I’ve just had my first coffee since coming back from East Timor where I was documenting the work of the East Timor Eye Program. It’s amazing how good a coffee tastes after not having one for eight days. The bill for lunch came to AUD$30 – a week’s wage for an eye care nurse in East Timor. Now, there’s a shot of perspective. Last week was a different story.
It’s 35 degrees and I’m sweltering in the cool of the RACS office in the Dili National Hospital. Virgilho Da c.Pinto (Gil), one of East Timor’s first eye care nurses, sits opposite me in thick jeans and hasn’t broken a sweat. He cracks up when I ask him why he wears jeans in this energy-sapping heat. He has an infectious smile and laugh. Over lunch we talk about the Indonesian occupation of East Timor.
Gil was born into a world where bombs and pistol shots were as familiar as sirens and planes overhead are to us. Only for him, the sound of a plane would have more violent consequences. He’s seen his friends shot in the face and killed at close range. Now in his early 30s, Gil has lost more friends than his years on earth. Aside from the deep scars inside, his only visible reminder of the carnage is a scar from a piece of bomb shrapnel that found its way into his forehead as a baby.
One night, when he was traveling home from college where he was studying to become a nurse, Indonesian soldiers stopped the bus to check for rebel fighters. Those with student papers would be ok. Those without would be taken from the bus and shot. Gil left his papers at home.
The East Timorese are a quiet and reserved people, whose smiles ripple through their bodies to the corners of their mouths where they break free for only a moment…
He had to think fast. Gil jumped out of the bus window and, with his heart in his mouth, casually walked up to the Indonesian soldiers and started telling jokes. While they were still laughing and backslapping Gil waved them goodbye and jumped back on the leaving bus.
Today, there are more than 30 eye care nurses and technicians in East Timor as a result of the primary care training instituted by the International Centre for Eyecare Education (ICEE) as well as Fred Hollows New Zealand (FHNZ) who also developed a Diploma of Eyecare Nursing course for the East Timorese. East Timor Eye Program likewise assist with the long-term training support and mentoring via workshops and training attachments. They’re all laid-back, very enthusiastic and have similar stories to Gil.
Passion for Developing Countries
When I was asked to document the work of the East Timor Eye Program team, I jumped at the chance. I’ve wanted to join a program like this from the day we launched mivision.
I have a passion for developing countries and have wanted to see the faces of the people we feature in the magazine. I’ve wanted to see those broad toothy grins break out as the bandages are removed. I’ve wanted to help.
I registered my travel details at the Smartraveller website, then baulked when the advice for East Timor popped up: “Exercise a high degree of caution. Pay close attention to your personal security at all times and monitor the media about possible new safety or security risks.”
High degree of caution? Security risks? That can’t be good.
As questions of the risk started spinning in my head, my phone rang. It was my brother calling to say goodbye. When I told him about the travel advice, he said: “Funny you should mention that. Did you see the feature on the Balibo Five?”
I put down the phone, remembering that the ‘Balibo Five’ was the name given to a group of Australian television journalists, who were killed on 16 October 1975, while filming Indonesian troop incursions prior to the invasion of East Timor from the border town of Balibo.
When I arrived on the tarmac in Dili Airport, all the fear and foreboding started to lift as a group of us waited to be picked up by newly appointed local ophthalmologist Dr. Andreas Kreis, ProVision optometry team member Micheal Knipe and ophthalmic nurse Helen Postma from RACS, who have been involved with the program from the early days.
Optometrists Anna Morse and Sophie Koh had been to Dili before and were keen to see how it’s changed; nurse Elise Crofts, who had been to the sub-districts many times before was joined by her husband Phil for the first time. He, like Bryn Twocock, the optical technician from Essilor, and myself, didn’t know what to expect and were very wide eyed.
The next day we were joined by program founder Dr. Nitin Verma, his wife Anu and daughter Shreya, who volunteer most years, as well as medical student Nick Starkey. Then, along came Kev.
‘Kev’, is Dr. Kevin Vandeleur, an ophthalmologist who does a lot of work in developing countries and has been an integral part of the team every year since its inception. He is larger than life, the life of the party, a hard working dedicated surgeon and passionate man who would do anything for anybody.
The Streets of Dili
Driving around the streets of Dili, the capital of East Timor, one of the first things that struck me was how young the people are. With more than 200,000 people (a third of the population up to 2002) wiped out by the Indonesian oppression, approximately 50 per cent of its people today are under 18 years and 45 per cent, under 15.
