Newsletter from the Sierra Madre #69 | January 2012

East Timor – The Challenge for Human, Environmental and Political Health

by David Werner

I. Introduction

Timor-Leste is the eastern part of an island in an Indonesian archipelago.

When I was invited to Timor-Leste this last November to share experiences in Primary Health Care, I jumped at the chance. I have long admired the Timorese people’s resolute struggle for liberation against overwhelming odds. At the same time, as a US citizen, I had a sense of shame at the role of the United States in supporting Indonesia’s brutal occupation of Timor-Leste from the mid-1970s through the 1990s: a crime against humanity that cannot be easily forgotten or forgiven. For this reason I deeply appreciated the warmth and good will with which people in Timor received me.

Traditional houses in Timor-Leste.

My visit to Timor-Leste was arranged by SHARE, the Japanese humanitarian Non-Governmental Organization (NGO) that has been promoting community-based health activities with disadvantaged villagers in the central mountainous area of the island. In 2010, SHARE was awarded the 5th Okinawa Peace Prize for its exemplary work in promoting health in challenging situations. I feel deeply honored that the SHARE team, led by its visionary founder, Dr. Toru Honda, decided to use part of the prize money to sponsor my trip to East Timor.

Providing assistance to newly independent East Timor is a high priority for SHARE because health conditions there remain critical, especially in rural areas. Despite impressive economic growth since it gained statehood in 1992 – and despite substantial efforts by the Health Ministry, the World Health Organization (WHO), UNICEF, and many international charities – the distressing health indicators have only slightly improved. Maternal and child mortality are still alarmingly high, and over 50% of children under 5 years of age are undernourished or stunted. Given these vast unresolved health needs, my challenge was to explore with local health workers possibilities for mobilizing communities to analyze their health-related needs and to work collectively toward solutions.

As I was soon to discover, the social and environmental determinants of health in Timor-Leste are incredibly complex. To better grasp the health situation on this small island, it helps to have some understanding of the Timorese people’s embattled history.

II. History

Timor-Leste’s long and valiant struggle for independence

Timor is a mountainous island at the eastern end of an Indonesian archipelago (Timor means ‘East’ in Tetun, so Timor-Leste actually means ‘East East’). It was long inhabited by diverse tribal groups, some Austronesian, others Melanesian. In the 17th century, Holland and Portugal fought for colonial rule of the island and utimately settled on Dutch control of the western half and Portuguese control of the eastern half. In 1949, Holland ceded possession of West Timor to Indonesia. In 1974, Portugal began a process of decolonialization in Portuguese Timor, and on November 28, 1975, the FRETILIN resistance movement announced the founding of the Democratic Republic of East Timor. However, freedom was short-lived. Nine days after it declared independence, East Timor was ruthlessly invaded by Indonesia, which occupied the country by military force for the next 24 years – an occupation that the Timorese people resisted resolutely. The US government – following the recommendation of Henry Kissinger – strongly supported the dictator Suharto in Indonesia’s genocidal assault and occupation. During the quarter century of military domination, nearly one third of East Timor’s population perished, yet the people continued to resist through guerrilla warfare.

Dili, capital city of Timor-Leste, seen from drive up into central mountains.

Finally, in 1999 the UN called for a referendum. Despite intimidation at the polls by Indonesian authorities, 80% of the East Timorese voted for independent statehood. Infuriated, Indonesia and its local supporters launched a campaign of terror, massacring civilians, burning farms and forests, and destroying schools and health-posts. They left the newly liberated country in ruins. For two years the ravaged territory was administered by the United Nations, until on May 20, 2002, the Democratic Republic of Timor-Leste became a self-governed nation. Timor-Leste’s first president was Xanana Gusmão, who had been deeply involved in the resistance movement for twenty-eight years.

David with a former guerrilla – now a Family Health Promoter – with his wife and son.

Timor-Leste today: a land of promises and contradictions

Since its Independence nine years ago, Timor-Leste has faced enormous challenges. Throughout its long struggle against oppression, the Timorese leaders built deep ties to their people. In 2011, the government drafted an ambitious 20-Year “Strategic Development Plan,” which charts a future based on an egalitarian vision of sustainable well-being for all. One of the Plan’s strongest points is its guarantee of universal healthcare coverage.

A major factor influencing Timor’s development has been the discovery of offshore oil. The oil is currently being extracted intensively by foreign corporations (mainly Australian), which pay Timor for the rights. Thanks to this oil bonanza, in recent years the small nation’s economic growth has been an amazing 12% per year! With oil revenue now paying for 95% of the national budget, the World Bank warns that Timor-Leste is now the world’s most oil dependent nation.

Urns for water storage.

