Imagine for a moment that you are a community health worker in Timor-Leste. You are the sole provider of basic medical services in remote rural villages. Your daily commute is two to three hours – usually on a motorbike over riverbeds and up dirt roads. Your clinic is the porch of the village headman. Your pharmacy is a cabinet stocked with essential medications – or the contents of your backpack. Your formulary is an A4 sheet which pair symptoms to drugs, “cough = amoxicillin”. You mostly work without diagnostic equipment: no stethoscope, no thermometer, no BP set. You have a couple of bandages – but no injectable medicines, no sterile gauze, no sutures, no delivery sets. You’ve completed some secondary school, and have been topped up with several of weeks of basic healthcare training by an international NGO. For the villages that you visit fortnightly, you are the closest (two hours by foot) point of access to conventional healthcare.
These are the daily challenges faced by the community health workers who were the focal point of our three-day training in March 2013. The ongoing “Timor-Leste Healthcare Worker Training Programme,” is a collaborative project by Care Channels Timor-Leste and clinicians from National University Hospital, in partnership with Liquica District Hospital, Timor-Leste. For the first two afternoons, our three volunteer trainers conducted workshops covering use of stethoscopes and BP sets, recognition of respiratory distress in children, and hypertensive emergencies. The 29 participants included 10 community health workers, in addition to nurses, midwives, doctors and medical students posted in the district hospital. The third day, we accompanied some of the participants in a primary health outreach in a mountain village.
Scarcity confronted us repeatedly during this trip – scarcity of time, training, manpower, money, food and empathy. The formal healthcare system lacks core resources – the hospital ambulance was out of action for want of diesel, the emergency room was depleted of IV infusions sets (!), and the health workers were routinely called upon to manage problems beyond their clinical expertise. The perennial challenge is to do one’s best with what is available, to maximize performance given severe constraints.
The donated stethoscopes and BP sets were glamorous, but arguably more useful were simple watches. They permitted training in identifying tachypnoea (fast breathing) – the most sensitive sign of lung infections in children. Videos of chest retractions and nasal flaring were crowd-pleasers, as were a series of audience quizzes using coloured flashcards to reinforce mastery of the limits of normal blood pressure.
On our journey home, our interpreter excitedly related to me that soon after completion of our workshops, a child in significant respiratory distress had been brought to the district hospital: “Your students recognized his retractions and fast breathing!” and the patient was appropriately transferred to the national hospital for care. It was an encouraging sign – God in his grace does use us to empower the Timorese health workers to better confront their enormous daily challenges.
By Dr. Lydia Wong