The LANCET 57

Kelly Morris
(Reprinted with permission of Kelly Morris)
Lancet 2001; 357: 873-77

6 Nimrod Road, London SW16 6SY, UK (K Morris BA) (e-mail:vital@dircon.co.uk)
Under Indonesian administration
Progress
Public health
Post-conflict research: malaria resistance
The future
References
In August, 1999, three-quarters of East Timorese adults voted to end more than
two decades of an Indonesian administration never recognised by the United
Nations. The ensuing spree of violence and destruction by militia backed by the
Indonesian military meant the birth of the fledgling nation became a complex
humanitarian disaster. 1 year on, progress was heartening: a transitional
government, a judiciary, and tax systems were in place, and East Timor was a
proud competitor in the Sydney Olympic games. Rebuilding a country from ground
level has brought a golden opportunity for fresh approaches. However, reconstruction
is also a slow, complex, and sometimes controversial process at the mercy of multiple
agendas. The health sector has seen basic care restored, establishment of a much-
needed public-health service, and planning for the future health system. An innovative
partnership between WHO/Roll Back Malaria and Merlin for post-conflict research has
provided data to guide malaria control. The story of progress from humanitarian
emergency to national health plan epitomises the triumphs and challenges of this
newest nations' first 18 months.

"Let us not be tempted to build and develop modern hospitals that are costly and in which
only half a dozen people benefit from good treatment. Let us concentrate above all on
planning intensive campaigns of sanitation, prevention, and the treatment of epidemics and
endemics for the whole population." Xanana Gusmão, de-facto President of East Timor
At night, Dili, capital of East Timor, is beautiful. Homely light shines from pastel-coloured
bungalows and street hawkers' fires along sleepy, palm-lined streets. The town centre houses
the colonial splendour of old government buildings that overlook the sea and the sparkle of
passing craft. Daylight brings a different story. Gardens that sport wondrous subtropical plants
are attached to roofless, blackened shells of bricks and mortar. A look through the broken
windows of schools and hospitals reveals the almost complete destruction of public systems
and resources. Street children stare wide-eyed at the heavy traffic full of foreigners and local
entrepreneurs. And the government buildings, the focus for frequent demonstrations over jobs
and prices, now house the United Nations Transitional Administration in East Timor (UNTAET).¹

Dili remains heavily damaged more than a year after the conflagration

The devastation owes entirely to "the conflagration": revenge wrought for the independence
vote in August, 1999, by departing militia backed by a regime never recognised by the UN.^2-4
With the immediate departure of the international community, ongoing violence, destruction,
and human-rights abuses spread unchecked. A month of freedom found many dead, at least
half the homes in western areas destroyed, and virtually the whole population displaced.
Much of the mainly Indonesian civil service had fled, taking with them essential technical skills
and knowledge. Widespread looting and damage was especially targeted at agriculture and
food stocks, leaving this mostly rural people to consume livestock and seeds. The
consequences for future food production were graphically highlighted by the militia graffiti
"Timor eat stone".⁵When the international community returned with humanitarian assistance,
it was clear that this half an island would need to start from scratch.

East Timor was illegally annexed in 1976, and public expenditure, including the bloated civil
service, was heavily subsidised by the Jakarta-based regime. However, as the World Bank
noted in September, 1999, "development outcomes do not appear to have reflected the
relatively high level of recorded expenditure",⁶ a polite way of saying that little money trickled
down to the majority East Timorese underclass. Before 1998, a third of households lived in
poverty, less than a third had drinkable water, life expectancy was around 55 years, and
under-5 mortality was 124 per 1000.^7,8State health care was centred around community
health centres, some with inpatient beds, which provided primary care for the widely spread
villages, and coordinated "outreach" care by health subcentres, mobile clinics, and village
midwives. Tertiary care was eight small district hospitals, the main Dili hospital with the
country's 11 specialist doctors, and the Central Health Laboratory. Few people seem willing
to talk about the Indonesian system, perhaps reflecting the relative lack of access to a
system designed, run, and staffed at senior level by outsiders.⁹ One nurse told me that a
visit to the doctor was usually a last resort. Drugs would be given solely on the basis of a
clinical diagnosis; available tests would not be ordered for East Timorese. Many locals relied
on traditional medicine involving specific herbal and heat treatments to drive out the particular
horok, or evil spirit, troubling the patient.