The overarching problem is this: at the current rate of extraction, Timor-Leste’s oil reserves are predicted to run dry in about 20 years. Faced with this reality, the Strategic Development Plan proposes to set aside a substantial part of the present oil revenues to generate income for future generations. Another sizable part of the oil income is supposed to be spent on developing post-oil sources of energy – wind, solar, hydroelectric, tidal, geothermal – so that by 2030 Timor-Leste will become a sustainable, fossil-fuel independent economy.

Other goals of the 20-year Plan are elimination of poverty and malnutrition, achievement of food self-sufficiency, and, as a top priority, development of “human resources,” meaning Health and Education. To this end, the Plan proclaims Universal Schooling and Universal Health Services as basic human rights.

Putting these lofty goals into practice, however, has proved easier said than done. Timor-Leste is a tiny emerging nation in a global economy where giant corporations and market-driven powers seek to manipulate the newcomer’s policies and exploit its resources. And some of Timor’s political leaders – for all their early revolutionary ideology – are not immune to the temptations of personal gain.

Solar panels are being in introduced in rural areas. The goal is to replace fossil fuels completely with alternative energy by 2030.

The result is that Timor-Leste is already embarking on paths contrary to those proposed in its Strategic Development Plan. Despite the resolution to put major investment into alternative energy, far greater investment is being devoted to an oil-based infrastructure and an electric grid based on fossil fuels. And despite the resolve to avoid foreign loans, the government has been baited into borrowing from foreign nations and banks to a degree that, when oil runs out, crushing debts will become due.

As for the high priority given to Health and Education, the government has fallen far short in its allocations. UNICEF calculates that for a developing country to achieve the “Millennial Development Goals” (of lowering mortality, improving overall health, and raising educational levels) at least 16% of its national budget must be allocated for Health and Education. Yet Timor-Leste is currently spending only 6% on Health and Education, and has budgeted an even lower percentage for the coming year.

Such contradictions between visionary plans and actual practice help explain the persistent poor levels of health and high mortality rates in Timor-Leste today. As I became increasingly aware, under the surface one finds a baffling array of interrelated and conflicting factors.

III. Health Situation

Conditions in Timor-Leste

Although the level of health in Timor-Leste remains distressingly poor, in some respects the country has come a long way since Independence. In 2002 the devastated population of one million had only 11 doctors, and virtually no formal health system. The UN and the International Red Cross came to the rescue. Cuba generously pitched in, as it has done for so many struggling nations. This small, socialist country sent over 300 doctors to Timor and is now training 700 Timorese doctors to take their place.

With over 70% of East Timor’s population living in remote villages and aldeas (small settlements), the logistics of providing health services are daunting. With guidance from WHO and a number of foreign NGOs, the Timorese Health Ministry worked out a hierarchical plan of health provision. Delivery of services in remote areas is carried out at basic health posts called “SISCa” (Servisu Integradu do Saúde Comunitária): locations at the sub-district level where pregnant women and mothers are summoned once a month for Pre-natal Screening, Growth Monitoring of infants, Vaccination, and Health Education.

David Werner with 4 Cuban doctors and 2 Timorese medical students.

Key to the functioning of the SISCa initiative is an extensive network of so-called Promotores Saúde Familiar or PSFs (Family Health Promoters). These are local village volunteers who act as messengers and information dispatchers for the professional health staff: a doctor and/or a nurse and two levels of trainers. It is the task of the PSFs to round up mothers and children in the outlying aldeas and make sure they come to the monthly SISCa assemblies.

Women and children waiting at a SISCa health gathering.

At these SISCa events, PSFs help with Growth Monitoring (which entails both weighing and measuring arm-circumference of children under five) and filling in Growth Charts and various forms. PSFs also assist with group health education, using colorful flip charts and occasionally flannel-graphs or role plays.

Baby being weighed using UNICEF hanging scales.

I had a chance to visit a SISCa event in the district of Ermera, deep in the central mountains, where I was given a ceremonious welcome as the author of Where There Is No Doctor. The book has been translated into the local language of Tetun, though it isn’t provided to the PSFs.

The Tetun translation of Where There Is No Doctor.

The SISCa event was highly impressive. Seventy to eighty colorfully-dressed mothers were present, most with a nursing infant and other children in tow. I marveled at the cheerfulness and patience of the mothers, many of whom had walked for hours from their distant aldeas. There were no benches, so they stood for additional hours outside in the sun, waiting to be seen. A number of elderly village patriarchs also attended, some to see an ophthalmological technician who had come to provide reading glasses and check for cataracts. The health staff was very busy weighing and measuring babies, giving out worm medicines, applying vaccines, and filling out forms. It was clear that a lot was happening, yet as I watched, a number of questions arose.

