East Timor–The Challenge for Human, Environmental and Political Health
When I was invited to Timor-Leste this last November to share experiences in Primary Health Care, I jumped at the chance. I have long admired the Timorese people’s relentless struggle for liberation against overwhelming odds. Yet at the same time, as a US citizen, I had a sense of shame at the role of the United States in supporting Indonesia’s brutal occupation of Timor-Leste from the mid-1970s through the 90s: a crime against humanity that cannot be easily forgotten or forgiven. For this reason I deeply appreciated the warmth and good will with which people in Timor received me.
My visit to Timor-Leste was arranged by SHARE, the humanitarian Japanese NGO that has been promoting community-based health activities with disadvantaged villagers in the central mountainous area of the island. In 2010 SHARE was awarded the 5th Okinawa Peace Prize for its exemplary work in promoting health in challenging situations. The SHARE team, led by its visionary founder Dr. Toru Honda, decided to use part of the prize money to sponsor my trip to East Timor–for which I feel deeply honored.
One reason SHARE is active in newly independent East Timor is that health conditions there remain critical, especially in rural areas. Despite impressive economic growth since it gained statehood in 1992—and despite the substantial efforts by the Health Ministry, World Health Organization (WHO), UNICEF and many international charities—the distressing health indicators have not improved much. Maternal and child mortality are still alarmingly high, and over 50% of the children under 5 years old are undernourished or stunted. Given these vast unresolved health needs, my challenge was to explore with local health workers possibilities for mobilizing communities to analyze their health-related needs and collectively work towards solutions.
As I was soon to discover, the social and environmental determinants of health in Timor-Leste are incredibly complex, and many have yet to be sorted out. To better grasp the health situation here, it helps to have some understanding of this small island nation’s embattled history.
Timor-Leste’s long valiant struggle for independence
Timor is a mountainous island at the eastern end of an Indonesian archipelago (Timor means ‘East’ in Tetun, so Timor-Leste actually means ‘East East’). It was long inhabited by diverse tribal groups, some Austronesian, others Melanesian. In the 17th Century, Holland and Portugal fought for colonial rule of the island, and finally settled on Dutch control of the western half and Portuguese control of the eastern half. In 1949 Holland ceded possession of West Timor to Indonesia. And in 1974 Portugal finally released East Timor from colonial rule. But its freedom was short-lived. Two weeks after it gained independence, Timor-Leste was ruthlessly invaded by Indonesia, which it occupied by military force for the next 24 years—during which time the Timorese people resolutely resisted. The US government—under the heartless directive of Henry Kissinger—strongly supported the dictator Suharto in Indonesia’s genocidal assault and occupation. During the quarter century of military domination, nearly one third of East Timorese’s population was killed. Yet through guerilla warfare the people continued to resist.
Finally in 1999 the UN called for a referendum. Despite Indonesia’s intimidation at the poles, 80% of the East Timorese voted for independent statehood. Infuriated, Indonesia and its local supporters launched a campaign of terror, massacring civilians, burning farms and forests, and destroying schools and health-posts. They left the newly liberated country in ruins. For two years the despoiled territory was administed by the United Nations, until in 2002 it became a self-governed nation. Timor-Leste’s first president was Xanana Gusmao, who headed FRETILIN, the Revolutionary Front that had led the popular resistance.
Timor-Leste Today: a Land of Promises and Contradictions
Since its Independence nine years ago, Timor-Leste has faced enormous challenges. From its long struggle against oppression, its people—and many of its leaders—gained empathy for the underdog and a strong sense of social justice. The government has just drafted (in 2011) an ambitious 20 Year “Strategic Development Plan” which charts a future based on an egalitarian vision of sustainable well-being for all.
A major factor influencing Timor’s development has been the discovery of offshore oil. The oil is currently being intensively extracted by foreign corporations (mainly Australian), which pay Timor for the rights. Thanks to this oil bonanza, in recent years the small nation’s economic growth has been an amazing 12% per year! With oil revenue now paying for 95% of the national budget, the World Bank warns that Timor-Leste is now the world’s most oil dependent nation.
The overarching problem is this: At the current rate of extraction, Timor-Leste’s oil reserves are predicted to run dry in about 20 years. Faced with this inconvenient truth, the “Strategic Development Plan” proposes to set aside a substantial part of the present oil income to generate income for future generations. Another sizable part of the oil income is supposed to be spent on developing post-oil sources of energy—wind, solar, hydroelectric, tidal, geothermal—so that by 2030 Timor-Leste will become a sustainable, fossil-fuel independent economy.
Other goals of the 20-year Plan are elimination of poverty and malnutrition, achievement of food self-sufficiency, and as a top priority, development of “human resources,” meaning Health and Education. To this end the Plan proclaims Universal Schooling and Universal Health Services as basic human rights.
