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

Balibo, Timor-Leste

13th September 2015

We have spent the day in Balibo, a place of significance to Australians, where five journalists and cameramen, who were reporting on the then rumoured impending Indonesian invasion, were killed by Indonesian special forces in October 1975.  Balibo itself is a small village nestled into the hills, very close to the Indonesian border.  It is fairly typical of a Timorese village with a market place, small school and grassy oval and has a few magnificent Banyan trees close to the main road.  It would all be fairly inconspicuous if it were not for the rejuvenation of the small house that the journalists sheltered in before they were killed.  The Australian flag and “Australia” was symbolically painted on the side of the building by one of the men, Greg Shackleton, in a desperate attempt to display their neutral and journalistic intentions.  This small house, known as the Balibo Flag House, has become a poignant shrine of remembrance to these men as well as the hundreds and thousands of East Timorese who lost their life during the Indonesian occupation.

The Balibo Five as they are known have been the subject of continuous inquiry surrounding the unknown nature of their death and handling of their bodies.  Tireless campaigns from family members and supporters saw a coronial inquest opened in 2007 in NSW, Australia, which found they were deliberately murdered by Indonesian special forces.  However no-one has ever been charged for their deaths.  There has also been multiple books written on the subject, particularly by journalist Jill Jolifee, whose book was the basis of the movie Balibo.

Recently in Balibo, the old Portuguese Fort has been renovated into a beautiful hotel.  Situated on top of the hill, just off the main street, it has been tastefully restored into 8 rooms of accommodation and the main building, a lovely dining room and kitchen.  Di Za, of Dili fame, runs the restaurant with tables on the old verandah as well as out in the garden with beautiful 180 degree views over town, the hills and down to the coast.  We saw a strikingly coloured kingfisher sunning itself in the long grass beyond the forts walls.  The old canon was of much interest to my children as was the great climbing trees (fairly sure they were not put their for that purpose!) in the garden.  

After visiting the Balibo flag house and having a short walk around Balibo and the fort, we had a lovely morning tea out in the garden and enjoyed the still cool breezes before setting off down the hill to the border town of Batugade and then on to Dili.  The coast road is very easy (comparatively to the rest of Timor-Leste) driving.  Once down the hill, the road is still gravel but well graded and fewer potholes and obstacles than many other roads I had been on.  Approximately half way back to Dili is the town of Maubara which has a lovely beach, drink stop and market.  There is also an old 17th century Dutch fort here but it was not open when we passed through.  The market with the basket weavers is definitely worth a look to support the local women who sell their creations here.   The road at times is fantastic, new bitumen and lane markings and heading up high into the rocky coast.  There are shrines and crosses at every corner and the views are definitely worth stopping for albeit with a degree of caution with the steep edges.  We then pass over the Loes river, with a long bridge and then onward back to Dili.  The road from Liquicia is still under construction so paradoxically this section is one of the longest of the day.  All in all, a wonderful way to spend a long weekend and we definitely feel rejuvenated, and inspired to see more of the country, even after a short time out of the heat and dust of Dili.  

Balibo Flag House, Balibo

Balibo Flag House, Balibo

Balibo Town, looking South-West from the old Fort

The Balibo Fort Hotel

Playing on the stairs leading up to the Balibo Fort Hotel

Local girls filling up their water containers, Balibo, Timor-Leste

The coast road heading East back to Dili, Timor-Leste

Basket weavers, Maubara, Timor-Leste

Atsabe, Timor-Leste

12th September 2015

Interesting clinical cases continue to present to the National Eye Centre.  We have a case of presumed severe cicatrices conjunctivitis secondary to TB.  Unfortunately TB is endemic in Timor-Leste.  The National Hospital is lucky however to have the new Xpert MTB/RIF machine which is is able to perform PCR on a sputum sample in 2 hours and also determine resistance.  This is vital to enable rapid diagnosis and commencement of tailored drug therapy thereby avoiding both the spread of disease as well as multidrug resistance TB strains.  In Timor-Leste traditional testing such as a mantoux (skin prick test) is expensive and difficult to interpret. Chest XRAYs are readily available but are often inconclusive and must be interpreted in the clinical context e.g. in conjunction with the patients symptoms and signs.  