A vision technician at a SISCa event checks sight for need of glasses.

Despite the effort to monitor the health and nutrition of children and mothers at the SISCa centers, child undernutrition and mortality remain distressingly high, and in the last couple of years have shown very little improvement.

One reason for the low impact of the SISCa program is the relatively low attendance. In part, this is due to the long distance many mothers have to walk, often over very difficult terrain. But the large crowds at the SISCa events were also an obstacle to individualized communication and care.

Worm medicine is giving routinely to young children.

I was concerned by how many children were visibly underweight. Most of the younger infants, who were still primarily breastfed, looked well nourished. But the majority of babies that had begun weaning appeared very thin. On viewing a number of the Growth Charts, a disturbing pattern was apparent. A child would gain weight for the first 4 or 5 months, then – after weaning began – would stop gaining weight for 2 or 3 months, and subsequently lose weight due to a bout of diarrhea or other illness. The low weight often lasted for several years and the majority of children remained stunted.

What concerned me most was that I didn’t see much individual advice being given to the mothers, even those whose children were seriously undernourished. When I asked about this, a nurse explained that with so many babies needing to be weighed, measured, recorded, and vaccinated in a single day, there simply wasn’t the time to counsel each mother. The prescribed health education for the whole group of mothers, I was told, had taken place earlier that morning, using flip charts to make the necessary points. As best I could tell, these were the orthodox health messages about hand washing and eating from the “4 food groups,” with little two-way communication to investigate the concerns and needs of individual mothers and children. When we asked some of the mothers the significance of the Growth Chart and the meaning of the little black dots that were marked on it each month, they showed little understanding.

While babies are exclusively breastfed they tend to gain weight well and look healthy.

This kind of communication shortfall with Growth Monitoring is not unique to Timor. More than 30 years ago, when UNICEF was avidly promoting Selective Primary Health Care through GOBI (Growth Monitoring, Oral Rehydration Therapy, Breast Feeding, and Immunization), evaluators were already distressed at the way Growth Monitoring had so often deteriorated into a pointless ritual. Babies were routinely weighed and the charts dutifully filled out with little if any useful advice, explanation, or follow-up provided to mothers.

Once mothers start giving weaning foods their babies often begin to loose weight.

The SHARE team is aware of weaknesses in the SISCa program. Their biggest worry is that these monthly events have had minimal impact in lowering the high rates of child undernutrition and mortality.

Needed: A Grassroots Participatory Epidemiology to Determine the Chain of Causes

As I observed the situation and talked with health workers and local people, a simple fact became apparent: it doesn’t work to keep repeating the same old nutritional messages that mothers have heard dozens of times. It is crucial that we find out what does work. What can impoverished mothers do so their weanling children don’t become too thin? What combination of factors or “Chain of Causes” contribute to the prevailing pattern of child malnutrition and high mortality?

An open-ended, participatory exploration is needed at the community level to address these questions. Such a study should not simply be conducted by qualified nutritionists and experts, but must include active input from local people, especially from village mothers. Data from Growth Charts can be used, not only to review which babies are too thin, but also to see which babies are growing well – to learn from their mothers what they are doing right. Based on the findings, a number of mini community-level experiments can be conducted to determine what approaches to weaning, feeding, and use of resources give the best results. If PSFs and mothers play key roles in this process, it could be an empowering experience for both – especially if they come up with some worthwhile answers.

Once a “map” of the causal chain begins to take shape (an ongoing process that should never be considered complete), everyone can stand back and try to figure out which of the causal links might be broken, with what action, by whom, and at what level – family, community, national, or beyond.

Routine health talks to mothers using colorful flip charts.

IV. Elements in the Chain of Causes

There is not space here to touch on all of the causal links contributing to the high rate of undernutrition and mortality of young children in Timor-Leste; in any case, after my short visit to Timor, I am no doubt still unaware of many significant factors. But I would like to briefly examine several of the elements that I did notice.

Poverty is clearly the most important root cause of children’s poor health. 60% of Timorese live on less than US $0.80 per day. This enduring poverty has a spectrum of causes, many social and political, which must be addressed if widespread poor health is ever to be eradicated. Given Timor-Leste’s rapid economic growth from oil revenues, a distressingly small percentage of the national wealth has “trickled down” to the destitute. This gross inequity has many causes, not least of which are centralized power and corruption at the national and international level. Clearly, far greater investment in Health and Education is called for.

Nutrition education in its current form is not accomplishing what it needs to. This is true at all levels, from university to the mass media to the community level. Both methods and content need to be reexamined. A new approach to research (participatory epidemiology) needs to be promoted, with mothers and community health workers (PSFs and TBAs) playing a leading role.

