Dili, Timor-Leste

14th December 2015

I have decided to treat my mum and dad to a weekend at the Balibo fort hotel for our last weekend in Timor-Leste, in part to say thank-you for helping me during my time in Timor-LEste.  I would not have been able to make it work as well without their support.  I have previously written a little on Balibo but I hadn’t yet had a chance to stay at the fort hotel.  We spent a very relaxing and peaceful two days and one night there and it was a magical 4-5 degrees cooler than Dili as its prominent site on the hill ensure thats it catches all the breeze.  Watching the sun set over the hills with a drink in hand was spectacular.  The rooms at the fort are tasteful done with an enormous comfortable bed which was certainly the most comfortable bed I have slept on in Timor-Leste.  The kids enjoyed running around and exploring the gardens in the fort and again climbing all over the old canons.  The fort hotel also thoughtfully provides up to date magazine, a range of DVD’s as well as games such as boule for guests.  I would thoroughly recommend it to anyone who has a weekend spare in Dili.

Back in Dili for the remainder of the week and we all have mixed emotions about going home.  We have certainly enjoyed Dili’s little charms; our beautiful tropical house and garden, endless games of hide and seek and exploring the markets and backstreets around Taibesse and beyond and our Sunday morning ritual of a run around Horta loop followed by breakfast and coffee on the beach. I have met so many wonderful, interesting and inspiring people in my short six months and my kids have made some wonderful new friends.  We will also miss our beautiful housekeeper Lucia who is so gentle and kind and patient!  We wish you could come home with us.

From a professional point of view I will miss my work colleagues and in particular working with the registrars on a daily basis.  Many of the patients are also unforgettable.  Having an eye operation must be such a foreign concept to such a lot of our patients that the level of trust that they place in the medical and other staff is truly incredible.  To lie on the operating theatre, have someone stick a large needle around their eye, get a drape placed over their mouth and nose and then lie there why some malae doctor talks while performing surgery on their eye must at times be truly terrifying for many of them.  Their stoicism, and in fact, bravery inspires me every day.  Doing my fellowship with the East Timor Eye Program is certainly a different path to one that most of my colleagues are doing but I gained so much more than just ophthalmology experience, I hope that this will set in motion a lifelong association with Timor-Leste and that we will be back soon. 

My generous farewell from the staff at the National Eye Centre

Reviewing patients in the clinic

Delicious local plums  - too easy to eat by the bagful!!

Timorese man, taken in Hatobuilico, 2005

Dili, Timor-Leste

3rd December 2015

I couldn’t write about my short time in Timor-Leste and in particular Dili without mentioning the Taxi’s.  At times I have relied on them for transport e.g. when the car was at the mechanics or getting to and from the airport.  They are apparently all old taxis from Singapore and the degree of ‘bling’ in them is truly inspirational!  Often they have an extremely dark tint all over the front windscreen with a small clear sliver at the bottom requiring the driver to be slumped down in the seat to be able to see anything (eg the road!).  The dashboard is inevitably covered with soft toys or bright shiny ‘things’.  Unfortunately there is a degree of variability in roadworthiness but on the whole the drivers are helpful and accommodating and I always got to my destination in one piece.

In my last few weeks I have seen two terrible cases, of women in the post partum period, who have what I assume is choroidal infarction from pre-eclampsia and eclampsia respectively (very high blood pressure in pregnancy).  Unfortunately the burden of perinatal morbidity and mortality is still very high in Timor-Leste.  Access to antenatal services is limited in the districts and for a variety of reasons many women receive no antenatal care.   I have never seen this condition in Australia, although it is well described photographed in text books.  Given both patients’ very poor visual acuity e.g. Count Fingers or worse in both eyes, it really is a tragedy.  Visual recovery in uncertain however in the two weeks I was able to follow these women, neither showed any visual improvement despite having delivered and their blood pressure returning to relative normal levels.