We have been lucky to hire a ‘proper’ 4WD to take a weekend trip through the Ermera and Bobonaro districts which is the regions South-West of Dili heading towards the border with Indonesia.   People have been recommending the rough trip through Gleno, Ermera, Letefoho, Bobanaro and then on to the market town of Maliana.  From Maliana, a loop can be taken back through Balibo and then the easy coastal road back to Dili.  

It is a little daunting setting off with two small children but I am very much looking forward to getting out of Dili.  Obviously we need to make sure we are self sufficient for 3 days including drinking water, food and money - in case of breakdown or emergency.  After ~ 10-15km along the coast heading East, the road then head almost due south and begins to climb immediately.  The road is initially bitumen but then turns to a graded but rough track.  Ermera and Letefoho townships are situated in the heart of one of the major coffee growing districts of Timor-Leste and indeed in both towns there is evidence of coffee production with drying of beans and bags of coffee.  The drive up to Letefoho is a bumpy and steep 2 hour drive from Ermera but is well worth the effort.  Situated at the top of a ridge I can appreciate the mountainous surroundings from where were have come from and also where we are heading down to the South as well as the steep peak of Mt Ramelau off to the East .  It is completely stunning scenery and at times very hard to determine where you are.  

The road then continues along a very bumpy track towards Atsabe.  There are lovely waterfalls in this area but given we are in peak dry season they do not have a large volume of flow at present.  Astable is a picturesque town on the side of a hill and I am surprised by the, larger than expected, population density.  I never feel as though we are in the middle of no where although people living in these areas, without reasonable access to private vehicles or public transport system, are still incredible isolated.   Everyone is exceedingly friendly and we have to stop many times to ensure that we take the correct ‘fork’ in the road.  The road to Bobanoro is very beautiful with tall peaks, rocky outcrops and vegetation in hues of green and yellow which is a contrasting relief from the heat and dust of Dili.  The track at times is only the two tyre widths and I am sure we got lost trying to direct ourselves to Bobanaro.  We have managed to get this far in good time without rushing however we are quite conscious of needing to find accommodation for the night and get our children fed.  They have been incredibly easy to travel with, I am always astounded how adaptable little children can be.  They enjoy spotting pigs, chickens, goats and cows and of course waving at everyone going past.  

We eventually head over the last pass and down into Maliana.  We have been told not to expect too much from the Pousada Maliana which unfortunately has seen better days.  The grounds are beautiful though and there are grand fig trees slowly reclaiming the site.  Rooms are incredibly basic but there is a toilet as well as a bath to give the children a quick wash.  We head down into Maliana to have the staple dinner of Nasi Goreng which was surprisingly delicious and we managed to have a quick walk around the market while we were waiting for our food.  We all slept well despite sharing a shaggy mattress with the kids and had fried eggs and bread rolls that seems to be the standard breakfast at accommodation in Timor-Leste.   We head off early to Balibo, keen to explore the town as well as the new hotel which has been developed from an old fort. 

Severe Ocular Cicatricial Conjunctivitis presumed secondary to TB

Letefoho

Coffee - one of the major agricultural economies in the districts

The hills around Atsabe

Small cemetery in Atsabe

My young daughters pictorial representation of our day's driving!

Market Day in Maliana

Oecussi, Timor-Leste

28th August 2016

We are continuing our outreach visit to Oecussi.  The screening team have done an excellent job in coordinating patients to come for surgery from the local villages.  The  patients are driven down in the outreach 4WDs, given meals, have their surgery and then stay the night for their review the following day before being taken home.  We manage approximately 20-30 cataract patients a day between two operating tables.  These patients are truly suffering from reversible blindness from cataract and often literally stumbling into the operating theatre due to their poor vision.  As a comparison of the impact of cataracts between the developing world and developed world, in countries such as Timor-Leste cataract extraction is normally indicated when visual acuity is worse than 6/60 where as is in countries like Australia, indication for surgery if often 6/12.  

While there are few studies on the prevalence of adult cataract in Timor-Leste.  Studies from Asia and South-East Asia estimate the rate of reversible blindness in adults from cataracts to be as high as 40%.  Major efforts have been made over the last 25 years to reduce and eliminate avoid blindness globally and this reflects the efforts of the World Health Organisation (WHO) and International Agency for the Prevention of Blindness (IAPB).  Blindness from cataract impacts significantly on individuals in terms of their daily activities such as cooking, toileting, employment and helping care for younger family members.  It also of course directly and indirectly impacts on the social and economic development of families and communities as a whole and therefore restoring sight through cataract surgery can be a small part in assisting developing countries overcome the significant hurdles to development .