Homes made of split bamboo with thatch roofs.

Imported prepackaged weaning foods are a problem.Partly as an incentive for them to come to the SISCa gatherings, mothers whose infants are measurably underweight are sometimes given a nutritious weaning food from UNICEF called PlumpyNut. However, this incentive may be counterproductive because it rewards those mothers whose babies remain underweight. Furthermore, PlumpyNut is frequently unavailable. So mothers often spend their scarce food money on an imported commercial weaning food called SUN, which costs US $0.50 a package. (Most of the cost of SUN goes into packaging, shipping and promotion.) Since the daily wage in Timor is about US $0.80, the family’s money soon runs out. So rather than using their limited funds to make a low-cost, nutritious weaning food from things like rice, peanuts and cooking oil, mothers typically make a weaning porridge using their home-grown staples: cassava and taro. However, these high-fiber tubers are difficult for infants to digest. Their bellies fill with watery, poorly digestible tuber porridges, leaving little room for more nutritious foods (including breast milk, if they are still partially breast feeding.) Thus the babies don’t get enough calories even though their bellies are stuffed and therefore fail to gain weight.

A contributing cause of child malnutrition is commercial weaning food. In Timor mothers have been tricked into spending their limited food money on an imported weaning food called SUN.

Lack of adequate birth spacing also contributes to child (and maternal) malnutrition and death. In the long term, Timor’s exceptionally high birth rate – averaging 6 children per couple – jeopardizes the nation’s future food security. (Currently, almost 70% of foodstuffs are imported, and agricultural objectives are not advancing as quickly as planned.) Equally problematic in the short term, frequent pregnancies and inadequate birth spacing contribute to endemic child undernutrition in several ways:

  • When a mother becomes pregnant soon after giving birth, she usually stops breastfeeding. This deprives the earlier infant of breast milk and creates competition for scarce food between the baby and the fetus.
  • A mother who soon becomes pregnant again doesn’t have enough time to rebuild her blood and her strength. Her next baby is more likely to be born premature and underweight.
  • A mother who is debilitated by frequent childbirth has a harder time providing for multiple small children at the same time – and all are more likely to become undernourished.

Frequent pregnancies and large family size have different causes. I was told that Timorese men want lots of children “to prove their manhood.” A more common reason in many countries is economic necessity. For a poor family – with little social welfare available, and no government programs assuring that people will be cared for in their old age – having lots of children provides a source of low-cost labor and a greater chance that in later life some of the children will help care for their ailing, aging parents. Also contributing to the high birth rate is the Catholic Church. Timor-Leste is 95% Catholic, and the Church forbids reliable contraceptives.

Low rates of vaccination also contribute to children’s malnutrition and death. When a child falls ill with measles or another preventable disease, he or she often loses weight, and those already malnourished are at higher risk. In Timor, immunization coverage is dangerously low. This is due in part to the long distances mothers must go to SISCa centers for vaccination, but it is also due to objections by the Church. A bishop in East Timor was apparently upset when he learned that women were routinely injected during pregnancy. The vaccine was to prevent neonatal tetanus, but the prelate evidently thought the injections were to abort or sterilize the fetus, so he launched a campaign of fear, saying that all vaccines were harmful. As a result, so many families are refusing immunization that there was recently an epidemic of measles in Timor. And because so many children are malnourished, the death rate from pneumonia as a complication of measles was unusually high.

HIV-AIDS, while still not prevalent in Timor, is increasing and is likely to become yet another cause of family distress affecting the nutritional status and survival of children, as well as their mothers. (In Timor-Leste, more women than men have AIDS.) Tuberculosis is already pandemic, and if AIDS escalates, so will TB. A dangerous drug-resistant strain of TB is currently on the rise. The Catholic Church is accelerating the spread of AIDS through its prohibition of condom use. The good news is that in Timor there are some progressive Catholic groups – such as the Maryknoll Sisters – who advocate vaccination and the health-protecting use of condoms, and who valiantly defend the rights of the poor. But they are a small minority.

Ill-conceived restrictions on what Family Health Promoters are taught and permitted to do represent a major obstacle to providing health services where they are needed. Given the fact that most of Timor’s population lives in aldeas far from health centers with doctors or nurses, it could save lives to train PSFs to provide a broad range of basic health services in their own communities.

