International Spotlight

Life in East Timor—McKenzie and More

Gill Cammell, NZDipPT, Cert. MDT

Ever since I was at Physiotherapy school (1974 - 1976, Auckland, NZ), I had wanted to work in the developing world.

As a new graduate, I had been particularly inspired by stories of those working in rehabilitation amongst sufferers of Leprosy and victims of landmines in various parts of Asia. I knew that, in these situations, it would be prudent to have a broad base to my clinical experience, so happily entered the public hospital system doing the mandatory rotations in different areas of the hospital.

Even as a youngster who was often mistaken for a school girl, I was at home in medical, orthopaedic, geriatric, paediatric and even burn wards and gymnasiums motivating people to reach towards that next level of function or independence … all except the dreaded Physiotherapy Outpatient Department.  Post-trauma and Post–op I could deal with, but necks and backs scared me. I could not see the pain producers nor understand the mechanics, just putting machines on people was not my cup of tea, and I didn’t really get the point of them either. “Get a real injury” I was often tempted to say. I avoided that area for many years.

A husband and two children later, I had been able to continue to work part-time in a variety of physio roles, even in the community health arena. Physiotherapy had been such a great career for this stage of life!  A two-year stint in the 1980’s working in Sydney followed, but still not yet in Asia.

McKenzie to the Rescue

Once my children were a little older and I was working four days a week in a rehabilitation gym, I was eventually asked to help in the outpatient area – aaaghhh the dreaded backs!!

I vividly remember the first in-service where the McKenzie approach was referred to. Now this was getting easier to understand. Encouragement followed from my senior colleague to go on a McKenzie Part A course and that sounded just like what I needed - it was!

After nearly 20 years working in the public sector, now in a smaller North Island town, I was invited to start a private practice in a local medical centre.

With Part C and lots of outpatient ‘miracles’ under my belt, I was ready. I completed Part D and Credentialing not long after.

Asia at Last

My husband and I had our first awareness of Timor Leste (East Timor) in the 1980’s when journalist John Pilger brought the nation’s plight to the western world with his documentary about the massacre at Santa Cruz cemetery in the occupied nation’s capital, Dili.

Pilger and two others were there to cover a protest march against Indonesia’s brutal occupation and were caught up in the ensuing drama. Their film footage was smuggled out, and finally, the world took the situation seriously. East Timor finally gained its independence in 1999. 

Our first visit was with a team from our town in 2003. We were looking to establish an ongoing relationship between an area of East Timor and our church and town. One week there, and we were sold! The poverty and brokenness of the nation was obvious, but so was the hope, resilience and gratitude of the people for international assistance and the chance to move forward as an independent nation.

My husband and I, along with others from our home town, made regular visits to Timor. I went every second year, spending some time at the National Hospital teaching the nurses who, after some extra input, were running a Physiotherapy Department. In later years, also encouraging Timorese who had returned from Physiotherapy training overseas via scholarships, helping community workers and visiting disabled people in their homes among other things. 

I enjoyed connecting with local physiotherapists in different ways over the years.  New graduates face many challenges on their return to government placements, not least of which is a general lack of understanding about physiotherapy and how to use it effectively in the health service. This is especially a problem when placed as sole physios in a district hospital.

As a keen amateur photographer, I also found Timor an excellent subject. I seldom tired of capturing the beauty and character of the land and people.

Living the Dream

It was not long before our children had left home and we were looking for an opportunity to move to Timor. As the nation developed, we wondered if a private physiotherapy clinic would be viable. There were certainly a lot of international NGO (Non-Government Organisation) and UN (United Nations) workers in the Capital.

By our next trip to Timor, there was already a private physiotherapy clinic advertising its services, started by an Australian Physio whose partner was stationed in Dili. “Would I like to do a locum next year?” and “By the way, it will be for sale at the end of the year”.  Come January 2011, and we were on another adventure, doing business in the developing world and in the world’s newest nation!

Timor Leste (East Timor)

At the time we arrived, the World Bank had just published its ‘Ease of doing Business’ survey results. Timor Leste was fourth from bottom, assisted only somewhat by its number 11 status in the tax category. I’ll not take up space in this article to elaborate on our challenges in this area, except to say it was nearly a year before we finally had a registered business.

The culture of health was the next, though not quite so steep, learning curve.  My clients were made up of aid workers, volunteers and business people from an amazing number of nations with widely differing beliefs about health and all things medical.  To add to that, very few of them understood about physiotherapy or had been exposed to a very different experience of physiotherapy in their home country than the way I practice. 

I saw many Chinese based health clinics and pharmacies pop up - to the point where I was initially refused a practicing certificate as the Health Department were clamping down on foreigners taking jobs from Timorese.

Often called ‘Dr Gill’, I have been asked to cure problems ranging from internal organs to psychological issues. Physio-wise, many were expecting to be given medicine, massage and sometimes acupuncture.

McKenzie

How do you take someone through a McKenzie MDT assessment with only low levels of common language? In my experience, I found that MDT had significant applications with many able to understand enough from the repeated movement and sustained posture testing for the ‘lights to go on’. Although a new concept, they experienced enough improvement to continue to work on their posture and home program with pleasing results.

At a quick glance through my assessments, my client’s complaints were: spine 53%, peripheral 44% and other 3%.

The big step was in convincing clients that they could play a major role in their own recovery, learn to manage their own pain without drugs and attain a full recovery with very little ‘hands on’ therapy. New Zealand and Australian clients were likely to expect this, but few others.

Ergo – What?

Poor ergonomics was by far the biggest pain-producing culprit. People were invariably working in desk jobs with poor quality, ageing furniture. Chairs were weak, and even if they had a new one, it was only a matter of months before the support had gone, especially for a foreigner who is usually many kilograms heavier. Few chairs and no desks are adjustable, which is also a challenge for the smaller Timorese.

A box, or similar, to put feet on under the desk was generally able to be arranged but lumbar rolls were my main challenge. Desperately needed, but not viable to import, I had to seek a local solution.  Rolled-up towels will only do the job for so long!  For me, the removable cover with elasticated band was as important as the roll itself, so I made a sketch, took it to a Brazilian dressmaker and we were away. The rolls left the clinic in a steady stream. They are now made by Timorese women at a local sewing co-operative, which I’m very pleased about.

Beds are generally firm and less of an issue, but a good pillow is very hard to find. I was excited to find one store that stocked feather pillows, as were my patients. These pillows even had a zip in the side enabling size adjustment. The small things that make your day in the developing world!

In my last year in Timor, I was also pleased to be invited to a few workplaces to teach spine care and do ergonomic assessments. I also had the opportunity to do a talk on back care for the local Rotary Club and to advise the European Union regarding the purchase of new office equipment.

After four and a quarter years in Timor, it was time to return to New Zealand. This was to be almost as much of an adjustment as it was to settle into Timor. It is amazing how fast everyday things have changed, not to mention the developments in physiotherapy practice and protocols. Here the challenge started again!

I am thankful for the adventure and also for the friendship and support of my longstanding McKenzie oriented friends and colleagues.