Subject: ApT: Health in East Timor
Date: Sat, 17 Apr 1999 08:33:37 -0400
From: Bruno Kahn <kahn@math.jussieu.fr>

[This is the translation of an article appearing in the April issue of the Agir pour Timor bulletin. This article was written before the latest events.]

HEALTH IN EAST TIMOR

In its rhetoric aiming to justify the annexation of East Timor, the Indonesian government has constantly claimed to contribute to the development of the territory and has argued that it builds hospitals, schools, roads and administrative buildings.

What assessment can be made of public health in East Timor today?

Such an assessment is difficult given the incompleteness of available data. We used statistics published every year by the Indonesian Health Ministry, but the figures given are sometimes totally incoherent and it seems, in view of other information, that their presentation plays down the seriousness of the situation.

We therefore also used testimonies of East Timorese as well as "tourists" and voluntary aides who have been able to assess health and medical conditions on the spot.

ORGANISATION OF THE HEALTH SYSTEM

The health system in East Timor is administered by a provincial director of the ministerial Health Department. According to reports of the Indonesian services, medical care is essentially provided by the 67 puskesmas (popular health dispensary) that exist in the territory (1 for each subdistrict). East Timor has 10 hospitals, including two reserved to the military. The only (civilian) hospital worthy of the name is that of Dili. 7 other hospitals, with worse equipment, are found in Baucau, Maliana, Viqueque, Ainaro, Suai, Oecussi and Los Palos.

Official statistics claim 1,355 nurses and 155 doctors for a population of about 800,000 inhabitants. In fact, the staff available to civilians and especially the rural population is much smaller.

Each puskesmas is in principle run by a doctor and a team of nurses. Its main activity consists in handling minor urgencies, births, infections and benign diseases. It also practices preventive medicine: vaccination, family planning. Puskesmas often lack resources, both material and human. Medicine is often lacking or is diverted by a corrupt administration.

Besides the institutions handled by the government, the local catholic church has created about 20 clinics in the territory, administered by members of religious orders, with some formation to medical practice. Their work consists in curing the various diseases affecting the population: tuberculosis, malaria, diarrhoea, pneumony, skin diseases, respiratory infections... the list is long. Tuberculosis is presented by the Indonesian government as the highest cause of death in East Timor. Its development has been largely favoured by the camps set-up at the end of the seventies and in the eighties, where starvation and terrible hygiene conditions were rife. The government, like the catholic institutions, have set up treatment programmes for tuberculosis, but it still affects many East Timorese.

MALNUTRITION

The various diseases strike the population all the more that it is undernourished. Although government reports totally ignore this phenomenon, all visitors mention a visible malnutrition in the whole territory. This state of food insecurity is directly related to the political situation. The years of war and occupation have led to an ecological disaster. Bombings and massive deforestation have considerably reduced the size of arable land and greatly fragilised the soils.

Until the invasion, East Timor's agriculture made it self-sufficient in food. The restrictions imposed by the military on the population (restricted cultivation areas, the obligation to use Indonesian methods of production, work under constant surveilance by the military) have significantly reduced the agricultural production. Rice, an important food for the population, is mostly imported from the other Indonesian islands.

According to a 1996 UN report, infant mortality is 135 per thousand in East Timor and life expectancy is 46 for men, 48 for women. The state of health of the population is much lower than that of the inhabitants of Indonesia.

FAILURE OF THE PUBLIC HEALTH POLICY

The population has a deep distrust of the doctors working in the puskesmas. The 183 family planning centres present in the territory have set up a coercive birth control. Many East Timorese women have testified of forced sterilisations to which they had been subjected in hospitals or during an operation or a delivery. Besides, young girls are given by the military, most often unknowingly, contraceptives in the form of injections. The assissinations that took place in the Dili hospital after the Santa Cruz massacre also explain the reluctance of the population to set foot in government institutions. East Timorese by far prefer to go to the catholic health centres. Although they sometimes get medecine from abroad, the catholic institutions also lack resources.

Besides, the doctors who practice in puskesmas, most of them Indonesian, are generally medical students, having just graduated or coming to East Timor to do their internship. They have little experience and work not under the supervision of medical doctors, but rather under military control. As they don't know the East Timorese language or culture, communication with patients is difficult and doctors often have little motivation for their work.

Finally, the East Timorese population is ill-informed of the various diseases and prevention: as they don't know how to recognise the symptoms of a given disease, the inhabitants often wait until it is in an advanced stage to go see a doctor, who sometimes cannot do anything to stop it anymore. This only worsens the bad reputation that Indonesian doctors already have.

AN EMERGENCY SITUATION

Recently, the medical situation has got even worse. Facing attacks led by pro-Indonesian militias, many people have fled their villages to take refuge in mountains, churches and schools, and lack all means of existence. The population faces a food shortage. Following the statements of Habibie on a possible independence of the territory, many shopkeepers, most of them Indonesian or Chinese, have left the country. Many informations also point to requisitions of rice stocks in stores by the army. Doctors and teachers have left the territory en masse, encouraged by the government.

According to an American doctor working in a catholic clinic, between 50 and 100 people die each day of perfectly curable diseases, especially tuberculosis, and 44% of the children under 5 are malnourished. Hospitals are all but at a standstill.

The Indonesian government denies all statements on a systematic exodus of the medical personnel. The reason seems to be that it does not want to see international humanitarian aid, hence an important foreign presence, arrive in East Timor. Stocks of medicine sent by Medecins sans Frontieres have been blocked in Jakarta for weeks and the government just refused the arrival of an Australian surgical team, although there has been no surgeon in the territory for almost a year.

Besides, several informations mention intimidations by the military of the medical personnel still present, preventing them to do their work. This could be related to attempts by the army to replace medical teams and other professional groups like teachers by military personnel, in order to destabilise the situation even more as a vote on the future of the territory gets nearer.

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