Timor-Leste, also known as East Timor, is a small nation of about 1.2 million people (World Bank) located less than one hour by plane from Darwin, Australia. It is a fairly new nation whose recent history is marked by a violent struggle for independence from Indonesia. Independence was officially declared in 2002, and Timor-Leste became the Democratic Republic of Timor-Leste (ZNET: East Timor Independence Day: May 20, 2002). Timor-Leste is one of the poorest countries in the world, with health indicators ranking amongst the lowest in the Asia-Pacific region. The country lacks the financial resources and the skilled professionals needed to address healthcare problems. In addition, access to existing services is hindered by geographic conditions (World Health Organization).
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The Royal Australasian College of Surgeons (RACS) has been involved in medical assistance programs in Timor-Leste and in other Asian-Pacific countries for many years. It provides essential surgical services through the Australia Timor-Leste Program of Assistance for Secondary Services (ATLASS), which is funded by the Australian Agency for International Development (AusAID). Ear, nose, and throat (ENT) and, more recently, audiological services have become part of the speciality teams.
ATLASS works closely with the Timor-Leste Ministry of Health to improve access to ENT services and provide specialist training for local healthcare professionals. The program's long-term aim is to ensure the transfer of skills to these workers in the hope that the country will become self-sustaining. Already, Timorese nurses have been trained to identify potential surgical candidates for future ENT team visits. The program also aims to provide audiological training to local healthcare workers soon.
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HEARING AIDS UNAFFORDABLE
Hearing impairment is prevalent in Timor-Leste, and, in our experience, largely preventable. In a recent study carried out through ATLASS, 18% of schoolchildren age 5 to 14 in the Baucau region had failed a hearing screen.
While hearing loss is common, audiological and interventional services are limited, with hearing aids in short supply. With the help of the local health staff, we were able to identify the only two hearing aid services in Dili, the capital and largest city; the staff members were unaware of hearing aids services in any other region of Timor-Leste. The hearing aids sold by these services are basic, and ongoing maintenance and clinical support are unavailable.
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In addition, the hearing aids are unaffordable in a nation where the average monthly wage is less than $US80 (“Opposition Raises Questions of Corruption in East Timor”). The private service sells behind-the-ear hearing aids for approximately US$420 and body aids for US$376, and the local government-funded pharmacy sells these types of hearing aids for US$75 and $55, respectively. Batteries cost 80 cents each.
Timor-Leste had two main education providers for people with hearing impairment until one closed, leaving only the Agape School for the Deaf, which was established in 2004 by Wennie Fernandez, a missionary from the Philippines. The school is run from the garage of Wennie's house in Dili, and it serves students with hearing, speech, or other impairment, who otherwise often are left to wander on their own or are confined to their homes. Classes are taught in American Sign Language, enabling the students to communicate effectively—an opportunity previously unavailable to them.
SCOPE OF PRACTICE
As audiologists, we have had the opportunity to travel with the ENT ATLASS team. Our involvement in the program has been challenging and rewarding. We have provided preoperative and, occasionally, postoperative hearing assessments for potential surgical candidates, who commonly have complex clinical requirements. Our role on the team is often outside the normal scope of practice, as the clinics are quite busy. Thus, triaging patients, scrubbing up for the operating theater, and even keeping a patient breathing during surgery are not unusual tasks for an audiologist.
Interpreters of Tetun, the most common Timorese language, aid in translating audiological instructions to the patients. When interpreters aren't available, a mixture of gesture and a very small amount of the local language can convey the message. Working conditions in the country can be tough. Power outages often occur midway through an assessment, and working in the humidity with no air conditioning adds to the challenge.
A typical trip involves a weeklong stay in a particular region, usually Dili, Baucau, or Maliana. Car trips to the more regional centers such as Baucau are bumpy, with unsealed roads and potholes marking the journey. Driving in the local style is a useful skill that the teams learn. Beeping is not considered rude here; it is more a courteous gesture if anything. Additionally, some unusual road rules exist, and locals have been kind enough to enlighten the teams so as to avoid confrontation. Some of these rules involve the farm animals that constantly wander onto the open road. If one should accidentally hit an animal such as a chicken, goat, or dog, the driver must pay a price nominated by the owner of an animal. If, however, a cat is run over, it is customary to remove the shirt off one's back, wrap the deceased animal in it, and bury it at the site.
Having done five trips between us over the past three years, we have seen the immediate advantages of ENT surgery and the difference it can make in an individual's life. However, securing long-term benefits for the community is a work in progress and will require continued partnership with the local healthcare workers and the Ministry of Health. While diagnostic audiology skills can be advanced within the scope of the surgery-based program, setting up sustainable care and transferring the skills needed to provide rehabilitation and hearing aid services require a different programmatic plan.
The authors wish to thank Malcolm Baxter, an otolaryngologist and key figure in the Royal Australasian College of Surgeons, for his role in including audiology services as part of the surgery-based program and for his mentorship. Thanks also to the wonderful health and education workers in Timor-Leste, who welcome us into their community.
AUDIOLOGY WITHOUT BORDERS
This column highlights the works of humanitarian hearing healthcare programs and is edited by active humanitarians Jackie Clark, PhD, and King Chung, PhD. Dr. Clark is a clinical associate professor in audiology at the University of Texas at Dallas and a research scholar at University of the Witwatersrand in Johannesburg, and Dr. Chung is an associate professor of audiology at Northern Illinois University in DeKalb.
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