While the outreach teams aim to be self-sufficient in terms of resources needed to perform cataract surgery, sometimes we have to be improvise with makeshift operating tables and operating chairs.  One of the operating tables is a desk with a mattress on it and the team is very creative in making do with limited resources.  A head ring is fashioned from a tightly bound patient gown with tape wrapped around it.  There is no anaesthetist but rather the peribulbar blocks are performed by the outreach team - either the Doctors or Nurses.  Patients are brought into surgery, have their biometry (measurements to ensure we place the correct power lens for their eye), receive their peribulbar block and then proceed to surgery.  The patients are remarkably stoic in what must seem a completely alien environment for them.   The following day patients are brought down from their accommodation, their eye pad removed, visual acuity checked and then a review on the slit lamp by the Doctors.  Patient are given their free drops and sunglasses and given an education session regarding drops installation and follow up by the outreach team.  Some are booked for second eye surgery if we have time although the priority is always first eyes in patients with very poor vision.  Most are told to represent the following year to get their second eye done if they wish.  

Oecussi town or Pantemkaser is a completely gorgeous laid-back oasis.  Large tree lined streets with little traffic, all surrounded by beautiful beaches.  An enormous about of infrastructure work is being done in Oecussi at present and we will routinely walk up to the hospital in the morning, only to find the road ripped up, ready to be resurfaced in the afternoon.  After work one afternoon we travelled up to the old fort sitting above town and were serenaded by a group of children.  As always, the old forts always have a lovely high vantage and the road up, while only short, is quite precipitous.   I have also managed to get a run in although I only ran west from town, which is pretty flat and boring albeit for the multitude of ‘Botardes’ I receive along the way.    On the last night we had a dinner with all the staff from the outreach team and those local staff who were assisting us.  They hotel we are staying at has done a remarkable job with a full spread of fish, beef, goat and vegetable dishes.   On the final day we see post op patients and then pack the theatre up and outreach cars ready for the trip home.  It will be nice to get home to my own bed after playing musical rooms at the hotel for the last 4 nights. 

References:

Chua J and Cheng C. Visually significant cataract: a global challenge.  Clinical and Experimental Ophthalmology 2016; 85-86

Pre-operative Peribulbar Block

Our home made head-ring

Patients walking to their post-operative assessment

Post-operative Education

Children at the local fort in Oecussi Town

A very wide running track - heading west from Oecussi Town

Our goodbye feast

Oecussi, Timor-Leste

24th August 2015

We are in Oecussi this week for an outreach surgical visit through the Royal Australasian College of Surgery (RACS).  The Oecussi enclave is a small area of land officially surrounded by Indonesia in West Timor.  It home to the local Dawan people but was settled by Dominican brothers in the 16th century, and later the Portuguese, for which it was the first permanent settlement in TImor.  It’s current border is a legacy from division between the Dutch and Portuguese colonies very early in the 1900’s.  In the past it has been notoriously difficult to reach, either with an overnight ferry from Dili or a pretty bumpy 12+ hour drive from Dili.  Thankfully we are going on a chartered Mission Aviation Fellowship (MAF) flight leaving from Dili airport.  With all the team and equipment we are on 4 separate flights.  Its a stunning flight West along the coast with the blue and greens of the waters and reefs contrasting with the browns and khaki of the coastline.  It also gives me a chance to appreciate some of the remoteness of the hilltop villages in Timor-Leste and Indonesia which are literally perched along the ridge line of some very precipitous mountain ranges.

The scenery changes quite significantly once we reach Oecussi, steep brown mountains arising almost straight from the coast.  The major town town in Oecussi is called Pantemakassar and is a small settlement between the coast the the mountains.  The landing strip is a gravel stip and I notice some goats up the far Western end.  The landing was surprisingly smooth and is didn’t take long to unpack the remainder of the gear and get settled in the ‘qantas club” - a tin shed to await the pick-up.  No drinks here.  

