Subject: ApT: Health in East Timor
Date: Sat, 17 Apr 1999 08:33:37 -0400
From: Bruno Kahn <kahn@math.jussieu.fr>[This is the translation of an article
appearing in the April issue of the Agir pour Timor bulletin. This article was written
before the latest events.]
HEALTH IN EAST TIMOR
In its rhetoric aiming to justify the annexation of East Timor, the Indonesian
government has constantly claimed to contribute to the development of the territory and
has argued that it builds hospitals, schools, roads and administrative buildings.
What assessment can be made of public health in East Timor today?
Such an assessment is difficult given the incompleteness of available data. We used
statistics published every year by the Indonesian Health Ministry, but the figures given
are sometimes totally incoherent and it seems, in view of other information, that their
presentation plays down the seriousness of the situation.
We therefore also used testimonies of East Timorese as well as "tourists" and
voluntary aides who have been able to assess health and medical conditions on the spot.
ORGANISATION OF THE HEALTH SYSTEM
The health system in East Timor is administered by a provincial director of the
ministerial Health Department. According to reports of the Indonesian services, medical
care is essentially provided by the 67 puskesmas (popular health dispensary) that exist in
the territory (1 for each subdistrict). East Timor has 10 hospitals, including two
reserved to the military. The only (civilian) hospital worthy of the name is that of Dili.
7 other hospitals, with worse equipment, are found in Baucau, Maliana, Viqueque, Ainaro,
Suai, Oecussi and Los Palos.
Official statistics claim 1,355 nurses and 155 doctors for a population of about
800,000 inhabitants. In fact, the staff available to civilians and especially the rural
population is much smaller.
Each puskesmas is in principle run by a doctor and a team of nurses. Its main activity
consists in handling minor urgencies, births, infections and benign diseases. It also
practices preventive medicine: vaccination, family planning. Puskesmas often lack
resources, both material and human. Medicine is often lacking or is diverted by a corrupt
administration.
Besides the institutions handled by the government, the local catholic church has
created about 20 clinics in the territory, administered by members of religious orders,
with some formation to medical practice. Their work consists in curing the various
diseases affecting the population: tuberculosis, malaria, diarrhoea, pneumony, skin
diseases, respiratory infections... the list is long. Tuberculosis is presented by the
Indonesian government as the highest cause of death in East Timor. Its development has
been largely favoured by the camps set-up at the end of the seventies and in the eighties,
where starvation and terrible hygiene conditions were rife. The government, like the
catholic institutions, have set up treatment programmes for tuberculosis, but it still
affects many East Timorese.
MALNUTRITION
The various diseases strike the population all the more that it is undernourished.
Although government reports totally ignore this phenomenon, all visitors mention a visible
malnutrition in the whole territory. This state of food insecurity is directly related to
the political situation. The years of war and occupation have led to an ecological
disaster. Bombings and massive deforestation have considerably reduced the size of arable
land and greatly fragilised the soils.
Until the invasion, East Timor's agriculture made it self-sufficient in food. The
restrictions imposed by the military on the population (restricted cultivation areas, the
obligation to use Indonesian methods of production, work under constant surveilance by the
military) have significantly reduced the agricultural production. Rice, an important food
for the population, is mostly imported from the other Indonesian islands.
According to a 1996 UN report, infant mortality is 135 per thousand in East Timor and
life expectancy is 46 for men, 48 for women. The state of health of the population is much
lower than that of the inhabitants of Indonesia.
FAILURE OF THE PUBLIC HEALTH POLICY
The population has a deep distrust of the doctors working in the puskesmas. The 183
family planning centres present in the territory have set up a coercive birth control.
Many East Timorese women have testified of forced sterilisations to which they had been
subjected in hospitals or during an operation or a delivery. Besides, young girls are
given by the military, most often unknowingly, contraceptives in the form of injections.
The assissinations that took place in the Dili hospital after the Santa Cruz massacre also
explain the reluctance of the population to set foot in government institutions. East
Timorese by far prefer to go to the catholic health centres. Although they sometimes get
medecine from abroad, the catholic institutions also lack resources.
Besides, the doctors who practice in puskesmas, most of them Indonesian, are generally
medical students, having just graduated or coming to East Timor to do their internship.
They have little experience and work not under the supervision of medical doctors, but
rather under military control. As they don't know the East Timorese language or culture,
communication with patients is difficult and doctors often have little motivation for
their work.
Finally, the East Timorese population is ill-informed of the various diseases and
prevention: as they don't know how to recognise the symptoms of a given disease, the
inhabitants often wait until it is in an advanced stage to go see a doctor, who sometimes
cannot do anything to stop it anymore. This only worsens the bad reputation that
Indonesian doctors already have.
AN EMERGENCY SITUATION
Recently, the medical situation has got even worse. Facing attacks led by
pro-Indonesian militias, many people have fled their villages to take refuge in mountains,
churches and schools, and lack all means of existence. The population faces a food
shortage. Following the statements of Habibie on a possible independence of the territory,
many shopkeepers, most of them Indonesian or Chinese, have left the country. Many
informations also point to requisitions of rice stocks in stores by the army. Doctors and
teachers have left the territory en masse, encouraged by the government.
According to an American doctor working in a catholic clinic, between 50 and 100 people
die each day of perfectly curable diseases, especially tuberculosis, and 44% of the
children under 5 are malnourished. Hospitals are all but at a standstill.
The Indonesian government denies all statements on a systematic exodus of the medical
personnel. The reason seems to be that it does not want to see international humanitarian
aid, hence an important foreign presence, arrive in East Timor. Stocks of medicine sent by
Medecins sans Frontieres have been blocked in Jakarta for weeks and the government just
refused the arrival of an Australian surgical team, although there has been no surgeon in
the territory for almost a year.
Besides, several informations mention intimidations by the military of the medical
personnel still present, preventing them to do their work. This could be related to
attempts by the army to replace medical teams and other professional groups like teachers
by military personnel, in order to destabilise the situation even more as a vote on the
future of the territory gets nearer.
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