The first thing you notice on your way into the Bairo Pité Clinic is a small collection of very grubby vehicles; some held together by stickers from sponsors and other aid organisations. Not a bit like the clean white UN Prados and Land Cruisers that line the streets of Dili, these vehicles take clinic staff and visiting volunteers to outreach clinics well beyond the city’s edge.
When your eyes adapt to the relative gloom under the awnings, you see a gaggle of prospective patients waiting their turn for an appointment with Dr Dan. Dan Murphy’s personality looms large in the Bairo Pité Clinic, an NGO that provides a large slice of the acute health care in Dili. An American physician, Dr Dan sees at least 250 patients per day and has dealt with over 500 at times of great need. His tall stature, commanding presence and sharp clinical acumen attract a stream of visiting medical students and junior doctors who join his daily clinical rounds for a regular dose of teaching on the run.
It isn’t long before you start to hear the rattling, productive cough that afflicts many of the clinic’s patients. When asked what the commonest medical complain was, Dr Dan replied that it was without any doubt tuberculosis. You don’t need surveillance data to work out that TB is a huge problem here. But with only acid fast stains available and no concentration or culture methods, laboratory-confirmed aetiology of pneumonia is an unimaginable luxury.
Not just TB. So many of the other conditions seen are either primary infection or the consequences of infection. A snapshot from just a couple of days at the Bairo Pité Clinic included malaria, pelvic inflammatory disease, HIV/AIDS, infective endocarditis, post-rheumatic heart disease mitral stenosis, meningitis, soft tissue abscess and tropical ulcers. Tragically, many of these conditions were easily recognisable because they had been allowed to run their course by patients who lacked the means to do anything about it. Further compounding this sorry tale were the family groups represented by several members attending the same TB clinic.
I was there with a colleague from the Lab Without Walls Foundation, looking at the feasibility of establishing clinical laboratory support for detection of several tropical infectious diseases. We flew in with various bits of portable lab gear in a small collection of air freight boxes, hoping to show the potential for direct molecular analysis of clinical samples in a clinic without much pathology support. We knew there was no culture, but did not know exactly what else had already been done. One thing we were clear about was the need to hose down unrealistic expectations. We were very careful to explain that we were not there to make a diagnosis or to replace an existing conventional approach.
Our planned programme was simple but ambitious. In four days we would run a series of molecular tests at a rate of one type per day: septicaemia, tuberculosis, malaria and PID. We took additional back up for genetic fingerprinting of tuberculosis bacteria, and for identification of other mosquito and tick-borne diseases (dengue, Japanese encephalitis and scrub typhus). But someone mischievous had other plans. First of all, a public holiday was called for the first two working days of the visit, bringing about a modest change of plans and a change of location for our lab work. Secondly, the party mood spilled over to delay our start by a day, and lastly the return to work on our last working day was accompanied by a series of power cuts. Power outages caused run failures on each item of equipment we used, requiring repetition of tests, a great deal of ingenuity and a monumental dose of patience.
In spite of it all, and quite possibly because of it, we had good reason to join the party mood at the end of our working week. The reason we felt an urgent need to pop a bottle of champagne was successful demonstration of the bacteria that cause tuberculosis in clinical samples, starting from scratch. Every bit as exciting (for crazy bug hunters) was the detection of malaria by our in-house molecular method in samples that had been checked and declared negative by standard microscopic examination. Evidently, the molecular (PCR) method is more sensitive than blood film examination. What of the other tests? Time and power supply didn’t allow us to complete our preliminary work on these tests during the deployment. Development will have to continue back at the Western Australian home base. Those celebrations will have to wait until the next Lab Without Walls project deployment.
You have to wonder what health expectations the youngest generation of Timorese have. It is clear to anyone involved in international health development how much could be achieved with a small fraction of the resources at our disposal in Australia. There is another thought nibbling away at the back of the mind – with the right tools and the community support, it might just be possible to eradicate at least one of the headline infectious diseases within a generation. A worthy goal that could be brought a step closer by your support.
More detailed reports on how the work was done will follow: travel reading [FEVER, Sonia Shah, 2010].
MicroGnome’s correspondent in Dili, December 2010.
Lab Without Walls project 2010/Dili/01 is supported by
- The Lab Without Walls Foundation
- PathWest Laboratory Medicine WA
- Rotary Club Applecross
- Applied Biosystems Australia
- Agilent Technologies
- Kyratech and Fisher Biotech
- Air Express Australia
- ConocoPhillips Australia
- Melville Friends of Lete Foho and Hatolia