Putting these lofty goals into practice, however, has proved easier said than done. Timor-Leste is a tiny emerging nation in a global economy where giant corporations and market-driven powers seek to manipulate the newcomer’s policies and recklessly exploit its resources. And at least some of Timor’s political leaders—for all their early revolutionary ideology—are not immune to the temptations of personal gain.
The result is that Timor-Leste is already embarking on paths contrary to those proposed in its Strategic Development Plan. Despite the resolution to put major investment into alternative energy, far greater investment is now being put into an oil-based infrastructure and an electric grid based on fossil fuels. And despite the resolve to avoid foreign loans, the government is been baited into borrowing from foreign nations and banks to a degree that, when the oil runs out, crushing debts will fall due.
As for the high priority placed on Health and Education, the government has fallen far short in its allocations. UNICEF calculates that for a developing country to achieve the “Millennial Development Goals” (in terms of lowering mortality, improving overall health, and raising educational levels) at least 16% of its national budget must be allocated for Health and Education. Yet Timor-Leste is currently spends only 6% on Health and Education, and has budgeted an even lower amount for the coming year.
Such contradictions between visionary plans and actual practice help explain the persistent poor levels of health and high mortality rates in Timor-Leste today. … However, as I became increasing aware, under the surface there is a baffling array of interrelated and conflicting factors.
III. The Health Situation
Promotion of Health in Timor-Leste
Although the level of health in Timor-Leste remains distressingly poor, the country has in some ways come a long way since Independence. In 2002 the ravaged population of one million had only 11 doctors, and virtually no formal health system. The UN and International Red Cross came to the rescue. Also Cuba generously pitched in, as it has done for so many struggling nations. Cuba sent over 300 doctors to Timor and is now training 700 Timorese doctors to take over.
With over 70% of the population living in remote villages and aldeas (small settlements), the logistics of providing health services are daunting. With guidance from WHO and a number of foreign NGOs, the Timorese Health Ministry worked out a pyramidal plan of health provision. Key to delivery of services in remote areas are basic health posts called “SISCa” (Servisu Integradu do Saúde Comunitária): locations at the sub-district level where pregnant women and mothers are summonsed once a month for pre-natal screening, growth monitoring of infants, vaccination, and health education.
Key to the functioning of the SISCa initiative the extensive network of so-called Promotores Saúde Familiar or PSFs (family health promoters), local village volunteers who act as messengers and information dispatchers for the professional health staff (a doctor and/or a nurse and a two levels of trainers). It is the task of the PSFs to round up mothers and children in the outlying aldeas and make sure they come to the monthly SISCa assemblies.
At these SISCa events, PSFs help with growth monitoring (which entails both weighing and measuring arm-circumference of children under five) and filling in growth charts and various forms. PSFs also assist with group “health education,” using colorful flipcharts and sometimes flannel-graphs or role plays.
I had a chance to visit a SISCa event in the district of Ermera, deep in the central mountains. I was given a ceremonious welcome as the author of Where There Is No Doctor, which has been translated into the local language of Tetun (though the book isn’t provided to the PSFs).
The SISCa event was visibly impressive. 70 to 80 colorfully-dressed mothers were present, most with an infant at breast and others in tow. A number of elderly village patriarchs were also present—some to see an ophthalmological technician who had come to provide reading glasses and check for cataract. The health staff was very busy weighing and measuring babies, giving out worm medicines, applying vaccines, and filling out forms.
At the SISCa gathering a lot was certainly happening. Yet as I watched, a number of questions arose. I marveled at the cheerfulness and patience of the mothers. Many had walked for hours from their distant aldeas. At the event they stood for additional hours, outside in the sun, waiting for hours to be attended. There were no benches.
Despite all the effort to monitor the health and nutrition of children and mothers at the SISCa centers, child undernutrition and mortality remain distressingly high, and in the last couple of years have shown very little improvement.
One reason for the low impact of the SISCa program is the relatively low attendance, as shown on the adjacent chart. In part this is due to the long distance many mothers have to walk—some often over very difficult terrain. But the large large crowds at the SISCa events also an obstacle to individualized communication and care.
I was concerned by how many children were visibly underweight—certainly the majority. The younger infants, while still primarily breastfed, mostly looked well nourished. But from 4 to 5 month onward, once they’d begun weaning, most looked very thin. On viewing a batch of the growth charts, a disturbing pattern was apparent. A child would gain weight well for the first 4 or 5 months, then—after weaning began—would stop gaining weight for 2 or 3 months, and susequently lose weight due to a bout of diarrhea or other illness. The low weight often lasted for several years and the majority of children remained stunted.
