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 no