On a brighter note, a fairly momentous occasion is occurring at the National Eye Centre in Dili this week.  Fred Hollows NZ, which was instrumental in setting up and maintaining the National Eye Service, have formally handed over the running of the centre to the National hospital and ultimately the ministry of health.  While there have been many speed bumps in the transition process it is ultimately a necessary evolution into a self-managed National Eye Service for Timor-Leste.  Their was an official ‘handing over’ ceremony from Fred Hollows NZ to the ministry of health which was then followed by a big Timorese BBQ (as we say in Australia).  Delicious!

The dashboard of a Dili taxi

Presumed Choroidal Infarction secondary to pregnancy induced Hypertension

Handover from Fred Hollows NZ to Ministry of Health

BBQ time (Timor style)

Dili, Timor-Leste

1st December 2015

This marks our last month in Timor-Leste and the six months have flown by.  The weather is getting hotter but we have had no rain yet.  The kids are enjoying school and have had many playdates and birthday parties to attend.  We seem to spend every weekend down at the beach, often running into many of the families from school - instant playdates!  I’ think I have mentioned that I am a bit wary about swimming given the recent crocodile citing, not very far down the beach.  There was a large crocodile getting fed chickens out the front of the US embassy not long ago. 

 I have been promising my daughter a ride on the big ‘banana float’  (basically a big yellow inflatable pulled along behind a jet ski) which frequents the beach every weekend and we finally went on - much to her delight.  I think she was a tiny bit young as she (and I) was a bit frightened every time the jet ski sped up.  The other kids were a bit older and urging the driver on while I kept yelling slow down.

We have kept on running every Sunday morning despite the heat.  We return from Horta loop looking like beetroots and dripping in sweat.  I do think it is one of the harder regular 10km tracks I have done.   I have also kept up my walks to work every day although I need to take a change of clothes now given it is so hot.   It is 2km one way, thankfully mostly along the ‘canal’ so I have at least half the walk away from the crazy Dili traffic.  I find the walk equal parts ‘therapeutic’ and stressful.  Its nice to say hello to everyone in the morning and recognise the familiar faces along the way.  The school kids are also so divine; happy, smiling and cheeky.  There is also almost always a soccer match underway in the canal in the afternoons which is very entering to watch.  I have had a few stressful moments, mostly the time i was accosted by a group of teenagers with what looked like a dead baby crocodile - harmless but also not very pleasant.   The traffic however is the most stressful part of the walk - particularly trying to cross the roads at the busy intersections.  However, nothing quite as bad as that i experienced in Hyderabad. 

The 'Banana Boat'

Soccer game en route to work

Our beautiful garden

Riding around our compound

Bacau, Timor-Leste

13th November 2015

I write this from the tail end of a week long outreach to Bacau.  Bacau is the second largest city in Timor-Leste and is~ 120km East of Dili although with the state of the road, the drive takes approximately 3 hours.  Some parts of the road are simply about trying to avoid doing a tyre in while avoiding potholes and the sharp edge of the road while other parts are narrow winding paths along steep but coastal scenery.  The contrast of the red, brown soil on the steep cliffs which then descend down to the turquoise water is truly spectacular.  The scattered acacia’s with their white trunks and green foliage is a little reminiscent of North-West Australia. One of the lovely things to do on the way to Bacau is to stop of ‘fish sticks’, local road sides stalls of grilled fish - all on a stick for your eating convenience.  

Bacau is mix of the new town, on top of the hill, and the older town about 2km down the hill.  At times it appears the town is built into a small cliff.  The hospital was a myriad of small pavilions and connected walkways at an elevated but central point in town.  There is a new hospital being built but currently the old one served our outreach team very well.  As like most outreach visits we screened patients early in the morning for surgery that day or later in the week.  Priority is always given to bilaterally blind patients.  Both myself and the head of outreach were surprised by the complexity of cases that presented.   Antidotally, one in two patients had evidence of pseudexofliation.  Usually combined with white or brunescent cataract and small dilating pupil - the triple tyranny of ‘terror’ for any cataract surgery.  We also had multiple patient present with presumed open angle pseudo exfoliation glaucoma, already blind in one eye and very high pressures in the other eye (again, usually with a dense cataract, poorly dilating pupil and some degree of zonular dehiscence).   After battling our way through these cataracts for three days we came to the conclusion that in an ideal world outreach to Bacau should happen twice a year to try and screen and thus treat such patients earlier.  Of course, this would be in an ideal world of endless resources, funding and outreach program.

