the last two years, and helped me run the clinic for these past five months.
We meet 6 am. Posters, flipcharts, stethoscope, a few meds. As usual, I'm the only dude geared up in boots, backpack and bottle of water. Our CHEs would bounce up Everest in their slippers and pyjamas.

The three-hour trek takes us along the river bed,

through the jungle path



and up the hills

A major adventure for me, but I'm episodically greeted by giggling kids heading the other way, daily walk to school. We arrive at the Kakrui cluster of houses, welcomed with smiles and cassava.

Brunch is followed by the main business of visiting homes. The CHEs teach basic health: nutrition, hygiene, mosquito avoidance, home treatment of children's diarrhea...

The main health problems here are still best addressed through simple education on prevention and improving living conditions. I count the time spent training and supervising our CHEs as my real legacy here in Timor - these guys will remain on the frontlines of the war against disease long after my Panadols are forgotten.

-raj

Penitence

20/3/2008

I've just returned from a 5-day trip to several villages in Los Palos on the eastern tip of Timor, to visit the resident missionaries, conduct community health talks and deworm children.

Gut worms are universal in rural Timor, mainly due to poor sanitation. When one infected child defecates behind a bush, rain and groundwater flow eventually carry the worms to the community’s well – everybody’s drinking water.
The government school health programme includes mass-deworming, but many places have yet to climb on board. So our plan was to carpetbomb our villages’ 2-5-year-olds with deworming meds.

Easier said than done.
Generations of threats from bulging-eyed mothers has left Timorese children with a deep confidence that if you’re naughty, the Evil Foreigners will kidnap you, and – depending on the creativity of your mother – beat/imprison/eat you, feed you vegetables, turn you into a goat or give you injections.
Predictably, being lined up to receive deworming medicine at our hands created much holy terror.
Some children gave wary assent:

Many went ballistic:

And this guy:

survived the ordeal with deworming meds everywhere except down his throat.
Exhausting. For all involved.

But rewarding. I’m told that entire villages are now abuzz about whose kid has passed out the most worms.
Let’s just hope it wasn't behind another bush.

-raj

Deficit

18/3/2008

I'm crunching statistics from the clinic records, in this last leg of my term here in Timor. An alarming 40% of the children I’ve treated are growth retarded.

Due to starvation.
Not the hollow-eyed skin-and-bones frank hunger that's familiar from TV images of '90s Ethiopia; but an insiduous, chronic lack of protein and energy foods that manifests itself in frequent illnesses and poor growth. The resulting physical and mental deficits are significant, and permanent.
Malnutrition here is rare in infants until about a year of age – when they’re abruptly displaced from the breast by a new arrival.

[Vexation]

The staples, cassava and corn, are both mostly fibre and water. So toddlers may fill their stomachs three times a day and still effectively starve.

[Breakfast/lunch/dinner: cassava, salt and chilli]

Concerned mothers stream to the clinic seeking ‘vitamins’ to fix their skinny kids, which I steadfastly refuse to dispense. The solution is upping the energy content of their meals. I’m on a campaign to encourage mothers to include a tablespoon of cooking oil in every meal.
Awkward. It’s exactly what I wouldn’t be advising back in childhood-obesity-smitten Singapore.

-raj

Ainaro district, in 10 photographs

11/3/2008

Timor is gorgeous.
I've just returned from a 5-day foray into villages in the central mountain region, running mobile clinics with a team from Singapore's CEFC.

Sunrise

Girl

Backside

Flowers

Daggers

Routine

Inn

Hut

Precarious

Aftermath

-raj

Steady As She Goes

14/2/2008

Things are better.
We're still wound tight. But Timor has been remarkably - almost supiciously - peaceful.
Regular updates on the radio (they've ditched the "remain calm" guy) and SMSed news clippings from friends in Singapore have made the story clearer.

