‘If you are bleeding a lot…go to hospital’. Cristiano, a community health volunteer gave a health seminar to 12 community members inside a dark concrete house, in a village outside a small town in Timor-Leste’s central mountains. Cristiano explained some of the danger signals to watch out for during pregnancy. ‘Go to hospital’, Cristiano repeated, as he described each symptom via illustrations on a small triangular flip chart. ‘Go to hospital’, some of the community members started to chime in, repeating Cristiano’s mantra with him. Cristiano’s delivery of the information was flawless, but it glossed over a key issue: getting to hospital.
Timor-Leste is the eastern half of the island of Timor, which lies between Southeast Asia and the Pacific. My research explores how life in Timor-Leste is being rebuilt and reproduced after periods of conflict and crisis. During fieldwork I lived with health workers in the central mountain town of Maubisse. Here, many health workers rented rooms in dormitories or family homes close to the hospital, unless their own families lived nearby. The hospital itself sits up on the side of the valley and is easily the largest building in town. Throughout my research, I encountered the hospital space as a researcher, a visitor and a patient. It often felt calm and serene: a clean white space in the mountain’s green landscape. Bougainvillea trees and roses bloomed in the gardens surrounding the single-story buildings. Staff worked on rotation to care for the patients, building and gardens alike. Some mornings, hospital workers lined up to pray at the grotto of the Virgin Mary outside the hospital doors and after 4pm staff played volleyball in the empty car park. At night and during frequent power outages the building became a beacon lighting up the dark valley; its generator kept lights and machines running, and mobile phones charged.
Despite this idyllic image, the hospital lacked a key resource: people. It is not that the hospital was empty, rather it lacked doctors and medical experts. Patients also struggled to get there. Actually ‘going to hospital’ required overcoming a range of logistical and socio-economic challenges: difficult roads, poor transportation, lack of money and social stigma. When patients did arrive at hospital there were not always the right human or material resources to treat them. What happens when hospitals lack the people who are most in need, or those most needed to treat them?
Here I provoke the image of a hospital without its most crucial element – people. Hospitals are sites of contradiction: places of life and death, illness and cure, progress and failure (Pinto 2018, Street 2014). A hospital without people is a place that attempts to save lives without lives to save in it. Why do hospitals embody such contradictions? As others have shown, hospitals and healthcare systems can be ‘haunted’ by colonial infrastructures of the past (Chabrol 2018) and by dissatisfaction with the present (Varley and Varma 2018), both of which can cast doubt on the future. I show how, in Maubisse, the hospital struggles with accessibility and availability of care, issues which simultaneously exacerbate one another. They are troubled by both the legacy of colonial violence and oppression, and unmet promises of progress in the independence era. This turns the hospital into a site of hope and salvation, but one which is difficult to reach and cannot always save lives.
‘Go to Hospital’
The hospital in Maubisse is one of Timor-Leste’s five regional referral hospitals. It sits on the site of a former Portuguese colonial barracks, which became a school in the brutal Indonesia occupation that followed (1975-99). The 24-year Indonesian military occupation was characterized by violence and oppression. Approximately a quarter of the population lost their lives to violence and starvation as the Indonesian military waged war against Timorese guerilla forces fighting for independence. When the occupation ended violently in 1999 much of the public infrastructure, including 75% of health facilities were damaged or destroyed (Alonso and Brugha 2006). Only 25 Timorese doctors and one medical specialist remained in the country (Tulloch et al. 2003). When Timor-Leste gained independence in 2002, the new state faced the huge task of rebuilding its health sector. In 2007 a brand-new hospital was built in Maubisse, financed by the European Union through the Trust Fund for East Timor, administered by the World Bank. Today, as a public hospital providing free healthcare, it is financed by the government through the Ministry of Health, and it receives support from bilateral donors and NGO partnerships.
Despite messages to ‘go to hospital’, getting there is challenging. At the end of Cristiano’s health seminar, Octavia a primary school teacher and mother of five spoke up, ‘I gave birth to five children at home, back then we didn’t have a large hospital and we were too shy to go….it takes us two hours to walk hospital, we can’t walk any faster, we need to stop and catch our breath, it’s hard when you are pregnant’. Another community health volunteer lamented: ‘You feel sad because they live too far from the hospital to walk. It’s hard….in the rainy season they want to come, but when they get to a point they turn around because of the rain or the river, they are scared. The Community Health Services team helps them, otherwise if you don’t go to hospital you are just sick in your house, it’s a pity.’