During the conflagration, health care was deliberately disrupted² and facilities specifically
targeted: a third were severely or completely destroyed, and less than 9% escaped damage.
An assessment by the joint working group on health services in January, 2000, found that
two-thirds still had no mains electricity, almost half had no mains water, and 67% lacked
vital equipment. In the eastern Lautem district, all ten health posts were destroyed, Los Palos
hospital was looted and damaged, and two nurses and one pharmacist were killed. I found one
particularly petty reminder of the militia's vindictiveness in the radiology room: an X-ray
machine left for the rats to chew any available flex, because the exposure button was
deliberately cut off and destroyed. A replacement button is unlikely to be found. The
Indonesian system, after centuries of Portuguese rule, left other legacies. Jim Tulloch,
international co-head of health, notes that the previous centralised and uniform service
"was based on a standard that was not relevant to local population needs, situation, or their
capacity to maintain it". Timorese co-head of health Sergio Lobo, who is widely tipped to be
the first Health Minister, points out that "under both the Portuguese and Indonesian systems,
Timorese had nothing to do with planning or managing the system". And if doctors were in
short supply before, they are now like gold dust. In 1998, the country had 133; now, there are
18 localdoctors and five medical students studying abroad who will graduate by 2001. The
situation is similarly dire for other health-care workers, and a "brain drain" of the most talented
individuals is already making matters worse.

As international agencies poured in, local health-care workers returned to what remained of
their workplaces and restarted work without remuneration or often even the basic tools. For
6 months, the priority was humanitarian relief. 18 months on, health is further along in
development than many other sectors. The Interim Health Authority (IHA) formed in February,
2000, when international experts from the UNTAET office of health paired with local
counterparts to specificallyenhance East Timorese sovereignty over their prospective health
system. Health-care development has accelerated with the June, 2000, announcement of a
US$12·7 million grant from World Bank and UNTAET trust funds, and the designation of the
Health Program Management Unit.⁹With humanitarian relief hailed as mostly successful,¹⁰ those
working within the expanded IHA structure are mindful that their decisions are laying the
foundations for the new health service. The trick, says Tulloch, has been to use international
resources to provide a breathing space to design the system and develop policy. To further
draw on international expertise, the coordinating non-governmental organisation for each
district was asked in June, 2000, to propose, with local consultation, a strategy for future
district health care. District health plans have now beenimplemented. But he and Lobo are
keen to emphasise that overall strategy will not be driven by these post-emergency plans,
which were instead useful to generate valuable data and innovativeideas locally. Despite
huge efforts, services are far from ideal. Of 150 health facilities functioning in June, 2000,
most still needed repair, and only 23 had inpatient beds. Of the 592 beds in the country,
half of them are in Dili. And even there, drug shortages are evident. Elsewhere, when roads
are cut off, lack of fuel for generators means power rationing. When I visited, Los Palos
hospital had no bed or window netting, rudimentary toilet and kitchen facilities, and no
incinerator--clinical waste wasburnt at the back of the hospital grounds. Head nurse Julio
Pereira told me that before thedestruction, the hospital usually had 30 patients in the 54
beds. Now, the 44 remaining beds arefull and sometimes more patients sleep on the floor.
The involvement of several, mainly international, players generates many of the key
difficulties, locally and nationally. Suboptimal coordination and communication has led to
frustrating gaps or overlaps in services. Most importantly, consultation with the East
Timorese has not been adequate, according to La'o Hamutuk, a Dili-based
non-governmental organisation that monitors international activity.¹⁰ Although great
efforts have been made in the health sector, conflicts of culture and clashes of interest
have arisen. Some examples are: offers of "high-tech" equipment; co-opting of health-
care workers as translators; adoption of international standards of clinical care; and
provision of surgical services by peacekeeping forces, all of which can seem reasonable
policies in the short-term, but may not be appropriate, affordable, or sustainable in the
longer-term. Local health-care staff face personal difficulties. A substantial minority still
work without remuneration, and the majority employed by UNTAET face the insecurity
of 3-month contracts, irregular salary payments, and the possibility of unemployment in
thenew health structure. Yet, local staff are expected to take on roles and skills they
may never have had, and international organisations usually expect longer working hours
than the standard Indonesian day of 0700-1100 h. These challenges and the rising cost
of living, undoubtedly inflated by the international presence, seem the main factors
involved in generating labour disputes, ranging from strikes to repeated informal requests
for wage increases.