What concerned me most was that I didn’t see much individual advice being given to the mothers of these children—even of those who were seriously undernourished. When I asked about this, a nurse explained that with so many babies needing to be weighed, measured, recorded and vaccinated in a single day, there simple wasn’t time enough to counsel each mother. The prescribed health education for the whole group of mothers, I was told, had already taken place earlier that morning, using flip charts to make the necessary points. As best I could tell, these were the orthodox health messages about hand washing and eating from the “4 food groups,” with little two-way communication to investigate the concerns and needs of individual mothers and children.
When we asked some of the mothers the significance of the growth chart and the meaning of little black dots that were marked on it each month, they had little idea.
This kind of communication shortfall with Growth Monitoring is not unique to Timor. More than 30 years ago, when UNICEF was avidly promoting Selective Primary Health Care through GOBI (Growth Monitoring, Oral Rehydration Therapy, Breast Feeding, and Immunization), evaluators were already distressed at the way Growth Monitoring had so often deteriorated into a pointless ritual. Babies were routinely weighed and the charts dutifully filled out with little if any useful advice, explanation or follow-up provided to mothers.
The SHARE team is aware of weaknesses in the SISCa program. Their biggest worry is that these monthly events have had minimal impact in lowering the high rates of child undernutrition and mortality. To improve the methods of health education, the SHARE staff has taken ideas from my book Helping Health Workers Learn. For example, they created a supersized flannel-graph Growth Chart, to help mothers understand how the charts work, and the significance of different patterns of the little dots. They were eager for new ideas.
In our workshops with the Family Health Promoters (PSFs) we explored a variety of hands-on, “discovery-based” learning methods. To further improve understanding of Growth Charts, I showed pictures from Mexico of how mothers, using a cardboard figure of a mother and a “gourd baby”, can actually weigh the gourd as it gains weight (due to the liquid that flows into it from a bottle that forms the “mother’s” breast). In this way mothers can see for themselves—and record their changing weight on the supersized Growth Chart—how a child grows well when breastfed, grows less when bottlefed or given inadequate weaning foods, and looses weight when diarrhea strikes. (To cause “diarrhea,” the plug in the gourd-baby’s backside is pulled out; as water runs out, weight is measurably lost. This method is illustrated on pages 22-16 and 22-17 of Helping Health Workers Learn.)
Both the SHARE team and the PSFs were excited by trying and adapting some of hands-on, problem-solving teaching methods developed in m Mexico and Latin America. They felt the need to work more closely with the mothers and families in trying to figure out more effective approaches to improve children’s nutrition and health.
V. Trabajando Hacia Soluciones
Reaching mothers and babies at highest risk—a question of scale
At the monthly SISCa events, babies are weighed using hanging scales provided by UNICEF. Because these scales are imported and relatively costly, numbers are limited. This is one reason why mothers have to trek so far to a central weighing station. And the long trek is a reason why, on the average, less than 60% of pregnant women and mothers attend the monthly check-ups. More worrisome still is the likelihood that the mothers and babies who don’t attend are those at highest risk.
In discussing this low attendance with the SHARE staff, an idea occurred to us. If enough scales were available, growth monitoring could be more decentralized. Mothers wouldn’t have to trek so far, and PSFs could do growth monitoring right in their villages or homes. Big crowds and long waits could be avoided, and the health services could be more personal, adapted to each mother’s and child’s individual needs.
But how, people asked, on a limited budget can so many scales be provided? The obvious answer is: through local production! I showed the health workers photos from Mexico of simple, hand-made “beam balances,” which the Timorese Health Promoters could easily make themselves at virtually no cost. The SHARE staff and the PSFs were excited about this possibility. They could better reach those at highest risk, right in their villages. It would allow more direct interaction between mothers and health workers, and perhaps more effective solutions to the persistent undernutrition and high death rates of children.
Addressing the high drop-out rate of health promoters
The Family Health Promoters (PSFs) help as volunteers in their own villages and aldeas, Typically they receive a token “incentive” of about US$5 per month. Often they start out with lots of enthusiasm, but many soon become “inactive” or drop out. One question I was often asked was: What might be done to prevent the high drop-out rate?
An obvious solution is to provide a greater incentive. But incentives are necessarily monetary. What inspires many of us to keep helping is the sense that the service we provide makes a real difference in people’s well-being, and that our efforts are appreciated and respected.
If the PSFs assistance in relation to the SISCa gatherings makes a visible difference in children’s nutritional health and survival, and if the community appreciates that difference, this could strongly motivate the PSFs to continue. But as it stands, child malnutrition and mortality rates remain high. In the two districts I visited, almost no improvement was recorded in the last two years. Similarly, vaccination rates remain so low that this year there was a major measles epidemic—with a high death rate due to complications of pneumonia in those children already undernourished. In Aileu district this year (2011) only 2.8% of pregnant mothers were immunized against tetanus—an all-time low!