The outreach team is a well oiled machine with very regular outreach visits all through the year.  Generally a 4WD goes ahead with the larger equipment such as the portable microscope, operating tables and chairs and sets up the OT and commences screening of patients.  This is in conjunction with the local eye technician, who has been trained with he National Eye Centre, who is permanently based at a particularly hospital in the districts.  This person provides a very important link with the other local health staff, hospital administration and of course patients and surrounding communities.   I think that they do a phenomenal job with limited resources and I am always very impressed by their referrals and communication to and with the National Eye Centre.

The Oecussi hospital is a relatively new hospital and I was told it was based on a similar design to Broome Hospital in Western Australia.  It certainly feels like some of the regional hospital in Australia with the low set design, wide verandahs and corrugated iron roof.   We have to be mindful of local theatre limitations as well as their need to continue to provide their regular surgical and anaesthetic service.  The eye team needs to take over a whole theatre for the entire week as well as utilising local staff and equipment.  We hope to do approximately 60-80 cataracts in the week and it looks as though the screening team have done an excellent job in reviewing and advising patients for surgery.  

Flying into Pantemakassar, Oecussi

The landing strip and MAF plane

Oecussi Hospital

Taibesse, Timor-Leste

1st August 2015

I have found a beautiful house to rent, which is in the suburb of Taibesse.  It is within 2 km of the hospital heading south towards the hills.  It is one of a few houses in a Timorese family compound and has the most beautiful tropical garden which I know my kids will love.  It is only two bedrooms but has a day bed in the lounge which I will be able to sleep on when my mum is here.  My street is well known for its stretch of Banyan trees which give it a lovely tropical Asian feel.  I did not realise that the Banyan trees are actually fig trees and found all throughout Asia, the Pacific and even parts of Australia.  They have a characteristic aerial root system that become very thick and woody and trunk like.   There is also a Futsal pitch and football field (not much grass) across the road so on the weekends there is often an epic amount of people and cheering due to a local match.

I have started to walk to work along the canal which is very pleasant for about one km of it due to the lack of traffic.  Its lovely to walk down the road and be greeted with Bon dia in the morning and Botarde in the afternoon, its definitely something we don’t do in Australia.  Given that the large fresh food markets are just up the road in Taibesse, I am usually walking behind the local vendors that sell from door to door.  I am starting to recognise the same vendors, often with a huge array of local green vegetable and herbs.  Sometimes it is live chickens, sometimes fish including large and colourful coral trout.  Fair to say on these days I walk a little further behind them to avoid the smell. 

I continue to see interesting cases at work.  As expected in a tropical country, microbial keratitis (corneal infection) is very common and unfortunately often leads to irreversible vision loss and even blindness.  The burden of disease is exacerbated by multiple factors in Timor-Leste, many which are common to many resource poor environments.  These include delayed presentation, lack of adequate primary care and early referral systems as well as limitations in diagnostic services and access to topical antibiotics.   Additionally, a lot of our patients have come from the districts, or rural areas, of Timor-Leste and have often acquired the infection through trauma, particularly agricultural based trauma which in itself puts them at a higher risk of atypical infections such as fungal and amoebic infections.  Unfortunately we do not have access to a pathology service or the agents to do our own microscopic examination of corneal scrapes; essentially where we take a sample of the cells of the cornea and attempt to isolate the particularly bug.  This normally helps immensely with streamlining treatment and is the mainstay of diagnosis in the health services that I have worked in previously.  Unfortunately I have seen quite a few patients with severe microbial keratitis, both adults and children, who have gone blind from perforations or  large corneal scars.  Services such as acute corneal transplantation are not available in Timor-Leste.

On the weekends I have found a local coffee shop; Letefoho Specialty Coffee Roaster, down on Beach Rd, in the Hotel Royal Beach Building.  It is a little way from my house but definitely worth the drive.  The staff are super friendly and make a good range of strong (just the way I like it) espresso style coffee. I could easily while away an hour or two getting thoroughly caffeinated and eyeing off some Banana or Sweet Potato bread.  

Banyan Tree, Taibesse, Dili

Soccer pitch opposite my house in Taibesse

My local fish vendor

Severe microbial keratitis (staining yellow with fluorescein), unfortunately very common in Timor-Leste 

The wonderful, friendly staff at Letefoho Specialty Coffee Roasters, Dili, Timor-Leste