The mantra ‘go to hospital’ simply did not overcome the challenges of walking several hours to get to hospital, finding transport or money for petrol, or waiting for one of the hospital’s transport vehicles, which were sometimes broken down, busy or unable to tackle the dangerous roads. Adding to this, the community health posts, through which people were meant to seek primary care and referral to the hospital, were sometimes empty. João, another community health volunteer put it bluntly: ‘They lose confidence in the medical staff. It’s stressful, how can I tell them to go to hospital if the doctors aren’t there?’. He complained about medical staff who were granted leave to attend funerals and lengthy mortuary ceremonies. ‘If they [health workers] have gone to the graveyard, what happens to the patients? They also go to the graveyard… people are important, the patients are important.’ João made the point that without health workers at health posts or hospitals, people in the community members might end up dying from their illnesses. This made the communities lives seem undervalued and the absence of health workers was designated as responsible for further loss of life.
Getting there and staying there
Beyond getting to hospital, patients had other costs to weigh. Bernardo, a coffee farmer in Maubisse, had recently been reunited with some extended family he had lost contact with during the Indonesian occupation. They lived near to the south coast and offered to bring him corn and crops they grew on the flat lowlands. In return Bernardo suggested ‘our place is not far from the hospital, if you need treatment you must come and stay’. Whilst inpatients at the hospital were provided with food and a bed, outpatients or anyone accompanying family needed food and accommodation. Most people depended on staying with family or friends, others slept on the roadside out the hospital gates and relied on kiosks selling cheap instant noodles.
Getting there and staying there also meant overcoming social differences and fears of poor-quality care (also see Price et al 2016). People often told me that they knew it was good to go to hospital but like Octavia, they would also say they were shy, embarrassed or ashamed. Older women described their clothes as dirty, their faces as ugly and their teeth as bad from chewing betel nut. After transport, clean clothes, new blankets and soap were high on the list of expenses for preparing to go to hospital. On Community Health Services outreach visits, patients were often late because they took time to shower and wash their hair before seeing the doctor. ‘They are not scared’, Cristiano explained, ‘but they are shy to let a doctor treat them, they are not used to hospitals.’
The legacy of stigma and exclusion during previous colonial regimes was extended in judgements passed by some health workers. ‘They lie, they say they will go to hospital but then they don’t’, a community nurse told me. ‘They are too lazy to walk’, I heard another complain. Stereotypes about people in the mountains as ‘uneducated’ also prevailed. A doctor who had trained overseas told me: ‘in Timor-Leste you have a lot of uneducated people, lots of people haven’t been to school. Many people are illiterate…they have a minimal understanding about health’. Ana, a local nurse who had trained in Indonesia explained: ‘in Indonesia patients are calm, but in Maubisse it is not the same, we are nervous and agitated…it’s a cultural thing’.
Ruined and abandoned buildings can be found in and around Maubisse. In a landscape that still bares the marks of the Indonesian occupation and lengthy Portuguese colonisation, racial stereotypes and social hierarchies can prevail, affecting interactions between people and healthcare services. Ana also linked people’s agitation to the quality of health services and human resources, ‘here the health equipment is lacking…we don’t yet have Timorese specialists…then our health is poor and when there is something serious, we send them overseas to Indonesia or Australia. Some equipment we don’t use, because the patients don’t come and then we store the equipment and it breaks’.
In Cristiano’s health seminar, I asked Octavia, the primary school teacher, what sort of health care the community would like in the future,. ‘We would like doctors and nurses in our community, we would also like our sons and daughters to become doctors and nurses, but we are poor’. Being treated by relatives rather than unfamiliar outsiders and being involved as a community are profound expectations. The legacies of conflict, colonial violence and racism linger in anxieties, continue discriminatory social hierarchies, and reproduce inequality.
‘Our health is in our own hands’
‘Is that the ambulance?!’ Doctors and nurses rushed to the windows of the hospital’s spacious training room. A number of medical staff and I were attending a training session on family planning. We had just heard that a bus from the south coast had crashed on a mountain road not far from the hospital. All staff were now on standby to treat any patients that arrived. We heard two or three people on the bus had been injured, including a mother and an infant who had broken a leg but no one turned up at the hospital. ‘Why are they not coming to be treated?’ I asked Sadie, a young doctor sitting next to me, ‘they will probably look for some local medicine, and anyway, there isn’t a specialist here, like a pediatrician, who could treat the child’s leg, …’ she said sympathetically. When I encountered people with broken limbs in Maubisse they told me they were being treated by local medicine, not at the hospital. ‘This is common’ my friend Mathilde told me, ‘people are scared of their leg being amputated at the hospital’. Not only lack of adequate care, but fear of biomedical interventions means that people seek alternatives through local medicine.