If local health workers are to gain credibility and respect in their communities, they should to be able to respond to the health needs people consider most urgent. In disadvantaged communities, people’s biggest felt need is often for curative care. A mother whose baby is dying from diarrhea has little interest in preventive advice. First she wants to cure the illness! Once her baby’s out of danger, she will take more interest in how to prevent the illness from coming back.
If we want people to get involved in a health program, we need to listen to them and start with what they want … which is likely to be curative care. If a health promoter has the basic knowledge and skills—and authorization—to help diagnosis and treat a few of the most common and dangerous ailments (like diarrhea and pneumonia), he or she will have more credibility. The satisfaction that comes from making a real difference is a big incentive to stay with the job and not drop out.
However the Timorese Health Ministry—in line with the advice of WHO—does not permit its Family Health Promoters (PSFs) to provide even the most basic curative care. At a workshop I facilitated for PSFs in Aileu, the district health officer repeated six times that “Treatment is strictly the job of the doctors, not the PSFs.” He made it clear that PSFs were messengers and information-dispatchers of the health professionals. The PSFs listened glumly and said nothing.
After his opening speech the health officer didn’t stay for the workshop. After he left, I asked the PSFs, “Who is it that treats most of the common illnesses in your villages?” A chorus of PSFs replied, “Mothers in the home!” I asked them, “What would happen if only doctors provided treatment?” One of the PSF’s replied ruefully, “If we waited for the doctors, we’d all be dead!” Everyone nodded and laughed.
Most of the doctors simply are not where there needed when there needed. The long delay and expense in reaching them can indeed be deadly. Even with the 300 Cuban doctors now in Timor, they rarely reach the more isolated villages. In Aileu District, the 4 Cuban doctors and 24 Timorese medical students stationed there all stay in the district capital, from which they take occasional forays into the countryside. When I talked with them, they agreed that the doctor-dominant healthcare model practiced in Cuba is not appropriate for Timor. They thought that local Family Health Promoters should play a much more capable role—including diagnosis and treatment of common health problems, with use of a few essential medicines including antibiotics for pneumonia. I fully agree.
The PSFs were enthused about learning more skills and assuming greater responsibility. On discussing the endemic undernutrition in children, it was evident that the routine “nutrition messages” given to large groups of mothers weren’t giving satisfactory results. The pattern of low weight gain after introduction of weaning foods showed virtually no improvement, And the end result too often was stunting, increased illness and death.
The Need for Grassroots Participatory Epidemiology
In talking with health workers it became apparent that: It doesn’t work to keep on repeating the same old nutritional messages that mothers have heard dozens of times. First we must find out what works! That is to say: What can impoverished mothers can do so their weanling children don’t become too thin? Open-ended, participatory study is needed at the community level, asking: What are the combination of factors (the “Chain of Causes, if you like) that contribute to the prevailing pattern of child malnutrition and high mortality. Such a study should not simply be conducted by qualified nutritionists and experts, but include the active input from village mothers. Data from Growth Charts can to be used, not only to review which babies are too thin, but also to see which babies are *growing well—*to learn from their mothers what they are doing right! Based on the findings, a number of mini community-level experiments can de conducted to determine what approaches to weaning, feeding and use of resources give better results. If PSFs and mothers play a key role in this process, it could be an empowering experience for both—especially if they come up with some worth-while answers.
The situation is complex. An initial problem-posing activity—which we discussed with the SHARE team—would be to thoughtfully construct a “chain” or “network” of causes, including the multiple interrelated factors that contribute to the prevalent “failure to thrive.” What is required is good “detective” work: careful observation of all possible factors, without pre-judgment or preconceived conclusions. It calls for open minds and a degree of humility: readiness to listen to fresh perspectives, and to realize the insights and observations of the villagers may be as valid as those of the outside professionals.
Once a “map,” of the causal chain begins to take shape (an ongoing process that should never be consider complete), everyone can stand back and try to figure out which of the causal links might be broken, with what action, by whom, and at what level (family level, community level, national level, or beyond).
IV. Links in the Chain to Child Undernutrition and Mortality
I do not have space here to touch on all of the causal links contributing to the high rate of undernutrition and mortality of young children in Timor-Leste. In any case, on my brief visit to Timor, I am no doubt still unaware of many significant factors. So here I’d like to briefly examine several of those links of greatest concern. I will do little more than list those I’ve already touched on, dwelling more on links that might be overlooked.