We also managed to catch up with a paediatric patient known to the eye team in Dili with significant orbital tumour.  In conjunction with the general surgeon we were able to proceed with a diagnostic biopsy in the hope that  we may be able to refer her outside of Timor-Leste for treatment.  

In total we did around 40 cataracts and 3-4 pterygiums.  Given the stuttering delay with theatre and screening of patients earlier in the week we thought this was a reasonable outcome for the visit.  Along with the principle surgeon and myself, one of the Timorese registrars was also operating.  It was very encouraging to see her manage outreach cataract on her own and very encouraging for the future of ophthalmology in Timor.

Operating Theatre Bacau, Timor-Leste

Screening the patients, Bacau Timor-Leste

Scrub bay Bacau Hospital, Timor-Leste

The "Pink Pousada" - our accommodation in Bacau

The Outreach Team

Heading for home, last day Bacau

Surprise passengers in the boot of our car making the trip back to Dili

Ossu, Timor-Leste

2nd November 2015

A long weekend in Timor-Leste to celebrate All Souls day was the perfect opportunity to explore further in Timor-Leste and head for the hills East of Dili.  It was also my Mum’s birthday this weekend and I wanted to thank her in part for living with us in Dili and helping look after my children.  I wouldn’t have been able to do it without her.  

We made our way to Bacau and then the ‘hard to find’ road south to Viqueque.  I alway love getting out of Dili especially into the mountains.  The road South is windy and bumpy but the slower pace ensures you take in the mountains, especially the spectacular vista to Mt Matebian which is the second highest peak in the country.  The road initially passes by rice paddies and small villages before climbing for then next 20-30km.  At the highest point there are glorious, almost semi-alpine views.   The guest house we were staying at is just before Loi Hunu on the bend of the river and is a local venture with a combination of small house rooms and small villas set in a beautiful little valley next to the river.   Even in the dry season there is still a small waterfall and deep pools to swim in and I imagine it would be a sight to see at the height of the ‘wet’. 

The highlight of a stay the region is the hike around “Mundo Perdido”  translated as the lost world.  While I didn’t have the opportunity to do this all day hike as I had my young children with me, my fellow guests returned enthusiastic about the 6-7 hour walk.  We did however have the opportunity to visit the local caves which were used as ‘hideouts’ by the resistance.  A small, steep walk to the entrance of the cave and then a guided tour by the local children was enjoyable, as much for its historical significance as the beauty of the caves.  My children were enamoured with the very small bats that we found in the last chamber as well as the tiny swiftest buzzing around their head.  A small fee goes to the land owner and $5 fee of the guide are all help support the local community.

Driving around the region on the 2nd of November we felt very privileged to see the Timorese people celebrate All Souls day.  Large processions of families with gifts, flowers and candles to celebrate their ancestors at grave sites and cemeteries around the country was a very beautiful thing to witness.  From an outsiders perspective, it seems a beautiful way of grieving for, honouring and celebrating deceased loved ones.  We also visited the brightly coloured Escola do Reino de Venilale in the village of Venilale.  The drive back to Bacau was again slow but we had a lovely pitstop and lunch at the culinary institution that is Restaurant Amelia.  It has an outside courtyard with beautiful big trees and plants and is a nice respite from what can be a long drive back to Dili.