It’s staggering to think that East Timor is only an hour’s flight from Australia – the Darwin to Dili leg takes less time than flying from Sydney to Melbourne or Brisbane. East Timor has a subsistence economy and is one of the poorest countries in the world with a nominal GDP of USD$648 (compared to AUD$66,984 for each Australian) and very high unemployment.
After the Indonesian troops withdrew from East Timor, Dr. Nitin Verma was working at the Darwin Hospital. Every day he saw a growing wave of refugees flood into the hospital with dense cataracts. Instead of the problem having to come to him, he decided to go to the problem. And, so the East Timor Eye Program (ETEP) was born.
The ETEP Program
In July 2000, ETEP came about as a response to an appeal from the World Health Organisation to re-establish eye health services in the country soon after it gained independence.
Nitin, with a team of ophthalmologists, nurses and optometrists, landed in the war-torn country with the smell of napalm still heavy in the air.
When they first arrived there were no eye services so the team had to start from scratch. They stayed in makeshift accommodation in the hospital wards. There were very few undamaged buildings, little infrastructure and the electricity supply was unreliable. Because there were so few cataracts removed during the time of the occupation, a backlog was created, so the primary focus of the program was on cataract surgery and refractive error correction.
Then, in 2002, the ProVision optometry team joined ETEP to provide primary eye care and then, later, to mentor and support the primary eye care workers.
To date, more than 34,000 East Timorese have attended the program’s eye clinics with over 28,300 people receiving spectacles and more than 5,500 undergoing life changing surgical procedures.
Nitin says the success of the program has led to its evolution and as a result, East Timor is slowly becoming more self-sufficient in its ability to provide primary eye care and surgery.
That means, “our focus has changed from numbers to quality. When we come in now we’re able to do more complicated procedures”. He said the patients have also become more relaxed about receiving treatment from foreigners.
“Over the last few years the program has matured, particularly with the patients because they don’t have the fear they did before. We have to move to a final end, which is redundancy.”
Nitin and the team are doing this through a range of approaches that together are equipping a local team to achieve long-term sustainability for the country’s eye care services. This is a huge mission in East Timor where fundamentals like sanitation and safe water are major issues.
One of the most important initiatives towards achieving self-sufficiency was to train East Timor’s first Ophthalmologist Dr. Marcelino Correia.
Another program was to train hospital based nurses, in India and in country, to become primary eye care workers. Now steps are being taken to train the first East Timorese degree qualified optometrist.
Together, Dr. Correia along with Dr. Andreas Kreis, and the local eye care nurses and technicians are now working from the new National Eye Centre, located next to the Dili Hospital.
The Centre was funded by the East Timor Ministry of Health, AusAID, the Fred Hollows Foundation, various companies and individuals, with equipment funded through ETEP by AusAID, ProVision and Optometry Giving Sight.
It was opened in July last year by East Timor President and Noble Peace Prize winner Dr. Jose Ramos Horta the Patron of ETEP.
With several consulting rooms and an operating theatre, more than 50 people a day can be treated in the Centre, but it has taken a number of months to fit-out. Nothing happens quickly in Dili and management skills are thin on the ground. Setting up the Centre to get it functioning was no exception.
One of Bryn Twocock’s main tasks was to get the new clinic up and running. He set up a new optical fitting lab, and with the help of some of the nurses, technicians and locals he was able to organise a team to build what seemed like hundreds of tables, chairs and cabinets.
“Joni, (one of the male technicians) and I tested all the equipment, and to no surprise, not much worked,” Bryn says.“I made an emergency phone call to my brother in the UK who’s an optician. When his phone rang at 3am he must have feared the worst.
“I needed his expertise as the focimtere was 30 degrees off axis and 1.5 dioptres of prism off centre and I knew he would be the man to talk me through it. Nearly three hours later it was good as new and the lab was almost there.”
One small problem was that there was no water for three days, as apparently 10,000 litres went walkabout overnight. Phil Crofts, who was settling into his role as ‘Jack of Everything’, came up with the goods again and somehow found enough water to get the edgers running.
The Patient Pathway
Kev has just completed a vitrectomy to the eye of a patient that had trauma the week before.
“The cataract fell backwards onto the retina so we did a vitrectomy to get it out,” he says.
“We would never have been able to do that sort of operation 10 years ago. Now we have the time to do more complicated surgeries.”
Kev becomes more enthusiastic when we talk about the impact the program has had in healing, not only the eyes of individual people, but that of the country.
