Karen Polglaze, Dili – Behind a drooping curtain in a poorly-lit clinic in rural East Timor, a technician armed with a microscope and a belief in the World Health Organisation (WHO) is fighting to save lives.
Indonesia has one of the highest rates of infection for tuberculosis in the world, and its 27th province, East Timor, has the top rate in the country, medical experts say.
Figures are hard to come by in these days of dwindling doctor numbers, but an American doctor working at a Catholic clinic in Dili says 30 per cent of his patients are infected and 50 of the hundreds he sees every week have active infectious TB.
Tuberculosis is the most obvious of many health problems which beset this half-island, and with funds from ruling Indonesia drying up ahead of a mid-year ballot that is expected to lead to independence, health issues are increasingly under the spotlight.
East Timor leads the nation in some horrifying health statistics. Its infant mortality rate was 70.12 per 1,000 live births in 1997, according to figures from the Indonesian Ministry of Health.
That's 85 per cent higher than the 1997 national rate of 41 deaths per 1,000 live births – and almost 14 times as much as the 1997 infant mortality rate in Australia of 5.3 per 1,000 live births.
Maternal mortality is also high – 373 deaths for every 100,000 live births nationally in 1995 according to health ministry figures obtained through a survey of 12 hospitals in the more prosperous west of Indonesia.
In rural East Timor where hospitals are in short supply, the figures would be certainly be significantly higher.
UNICEF area representative for Indonesia and Malaysia Stephen Woodhouse said his organisation was very worried that infant and maternal mortality rates would increase in East Timor in the short term. "I'm very concerned, I think that this will be a big problem," Woodhouse said.
In the weeks following Indonesia's announcement that it might release the province if the East Timorese reject an offer of wide-ranging autonomy, there has been an exodus of skilled workers, including doctors, who fear an independent East Timor would not welcome them.
Rural health centres, although often poorly equipped and with an uncertain supply of medications, have suffered severely. "Only about half – 53 per cent – have got doctors now," Woodhouse said.
Increasing levels of violence as both sides of the political debate seek to consolidate their positions ahead of the ballot have also impeded health care, worsening an already precarious situation.
"People who need health care are afraid to go to health centres," Woodhouse said. "Health workers are afraid to go to villages. That's a huge issue, access to health care."
Tuberculosis is the number one killer disease in East Timor, according to Dr Nelson Martins, one of a small handful of indigenous East Timorese qualified to practise medicine.
Indonesian health officials have estimated that each person with active TB can infect 10 other people a year and in East Timor, where sections of the frightened population regularly flee violence and seek refuge in crowded churches and homes, the circumstances are ideal for the potentially fatal disease to rip through large groups of people.
The uncertain situation also impacts heavily on treatment regimes. While technicians can often diagnose the disease with only a microscope, the most effective treatment recommended by the WHO requires continuing observation for six months and courses of antibiotics which must not be interrupted. If people are on the move, they stop going to the clinic for their antibiotics.
Supply of medication for all sorts of treatments is also a problem in East Timor. Requisitions often take months to fill or simply never arrive, and a thriving black market among officials means that those medications which are most highly prized are often only available for those with lots of cash, according to spokesman for the CARE organisation in Dili, Antonio Da Conceicao
When supplies do filter through to local clinics, there is often not enough to complete treatment regimes. "Sometimes they just give another medicine that is not related to the disease because they want to sell the right medicine to make money," Antonio said. "Every day there are clinics where they have little medicine but there are hundreds of people waiting."
For about a year there has been no surgeon available in the public system in East Timor. There is a military surgeon, but many people are either too afraid to seek help from the military – especially when they need surgery for bullet wounds – or they cannot afford his fee.
Australia recently offered to send in a surgical team, but that was rejected by Indonesia, a situation that has also applied in the past when humanitarian organisations have sought permission to bring in doctors, Dr Martins said. Malaria is another severe problem as are diarrhoea and upper respiratory tract infections.
Medication and correct, timely treatment could go a long way towards alleviating these health problems without too much investment in infrastructure, but the most important question is whether the many organisations offering to help out will be given permission to go in soon enough to stop preventable deaths or whether they will have to wait until a political solution is secured. "We don't care about the political situation, people here need help," Dr Martins said.