Women’s Health in East Timor:

by Megan Lavelle
Pacific Vision Contributed Article

Mother and child in a camp for displaced persons. Photo by Megan Lavelle (7/11/2006).

I am excited to have been invited to contribute to this issue of Pacific Vision. I was asked to write a short piece on women’s health in East Timor, and given the crisis of violence that began in May 2006 and the recent round of elections, the topic couldn’t be more germane.

I have been working as a volunteer, on and off, in East Timor since 2004. At that time, I was a graduate student in medical anthropology conducting pilot research. My work originally focused on maternal and child health and nutrition, and I volunteered with HIAM Health 1 , a non-profit and independent Timorese-run health and social services organization. The violent crisis, which erupted in 2006 [see the preceding article, on page 12], was the result of long-standing political and social tensions in the country. This period of time has been incredibly disruptive to people’s daily life, especially in Dili, and has hindered the daily function of many non-government organizations (NGOs).

I returned to Dili in June 2006 as a volunteer in response to the crisis, to support HIAM in its efforts to regain its foothold due to the chaos. Most significantly, however, I’ve been able to observe and to participate in the country’s health promotion efforts; to see the good and the bad, and the challenges that face stakeholders in healthcare. My work has also grown to encompass gang behavior and economic equality.

The recent crisis in Timor Leste has been yet another hit to the young, burgeoning nation. Media reports put the death count at around 20, but those closer to the violence report that 60-80 (possibly 100 2 ) people died in the crisis last year. The violence also drove some 70,000 3 people as IDPs (internally displaced persons) into camps throughout and surrounding Dili. Of course, these condensed clusters of people living in camps are prone to the public health dangers as the risk of cholera, watery diarrhea, increased rates of malaria and tuberculosis infection.

The health outlook for women and children in Timor has remained grim—out of every 1,000 live births, this poor nation sees between 64 4 and 1235 (depending on source) children die before their first birthday, and between 69-91 6 and 183 before their fifth birthday. For those who make it out of childhood, adult life expectancy is about 638 years.

Women’s health services in Timor are tenuous at best. I attended a workshop on cervical cancer in Dili last year. The core theme of the talks was about the preventability of cervical cancer. With regular gynecological checks and a proactive physician ready to deal with any cellular irregularities, no one needs to die from cervical cancer again. There was even a proactive group of young medical professionals signing women up for Pap smears at the main hospital in Dili— a pilot project of their own making. The only downside to the energizing, educational workshop was the stark reality that the hospital could not provide any of the necessary services to treat abnormalities found in the Pap smears.

Text Box:    The team of HIAM Health. The director, Rosaria Martins da Cruz, is pictured on the very front row, second from right. The author of this article is standing, second from right.  An example of this despairing situation can be found in one of the female palliative patients that HIAM Health cared for last year. She had been discharged from the hospital with advanced cervical cancer, a blister packet of Tylenol, and a month’s worth of multi-vitamins. It was thus that she was sent off to her home, several hours from Dili, to die. The stench her body secreted was overpowering. The pain she endured was crippling. The dignity this woman held every time the HIAM staff visited to help care for her was astounding. She was strong. This 30-something mother of 4 was gracious and composed, confined to her woven sleeping platform over a dirt floor, until and despite the inhumanity of her death.

Even relatively healthy women face danger in childbirth, and the maternal mortality rates in East Timor are among the highest in Southeast Asia. The National Strategy for Reproductive Health notes that the estimated maternal mortality rate of 8609 mothers dying for every 100,000 live births can be attributed, partly, to the:

low utilization of skilled assistance for antenatal care, deliver, and postpartum care services (East Timor Health Policy Framework, 2002) however, more recent research suggests that more than 60% of delivery complications cannot be detected prior to birthing with shock and excessive bleeding being unpredictable and requiring well organized referral systems to higher level emergency care facilities. 10

Access to health care is a significant problem facing people in East Timor 11 but it is also important to remember that no one is “home-free” if and when they finally do reach the hospital. The capacity of the main hospital is perhaps improving, but lack of resources and staff, in addition to the need for additional training of health professionals is evident in the care received by so many patients in its halls.

Insecurity for the people of Timor radiates beyond an isolated realm of healthcare. Unemployment in East Timor, and in Dili particularly, is very high. Dr. Richard Curtain 12 calculated from the 2004 National Census that 46.7% of males and 71.5% of females are ‘out-of-school and out-of-work’ in Dili. It is no secret that lack of employment and economic opportunities leads to and/or exacerbates social breakdown, and we can see this played out on the streets of Dili whenever there’s a rock fight or riot.

It’s grim. It’s a challenge. I’m optimistic.

The problems facing Timor right now are the problems that face countries when they first gain independence—there’s political turmoil while the system equilibrates. High unemployment rates coupled with a population bulge of youth 13 will lead to increased violence, crime, and social breakdown in any country. Lack of access to clean water makes people sick 14 . The trickle-down effects of poverty usually hit women, children, and other marginalized people the hardest. These things are not specific to East Timor.

What is exciting, however, is how fundamental East Timor’s problems are and how very attainable massive improvements to the quality of life of its citizens are. Oil revenues will increase dramatically in the future, but the government already has substantial funds in its budget to jumpstart employment with public works and maintenance programs, employing many citizens in un- or low-skilled labor with a living wage. The ongoing elections will hopefully yield a President and Prime Minister with a pro-active, pro-poor plan for Timor.