“It’s been exciting over 12 years to see the evolution of the program and the impact it’s had on the people’s health here. It’s incredible. It’s about putting in the pathways. You can see that there is a
self-sustaining build-up to the whole thing,” he says.
One of the pathways is that of the patient.
In the East Timor Eye Program, I saw one of the great examples of how seamless the patient pathway can be when nurses, optometrists and ophthalmologists work together to provide best patient outcomes.
The work is intense and days are frenetic. Each specialist is flat-out but works side-by-side, as part of a team, doing eye tests and post ops, referring patients, talking with patients and families, training the local nurses and technicians.
They couldn’t achieve as much as they do if it wasn’t for the local primary eye care workers who screen locals in the sub-districts before ETEP get there and prepare them for the treatment ahead.
Locals arrive to clinic dressed in their best clothes. Few come by themselves, most arrive with family and may have travelled from the other end of the country.
They wait patiently to be seen by the team and to have their eyes tested. Those referred for operations have their procedures explained by the local eye care nurses. Having the nurses do this is so important because many people, both now and in the past, have believed the surgeons were going to remove their whole eye.
To see the faces of these people who are so poor, but so content, appreciate every little thing the team did for them, was humbling.
The day after surgery, when it was time to remove the bandages, they didn’t jump up and down and say “I can see now!”… Their response was subtle. The East Timorese are a quiet and reserved people, whose smiles ripple through their bodies to the corners of their mouths where they break free for only a moment, before recoiling back to position.
In the West cataracts are caught early and are a quick procedure. Here, they are 20 minute miracles, because people who come to the clinic have been walking around blind, in one or both eyes, for years.
As Kev and I chat, Anu Verma comes over and tells him that a couple of local eye care nurses have been scrubbed and are gowned up ready to observe some eye surgery. He’s very keen to show them the theatre and says they can watch the surgeons operate through the teaching arm.
The nurses, from Dili and 13 district eye clinics set up by the program are here for a week’s intensive training by the ProVision optometry team.
Optometrists Anna and Sophie have been teaching and conducting one-on-one skills and knowledge assessments with all the nurses and technicians, while Bryn has been running seminars to teach them about lens materials and designs.
The aim of the training has been to help give a better understanding of current competency levels so that any future training can be delivered to address gaps.
Working with interpreters Anna and Sophie have found the going slow and tough but have been incredibly patient and thorough.
Nuno Da Costa, an eye care nurse based in Baucau and the inaugural President of the Ophthalmic Association of Timor Leste, is being asked by Sophie what myopia is. The interpreter translates for Nuno who provides considerable detail in his answer back to the interpreter, who relays the response to Sophie, who nods and places another tick on her chart.
The optoms have been exceptionally busy, also supervising the nurses and technicians at the outpatients’ department, as well as seeing and assessing patients themselves.
Sophie was last in East Timor in 2003 as an optometry student. Back then there was no local eye nurse or ophthalmologist.
“I was just so amazed by the change in the country over these short years,” she says. “It’s an immense privilege to chat to and help train these new eye care nurses and work alongside Timor’s first ophthalmologist. I was humbled by their commitment to help their own community.”
Bryn has been traveling between the Dili eye clinics and Fo Naroman Timor-Leste (FNTL), a local NGO dispensing clinic and the Motael Eye Clinic run by Sister Isabel, where he’s provided skills training, mentoring and donated all of his own hand held lens fitting equipment.
In running the seminars for the nurses and technicians, he said that while they were all familiar with single vision and most knew bifocals, progressives seemed like a myth that they had only ever heard about.
“Luckily for us, Micheal Knipe was sitting in on the lecture and was wearing a progressive rimless frame,” says Bryn.
“We were able to show everyone how
to identify the engravings on the lenses and how different materials would be suitable for Micheal’s frame type. Poor Micheal spent the rest of the lecture without his specs.”
Where to Now?
In the future Nitin said there will be increased cooperation between ETEP and Fred Hollows New Zealand.
“During our visit we had a number of meetings to discuss formal glaucoma screening and a singular education curriculum. From now on the National Eye Clinic will take more responsibility with logistics. The aim is that the whole of eye care in East Timor will now come under one roof.
“This is evolving into a more mature program. Outreach programs will increase into the sub districts from five to 15 visits a year to make greater penetration.
“We want greater opportunity to get closer to the people,” he said.
It has always been about the people.
To come to Dili with ETEP was life-changing. It was a challenging and rewarding experience.