The Health Ministry’s failure to officially recognize Traditional Birth Attendants (TBAs)is another big obstacle to mother and child health in Timor-Leste. A graph published by the Health Ministry shows that about 20% of babies are delivered by health professionals in hospitals; nearly 30% are delivered by trained midwives (educated women officially trained in childbirth); and half of all babies are delivered by “other.” “Other” refers mostly to Traditional Birth Attendants, who do deliveries in homes and whom most mothers (including city dwellers) prefer. However, the graph doesn’t refer to them as TBAs because, following a directive of the World Health Organization, they are no longer recognized by the Timorese Health Ministry. Given that TBAs attend the vast majority of births in remote areas where the titled midwives almost never go, the WHO directive makes little sense. If the Ministry of Health provided basic support, back-up, and sterile birth kits to the TBAs, it could have a significant impact on maternal and child health. And the impact could be even greater if TBAs were encouraged to cooperate with Family Health Promoters in pre- and post natal care, including nutrition and immunization.

Misguided World Health Organization directivescreate problems. In addition to obstructing the Health Ministry’s cooperation with TBAs, WHO has also mandated the disempowerment of community health workers, limiting them to a subservient role as messengers or lackeys of health professionals. This unwillingness to enable community health workers to treat common illnesses (like pneumonia, where prompt local treatment can be life-saving) verges on genocidal.

Delayed and inadequate treatment of pneumonia is fatal for many children. Pneumonia is one of the biggest killers of young children, especially those who are weak or malnourished.

V. Working Toward Solutions

Reaching mothers and babies at highest risk

At the monthly SISCa events, babies are weighed using hanging scales provided by UNICEF. Because these scales are imported and relatively costly, numbers are limited. This is one reason why mothers have to trek so far to a central weighing station. And the long trek is a reason why, on average, less than 60% of pregnant women and mothers attend the monthly check-ups. More worrisome still is the likelihood that the mothers and babies who don’t attend are those at highest risk.

In discussing this low attendance with the SHARE staff, an idea occurred to us. If enough scales were available, Growth Monitoring could be more decentralized. Mothers wouldn’t have to go so far, and PSFs could do the monitoring right in their villages or homes. Big crowds and long waits could be avoided, and the health services could be more personal, and adapted to each mother’s and child’s individual needs. But how, people asked, on a limited budget can so many scales be provided? There was an obvious answer: through local production! I showed the health workers photos from Mexico of simple, hand-made “beam balances,” which the Timorese Health Promoters could easily make themselves at virtually no cost. The SHARE staff and the PSFs were excited about this possibility. They would be better able to reach those at highest risk, and it would allow more direct interaction between mothers and health workers, perhaps leading to more effective solutions to the persistent undernutrition and high death rates of children. 

An example of Inappropriate Technology: To increase the supply of scales for growth monitoring, a foreign NGO donated expensive glass floor scales which use a battery unavailable in Timor!

To improve the methods of health education, the SHARE staff has taken ideas from my book, Helping Health Workers Learn. For example, they created a supersized flannel-graph Growth Chart to help mothers understand how the charts work and the significance of different patterns of the little dots.

In our workshops with the Family Health Promoters, we explored a variety of hands-on, “discovery-based” learning methods. To further improve understanding of Growth Charts, I showed pictures from Mexico of how mothers, using a cardboard figure of a mother and a “gourd baby,” can actually weigh the gourd as it gains weight (due to the liquid that flows into it from a bottle that represents the mother’s breast). In this way, mothers can see for themselves (as they record the gourd baby’s changing weight on the supersized Growth Chart) how a child grows well when breastfed, grows less well when bottle-fed or given inadequate weaning foods, and loses weight when diarrhea strikes. (To cause “diarrhea,” the plug in the gourd baby’s backside is pulled out; as water runs out, weight is measurably lost. This method is illustrated on pages 22-16 and 22-17 of Helping Health Workers Learn.)

The National Coordinator for Health Education took part in “discovery based learning” using the “gourd baby.”

Both the SHARE team and the PSFs were excited by trying and adapting some of the hands-on, problem-solving teaching methods developed in Mexico and Latin America. They felt the need to work more closely with the mothers and families in trying to figure out more effective approaches to improve children’s nutrition and health.

Expanding the role of health promoters  

The Family Health Promoters help as volunteers in their own villages and aldeas and typically receive a token “incentive” of about US $5 per month. The majority of PSFs start out with great enthusiasm, but many soon become “inactive” or drop out. I was frequently asked: What might be done to prevent the high drop-out rate?

The obvious answer is to provide a greater incentive. But money isn’t the only thing that motivates people to make greater efforts. What inspires many of us to keep helping is the sense that the service we provide makes a real difference in people’s well-being, and that our efforts are appreciated and respected.