‘Some sicknesses are caused by things from ‘outside’, like imported foods, they must be treated with medicine from the hospital, but some illnesses cannot be treated by hospitals’. Jorge, a local coffee farmer, described to me how sometimes people went to hospital, but the doctors would be unable to find anything wrong with them. He did not link this to lack of medical expertise but rather to local conceptions of health and illness. ‘Spirit ecologies’ are part of relations with ancestors, the land and spirits that inhabit it (Palmer and McWilliam 2019). They affect people’s health and wellbeing in ways that biomedicine cannot treat (also see Trindade and Barnes 2018). Such beliefs are bemoaned and blamed for people not seeking care at hospitals; however when an illness can’t be treated by biomedicine, or when healthcare is inaccessible or unavailable spiritual ecologies are part of plurality of health treatment.
‘Our health is in our own hands’, the Ministry of Health motto, is meant to promote community participation in public health. However the phrase rings too true for those in rural communities who struggle to access hospitals, or when public health care is not available. Despite the government’s efforts and promises to make healthy citizens (RDTL 2018), the media frequently report complaints of inadequate health services linked to lack of staff and facilities (Cardoso da Cruz 2020a). In recent years Timor-Leste’s health sector has faced a declining budget as well as restricted donor funding (Hou and Asante 2016, World Bank 2019). But if people are the country’s most important resource, as the government recently professed during the coronavirus pandemic, then citizens’ welfare should be the highest priority (Cardoso da Cruz 2020b, Neves 2020). In Maubisse, those that can afford it take their health to the hands of private hospitals in the capital or even go abroad. Others rely on traditional medicine and cultural practices that are part of local understandings of health and wellbeing. Unfortunately persisting inequalities and under resourced health services don’t build confidence in a healthcare system that many health professionals are working hard to rebuild through family and community engagement.
Saving lives, saving people
One afternoon I arrived back at the house to find a few of my housemates looking forlorn. They were all health workers. Two days earlier a colleague of theirs lost her child when she didn’t make it to the hospital in time. Today there was news of another death. This time a mother arrived at the hospital in time for delivery. She had attended all her checkups throughout her pregnancy, but unfortunately her son was premature, and the hospital had been unable to save him. ‘He was too early’ Xavio, my housemate said. ‘It’s very sad. We lost a person today’.
The stories of these two newborns show how even when messages of ‘going to hospital’ are heeded, lives can still be lost. Xavio’s feelings of inadequate healthcare were clear ‘This wouldn’t happen in a developed country would it?’ Xavio shook his head and lamented ‘Timor, Timor.’ When people were frustrated at conditions in Timor-Leste, they often reasoned ‘We are a young country, slowly but surely we will move forward’. This encapsulates how the legacy of the Indonesian occupation, its violence and destruction is an obvious obstacle to overcome. It also shows the dissatisfaction with the slow progress of the independence era, a time where healthcare often still falls short of expectations and promises.
The destruction of conflict can haunt a place that has recovered and been rebuilt, but so too can the promise of improvement. Hospitals without people sit in the space between progress and failure, past and present. They are spaces of historical and present experiences, representing salvation and modernity, but also past colonial intervention, racism and persisting inequality. A calm and quiet hospital with fewer patients may be considered desirable in contrast to overcrowded hospitals. In Europe during the coronavirus pandemic people have even been told to stay at home and away from hospitals. However, this means that some categories of people have been excluded from the humanitarian politics of ‘saving lives’ (Fassin and Lipman 2020). Timor-Leste has not lost any lives to coronavirus so far, and the pandemic has forced some improvement to be made to public health, but during my fieldwork many were excluded from accessing everyday healthcare whilst at the same time hospitals represented the promise of change and improvement. ‘Hospitals without people’ are produced in part by the legacy of conflict and colonial occupation, but also linked to visions of the future and development in which biomedical healthcare takes center stage but does not always deliver.
Laura Burke is a final year PhD candidate in Social Anthropology in the School of Anthropology and Conservation at the University of Kent, UK. Her ESRC funded PhD project investigates how narratives about population shape reproductive politics in post-conflict Timor-Leste. Drawing on ethnographic fieldwork in the central mountain town of Maubisse, Ainaro Municipality, her research considers how economic logics, concepts of the environment, and past conflict inform competing narratives about reproduction, population, and prosperity. Engaging with frameworks of reproductive governance and reproductive justice her thesis explores the politics of rebuilding and reproducing life after conflict and crisis. Prior to her PhD research, Laura worked in the UK social sector in human rights and social justice.
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