The drive to Bacau from Dili

Driving south of Bacau with view to Mt Matebian

Loi Hunu Guesthouse - heading down to for a swim

Swimming Hole, Loi Hunu

Escola do Reino de Venilale

All Souls Day Venilale, Timor-Leste

Families heading to the cemetery, All Souls Day, Venilale

Dili, Timor-Leste

25th October 2015

A momentous occasion this week with three ophthalmology registrars sitting the Postgraduate Diploma in Ophthalmology (PGDO) for the first time.  These registrars have been training for a minimum of 18 months with no previous ophthalmology training. All three passed so a big congratulations to the next cohort of Timorese ophthalmologists.  The exam ran over two days with external examiners from Australia and was made up of a written component, an OSCE style clinical examination and short answer written question.    Hopefully the will be able to graduate with a PGDO from  the National University of East Timor (UNTL) at the end of the year.  

This week also saw a difficult case load of patients present to the clinic.  We had our second baby under 3 months present with a preseptal abscess requiring surgical drainage.  I can honestly say  have never drained 8mls of pus from an upper lid of a 5kg baby (and perhaps I never will again). Unfortunately the collection re-accumulated and we had to take the child back to theatre to drain the upper and lower lid and leave very small drains in situ (modified from latex gloves that have been rolled up to act as a pseudo drain).  The child proceeded to improve after a week on intravenous antibiotics and one month later at follow up it was difficult to determine which eye had been affected apart from the very small scars.  I am always in awe of the power of antibiotics given the rapidity, severity and potential consequences of periorbital cellulitis in children and infants; never more so than in a country like Timor-Leste.  

I haven’t really written much about eating out in Dili - it is surprisingly good and an unimaginable variety.  Our favourites with the children are Osteria Italiana - homemade Italian mostly pasta and pizza.  This is down on the waterfront and we would probably frequent at least once a week.  The spaghetti bolognese is always a big hit and easily feeds 2 hungry children.   Our children’s other favourite is the Turkish restaurant which is now on the waterfront approximately 2km west of Dili.  The menu is rather limited to kebab, salads and dips but everything is home made and it is a good source of hummus to take home.  The staff are very friendly and alway finish of the meal by giving my kids a Kinder surprise, so of course they alway want to go there.   There is also a variety of Thai, Chinese, Indonesian, Portuguese and Brazilian on offer so there is always plenty of options.  One of my little favourites is the Portuguese Bakery Padaria Brasao - really yummy bread and pastries.  

One of my other favourite things to do in Dili (aside from eating) has been my regular Sunday morning 10km run from Areia Branca up Horta Hill, around back beach and then up and down Christo Rei.  There is a wonderful group of women (and sometimes men) who meet up early to do the walk/run and then have coffee afterwards.  Even starting at 6.15am means that it is still very ‘steamy’ by the time we finish.  I think it is probably one of the hardest 10km circuits I have done but it is certainly one of the most scenic and crossing over Horta Hill down the other side is just a beautiful way to start the morning.

Medical Staff at the National Eye Centre, Dili Timor-Leste

Modified drains, from latex gloves

Dili waterfront, just opposite from Osteria Italiano

Early morning Sunday run, Back Beach, Dili Timor-Leste

Early morning run, no crocodiles to be seen

Atauro Island, Timor-Leste

17th October

The previous three days we were conducting another surgical outreach program, this time on Atauro Island, focusing on refraction, prescribing glasses and treating surgical conditions such as cataract and pterygium.  We were fortunate to have two visiting international faculty however due to unforeseen local political forces we found ourself without any patients to operate on.  This was unfortunate given the remoteness and inaccessibility of medical care to many people on the island, quite simply a trip to Dili for them is not an option for ‘elective’ surgery.  For many people, particularly on the remote West coast of the Island, it is either a 4-6 hour walk to Beloi to then catch a ferry/boat to Dili or a 4 hour boat trip either around the Island to reach Beloi and then find transport into Dili. 

There is a purpose built eye clinic and operating theatre on the Island and it was disappointing to see the under utilisation of these facilities.   We hope that some of these issues will be resolved for next year.   We did manage to do some rudimentary screening at the primary school next door to the eye clinic while we were waiting for patients.  We set up a three step process of cover testing (looking for squints), examining for a red reflex (to identify cataract or other opacities) and examination of eyelids (mostly for trachoma).  We screened 3 classes of approximately 30 children and only found one with a red eye and eyelid changes - probably more indicative of an acute infection rather than trachoma.