For Bryn, it was far more than setting up equipment and talking about lenses. It was about experiencing a totally different culture “a country so barren but so beautiful – people so poor but so happy,” he said.
“My role was minor compared to those that I now class as friends – surgeons, specialists and optometrists who give the gift of sight every day. For as long as Dili requires our services I will always be in the front of the queue and if a time comes when they do not require us. I will still be front of the queue.”
This sentiment was reflected by each member of the team. For Anna Morse and Sophie Koh, they’re keen to continue working one-on-one with the eye care nurses to get them up to speed, until their role too is redundant.
“It’s exciting to think that one day, there won’t be a need for us ‘Malae’ (foreigners) and eye care in Timor Leste will be self-sustainable,” said Sophie.
The dedication and passion the team had for the locals was inspirational. Each specialist was there, not for themselves, but to help others.
Even as we were heading off to the airport I heard the girls saying: “there are a couple of people who need to be followed up on Saturday, so who can do it?”
Then they took a breath and remembered that Gil would be there.
Domingos the Freedom Fighter
Domingos Fernandez is much older than his 50 years portray.He’s had a very hard life.
He lives 200 km from Dili in the far east of East Timor near Lospalos, an area so deserted now it’s referred to as “dead earth” because little grows there.
He makes mud-blocks for a living, which he sells to construction companies, who use them to build houses.
In late 1975 Timor was highly volatile as the Fretlin political party took over a collapsed Portuguese territory. Following centuries of Portuguese rule, East Timor was declared independent by the Fretlin on 28 November 1975. There was talk of an Indonesian invasion and it came just nine days later.
Domingos was 12 at the time. As the Indonesian troops crossed the border, he, along with all the other boys and men in the rural villages, decided to join the freedom fighters to hold off the invasion.
The fighters knew how to exploit the dense mountainous terrain of the Timor jungle. As the Indonesian army tried to advance, the guerilla fighters delivered lightning blows at night and early in the morning, before the fog lifted. Then, they’d head back to the refuge of the jungle. They fought to survive. It was the only thing they could do. Domingos fought for the 25 year occupation until the end of the conflict.
In 1976, while he was preparing for an assault, a sharp tree branch stabbed him in the right eye causing severe trauma. He lost the natural lens from his eye and became aphakic. This injury he would carry for over 30 years.
Over the past year, the vision in his eye has degenerated so badly he’s found it increasingly difficult to work. And Domingos needs to work – he has 11 in his family to provide for.
He was referred to ETEP by the eye care nurse at Lospalos and made his way, for the first time, to Dili.
When I first saw Domingos heading towards the clinic he stood out from the mass of people around him. He walked in alone with a slow and deliberate gait, his gaze sure. He was dressed neatly, with his grey hair brushed to the side, his face weathered and worn. Directed to sit in line, he waited patiently to be checked by an eye care nurse.
He was told he’d have an operation that afternoon, so he walked up to theatre where he waited again, until Dr. Marcelino Correia operated on his eye and slid in an IOL.
I didn’t see him leave the theatre but he was one of the first to arrive at outpatients the next day
He nodded to the nurse as she held up her fingers in front of his eyes. He nodded when she pointed
Domingos left the clinic as quietly as he came and started his long journey back to Lospalos.
Each year, in Dili, a large ETEP team from Australia of about 12 eye care professionals and volunteers provide their time and skills at no charge for a week or more to travel to East Timor to do eye tests, dispense scripts and operate.
During the year, smaller teams make another five specialist visits to district referral hospitals to service the remote sub-district communities and mentor the local eye care nurses and technicians.
Over the years, the program’s work has shifted from primary service delivery towards helping the East Timorese become self-sufficient in the provision of eye care services by 2015 and to eradicate preventable blindness by 2025.
The East Timor Eye Program is reliant on donations from the corporate sector, community groups and the public. The Royal Australasian College of Surgeons absorbs the administration costs of the program, which enables 100 per cent of every donation to go towards supporting ETEP activities. To support ETEP go to: www.etep.org.au/support-us or donate through Optometry Giving Sight: www.givingsight.org/donate-now
Below: East Timor President, Dr. Jose Ramos Horta has his eyes tested by ETEP
I’d like to thank Micheal Knipe from ProVision and Clive Miller from Optometry Giving Sight for inviting me to join the East Timor Eye Program this year, and Kate Moss from RACS, for organising my trip and answering every little question I had. I was funded by mivision.