Currently, the IHA national plan divides services into basic, specialist (eg, mental health),
and health promotion (including public health). Although the prominence of public health
has been criticised as too low, Tulloch counters that basic-service priorities--
immunisation, health promotion, tuberculosis control, and nutrition--are key public-health
issues. And, he adds, "future health policy is likely to be strongly oriented towards
prevention and health promotion". Infectious diseases are the main public-health threat,
with high rates of malaria, dengue, diarrhoeal diseases, tuberculosis, and acute
respiratory infections. In addition, new data suggest that Japanese encephalitis may be
endemic, and cutaneous leishmaniasis has also been newly reported.¹¹So far, the public-
health system consists of vertical programmes for tuberculosis, malaria control, and
disease surveillance. Tuberculosis control was readily revitalised as a public programme
from the private Catholic diagnostic and treatment programme, with assistance from
Caritas--an international confederation of Catholic organisations--and WHO. Meanwhile,
the WHO/Roll Back Malaria initiative has taken the unique step of partnering with a
non-governmental organisation--UK-based Merlin--that would research and implement
a national malaria-control strategy in the field.¹²When Merlin arrived in January, 2000,
emergency health services were treating record numbers of people with fever,
particularly children. However, incidence and prevalence surveys suggested that
although Plasmodium falciparum and P vivax are almost equally prevalent in East Timor,
malaria transmission is not intense. Moreover, the data suggested that parasitaemia
was not well associated with fever, making dengue the most likely diagnosis in patients
presenting with fever. In this situation, diagnostic services are essential to reduce
inappropriate treatment, and Merlin has now retrained technicians and ensured that
each affected district has a basic malaria diagnostic laboratory. Because development
can only build on what is left, one future issue is the reconciliation of tuberculosis and
malaria diagnostics within district-level laboratory facilities. As for agencies throughout
the country, the key challenge for Merlin has been to fit in with other players and their
work, thus avoiding duplication or omissions while ensuring uniform standards, explains
Nadine Ezard, project coordinator. Merlin's priority therefore has been liaison with
numerous agencies, like the IHA, peacekeeping forces, and diverse non-governmental
organisations--at district level and in national programmes (eg, International Rescue
Committee for bednet treatment and distribution, Oxfam for health promotion, Aide
Medicale Internationale for nursing education). As a small non-governmental
organisation implementing a national programme, Merlin initially faced resistance. One
senior WHO official privately admitted to me that he was "critical in the early stages",
because he did not believe that a non-governmental organisation would offer the same
quality as a UN institution. In turn, at a Roll Back Malaria conference in June, 2000,
Ezard indicated that future partnerships would benefit from improved information,
communication, and technical support from WHO.^12,13One of the most touching
stories of health-care reconstruction is that of the Central Health Laboratory, which
reopened as a reference facility in June, 2000. Head of the laboratory Vicente da
Conceiçâo Reis told me how staff hid laboratory stock, including 22 microscopes, in
their houses, away from destruction by militia. After resuming work at the end of
September, 1999, staff were not paid until May, 2000, yet all of them subsequently
contributed money towards reconnecting water supplies and tending the gardens--
a prized feature of all Timorese health-care facilities. Reis also managed to organise
an outbreak investigation in late 1999, on a shoestring budget with volunteer staff.
The laboratory now offers standard pathology testing, although reagents are lacking
for pregnancy and HIV tests, and a telephone and car are unaffordable. Reis's main
wish, however, is for easier access to international experts. "We have many, many
problems, and we have no money, but we want to see and learn more." Diagnostics
represent a major advance for the WHO-run surveillance system, and will hopefully
soon resolve the major question of how many suspected malaria cases are due to
dengue viruses and other pathogens. Rob Condon, head of the WHO Infectious
Disease Surveillance and Epidemic Preparedness Unit in Dili, believes that efforts
should now be focused on vector-borne disease control to ensure that all aspects
are in place before a serious epidemic emerges. To this end, Condon has started
an advocacy group of interested parties, but his major concern is lack of human
resources. When I visited in July, 2000, he was cheered to discover a qualified
epidemiologist and two individuals training in public health, although none is
medically qualified. The public-health system might need to be run by an
epidemiologist and a nurse practitioner, he suggests, "and there will probably be a
need for technical support from outside East Timor for some time".

