Jessica Waters
Cmiel reflection
When I first began researching possibilities for a clinical global health elective during the summer following my first year of medical school, I did not know very much about what would become my host-country, East Timor. This is not surprising, as prior to this year, I would not have been able to pick it out on a map. I relied heavily on sources like the CIA world Fact Book, which told me that women in East Timor give have, on average, around six children, and that the median age for both men and women is 19 – a young population that reflects both the high birth rate and the Indonesian occupation that wiped out nearly an entire generation of Timorese. Due the high neonatal mortality rate in Timor and the prevalence of lay midwives as birth attendants, my classmate Amelia Hurst and I initially designed a project that would allow us to see if neonatal resuscitation training was provided to these midwives. The BairoPite Clinic, where we would be working for the summer, seemed like an ideal place to conduct such a project, as professional midwives staffed the maternity ward and conducted periodic training for lay community midwives that would remain in more rural villages. It did not take much time for us to realize that our project, while not ill-conceived, was perhaps a bit ambitious.
The BairoPite Clinic is a 45 bed outpatient and inpatient clinic that was founded by Dr. Dan Murphy 17 years ago, in the midst of the fallout from the Indonesian occupation.
A typical day at the clinic begins at 8am, when the team gathers at the Maternity ward to begin a walk-through of the inpatient units. After the morning round, everyone gathers to run through the list of patients and to assign the jobs (following up on labs, repeating physical exams, etc.) that have been discussed on the round. Once these are completed, everyone tends to split off to various parts of the clinic depending on interest and patient assignments. The clinic is divided into a number of areas: Maternity, Malnutrition, BTA (TB suspects), SPOT (confirmed TB or TB treatment started), Baixa (general inpatient), and the treatment room.
When Amelia and I first arrived, our intention was to spend most of our time in the maternity ward. However, a week after our arrival, I was assigned to the treatment room, which was being very efficiently managed by a volunteering Australian emergency medicinedoctor. Ultimately, this provided an ideal learning environment, one in which I would end up staying for the duration of my time at the clinic. Under the tutelage of the inpatient doctors, I was adequately supervised in all things, mentored, and given gradually increasing responsibility as my physical exam skills improved and everything started to ‘click’ with my didactic education.
One of my housemates about a month in to my time in Timor is an anthropologist who has been studying the country for years. Something that he said to me over dinner one night regarding healthcare is something that I wish that I had known from the beginning. Ancestor worship is prevalent in Timor, and everything that happens in your life has a spiritual source. While Timorese have scientific minds and often seek western medical care, it is usually after they have already sought a spiritual remedy from traditional medicine – and even then, because the source of whatever ails them is spiritual at its core, doctors, for all they’re worth, are really only treating the symptoms. To me, it seemed like the equivalent of going to the pharmacy for a cough suppressant after you’ve realized that your cough is viral and antibiotics aren’t going to cure you. After spending a month in the treatment room at BPC, what he told me explained a lot about the point in an illness trajectory at which a patient will actually seek non-traditional medical care (late), as well as compliance (which usually isn’t great).
Because patients seek care at such late stages in their illnesses, the signs that I saw on a daily basis were incredibly pronounced, often textbook. I saw many cases of hepatomegaly and splenomegaly; TB in its myriad forms; listened to lung creps, crackles, rales, bronchial breath sounds, pleural rubs; heard diastolic and systolic murmurs and felt palpable thrills, and found a pleural effusion almost every day (TB, usually…it’s always TB). I saw a six-year-old with a case of neurocystercircosis and swabbed a Buruli ulcer.
I obtained an incredible learning experience thanks to the BPC’s staffing physicians and their willingness to both come and practice in an incredibly stressful environment and to teach at the same time. While the experience become more clinically oriented than research, Amelia and I were still able to gather data to investigate monthly trends in birth weight, and to match this data with the government of East Timor’s seasonal malnutrition data. We hope to provide information to the BairoPite Clinic regarding these trends so that it might help them provide effective prenatal care and counseling to their patients.
Picture 1: A traditional home in the mountains
Picture 2: A man selling mandarins on the beach