 We also managed a trip into the centre of the Island to the village of Macadade, with stunning scenery along the way - again reminding me in part of North West Australia with barren hills dotted with Eucalyptus with beautiful white trunks.  There were small grassfires burning, which as an Australian well educated in bushfire danger, freaked me a little when we drove right through it!   We got some great vistas down to the West coast and beyond to the surrounding Indonesian Islands .  There is a local group trying to establish community garden’s/planting near one of the major villages as malnutrition is reportedly a concern amongst the community with limited access to fresh food, aside from fish.   Earlier in my time in Dili, I had seen a terrible case of Xerophalmia in a very small infant with severe malnutrition/Vitamin A deficiency who was from this area of Atauro Island.  I have never seen a case before and it is due to extreme dryness of the cornea which progresses to thinning of the cornea and in extreme cases corneal scarring, perforation and ultimately blindness.  Unfortunately the poor child had already perforated one cornea and the other was extremely scarred.  Such a terrible start to life. 

After three days, again staying at Barry’s, we headed back to Dili via a very small speed boat this time - while quicker, I certainly was glad we all had life jackets!

Bushfire burning Atauro Island

View towards the West coast of Atauro Island

Screening at the primary school in Beloi, Atauro Island

Schools Out

Talking to locals, Macadade, Atauro Island

Barry's, Atauro Island

Heading home for Dili

Black Rock, Liquica, Timor-Leste

3rd October 2015

Our month of ‘touring’ continues with a trip to the Caimeo Beach at Black Rock at Liquica, approximately 30km West of Dili.  It is a ‘glamping resort’ with permanent tents and camp beds built on the waters edge.  It has a nice little restaurant and is generally a great place for relaxing, enjoying the ocean views and breeze.  On a calm day the ocean is like bathtub but often there is a reasonable shore break which makes it a little tricky for the little kids to enjoy.  Crocodiles are also in the back of my mind although i’m not sure if there have been any recent attacks (but given the recent and regular crocodile sitings on the beaches in Dili - it doesn’t seem an unreasonable anxiety given that Dili is really not that far away by coastline).

Liquica itself it also an interesting place to walk around.  Unfortunately it was one of the towns that was hardest hit by the scorched earth policy of the retreating Indonesian military and ‘militia’ but the town has been largely rebuilt.  There are also some old, but rather dilapilated,  Portuguese administrative buildings which still remain and have been developed into a small heritage trail.   The road to Liquica is currently being re done and as such it is a very slow trip out there at the moment but I imagine it will be a pretty speedy trip in the future.  I certainly felt for one of the registrars who had a period of time doing the daily commute from Liquicia to Dili on a motorbike to get too and from work every day.  

It was world sight day on October 8 2015.  This was an initiative of the Lions Club International Foundation and is now incorporated into VISION 2020 and managed by the IAPB (International Association for the Prevention of Blindness) and the WHO (World Health Organisation).  In Dili, a large tent has been set up in a park down near the waterfront.  There has been speeches by officials as well as skits by a local performing group regarding the prevention of ocular trauma.  The main event of the day is a large screening program by the eye health workers.  Patients have their vision tested, their refraction tested (need for glasses) and then if needed a referral to the National Eye Centre for treatment - usually for cataracts or pterygium.  It is of course a free service to the community and we have a busy upcoming 2 weeks to get through all the extra surgical load.

One of our favourite things to do in Dili, particularly on a Friday night is head down to Areia Branca, the beach down the Eastern end of the harbour, just before Cristo Rei.  There are some great restaurants where you can sit right on the beach and eat dinner as the sun goes down.  Lots of Dili families do the same an often the kids have an instant playdate - climbing trees, running along the beach and playing on the makeshift swings slung up in the nearby trees.  The pizza and pasta from Caz bar are clear favourites with everyone but also the homemade curries and sate are equally nice.  Our ‘go to’ dessert comes in the form of crepes with a variety of toppings such as maple syrup or chocolate sauce.  All in all a fun and social night and the kids sleep of the dead on that particular night. 