Public health was never a priority for the Indonesian regime, and with the increasing
groundswell of support for independence, many initiatives, such as insecticide
spraying, were stopped in 1998. The post-conflagration situation comprised almost
all of the factors that increase malaria risk: a long rainy season, a displaced
population, crowded housing, problems with water supply and sanitation, reduced
food supply, no surveillance, poor clinical facilities and drug shortages, lack of
bednets and insecticide, and, potentially, drug resistance. Unsurprisingly then, a
massive rise in acute febrile illnesses was seen. Around 10000 suspected cases of
malaria were diagnosed in 1998, but between September, 1999, and mid-January,
2000, more than 30000 clinical cases were seen.During the initial emergency, WHO
drew up an interim treatment protocol. Chloroquine resistance was reported in
Indonesia as early as 1974, and high rates were found in East Timor in 1992 and on
nearby Sembeh island in 1998.^14,15 So for clinics with no diagnostic facilities or for
proven falciparum malaria, the protocol recommended chloroquine with Fansidar
(sulphadoxine/pyrimethamine) as first-line treatment for mild-to-moderate disease.
Merlin's first job was to disseminate the protocol throughout the country. But, notes
Ezard, the proposed treatment of mild-to-moderate malaria was controversial, and
many non-governmental organisations decided not to implement the recommendation,
"partly because they did not feel the [previous] data were 100% solid and partly
because they were not seeing treatment failures with chloroquine alone".

Recruitment for post-conflict malaria research
Joãzinho da Cruz--an East Timorese nurse employed by Merlin--recruits volunteers to
study clinical chloroquine resistance.