If the PSFs’ assistance in relation to the SISCa gatherings made a visible difference in children’s nutritional health and survival, and if the community appreciated that difference, it could strongly motivate the PSFs to continue. But as it stands, child malnutrition and mortality rates remain high. In the two districts I visited, almost no improvement was recorded in the last two years. Similarly, vaccination rates remain so low that this year there was a major measles epidemic. In Aileu district in 2011, only 2.8% of pregnant mothers were immunized against tetanus – an all-time low!

If local health workers are to gain credibility and respect in their communities, they should be able to respond to the health needs that people consider most urgent. A mother whose baby is dying from diarrhea has little interest in preventive advice. She first wants to cure her baby’s illness! Once her child is out of danger, she will take more interest in how to prevent the illness from coming back.

A village patriarch.

If a health promoter has the basic knowledge and skills – and authorization – to help diagnose and treat some of the most common and dangerous ailments, like diarrhea and pneumonia, he or she will have more credibility. The satisfaction that comes from making a real difference is a big incentive to stay with the job. However, the Timorese Health Ministry – in line with a directive from WHO – does not permit its Family Health Promoters to provide even the most basic curative care. At a workshop I facilitated for PSFs in Aileu, the district health officer repeated six times in his opening speech that “Treatment is strictly the job of the doctors, not the PSFs.” He made it clear that PSFs were only messengers and information-dispatchers for the health professionals. The PSFs listened glumly and said nothing.

The health officer didn’t stay for the workshop, and after he left, I asked the PSFs, “Who is it that treats most of the common illnesses in your villages?” A chorus of voices replied, “Mothers in the home!” I then asked, “What would happen if only doctors provided treatment?” One of the PSF’s replied ruefully, “If we waited for the doctors, we’d all be dead!” Everyone nodded and laughed.

The health officer tell PSFs that treatment is the job of the doctors, not theirs.

Most of the doctors simply are not available where or when they are needed. The long delay and expense to reach them can indeed be deadly. Even with 300 Cuban doctors now in Timor, they rarely reach the more isolated villages. In Aileu District, the 4 Cuban doctors and 24 Timorese medical students stationed there all stay in the district capital, from which they make occasional forays into the countryside. When I talked with them, they agreed that the doctor-dominant healthcare model practiced in Cuba is not appropriate for Timor. They thought, and I fully agree, that local Family Health Promoters should play a much more capable role – including diagnosis and treatment of common health problems, with the use of a few essential medicines including antibiotics for pneumonia.

In a workshop PSFs conduct a “Community Diagnosis in which they identify common health-related problems and they figure out the links between them.

The PSFs were enthusiastic about learning more skills and assuming greater responsibility. Some of their responsibilities in an expanded program might include the following:

  • Growth monitoring using homemade scales, including appropriate follow-up for underweight or sick children.
  • Participation in community-based research (participatory epidemiology) to learn more about the causes of child undernutrition and design appropriate courses of action.
  • Diagnosis and treatment of common health problems – including use of antibiotics for pneumonia.
  • Application of vaccines to children and pregnant women at the village level.
  • Health education that is discovery-based and empowering – including and involving mothers, fathers, and schoolchildren (Child-to-Child).
  • Organization of local Health Committees to cooperate in community projects that address specific local health-related needs, and to make necessary demands of the health authorities.
  • Collaboration with traditional birth attendants and healers – acting as a liaison between these persons and the health system.

An important example of how expanding the job responsibilities of PSFs could be lifesaving is the treatment of pneumonia. Early diagnosis and treatment of pneumonia with antibiotics greatly reduces mortality. Where antibiotics can only be prescribed or given by health professionals, and health professionals are not readily available because of distance or cost, the death rate from pneumonia is especially high. In such circumstances, it has been shown – and documented in Lancet – that when community health workers are enabled to diagnose and treat pneumonia promptly with an appropriate antibiotic like amoxicillin, the death rate can be significantly reduced. We talked about this with the SHARE team and the PSFs, who were eager to learn how to diagnose and treat pneumonia. Rapid, shallow breathing is a diagnostic sign of pneumonia. We taught the PSFs to time the rate of breathing using a pendulum made of a rock tied to the end of a string. A baby (at rest) who breathes faster than a rock swings on 35 cm of string (which swings 50 times a minute) probably has pneumonia.

Here the SHARE team learn to time the rate of breathing using a rock swinging on a string. A healthy adult breathes at about 31 breaths a minute (speed of the rock swinging on 2 meters of string.) A baby who breaths faster than a rock swings on 35 cm. of string (50 swings a minute) probably has pneumonia.

The PSFs understood the importance of early treatment and wondered what do. The SHARE staff felt that every effort should be made to change the WHO and MoH guidelines. However, everyone realized this was unlikely to happen soon, despite the numerous studies and publications proving the rationale.

