The Age (Melbourne)

December 21, 2002 Saturday

SECTION: Insight; Pg. 5

Healing A Nation's Wounds

Alan Saunder

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.

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 wairung 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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