World Sight Day (Loron Mundial Matan), National Eye Centre

Screening in Dili, World Sight Day (Loron Mundial Matan)

Black Rock Restaurant, Caimeo Beach

Caimeo Beach

Aipelo Prison, on the way to Liquica

Friday Evening, Areia Branca - awesome tree climbing!

Sunset at Caz Bar Areia Branca

Atauro Island, Timor-Leste

26th September 2015

I am always amazed at the scope of clinical cases that walk into our Eye clinic on a daily basis.  Even relatively routine things like pterygium, which is a growth over the cornea normally caused by exposure to UV light, often take on extra significance in Timor-Leste.  This week a gentleman came down from the districts with both eyes affected by very large pterygia, on both sides of the cornea.  On one eye he only had a very small window of clear cornea from which to see.  As such his visual acuity was worse than 6/60 (20/200) and he had considerable astigmatism (distortion or warping of the shape of the cornea from the pterygia).  I have never seen such extensive pterygia in Australia and I booked him for surgery the next day to at least try and improve his vision in one eye.  As expected the surgery took considerable time and required a very large autoconjunctival graft however thankfully his vision even one day after surgery had considerably improved. 

I have also seen a patient this week with presumed chloroquine induced maculopathy.  Malaria is quite widespread in Timor-Leste outside of Dili, and I was informed by the registrars that many patients self treat themselves with Chloroquine whenever they have a temperature or feel unwell.  This patient was in in their 60’s and had been taking large doses of self prescribed chloroquine, up to 2g/day for many many years.  They had reported that their visual acuity had started to decline in both eyes over the previous 2 years.  Normally in Australia I would confirm diagnosis with electrophysiology testing however this is of course unavailable in Timor-Leste.  While we can never prove definitely that Chloroquine was the cause, we felt that the clinical history of significant longitudinal exposure to chloroquine, in conjunction with the changes seen at the macula, was likely consistent with chlorine toxicity

We are now currently on Atauro Island for the weekend.  Atauro is a small island to the north of Dili, accessible by an hour long fast boat ride or 4 hours on the old ferry (or 2 hours in an outrigger as the last time I did it 10 years ago).  It is a wonderful tourist drawcard for Timor-Leste with world class diving, hiking and a unique cultural experiences and as someone mentioned to me ‘jurassic park’ like - obviously minus the dinosaurs.

While on the Island we stayed at Barry’s - a Timor institution, near the main jetty of Beloi.  Barry runs an eco-resort on the Island with beach bungalows and a central dining room serving 3 local meals a day.  The kids love running around the resort with the other kids and Barry’s kids are very gracious in letting the visiting children play with toys, trampoline and swings.  As my daughter says “we love it here because we can run around without the adults” .

For the adults, there is wonderful snorkelling just off the beach as well as fantastic diving, particularly around the other side of the Island.  Fishing is also a predominant activity on the Island for both locals and tourists, although my husband had no luck on his early morning fishing trip.  The small nearby town of Vila, has some lovely Portuguese style buildings and currently a big draw card is the local NGO called Bonecas de Atauro, which handmake dolls, bags and soft toys and provide employment for local women.  If nothing else, Vila has lovely wide, shady streets on which to walk around and just enjoy the atmosphere.  Again, a lovely relaxing weekend away to escape the heat of Dili.

A very big Pterygium!

Presumed Chloroquine Maculopathy (appearance identical in the other eye)

Dili Harbour, early morning - leaving for Atauro Island

Arriving Beloi, Atauro Island, Timor-Leste

Late afternoon run, Atauro Island.  Looking south back towards Barry's and Beloi village

Hammock love, Barry's Eco Resort, Atauro Island

Bonecas de Atauro - a great gift from Timor-Leste

Inside the Bonecas de Atauro showroom