“Then what can we do?” asked one of the PSFs. “When a child’s life is in danger and you can’t get her to a doctor in time, do we follow the rules and let the child die?” “Sometimes,” I ventured, “you have to decide between following rules and saving lives.”

Redefining the balance of power

Health in a country or community, and in the world as a whole, is largely determined by the distribution of wealth and power. Greater equality leads to a healthier, more cohesive population. To build a healthier, more egalitarian society, everyone needs to relate to one another as equals. In Health Care, as in other fields, the typical “pyramid of authority” needs to be turned on its side:

In the conventional healthcare pyramid, the community is on the bottom, the local health promoter is just above the community, and the doctor is on top.

To gain more equality, this top-down pecking order must change. But we don’t want to turn the pyramid upside down, because we want no one on top of anyone else.

Instead, we need to tip the pyramid on its side. This way, everyone is on the same level, as equals. The community comes first. The health promoter is at the service of the community. And the doctor is at the service of both the health promoters and the community. The doctor is ON TAP, not ON TOP.

Health education for change

In the chain of causes that leads to given patterns of health, it is important to consider the role of education, in public schooling and in health education particularly. “Education,” for better or for worse, is important for the health of society. The way learning is approached can influence the equality or inequality within a population. Above all, it can influence the balance of power, a fundamental determinant of health.

To build a healthy society, a population must be alert to the tendency of leaders – even those they elect – to place their personal ambitions before the common good. To build and sustain a just, egalitarian society, the common people need to be watchful and well-informed. They need to be able to make their own observations and draw their own conclusions, not simply to obey orders, memorize lessons, and do as they are told.

Such obedience training of conventional top-down schooling can be an obstacle to health. In countries where wealth and decision-making power are concentrated in the hands of an elite minority (as is the case in most so-called democracies), the school system serves as an instrument of social control. Its goal is to turn young people into complacent adults who will embrace the status quo, obey authority, and fit into the social hierarchy. It aims to create obedient followers, not agents of change.

If a country in transition like Timor-Leste is to build a healthy, equitable, sustainable society free of poverty, it will need to radically transform its approach to education. Teaching will need to focus on helping young people think for themselves, analyze their common needs, and work together to improve the well-being of all – now and into the future. With this in mind, in the workshops I led in Timor-Leste, I placed emphasis, not just on the content of health education, but also on the methodology. We spoke of  Brazilian educator Paulo Freire’s Pedagogy of the Oppressed. In his “awareness-raising” approach (conscientização), Freire helped groups of marginalized people critically reflect on their common needs and take collective action to (in Freire’s words) “change the world.” In Latin America, Freire’s “education of liberation” methods have been widely adapted to grassroots health promotion – sometimes with revolutionary results.

The low vaccination rate in Timor led to a recent epidemic of measles. Here David Werner shows the SHARE team a street theater skit in Nicargua, in which the “Measles Monster” attacks unvaccinated children.

In the Timor workshops we introduced a number of discovery-based “Education for Change” activities and teaching aids developed in Mexico and elsewhere. One highly imaginative PSF, Julio, was especially talented in making eye-catching educational materials. To teach oral hygiene, he created a comical Muppet-like head from a coconut, with a huge mouth that opened and closed. To teach the importance of insecticide-impregnated bed-nets for preventing malaria, he made two miniature beds with dolls in them, one covered with mosquito netting, the other not. Out of old rubber sandals he made giant mosquitoes, which viciously attacked the unprotected doll. People with Julio’s rich imagination and creativity can be a valuable resource to a health team. They make learning more fun and thereby more memorable.

Dr. Aida

While in Dili, I had the good fortune to meet Dr. Aida Goncalves, a courageous Timorese doctor who, despite the World Health Organization directive, has been working with Traditional Birth Attendants in a remote mountainous part of the country. Her TBAs have achieved far better rates of maternal and infant survival than has the nation as a whole. Last year, Dr. Aida asked the Health Minister to visit her program, and he was so impressed he told her (privately) that her approach should be scaled up to cover the whole of Timor-Leste.

Julio the PSF show the models he made of bed-nets and mosquitos, to show how the nets protect a child from malaria.

Meanwhile, Dr. Aida won approval of a grant from the Japanese Embassy of one million dollars to expand her TBA program. All she needs to finalize the donation is authorization from the Timorese Ministry of Health. But up to now, the Health Minister has dragged his heels – fearful of losing WHO support.

Dr. Dan Murphy (center) with Dr, Toru Honda, founder of SHARE, and David Werner.

