Potholes, Road blocks and Detours in East Timor and other countries Eric Vreede Anaesthetist and ATLASS Team Leader Melbourne, 21 August 2009 Potholes, road blocks and detours is the perfect analogy describing the nature of working in developing countries. Just as you would carefully negotiate a pothole or any road obstacle, you need to carefully adjust your approach when faced with an obstacle in development. Steamrolling straight over the obstacle will rarely lead to success, rather you step back and re-adjust. After more than 25 years working in developing countries I have made more than my share of mistakes, diplomatic blunders and other stupidities.
Lesson number zero; unpaved roads are often more comfortable to negotiate than paved roads with sharp potholes. One can read this as an analogy for appropriate technology. When driving from Dili, the capital or East Timor, to Suai on the south coast you drive over some good roads over mountains and past rice fields, but you also come across many potholes and collapsed bridges making detours through the river bed necessary.
And when after a 5 hour drive through some stunning landscapes you arrive in Suai, you are happy and want to celebrate your safe arrival with cold beer at the beach. But when you get there you see a crocodile. Recently I have learned that there is a crocodile at the end of the road. The Paradox There is logic, when designing a training of nurse anaesthetists for district hospitals, to say that they will be allowed to deal with ASA 1 and 2 and maybe ASA 3 patients. The course is typically 12 or 18 months and the higher risk patients should be done by better qualified staff. This logic is however, misplaced because of the Paradox which says that the least qualified deal with the highest risk patients. This is the reality in the
districts in most countries (the better qualified doctors will stay in the capital and the larger towns). It is not acceptable to say to the patient sorry, I cannot anaesthetise you for your emergency CS for severe-pre-eclampsia because I have not been trained to do this. If it is not done at the district hospital by the staff available there it may well not be done at all. This paradox is the reality and the training course must reflect this and the course must prepare the trainees for this reality. When I arrived in Dili in 2004 anaesthetists such as Haydn Perndt and Sally Troedel had been trying to set up a basic nurse anaesthetist training in Dili. In spite of several meetings, writing of the syllabus etc. there was resistance to the course and it could not be started. Early 2004 Alan Thompson, the then RACS anaesthetist, realised that something was changing and he decided to try and re-start preparations for the course. Within one week of the arrival of Brian Spain and me, general agreement for a Nurse Anaesthetist training was reached and a few months later the first course started. In hindsight this probably happened because resistance on the part of the Indonesian trained Nurse Anaesthetists decreased; the withdrawal of the UN hospitals in the districts unmasked the total lack of emergency service because thus far the UN had been providing some emergency surgery; and the Paradox had been addressed. Things fall into place when the time is ripe. I have seen this often. This is of course frustrating for the ones who have tried in vain to start a programme, but it is also true that without prior pushing and trials nothing would have come out of it in the end. Trial and error is the norm.
The ATLASS programme has on a number of occasions tried to improve trauma care in Timor. we organised 2 Primary Trauma Care (PTC) courses. However, after the course no noticeable improvement in trauma care occurred. The reason for this was that there had not been any follow-up after the courses to ensure that what had been learned was being put into practice. Increased knowledge was not translated into implementation. Training without follow-up is not capacity building. It does not lead to sustainable change. With this in mind the programme organised another amended trauma course. At the end of the course a long session was held to discuss how better trauma care could realistically be implemented in the hospital. Although this seemed promising, few attended the follow-up meeting and still no improvement could be seen.
Now the MoH and the hospital have come to see improved trauma care as an increasingly important issue and a number of changes have been implemented. In addition the ATLASS programme will post a full time ED physician and all these efforts together may now make sustainable change possible. Again things fall into place when the time is ripe. We are all fluent, unfortunately in different languages We are all fluent, unfortunately in different languages. This is the biggest pothole of them all; it swallows the entire Landcruiser and you cannot crawl out of it nor can you avoid it. In the Dili hospital patient notes are written in 5 languages; Indonesian, English, Portuguese, Spanish and even sometimes you can see Chinese characters. It is a real nightmare to communicate with colleagues. Another problem that arises from the linguistic confusion is that the medical trainees are difficult to place in overseas training posts; their English is often insufficient. Apart from Indonesia all countries in the region are anglophone in medical training; Fiji, PNG, Malaysia, Singapore, Philippines etc. Even though it is so obvious that without a common language communication is very difficult/impossible, our programme and many others seem to continue to underestimate this.
I did my first overseas mission more than 25 years ago in Equatorial Guinea, West Africa, a beautiful country without electricity or running water. After all these years I am still not certain what the aim of the mission was and unfortunately we did not achieve much, but this is another talk altogether. One thing we tried to do was to teach village health workers such as this woman, primary care and to refer to the hospital if necessary. But wait, there was no functioning hospital and as a result the whole system did not function well. Primary Health Care without referral does not work. This was not a popular thought in the days of Primary Health Care, but I mention this because primary maternal care extends into the hospital when blood a transfusion or CS
are needed. And in addition, the WHO has the new safe surgery saves lives initiative. Thus secondary care is back on the agenda which is nice since many of us here today are hospital based specialists. The way to handle all the obstacles is to keep your eye on the ball. As long as you know where you are headed for, it does not matter whether you turn left or right or whatever. The challenge is to know when to push and when to back off or push harder. If you push too hard doors will close, if you push not hard enough nothing will happen. This is not any different from what it is like back home, but the different context makes for an interesting challenge. We have now safely negotiated the obstacles on the road to Suai and it is time for our cold beer on the beach. For me this cold beer of success is my registrar Dr Flavio, who will come back as a specialist anaesthetist in 2 ½ years time form Fiji.
How good can life be; having taken him by the hand for his first anaesthetics, I now have the chance to see him come back as a specialist. This is a unique and satisfying opportunity. How often do you have the chance to complete the loop. Oh, and don t forget the crocodile at the end of the road. Thank you