Taking the pulse of Timor‐Leste’s cardiac needs: a 10‐year descriptive time‐trend analysis

Abstract

At the time of Indonesian withdrawal in 1999, there were only twenty general doctors for a population of seven hundred thousand (2). By comparison, in Australia at the same time there were 1,787 doctors per seven hundred thousand people (3). In Timor-Leste today, the density of skilled health professionals -1.3 per 1000 population -remains well below the World Health Organisation's recommended lower threshold of 2.3 per 1000 population, and far below Australia's current density of 16.2 health-workers per 1000 population (4, 5). The majority of specialist medical care over the last two decades in East Timor has been provided by outreach medical services from Australian physicians and surgeons (6).The East Timor Hearts Fund (ETHF) commenced work in Timor-Leste from 2002, and was formally created as a charitable foundation in 2010. Specialist cardiologists volunteer in Timor-Leste and perform clinical and echocardiographic assessment . Patients identified as suitable candidates are referred for cardiac intervention (surgical or percutaneous) in Australia, with costs paid for by charitable donations (7). Through ETHF's efforts, Timor-Leste has been identified to have one of the highest rates of rheumatic heart disease in the world; approximately 2% prevalence identified on aThis article is protected by copyright. All rights reserved. screening study of school children in 2016 (8). Two key goals of the ETHF are to provide high-quality specialist cardiac care to Timor-Leste's citizens and to develop in-country resources and training in cardiology, with the ultimate goal that Timor-Leste does not require the services of Australian physicians for the provision of cardiac care. We undertook a review of one decade of clinical activity in order to assess demographics and patterns of cardiac disease presenting in Timor-Leste, quantify our clinical coverage, and assess evolving trends.This study is intended to 'take the pulse' of Timor-Leste's cardiac needs by highlighting areas of evolution to facilitate healthcare planning for the future decade. We anticipate that our experience will be of interest to physicians working in a range of developing countries with limited healthcare resources. Methods:Australian cardiologists travel to East Timor with the ETHF three times per year during the non-rainy season (7). The medical team comprises up to four adult cardiologists and ideally at least one paediatric cardiologist and echocardiographer . Additional medical volunteers may include a general practitioner or cardiac nurses, who assess vital signs and perform six-minute walk tests. Two Timorese interpreters are present at all clinics: one at the reception desk and one moving between clinical rooms. Clinics are primarily based at the national hospital in Dili (the Hospital Nacional Guido Valadares (HNGV) with one outreach day to a different rural area each trip.

Telemedicine to Timor‐Leste: implementing an international cardiac telehealth service during population dislocation, floods and COVID‐19

“…Approximately 300 patients were seen at each clinic over several days, with each patient receiving an interpreter‐guided history, physical examination and focussed echocardiogram performed by Australian cardiologists. The clinics comprise patients invited for review, new referrals from local healthcare facilities and walk‐in patients with self‐reported cardiac symptoms 1 . Data from the February 2019 (face‐to‐face) clinic was extracted for comparison with the online clinics.…”

“…The clinics comprise patients invited for review, new referrals from local healthcare facilities and walk-in patients with self-reported cardiac symptoms. 1 Data from the February 2019 (faceto-face) clinic was extracted for comparison with the online clinics. Parameters included number of attendees, city/town of residence and rates of attendance of patients invited for review.…”

“…In previous publications, we have detailed the difficulties of following up patients given Timor-Leste's minimal postal service and fixed-line telephone services (0.2 fixed-line connections per 100 people). 1,8 While there are 119.2 mobile phone subscribers per 100 people, only 33.6 subscribers are active at any time, reflecting high rates of mobile service turnover and cancellation. For those who had returned to rural areas with a working mobile telephone, only just over half would be anticipated to have telephone coverage.…”

“…The East Timor Hearts Fund (ETHF) is a non‐governmental organisation operating from Australia to assist the cardiac needs of Timor‐Leste. It was created in 2010, and its cardiologists have reviewed more than 2000 patients, 1 with almost 100 cardiac procedures performed 2 . As Timor‐Leste is a low middle income country (LMIC) without in‐country capacity for cardiac interventional procedures or surgery, ETHF plays an important role in the country's health infrastructure.…”

Doctors with borders: the impact of international border closures on Timorese people who need cardiac procedures

“…The prevalence of rheumatic heart disease in Timor‐Leste, a lower middle income country of about 1.3 million people and one hour from Australia, is among the highest in the world 1 . The East Timor Hearts Fund (ETHF; https://easttimorheartsfund.org.au) is the primary facilitator of access to cardiac procedures for people in Timor‐Leste 2 . At the start of the coronavirus disease 2019 (COVID‐19) pandemic, both Australia and Timor‐Leste closed their international borders, and no Timorese patients have undergone cardiac surgery in Australia since March 2020.…”