Doctor Dan

One of my delights while in Timor was the opportunity to spend some time with Dr. Dan Murphy, an American doctor who has spent much of his life serving in places where health needs are huge. I first met Dr. Dan in the 1980s in Delano, California, when he was volunteering with César Chávez and the United Farm Workers. He also spent years in Mozambique soon after its liberation from colonial rule. For the last 10 years, Dr. Dan has worked in Timor-Leste, running a large clinic in a poor section of the capital city of Dili. The clinic has an average of 60 inpatients, and with the help of volunteer doctors and students from various countries, Dr. Dan personally attends over 300 outpatients per day – showing heartfelt concern for each! One large ward is full of people with tuberculosis, and Dr. Dan makes a great effort to obtain the urgently needed, costly medication for the growing numbers with multiple-resistance TB.

Dr. Dan feels strongly that for Timor-Leste to meet its enormous health needs, much stronger emphasis must be placed on a community-based approach in which local health promoters, traditional birth attendants, and native healers are fully integrated – with the back-up and respect of the national health system. He cooperates closely with Dr. Aida and others who are pioneering in that direction. 

Dr. Toru Honda and David Werner with the National Coordinator of Health Education.

National Seminar in Dili

Toward the end of my stay in Timor, I spent a full day with representatives of the Ministry of Health and the Ministry of Education, in a morning seminar and afternoon workshop. I was extremely fortunate to have Dr. Dan translate my presentations into Tetun – which he wisely didn’t do word for word, but idea for idea. In the afternoon session we involved the audience, using the “gourd baby” in discovery-based learning about dehydration and management of diarrhea. The person in charge of health education nationwide was excited about the concept of “Education for Change,” and he spoke with me during lunch about introducing into the schools a discovery-based, learning-by-doing approach to Child-to-Child. He was already familiar with Child-to-Child, but not the empowering methodology used in Latin America.

At the seminar, people from the Ministry of Health also took interest in the possibility of giving a more important role to the Family Health Promoters, and of recognizing and working more closely with Traditional Birth Attendants. Unfortunately, no one from the World Health Organization was present at the seminar. It is still too early to see in what direction the Health and Education systems will evolve, but at least we triggered a thought-provoking dialog. Most participants agreed that much rethinking and many innovative changes are needed.

East Timor as the Canary in the Coal Mine

I found Timor-Leste’s current struggle for self-determination very moving. As a small island nation that has won its relative independence at a historical time when the future of humanity and all life on the planet hangs in balance, I see Timor-Leste as the proverbial canary in the coal mine. Faced with looming climate change from global warming, the imminent end of its oil reserves, and the island’s unsustainable dependence on imported produce, what happens during the next few years in Timor may foreshadow what could soon occur globally. Let us hope the people of Timor don’t just listen to outside development pundits and corporate interests, but find the courage and resolve to collectively build a healthy and sustainable future.

VI. Suggestions for Sustainable Health in Timor-Leste

Long term:

  • Work toward an empowered, well-informed, politically alert populace that can elect and hold accountable leaders who will work toward sustainable health for all.
  • Transform public education to help children think for themselves, analyze common needs, and work together for the common good.
  • Use Discovery-Based Learning and Child-to-Child “Education for Change” activities to help prepare them as future agents of change.

More immediate suggestions:

  • Increase the responsibilities and relevance of the Promotores Saúde Familiar, prepare and enable them to play a more direct health-promoting role in their communities
  • Enable the PSFs to diagnose and treat common health problems such as diarrhea and pneumonia in children.
  • Teach PSFs to make their own simple beam balances (scales) for weighing Under-5 children. Then, in their aldeas, have them go to the homes of the mothers who do not take their babies to the SISCa events, weigh and measure them, and take appropriate steps to help the underweight or sick babies become healthy. To do this successfully, more community-based research is needed to learn why so many children stop gaining weight when they go on to weaning foods.
  • To conduct such research, NGOs like SHARE – hopefully in cooperation with the Health and Education ministries – might undertake pilot participatory study projects, finding out precisely what mothers are feeding their weanlings, trouble-shooting the problems/obstacles (at all levels) and experimenting with other, hopefully more optimal, feeding alternatives.
  • In the SISCa projects and the training of PSFs there seems to be a big gap in their training when it comes to childhood pneumonia – reportedly one of the biggest causes of death in Under-5s. If PSFs could recognize the common signs of pneumonia and see that children get early antibiotic treatment, this single intervention could significantly lower the mortality rate for Under-5s.
  • Try to find ways to gain Ministry of Health acceptance, support, and upgrading of skills of Traditional Birth Attendants, following the very successful model of Dr Aida. Since at least 50% of babies are still delivered, unofficially, by lay midwives, this is imperative. Every effort should be made to alert the World Health Organization to this need and to urge them to change their policy.

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