Poverty is clearly the root cause of children’s poor health. 60% of Timorese live on less than US$0.80 per day. This enduring poverty has a spectrum of causes, many social and political, which must be addressed if wide-spread poor health is ever to be eradicated. Given Timor-Leste’s rapid economic growth from oil revenues, a distressingly small percentage of the national wealth has been trickling down to the destitute. This gross inequity has many causes, not least of which are hegemony and corruption at the national and international level. Cleary, far greater investment in Health and Education is called for. Educational reform is needed that enables people to critically examine the social determinants of health and take collective action to elect representative, forward-looking leaders.
Nutritional education in its current form is not accomplishing what it needs to. This is true at all levels, from university to the mass media to community level. Both methods and content need to be reexamined. A new approach to research (participatory epidemiology) needs to be promoted, with a leading role played by mothers and community health promoters.
Imported Pre-packaged Weaning Foods
There are problem with imported prepackaged weaning foods. Partly as an incentive for them to come to the SISCa gatherings, those mothers whose infants measurably underweight are sometimes given a nutritious weaning food from UNICEF called PlumpyNut. However this incentive may be counterproductive, because rewards those mothers whose babies remain underweight.
However PlumpyNut is often unavailable. So mothers often spend their scare food money on an imported commercial weaning food called SUN, which costs them US$0.50 a package. (Most of the cost of SUN goes into packaging, shipping and promotion,) Since the daily wage only US$0.80 a day, the family’s money soon runs out. So rather than using their limited money to make a low-cost, nutritious weaning food from things like rice, peanuts and cooking oil, mothers typically make a weaning porridge using their home-grown staples: cassava and taro. However these high-fiber tubers are hard for infants to digest. So their bellies fill up with watery, poorly digestible tuber porridges, leaving little room in their stomachs for more nutritious foods (including breast milk, if they are still partially breast feeding.) Thus the babies don’t get enough calories even though their bellies are stuffed full—and they fail to gain weight.
Far more study, with full participation of mothers and PSFs, is needed on the spectrum of interrelated factors that cause the current crisis in underweight children. This needs to be followed by the redesigning of nutritional education so as to better adapt it to this complex local reality.
Lack of Adequate Birth Spacing
Lack of adequate birth spacing also contribute to child (and maternal) malnutrition and death. In the long term Timor’s exceptionally high birth rate –averaging 6 children per couple—jeopardizes the nation’s future food security. (Currently almost 70% of food stuffs are imported, and agricultural objectives are not advancing as quickly as planned.) Equally problematic in the short term, frequent pregnancies and inadequate birth spacing contributes to endemic child undernutrition—in several ways:
When a mother again becomes pregnant soon after giving birth, usually she stops breast feeding. This deprives the earlier infant from breast milk and creates competition for scarce food between the baby and the fetus.
A mother who soon becomes pregnant again doesn’t have enough time to rebuild her blood and her strength. Her next baby is more likely to be born premature and underweight.
A mother who is debilitated by frequent childbirth has a harder time providing for both small children at a same time—and both are more likely to become undernourished.
Frequent pregnancies and large family size have different causes. I was told that Timorese men want lots of children “to prove their manhood.” A more common reason in many countries is economic necessity. For a poor family with little social welfare, having lots of children provides a source of low-cost labor and a greater chance that in later life some of the children will help care for their ailing, aging parents.
Also contributing to the high birth rate is the attitude of the Church. Timor-Leste is 95% Catholic, and the Church forbids reliable contraceptives.
Low Rates of Vaccination
Low rates of vaccination also contribute to children’s undernutrition and death. When a child falls ill with measles or another preventable disease, he or she often looses weight. And those who are already malnourished are at higher risk. In Timor immunization coverage is dangerously low. In part this due to the long distances mothers must go to SISCa centers for vaccination. But in part it is due, once again, to objection by the Church. A bishop in East Timor apparently got upset when he learned that women were routinely injected during pregnancy. Though the vaccine was to prevent neonatal tetanus, the prelate evidently thought the injections were to abort or sterilize the fetus. So he launched a campaign of fear, saying all vaccines are harmful. As a result, so many families refuse immunization that recently there was an epidemic of measles in Timor. And because so many are malnourished, the death rate from pneumonia as a complication of measles was unusually high.
HIV-AIDS, while still not prevalent in Timor, is on the rise and likely to become yet another cause of family distress affecting nutritional status and survival of children. In Timor-Leste more women have AIDS than do men. Tuberculosis is already pandemic, and if AIDS escalates, so will TB. Drug-resistant TB is dangerously on the rise.
The Church is accelerating the spread of AIDS through its prohibition of condom use—which likewise diminishes birth spacing, thus compromising the health and nutritional status of both mothers and children.