From CNN.com:
[[DILI, East Timor (AP) -- East Timor declared a state of emergency Tuesday... assassination attempt Monday against President Jose Ramos-Horta and the failed attack on Prime Minister Xanana Gusmao.
The country's top fugitive, Alfredo Reinado, and one of his men were killed in the attack on the president. One of the president's guards also died.
...international soldiers and police patrolled the streets of the capital, Dili, where many shops and businesses were closed. There were no immediate reports of unrest.
Reinado was among 600 mutinous soldiers dismissed by the government in 2006 -- a move that triggered gunbattles between security forces that later spilled over into gang fighting and ethnic unrest.
At least 37 people were killed and more than 150,000 people forced from their homes in the unrest, which also led to the resignation of the country's first post-independence prime minister.
Reinado was arrested but escaped from prison after several months.
He was charged with murder in connection with the 2006 violence, but had remained in hiding and had threatened armed insurrection against the government.
The streets of Dili were calm after the attacks, and Gusmao said an overnight curfew was in place. The United Nations, which controls security in the country, said checkpoints had been set up on main roads.]]

I had to squeak through two checkpoints, getting to Dili today.
Just outside laid-back Liquica, it's all smiles, backslapping and "how-ya'-doin". But Dili's fortified checkpoint greets me with the less-than-neighbourly barrel of an M-60.
The Portuguese UN troops immediately single me out for interrogation - the only foreigner, and a bestubbled one with a fancy laptop computer at that. The furrowed eyebrows, unslung rifles and clipped tones quickly dissipate, however, upon a shameless flourish of my stethoscope. Ah, a medic! I'm merrily planted back on my truck with fresh smiles. And another backslap.

Timor's not out of the deep waters yet, but the crisis appears to be over. We're drifting back toward normality.

- raj

Crisis

11/2/2008

Timor is in crisis. Attempted assassination of the president and the prime minister in the capital Dili this morning.
At least three dead, several wounded. Prime minister has been evacuated to Darwin with bullet wounds. Curfew declared in the late afternoon, we're expecting state of emergency soon.

I found out en route to Dili.
Vehicles being turned away by a new military checkpoint just outside the city. Tension rising among the dozen passengers stuffed into the back of the minivan with me. Ominous snippets filtering to us from shouted warnings of drivers heading the other way: gunfights in the streets, dozens killed, mobs and looting. The women start crying.
Word of violence rapidly puts Timorese on edge - they've been through this too many times. The last outbreak in 2006 saw running gunbattles between the police and mutinous soldiers in Dili's streets, turning into inter-ethnic violence leaving 40 dead and 150,000 in refugee camps.
Our minivan turned back.

Home now.
No electricity, so no TV. The surviving cellphones only do incoming. The radio plays patriotic anthems, punctuated by a grating appeal to 'remain calm'.
Passports, cash and laptops sit in our backpacks, should we need to evacuate (to where?). Yudha gets the golf club, I sleep with the machete. I tell myself that we are fairly safe in Vatunau - agitation rarely reaches this far out into the sticks.

But we legitimately worry for the dozen or so missionaries and friends in Dili.
We worry for Timor. We know maddeningly little about the state of the nation right now, beyond the end of our street. We're sitting on a tinderbox, we don't know if the fuse is alight.
The uncertainty is bewildering.

Back In Timor

5/2/2008

Back after 10 days in Singapore/Batam. Feels like I've returned home.

Top 5 things I've missed in Singapore:
1. Hot showers
2. Cold coffee
3.
4.
5.

Well... can't think of much else, really.

- raj

Traffic

20/1/2008

We've had quite a turnover of assorted animals through our household lately.
The chicken population has exploded, thanks to new-year presents from several villagers. At its peak, we had fifteen chickens of various sizes running amok in the yard. It's down to a (slightly) more manageable 12 now. Two were curried, one fried.
Pak Leo, the village headman, has temporarily parked his scowling cow in our front yard, as the river that runs by his house is in danger of overflowing its banks.