As usual, more data were needed, but research in an emergency situation, despite
becoming Merlin's forte, is not easy. The drug-resistance studies were affected by
the common enemies of researchers everywhere: financial constraints and
bureaucracy. Meanwhile, in-country logistical difficulties, such as strikes and the
lack of housing, meant that the four-way study proposal became a single-drug
efficacy study in one site, Los Palos, where Merlin's data indicated 40% parasitaemia,
with splenomegaly in 72% of children aged 2-9 years and in 43% of adults.
Joãzinho da Cruz, an emergency-room nurse, and Edmundo Vieira, a paediatric nurse,
were paid a standard R30000 (US$0·30) per day for additional study work. They
recruited children with fever within 24 h--almost no one refused. One participant,
5-year-old Julieta, had had fever for 30 months, but was brought to the hospital
when she developed chills, cough, abdominal pain, diarrhoea, and vomiting. After
da Cruz checked inclusion criteria and obtained verbal consent from her parents,
Vieira found she had hepatomegaly, severe anaemia, scars from heat traditionally
applied to an enlarged spleen, and a positive rapid malaria assay. Merlin vector
biologist Matthew Burns was not surprised to find positive thick and thin films
with a P falciparum count of 26667 per µL. Julieta was given chloroquine treatment
alone, then followed up for treatment failure five times in the next month. Follow-up
was virtually 100% because a driver was sent to pick up absentees. This meant the
nurses worked long hours, such as the occasion when I visited: 8-year-old Justina
had a rising parasite count at follow-up, but the driver looked around her village in
vain for hours. It was gone 1700 h after a night shift, and the research nurses
remained wholly enthusiastic about the need for the study. They were looking
forward to moving offices because it meant an end to the leaky roof and research
by torchlight in the blackouts. After 3 months of slow recruitment, partly due to
heavy rains when no one could get to the hospital for weeks, Merlin have analysable
data from 48 patients. 32 had treatment failure (66·7%); in 31, treatment failed
after day 3, and in many, anaemia persisted to 28 days. Genotyping is awaited to
determine whether failure was due to reinfection, or as is more likely, recrudescence
of disease due to drug resistance. Meanwhile, Merlin has recommended to the IHA
that chloroquine is inappropriate for first-line therapy in a setting of such high
resistance, a situation likely to be found throughout East Timor.

With first elections proposed as early as August, 2001, the future for the fledgling
nation seems hopeful. However, the Jakarta-based government's already loose grip
may be weakening on militia active in West Timor. In September, 2000, insecurity
necessitated withdrawal of international staff from Oecussi--the vulnerable East
Timorese enclave situated well into West Timor. The fate of some 100000 East
Timorese refugees in the enclave looks increasingly bleak. And despite the urgent
need for the international community to plan its withdrawal as soon as possible to
avoid further economic and social distortion,^10,16 an ongoing UN presence is likely
to be felt for years. In the health sector, as in the nation, the challenge is to
minimise international impact and maintain motivation of the populace in the face
of the inherent difficulties of reconstruction--what Lobo describes as "our new
national realities". Not all expectations will be realised easily, if at all--a fact that is
already leading to discontent and political fractionation. "People fought for and are
full of hope for full independence and all that goes with that", observes Tulloch, yet
the persisting need for international support "inevitably has postponed their ability
to take the situation into their own hands". Quick, high-profile results, such as
childhood immunisation, are a priority for improving not only health but also public
opinion, although the concern is that less visible, more complex issues such as human
and gender rights, could languish longer on agendas. Full East Timorese participation is
the only way to appreciate the complexity of certain issues. For example, condom
promotion for HIV prevention might be unacceptable in a Catholic country that
harbours not unreasonable historical fears about birth control as a tool of the state.
This message would be even less palatable if the country's greatest HIV risk were
found to be from international staff, as in Cambodia.¹⁷ And although careers will be
made for all those who pioneer future systems, these individuals will have to remain
sensitive to public perceptions, given the history of occupation and inequity.¹⁸ Public
notices to conserve water are difficult to swallow alongside the litres of daily mineral
water in the UN staff allowance. Perhaps the greatest test will be long-term health
financing. In September, 1999, the UN Development Programme suggested that
"conflict for other social resources such as public investment in education suggests
that a significant subsidy on the local health system can not be sustainably
institutionalised".¹⁶ The World Bank has promised a review of health funding, but is
clear that "options for medium-term financing include fee for services, private
co-payment, and a long-term social insurance scheme".⁸ The concern is that, post-
transition, substantial state funding for health will not sit easily with the focus on
economic growth preferred by the Bank and donors. However, clear indications have
come from de-facto president Xanana Gusmão for the need for "free health
assistance" and from the IHA, which in its minimum standards document calls for
services that are "universally accessible to all citizens". So far, the independence
movement's clear vision for their nation has held true, perhaps because as the
stoical leader of an enduring people put it at the 1999 World Bank Information
Meeting, "we have had a long time to think about it". Freedom is just the start.
I thank WHO/Roll Back Malaria for financial assistance with air travel; to Merlin
and their in-country team, especially Nadine Ezard, for facilitating my trip and for
supporting and accommodating me in my work; and to everyone, named and
un-named, who took time out from reconstruction work to comment.