The good news is that in Timor there are some progressive Catholics groups—such as Maryknoll Sisters—who advocate vaccination and health-protecting use of condoms, and who valiantly defend the rights of the poor. But they are a small minority.
Unrealistic Restrictions on Family Health Promoters (PSFs)
There are unrealistic restrictions on what Family Health Promoters (PSFs) are taught and permitted to do. They could do more. Given the fact that most of Timor’s population lives in aldeas far from health centers with doctors or nurses, it could save lives to capacitate PSFs to provide a broad range of basic health services in their communities. Such responsibilities might well include:
Growth monitoring using homemade scales, including appropriate follow-up for underweight or sick children.
Participation in community-based research (participatory epidemiology) to learn more about the causes of child undernutrition and design appropriate courses of action.
***Diagnosis and treatment of common health problems—***including use of antibiotics for pneumonia (see below).
Application of vaccines to children and pregnant women at the village level.
Health education that is discovery-based and empowering—including and involving mothers, fathers and school children (Child-to-Child).
Organization of local Health Committees to cooperate in community projects that address specific local health-related needs, and to make necessary demands of the health authorities.
Collaborate with traditional birth attendants and healers, acting as a liaison between these persons and the health system.
Failure to Officially Recognize Traditional Birth Attendanrs (TBAs)
Another big obstacle to mother and child health in Timor-Leste is the Health Ministry’s unwillingness to recognize or work with Traditional Birth Attendants (TBAs). A graph published by the Health Ministry shows that about 20% of babies are delivered by health professionals in hospitals; nearly 30% are delivered by trained midwives (educated women officially trained in childbirth); and half of all babies are delivered by “other.” “Other” refers mostly to traditional birth attendants, who do deliveries in homes and whom most mothers (including city dwellers) prefer. However the graph doesn’t refer to them as TBAs because they are no longer recognized by the Health Ministry—under orders of the World Health Organization (WHO).
Misguided WHO Mandates
Given that TBAs attend the vast majority of births in the remote areas where the titled midwives almost never go, the fact that WHO counsels the MoH not to work with TBAs is makes little sense. If the MoH could provide basic support, back-up, and sterile birth kits to the TBAs, it could have a significant impact on maternal and child health. And the impact could be even greater if TBAs were encouraged to cooperate with Family Health Promoters in pre- and post natal care, including nutrition and immunization.
In addition to obstructing the Health Ministry’s cooperation with TBAs, the WHO has also mandated the disempowerment of community health workers, limiting them to the subservient role as messengers or lackeys of health professionals. This imperious unwillingness to enable community health workers to treat common illnesses (like pneumonia, where prompt local treatment can be life-saving) verges on genocidal.
Delayed and Inadequate Treatment of Pneumonia
Pneumonia is one of the biggest killers of young children, especially ones who are weak or malnourished. Early diagnosis and treatment of pneumonia with antibiotics greatly reduces mortality. Where antibiotics can only be prescribed or given by health professionals, and health professionals are not readily available because of distance or cost, the death rate from pneumonia is especially high. In such circumstances it has been shown—and documented in Lancet—that when community health workers are enabled to diagnose and treat pneumonia promptly with appropriate an antibiotic like amoxicillin, the death rate can be significantly reduced.
We talked about this with the SHARE team and the PSFs, who were eager to learn how to diagnose and treat pneumonia. Rapid, shallow breathing is a diagnostic sign of pneumonia. We taught the PSFs to time the rate of breathing using a pendulum made of a rock tied to the end of a string. A baby (at rest) who breaths faster than a rock swings on 35 cm.of string (which swings 50 times a minute) probably has pneumonia.
There is a strong argument for having Family Heath Promoters learn to recognize the signs of pneumonia and to treat it at once with antibiotics— rather than delaying treatment by requiring it only be done by an (often very distant) doctor. However the current rules—promoted by WHO—strictly forbid community health workers to use antibiotics.
The PSFs understood the importance of early treatment, and wondered what do. The SHARE staff felt that every effort should be made to change the WHO and MoH guidelines. But everyone realized this was unlikely to happen soon—despite the numerous studies and publications proving the rational.
“Then what can we do?” asked one of the PSFs. “When a child’s life is in danger and you can’t get her to a doctor in time, do we follow the rules and let the child die.”
“Sometimes,” I ventured, “You have to decide between following rules and saving lives.”
VI. Redefining the Balance of Power
If PSFs were empowered to fill a broader, more useful range of responsibilities at the village level, there is likelihood that child and maternal health could significantly improve. And if PSFs learned to take a discovery-based, participatory approach to help people analyze and address the underlying causes of poor health, improvements might be even greater.