[Picture: Scowling Cow]

Our two piglets have died. To be more precise, one died (malaria?); and the other looked moribund, so we killed and ate him. 'Tis life.

[Picture: Moribund Pig.]

Bagong, Pedro and Darling we picked up from the new litter at Pak Leo's. It's a challenge to get my slippers on every morning, with a trio of month-old puppies suckling my toes.

[Picture: Disgustingly Adorable.]

Sadly, two of our other dogs have met untimely deaths under the wheels of some 4WD hurtling along the road in front of the house. Chocolate, we buried. Taus, eaten by our neighbours. Ouch.

Of course with this many animals loose in the compound, the primary question to ponder is, 'but does it bite?' The answer, I've discovered, depends on the particular specimen's personality as much as on the species it belongs to.
So far, I have survived three chicken-bites.

-raj

It's a boy

18/1/2007

Deliphina De Nunes delivered her first child today in somewhat better surroundings than Maria did (see "It's a girl", 30/12/2007).
Labour began at about 5pm. Baby delivered at 8, on a couple of sheets thrown upon on the earthen floor in the corner of the bedroom. Mama Leonarda, the village chief's wife, was again by my side to help; but no sign of El Mustachio this time round. I walked her through the delivery and aftercare, I wonder if she'll be able to do this on her own when I'm gone.
The neighbours' wives gathered outside the door were an opportune target for my routine sermon on breastfeeding - a subject I've become a rabid advocate of.

Having learnt my lesson from the shock of being asked to name the last baby, this time I had come prepared with a list. Sadly, proud mum and dad had already thought of a name. Oh well.

'Reuben', Hebrew, meaning "see, a son."

-raj

Earth

18/1/2008

I had never really understood, back in med school, why so much time was spent learning about 'soil micro-organisms'. I think I do, now.
Earth, like air, is an ubiquitous part of life here in rural Timor. Most are born on the bare earth, spend their early years playing in it, expend the major part of their life working it... and finally laid to rest in it.

Not surprisingly, a significant proportion of the sicknesses we treat in our clinic are soil-transmitted.
Every other kid has a belly full of worms. The symptoms aren't too impressive: intermittent stomach pain, constant tiredness, the occasional disturbingly mobile bowel movement. The greater, more permanent damage lies in the stunted growth. The worms compete with the already malnourished kids for their limited food.
I dish out albendazole like candy. But the deworming meds don't stop the kids from running around barefoot and picking the worms right back up, the very next day.

Earth also features prominently - and frustratingly - in many traditional remedies.
I spent an excruciating hour last Saturday cleaning out the left ear of a resolutely noncooperative two-year-old. Her mum had packed it to the brim with soil and leaves, to treat a budding ear infection the week before. By clinic day, of course, the infection was positively fruiting. An unappetizing experience for all involved.
Traditional Timorese first aid for cuts while farming: handful of soil, dry leaves, hearty mouthful of spit. Mixed evenly, then slapped onto the bleeding wound before proudly presenting it to the doctor. Bad-tempered doctor then painstakingly cleans away the muck while delivering a long and animated dissertation on 'germs'. When the bleeding is controlled, I just dress the wounds - any attempt to stitch the skin after such overwhelming contamination would only worsen the infection.

Convincing a community that invisible germs exist, that earth is best left on the ground and not on or in their kids, is not an easy task. We teach, we teach, we teach. But until those ideas take root, someone'll have to continue cleaning the ears and the wounds, and dispensing the albendazole and antibiotics.

-raj

Skin And Water. And Skin.

9/1/2008

Nothing frustrates me more than the endless line of filthy kids with skin diseases that attend our clinics. Rashes, sores, pustules and abscesses in assorted combinations. Nearly all of them preventable with just one intervention: soap and water.

Timorese kids don't like soap any more than kids anywhere in the world. But the biggest factor contributing to the universally poor skin hygiene is the lack of water.

