2/1/2010

So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.

As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.

Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.

Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.

Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.

So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)

While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.

With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J

I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.