It is equally important that the Health Ministry recognize and work with the TVAs (traditional birth attendants), inviting them to play a much stronger role in pre-natal and post-natal care.
But for these things to happen, a radical transformation in the health system (and the overriding power structure) will be needed. Officials will need to be more humble: less in command and more at the service of the people. Likewise the Health Ministry needs to listen more closely to the real needs of the people, and challenge the mandates of WHO that stand in the way of realistic problem-solving.
Revolution of the Conventional ‘Skills Pyramid’
Health in a country or community, and the world as a whole, is largely determined by the distribution of wealth and power. Greater equality leads to a healthier, more cohesive population.
To build a healthier, more egalitarian society, everyone needs to relate to one another as equals. In Health Care, as in other fields, the typical “pyramid of authority” needs to be turned on its side:
In the conventional health-care pyramid, the community is on the bottom, the local health promoter is just above the community, and the doctor is on top.
To gain more equality, this top-down pecking order must change. But we don’t want to turn the pyramid upside down, because we don’t want to see anyone on top of anyone else.
Instead, we need to tip the pyramid on its side. This way everyone is on the same level, as equals. The community comes first. The health promoter is at the service of the community. And the doctor is at the service of both the health promoters and the community: The doctor is ON TAP and not ON TOP.
Health Education for Change
In the chain of causes that leads to given patterns of health, it is important to consider the role of education, whether public schooling or health education in particular. “Education,” for better or for worse, is important for the health of society: The way learning is approached can influence the equality or inequality within a population. Above all, it can influence the balance of power, a fundamental determinant of health.
To build a healthy society the population must be alert to the tendency of leaders—even those they elect—to put their personal ambitions and neuroses before the common good. To build and sustain a just, egalitarian society, the common people need to be watchful and well-informed. They need be able to make their own observations and draw their own conclusions, not simply to obey orders, memorize lessons, and do as they’re told.
Such obedience training of conventional top-down schooling can be an obstacle to health. In countries where wealth and decision-making power are concentrated in the hands of an elite minority (as is the case in most so-called democracies) the school system serves as an instrument of social control. Its aim is to turn young people into complacent adults who embrace the status quo, obey authority, and fit into the social hierarchy as it exists. It aims to create obedient followers, not agents of change.
If a country in transition like Timor-Leste is to build a healthy, equitable, sustainable society free of poverty, it will need to radically transform its approach to education. Teaching will need to focus on helping young people think for themselves, analyze their common needs, and work together to improve the Well-being for All—now and into the future.
With this in mind, in the workshops I led in Timor-Leste, I placed emphasis, not just on the content of health education, but also on the methodology. We spoke of the Brazilian educator, Paulo Freire’s Pedagogy of the Oppressed. In his “awareness-raising” approach (conscientizacao) Freire helped groups of marginalized people critically reflect on their common needs and take collective action to (in Freire’s words) “change the world.” In Latin America Friere’s “education of liberation” methods have been widely adapted to grassroots health promotion—sometimes with revolutionary results.
In the Timor workshops we introduced a number of discovery based “Education for Change” activities and teaching aids developed in Mexico and elsewhere. One highly imaginative PSF, named Julio, was especially talented in making eye-catching educational materials. To teach oral hygiene he’d created a comical Moppet-like head from a coconut, with a huge mouth that opens and closes. To teach the importance of impregnated bed-nets for preventing malaria he made two miniature beds, with dolls in them, one covered with mosquito netting and the other not. Out of old rubber sandals he’d made giant mosquitoes, which viciously attacked the unprotected doll. People with Julio’s rich imagination and creativity can be a valuable resource to a health team. They make learning more fun and thereby more memorable.
While in Dili I had the good fortune to meet Dr. Aida, a courageous Timorese doctor who—despite the WHO mandate—has been working with TBAs in a remote mountainous part of the country. Her TBAs have achieved far better rates of maternal and infant survival than has nation as a whole. Last year Dr. Aida asked the Health Minister to visit her program, and he was so impressed he told her (privately) that her approach should be scaled up to cover the whole of Timor-Leste. However the Health Minister is so intimidated by WHO that he dares not take act on his wish.
In the meanwhile, Dr. Aida won approval of a grant from the Japanese Embassy of one million dollars to expand her TBA program. All she needs to finalize the donation is authorization from the Timorese MoH. But up to now the Health Minister has dragged his heels—fearful of losing WHO support.
One of my delights while in Timor was the opportunity to spend some time with Dr. Dan Murphy, a American doctor who has spent much of his life serving in places where the health needs are huge. I first met Dr. Dan in the 1980s in Delano California, when he was volunteering with the Cesar Chavez and the United Farm Workers. He also spent years in Mozambique soon after its liberation from colonial rule.