Vatunau has a population of 2000, five wells, and a patchwork water piping system from the two rivers that flow through our village. A few households have small tanks rigged to the pipes, but most families still walk several hundred metres a day to fetch water. A precious commodity, not often expended on extravagances like daily bathing.
Various NGOs and government bodies have assisted with the water piping system since the late 80s, PPH has contributed to significant improvements in the last two years. Work in progress.

I can't, however, attribute my own rashes to a want of showers.
Right now, my legs are sporting five dressings over sores of various shapes and stages of evolution. Annoying, but not comparable to the awful 'cellulitis' skin infection crawling up my left ankle over Christmas - resolving now, thanks to the self-prescribed antibiotics.
No thanks to the bug bites from the garden, which likely got the infection going in the first place.

In the balance of things, I should be grateful for my cellulitis - it's made me more sympathetic now to the unwashed kids.

-raj

Floods

7/1/2008

Unusually heavy rains for the last week. Several areas in the North-West of Timor have experienced landslides and floods.
Liquica market, five kilometres from our home, is a sobering scene of ruin. The overflowing river has wiped away several houses and damaged the market's permanent structures. A couple of electrical poles are down, those of us to the West of Liquica will likely be without power for a week or so.

The damage may not be dramatic in scale, but to those who don't have much, it is significant.
I'm worried.

-raj

Bernardo

6/1/2008

We buried Bernardo, age 19, today. Died of internal injuries sustained from a traditional martial arts class a week before. Not a common event.

But evidence of a troubling underlying phenomenon: the recent proliferation of violent youth gangs often associated with 'martial arts' groups. The weekend fights are drug-and-alcohol-fuelled mass brawls, featuring knives and machetes. 'Martial,' yes; but not much 'art'.
The gangs are concentrated in the capital Dili, 50 kilometres from where we live, but we do see episodic disturbances in neighbouring Liquica, and occasionally even in Vatunau. Gang insignia has recently shown up spray-painted on the village bridge.
The police have been asserting themselves, particularly the 'Task Force', outfitted with riot gear and building a fearsome reputation for breaking bones first and asking questions later.

Timor is awash with NGOs and churches seeking to cope with the concrete problems of a nation emerging from a long and brutal occupation. But we may not have enough labourers addressing the social needs of a traumatized generation, now coming of age.
We're losing the youth.

-raj

Singapore 26/1/2008-3/2/2008. Help.

Hello again, guys.
I'll be back in Singapore to attend a couple of church meetings, arrive 26/1/2008, depart 3/2/2008.
There are several items for the clinic I'll need to acquire then, to carry back with me to Timor. I'm planning to purchase these, but would be glad to take donated items. If you can help, do email me at rajrman@yahoo.com.

***

List of items to acquire for clinic from Singapore 1-2/2008
- MIMS drug directory x 1
- Pregnancy calendar/wheel x 5
- Latex gloves, medium size x 1 box
- Vaginal speculum
-- Medium x 5
-- Small x 5
- Urine Pregnancy Test Kits x 2
- Glucometer x 2
- Glucometer strips x 50
- Gauze squares x 200 pieces
- Alcohol swabs x 100 pieces
- Syringes
-- 50cc x 10
-- 20cc x 10
-- 10cc x 10
- Needles
-- Green (18G?) x 50
- IV cannulae
-- Blue x 10
-- Green x 10
- IV giving sets x 5
- Tegaderm Dressing
-- Various sizes x ?20
- Sterile sheets x 10
- Nonabsorbable suture, eg. Prolene
-- 3-0 x 10
-- 5-0 x 10
- Surgical ties x 100
- Micropore tape
-- Various sizes x 10

Acquire for clinic (meds)
- Paracetamol suppository x 5
- Emmolient cream x 20
- Pilocarpine 2-4% eye drops x 2 vials
- Becotide (Beclomethasone 50mcg/puff) MDI x 4
- Cloxacillin capsules 250mg x 400capsule
- Lignocaine/Lidocaine 2% x 20ml/vial x 10vials
- Ketamine for IM sedation