Sunday, March 10, 2013

Over the hill and across the river.

In order to better reform the Bairo Pite mobile clinic program we were recommended to accompany Dr. Aida Goncalves (a Timorese doctor trained in the US who runs her own community health program with funding and support from a Japanese NGO called Frontline) on several of her community visits.

Our four wheel drive vehicle before we got a
flat tire.
Dr. Aida (left) and nurse Pinky (a volunteer from the
Philippines); Aida may be petite but she is a firecraker!

And what great experiences they were!

We have now accompanied Aida to two communities and learned a great deal on what it takes to make community based health promotion successful as well as learning about the challenges inherent to such work in Timor.  What follows is a description of a trip with Aida and team from February 15th 2013 with several clinic pictures spliced in from our first trip.

The ride out to the rural community of Sare (pop. Approx 3000) started along the main road heading west out of Dili.  You might think this would be a decent size highway but the truth is there are no highways in Timor.  Nope, none.  Barely wide enough for two cars to fit past each other, pot holes a welcome site compared to the many rough unpaved sections, enough swerving turns to make almost anyone lose their breakfast, well, it all makes for eventful car travel to say the least.  This country has redefined what a “bad road” is for me.  Four-wheel aficionados would think they had died and gone to heaven!

A typical home in the community of Sare. We were told a
roof like this can be fabricated in one day by the community
helping one another and using palm leaves.

The last hour or so we turned off the “main road” and made our way across grassy plains, past flooded rice fields, through forests and finally across a wide river comprised of many rivulets – maybe 500m across – with the deepest water at about 1 foot.  With no rain for a few days I could only imagine what would happen after a good downpour…

Arriving in Sare Aida’s team sprang into action – and it was a sight to see!  (Sabino, our team driver, had of course already done his work safety shepherding us to our destination.)  In each community where Aida works she has trained two community healthcare workers (CHWs) – selected by the community itself - who monitor the health of their neighbors (detecting TB, child malnutrition, severe diarrhea, and other illnesses) and assist during the community visits.  They receive $75 per month in compensation.  The two CHWs along with Aida’s staff member/records keeper/pharmacist set up the tables and equipment while Stephanie, Lorenzo and I distributed donated dolls and clothes to young children and expectant mothers.  The open-air tin-roof building ready to go, the CHWs then held a community education session with all present (mostly women and children this time as it is rice planting season – maybe 75 people in total) about TB: warning signs mostly such as chronic cough, weight loss, night sweats/fevers, and coughing up blood.

A community health worker presenting on diarrhea
and dehydration warning signs.
In each community Aida has also asked the community to select one woman to be trained as a midwife.  Such women receive 3 months of hands on intensive training at Bairo Pite Clinic participating in nearly 300 deliveries and once finished are capable of dealing with breech and twin deliveries, post partum hemorrhage and more.  They are highly respected in their communities and receive $150 per month.  Aida told us the midwife in Sare is one of their champion graduates – she had just delivered a baby in the wee hours of the morning and was ready at clinic to help Aida do pre-natal checks on all the pregnant women several hours later!

Community education session complete it was time to run the consults.  Aida did all the pre-natal checks (roughly 15-20) and saw the adult consult patients (roughly 40).  She had me see all the pediatric patients, 48 in total, ranging in age from 2 months to 16 years.  Most presented with colds or other viral illnesses but several children were truly ill including the adolescent who had been suffering bloody diarrhea for 1 week – not good! - and a small infant with copious amounts of pus leaking from one ear.  Doing consults in this environment is much different from the US.  Mothers, their teeth and gums stained bright red from years of betle nut chewing (a mild stimulant commonly used in Timor) press in close clutching their children.  Privacy?  No way!  Children scream as I try to hear whether the two year old in front of me has any wheezing.  Then the rain starts, intensifying it’s barrage of the tin roof over our heads until I can hardly hear what the patients are saying.  Lorenzo however, can still decipher the complaints and we keep moving.  Stephanie takes on record keeping and note keeping in addition to taking temps to help us move more efficiently.  The rule with Bairo Pite (and with Aida’s clinics) is you stay until all patients are seen.  Aida and Dr. Dan can fly through patients but I am not so speedy yet. 

Lorenzo and I consulting with patients. Stephanie behind
keeping records, handling medicine and snapping photos.
Lighting not ideal...

It seems like the crowd of patients pressing in around us will never end but finally they thin and then suddenly, the last patient!  Quick, quick we pack the car, rain still falling, and then head back down the road.

Dr. Aida checking on the river, at this point too high to
cross. She arranged our accommodations and told us
being unable to cross the river has not happened in 5 years.

Once down at the river I join Aida outside to assess the situation.  Our peaceful river from hours prior has turned into a torrent, sweeping small trees by, waters a muddy grey brown.  Last year a large truck was swept downstream trying to cross in a similar situation (luckily no one died).  Looks like a night out in the community!  Fortunately the Chefe Suko (local community leader) is happy to take us in.

Back in the community we are provided with tea and crackers.  Sitting for some type of hot beverage when hosting guests is, I am coming to see, a very important social event/obligation.  After tea, Stephanie and I decide to take a walk before dark.  The rain has stopped and we go barefoot, the mud squelching through out toes.  Soon curious children start to join us and before long we have invented the “count to three and then start running and screaming down the road game.”  Everyone shrieks with joy and at one point we grow to perhaps 30 strong.  Neighbors come to the edge of the road to see what all the commotion is about.  An experience we will not soon forget:)

Barefoot running with the joyous children! This is an
activity Stephanie and I greatly enjoy. Wherever we go,
the kids love running along side us :)
After a tasty communal dinner of rice, veggies and chicken we settle down on a guest bed under our mosquito net and try to sleep.  At one point in the night I awake at a slight noise.  Soon a small puppy pops out from under our bed – where did he come from?!  Dogs are always underfoot here.

The next day it’s time to try the river again.  Once down on the riverbank we see it is still quite high but fortunately the husband of the local midwife has agreed to use his tractor to test out a safe route and guide us across.  After that it’s the familiar bumpy road 3 hours back to Dili.

Shot of the river from the passenger seat.  The river was
comprised of multiple water channels like this one, some even deeper,
totaling roughly 150-200m across and took us perhaps
10 minutes to fully cross!

Take away lessons from the experience:

- Rivers change fast here!
- Always be prepared to spend the night out.  Pack supplies accordingly! (we did not:)
- The relationship with the community is key. Aida has formed a solid partnership with those communities she is working with and the benefits go both ways.
- Community health workers are vital to the success of rural health programs.
- Laughter and smiles transcend language and culture.

The future of Timor- Leste.  Smiling and hopeful.  The
children make our  long days worth it.