For the last 10 years Dr. Dan has worked in Timor-Leste, running a large clinic in a poor section of the capital city of Dili. The clinic has an average of 60 in-patients and with the help of volunteer doctors and students from various countries, Dr. Dan personally attends over 300 out-patients per day—showing heartfelt concern for person! One large ward is full of people with tuberculosis. Dr. Dan makes a great effort to obtain the urgently needed, costly medication for the growing numbers with multiple-resistance TB.
Dr. Dan feels strongly that for Timor-Leste to meet its enormous health needs, much stronger emphasis is needed on community-based approach into which local health promoters, traditional birth attendants, and native healers are fully integrated, with the back-up and respect of the national health system. He cooperates closely with Dr. Aida and others who are pioneering in that direction.
National Seminar in Dili
Toward the end of my stay in Timor, I spent a full day with representatives of the Ministry of Health and the Ministry of Education, in a morning seminar and afternoon workshop. I was extremely fortunate to have Dr. Dan translate my presentations into Tetun—which he wisely did not word for word, but idea for idea. In the afternoon session we involved the audience in using the “gourd baby” in discovery-based learning about dehydration and management of diarrhea. The person in charge of health education nationwide was excited about the concept of “Education for Change.” and spoke with me at lunch about introducing into the schools a discovery-based, learning-by-doing approach to Child-to-Child. He was already familiar with Child-to-Child, but not the empowering methodology used in Latin America.
At the seminar, people from the Ministry of Health also took interest in the possibility of giving a more important role to the Family Health Promoters, and of recognizing and working more closely with Traditional Birth Attendants. Unfortunately no one from WHO was present at the seminar. It is still too early to see in what direction the Health and Education systems will evolve. But at least we triggered a thought-provoking dialog. Most agreed that a lot of rethinking and innovative changes are needed.
VII. East Timor as the Canary in a Mineshaft
In conclusion, I found Timor-Leste’s current struggle for self-determination very moving. As a small island nation that has won its relative independence at a historical time when the future of humanity and life on the planet hangs in balance, I see Timor-Leste like the proverbial canary in the mineshaft. Faced with looming climate change from global warming, the imminent end of its oil reserves, and the island’s unsustainable dependence on imported produce, what happens during the next few years in Timor may foreshadow what may shortly happen globally.
Let us hope the people of Timor don’t just listen to outside development pundits and corporate interests, but find the courage and resolve to collectively build a healthy and sustainable future.
Suggestions for Sustainable Health in Timor-Leste
Work toward an empowered, well-informed, politically alert population that can elect and hold accountable leaders who work toward sustainable health for all.
Transform public education to help children think for themselves, analyze common needs, and work together for the common good.,
Use Discovery-based learning and Child-to-Child “Education for Change” activities to help prepare them as future agents of change.
More Immediate Suggestions
To increase the responsibilities and relevance of the PSFs, prepare and enable them to play a more direct health-promoting role in their communities:
Enable the PSFs to diagnose and treat common health problems such as diarrhea and pneumonia in children.
Teach PSFs to make their own simple beam balances (scales) for weighing U5 children. Then, in their aldeas, have them go to the homes of the mothers who do not take their babies to the SISCa events, weight and measure them, and take appropriate measure to help the underweight or sick babies become healthy.
To do the above successfully, more community-based research is needed to learn why so many children under 5 stop gaining weight when then go onto weaning foods.
To conduct such research NGOs like SHARE—hopefully in cooperation with the health and education ministries—might undertake pilot participatory study projects, finding our precisely who mothers are feeding their weanlings, trouble-shooting the problems/obstacles (at all levels) and experimenting with other, hopefully more optimal, feeding alternatives.
In the SISCa projects and the training of PSFs there seems to be a big gap in their training when it comes to childhood pneumonia—reportedly one of the biggest causes of death in Under-5s. If PSFs could recognize the common signs of pneumonia and see that children get early antibiotic treatment, this single intervention could significantly lower the Under-5s mortality rate.
Try to find ways to gain MoH acceptance, support, and upgrading of skills of TBAs—following the very successful model of Dr Aida. In view of the fact the at least 50% of babies are still delivered, unofficially, by lay midwives, this is imperative. Every effort needs to be made to wake up WHO to this need and stop its “expert” from imposing their mandates on countries w/o fully understanding the local situation.
|Board of Directors|
|International Advisory Board|
|Allison Akana — United States|
|Dwight Clark — Volunteers in Asia|
|David Sanders — South Africa|
|Mira Shiva — India|
|Michael Tan — Philippines|
|María Zúniga — Nicaragua|
|This issue was created by:|
|David Werner — Writing, Photographs, and Drawings|
|Jason Weston — Editing and Layout|