While ongoing public health campaigns, betterments in medical services, and public works efforts will undoubtedly improve the quality of life for many people in Timor, so would an aggressive agenda promoting education, employment, and security for the citizens of Timor. Economic stability and an aggressive employment campaign, I firmly believe, would have an almost immediate effect on the volatility of Dili. When people have no hope, poor options, and a self-awareness of their unnecessarily dire living conditions, they have nothing to lose. This will be reflected in their behavior. The problem of gangs in Timor is, of course, partially due to political manipulation from higher echelons, but it is made possible, and accessible as a widespread tool for chaos, due to the lack of viable opportunities for many citizens. In many ways, those who have participated in gang activity, and those who have become leaders have “succeeded” in their given context. With so few options, they have made sense of their environments to harness some sense of security and material gain for themselves and their families 15 .

Changing that context — i.e., making education (English classes, computer classes, trade classes) free and accessible for everyone; and opening up viable employment opportunities (and ongoing employment not solely dependent on Westerners)—would not only give them another avenue to attain a better life, it would give them something to lose.

Meanwhile, there are many East Timorese heroes who work everyday to improve their country and life for the less fortunate among them 16 .

There are also many non-Timorese activists who continue to support the people of East Timor in tangible enduring ways. This kind of support, I believe, is absolutely essential for this interim period for East Timor. And by supporting ongoing projects, you can make a direct difference in the lives of real people. I’ve listed a few of my favorite organizations whose work I have witnessed in my time in East Timor.

HIAM Health- http://www.hiamhealth.org

HIAM-Health provides vital services to reduce high infant and maternal mortality rates and to reduce unacceptable health and social conditions in poverty stricken Timor-Leste (East Timor), the poorest nation in South-East Asia. —See especially the Malnutrition Rehabilitation Centre project.

SETRA – 1-206-523-3656

The Seattle East Timor Relief Association is a Seattle-based non-profit organization dedicated to helping the people of East Timor through health, education, and core social change. 

Friends and partners with East Timor- http://www.fpet.org.au/

FPET is a Brisbane-based non-profit organization working with the people of Atabae sub district to re-establish self-sustaining communities.

Alola Foundation- http://alolafoundation.org/

The Alola Foundation was established in 2001 to raise awareness of and campaign against the sexual and gender-based violence experienced by women and young girls in Timor-Leste. In response to the needs identified by East Timorese women, the Alola Foundation has grown to provide services and programs in areas such as advocacy, employment, education, maternal and child health and humanitarian assistance.

Ba Futuru- http://www.bafuturu.org/

Ba Futuru, meaning “For the Future,” is a peace-building organization located in Timor-Leste (East Timor). The organization’s mission is to build a culture of peace and non-violence by providing Timorese people with the skills and knowledge necessary to create a positive future.

Children at the Dili hospital’s displaced-persons camp. Photo by Megan Lavelle (7/11/2006).

I would also like to extend my sincere thanks and solidarity to the progressive community in Seattle, especially to SETRA (the Seattle East Timor Relief Association) for its long-lived and ongoing support for grassroots organizations supporting the people of East Timor. While continued long-term structural improvements to the medical system in Timor are essential, the day-to-day help that ordinary people can give in solidarity makes a huge difference. This kind of support, circumventing massive bureaucracies and political untidiness, gives people hope in precisely those times it seems there is none.n

Megan Lavelle is a long-time member of the East Timor Action Network and of the Seattle East Timor Relief Association. While working in East Timor, she is seeking out health, social, and economic disparities, teaching herself Tetum, and working with friends.

1 HIAM Health is a Timorese-run permanent NGO in Dili. In addition to providing palliative care, they run a crucial follow-up and rehabilitation program for malnourished children, provide social services to the poorest of the poor (including repatriation of bodies from Dili National Hospital to the districts), health education workshops, and pastoral care. For more information, or to donate, visit www.hiamhealth.org

2 Major Michael Stone of the Australian Army, personal correspondence, 11 April 2007. For background on Major Stone and his work in East Timor, visit www.abc.com.au/austory and watch ‘The Peacemaker’ online.

3 WHO Health Action in Crises Timor Leste brief, May 2006.

4 Id.

5 Country Profiles for Population and Reproductive Health, Policy Developments and Indicators 2005, produced jointly by UNFPA and Population Reference Bureau.

6 WHO Health Action in Crises Timor Leste brief, May 2006.

7 Country Profiles for Population and Reproductive Health, Policy Developments and Indicators 2005, produced jointly by UNFPA and Population Reference Bureau.

8 Health Action in Crises Timor Leste brief, May 2006.

9 WHO Health Action in Crises Timor Leste brief, May 2006 puts the maternal mortality rate at 660 per 100,000 live births.

10 National Reproductive Health Strategy, 2004 – 2015, p. 9.

11 Although 80% of East Timor’s citizens have access to some modest health services, the average walking time to the nearest healthcare facility is 70 minutes.  (Ministry of Health, 2004)

12 Pricipal consultant for Curtain Consulting and a specialist on public policy.

13 See, for example, Richard Curtain’s 2006 Working Paper Crisis in Timor Leste: Looking Beyond the Surface Reality for Causes and Solutions. Also, see  J Goldstone, 2002, ‘Population and security: how demographic change can lead to violent conflict’, Journal of International Affairs, vol. 56, no. 1; and R Cincotta, R Engelman, and D Anastasion, 2003, The Security Demographic: Population and Civil Conflict After the Cold War as cited in Curtain.

14 And, according to the aforementioned WHO crisis report (footnote 9), “Only a third of the population has access to improved sanitation and 52% to improved water sources.

15   Please do not mistake this idea for any kind of approval for violent behaviors—or as a lack of acknowledgement for the many, many pro-active, pro-peace youth and citizens who have accomplished amazing feats, started NGOs, promote education, and work every day for a better Timor for themselves and the future.

16   For a small sampling of the kind of valiant work I’m referring to, learn about Rosaria Martins da Cruz, director of HIAM Health at http://www.hiamhealth.org/history.aspx; read about the work of Ba Futuru at http://www.bafuturu.org/

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