1 UN security council resolution 1272 of Oct 25, 1999.
www.un.org/Docs/scres/1999/99sc1272.htm (accessed March 5, 2001).
2 Stein D, Ayotte B. East Timor: extreme deprivation of health and human rights.
           Lancet 1999; 354: 2075-77. [Text]
3 UN security council resolution 384 of Dec 22, 1975.
www.un.org/documents/sc/res/1975/75r384e.pdf (accessed March 5, 2001).
4 UN security council resolution 389 of Apr 22, 1976.
www.un.org/documents/sc/res/1976/76r389e.pdf (accessed March 5, 2001).
5 Clausen L. Under clearing skies. Time 2000; 24: 44-53.
6 World Bank East Asia and Pacific region. Background paper prepared for the
   information meeting on East Timor. Washington DC: World Bank, 1999.
7 East Timor Joint Assessment Mission. Report of the Joint Assessment Mission
   to East Timor. Washington DC: World Bank, 1999.
http://wbln0018.worldbank.org/eap/eap.nsf/beeea2c8b5bc212785256812004eb9c7/
       4fa8c8db2a22bdd18525682c0059699e?OpenDocument (accessed March 5, 2001).
8 East Timor Joint Assessment Mission. Health and education background paper.
   Washington DC: World Bank, 1999.
   http://wbln0018.worldbank.org/eap/eap.nsf/beeea2c8b5bc212785256812004eb9c7/
        a67abe6406537dcb85256847007dff36?OpenDocument (accessed March 5, 2001).
9 World Bank East Asia and Pacific region. East Timor Health Sector Rehabilitation and
   Development Project. Washington DC: World Bank, 2000.
10 Anon. Evaluation of humanitarian relief process released by UNTAET.
    La'o Hamutuk Bulletin 2000; 1: 4-6. http://etan.org/1h/bulletin02.html#_04
   (accessed March 5, 2001).
11 Carrette P, Petit D, De Mauleon P, Pourriere M, Martinie C, Didier C. Report of
   the first cases of cutaneous leishmaniasis in East Timor. Clin Infect Dis 2000; 30: 840.
12 Morris K. Malaria-control partnerships key to combat disaster deaths.
   Lancet 2000; 356: 144.
13 Ezard N. Research in complex emergencies. Lancet 2001; 357: 149.
14 Pribadi W. In vitro sensitivity of Plasmodium falciparum to chloroquine and other
    antimalarials in east Timor and east Kalimantan, Indonesia.
    Southeast Asian J Trop Med Public Health 1992; 23 (suppl 4): 143-48.
15 Fryauff DJ, Soekartano, Tuti S, et al. Survey of resistance in vivo to chloroquine
    of Plasmodium falciparum and P vivax in North Sulawesi, Indonesia.
    Trans R Soc Trop Med Hyg 1998; 92: 82-83. [PubMed]
16 UN Development Programme. Conceptual framework for reconstruction, recovery
    and development of East Timor (draft). New York: UNDP, 1999.
   www.undp.org/erd/archives/concept_paper_east_timor.pdf (accessed March 5. 2001).
17 Soeprapto W, Ertono S, Hudoyo H, et al. HIV and peacekeeping operations in Cambodia.
    Lancet 1995; 346: 1304-05. [PubMed]
18 Morris K. email KellyMorris@Dili. The Guardian July 10, 2000.
top