Ignorance that kills

Ignorance that kills:

Many Indonesian women face great difficulties in accessing safe terminations of unwanted pregnancies

Inna Hudaya

At the global day of action for safe and legal abortion, 28 September 2012, in Yogyakarta. Activists participated in a street campaign and mural art - Samsara
I was 22 years old when I had an abortion at six weeks. The abortion took place in a hotel room in Solo, Central Java. A lady in her fifties performed the procedure; I had never met her before and I still do not know her name. It was a confronting situation to open my legs and let her place her hands in my vagina without even knowing who she was. Stressed, and without any pain killer, I could feel my vagina tightening, but I had to hold the pain.
After it was over, I handed her an envelope with the money inside. Transaction completed. I had no right to ask any more of her. As long as she performed the abortion I needed, that was as much as I could hope for.
A few years later, in 2007, I started a blog that shared my abortion experience and related how I had recovered from it. I began to receive many emails from women all over Indonesia whose experiences were similar. Today, five years later this blog is the first page that comes up in a google search when women in Indonesia look for information about the choices they might make when dealing with an unplanned pregnancy and seeking a safe abortion.
It turns out I was far from alone. Women all around Indonesia face great difficulties in getting access to safe abortion, and in dealing with the aftermath of their ability, or inability, to access the procedure. Many people blame us (women) for this situation. They say we are stupid for having unsafe sex leading to pregnancy. But in fact, the sources of the problem go much deeper. I would like to challenge all of us to go beyond the personal, and start examining the social, political and legal dimensions that lead so many Indonesian women into dangerous, stressful and damaging experiences with reproductive health. The problems start with Indonesian law.

Government policies

Article 75 of the Health Law of 2009, states that abortion is illegal except in a limited number of cases including when pregnancy endangers the mother, when the foetus shows signs of abnormality such that it would be unlikely to survive outside the womb, and when the pregnancy is the result of rape. Anyone who has an induced abortion for other reasons can be punished by up to 10 years imprisonment, or a fine of up to one billion rupiah (approximately US$ 105,000).
The law adds a critical qualification: abortions meeting this narrow set of criteria can only be performed before the sixth week of pregnancy. In addition, women seeking an abortion should go through a process of counseling; the procedure should be carried out by a certified and authorised medical practitioner. Women also need the permission of their husband, except in cases of rape.
In short, though the law appears as if it expands access to safe abortion when compared to the preceding law it is so restrictive that it effectively makes it impossible in most cases. Many women do not even know they are pregnant until after six weeks, and, as the law is written, it even suggests that abortion in cases of rape cannot happen after this time frame. The law ignores the interests of most women who might seek an abortion. Most importantly, it fails to see women as empowered individuals capable of making decisions about their own lives. And to make matters worse, despite the law’s ambiguities, there is still no implementing regulation which might provide a more clear set of guidelines.

Social realities

A flashmob event in October 2011 in Yogyakarta to launch Samsara’s hotline number - Willow Paule
One of the many problems with the law is that it assumes that all women wanting an abortion will be married. In this respect, it is like most laws and policies related to sexual and reproductive health services in Indonesia, which target only couples or married women.
Yet every year in Indonesia, many young, unmarried women become pregnant. The reality for many of these young women who experience an unplanned pregnancy is that they will have diminished access to education, health and employment. Young girls who become pregnant are often forced to marry, even though they may not have been planning to start a family. Becoming economically dependent, many such women end up powerless and stuck in unhealthy relationships, experiencing poverty or domestic violence. Such women cannot contribute to their communities, the broader society or the economy.
By ignoring young unmarried women, the state simply fails to protect women from the risks that can result from pre-marital sex. In other words, it makes the right to health available only to those who are married. Even simple procedures like the papsmear test are not available to unmarried women in most public hospitals. And the situation can be even worse for unmarried women seeking an abortion. Let me share just a couple of the stories that have come to me through my counselling work, though of course I will not use the real names of the women concerned.

Maria and Dian’s stories

Maria, a young girl from Bandung, was diagnosed with an incomplete abortion. Her doctor advised a D & C (Dilation and Curretage) should be performed immediately in order to save her life. While she was laying in the operating theatre, the doctor found out that she was not married. He decided to cancel the D & C. He stated that hospital rules do not allow staff to perform such procedures on unmarried women without family consent.
Dian had her abortion at 16 weeks of gestational age. This was a very traumatic experience for her. Because she did not have enough money, a clinic in Jakarta referred her to a cheaper place. She was driven by a person she did not know and dropped off on a street where she had to wait for another car. Several other women were in the car, all experiencing the same situation. All had their abortions that evening. Dian had her procedure without painkillers or anesthetics. She was told just to withstand the pain. She remembers that she could hear other women moaning miserably. Before the morning came, she was told to leave. Still struggling with the pain, confused and alone in an unfamiliar place, she had to find her own way home.
We all expect healthcare providers and medical staff to promote our health and protect our lives. Maria and Dian’s experiences show, however, such people often exhibit arrogant and uncaring attitudes towards women in need. Part of the problem is that the lives of women become secondary to the moral judgments enshrined in state policies. Women who are unmarried get shunned, for example. And because the state’s policies fail to provide all women (for instance, those who are more than six weeks pregnant) access to safe abortion services, abortion is driven into the shadows. It stops being a matter of public health and women rights, and is turned into a business. And business without clear regulations or enforcement is exploitative. In the end, women's bodies become commodities that are exploited for profit.
Having an abortion at 16 weeks without anesthesia is something you can’t imagine. It should not be experienced by any woman. Yet Dian’s experience is not unique. Many women have these procedures without pain relief. And many of them experience violence or other humiliating treatment.
One of the problems with the illegality of most abortions today is that women who seek the procedure end up having to deal with what is best described as an abortion mafia: a network of brokers and shady clinics, many of which cheat the women financially, or subject them to abuse. One woman, for example, told me that she was asked to have sex with a broker before she was taken to a clinic because the money she carried was not enough for her abortion. Another recalled how when her abortion was performed, she was in the same room with three other women, and had to watch their procedures.

A better way is possible

In September 2012, I had the opportunity to visit a health clinic in Penang, Malaysia. One service it offers is safe abortion. For three days, I observed all the procedures in the clinic, starting from administration, through to counseling, examination and the abortion procedure itself.
It was quite an amazing experience for me. How they dealt with abortions shook my reality. They allowed me to be in the operating room and I observed an abortion performed by a doctor on duty. The doctor explained the procedure step by the step, including how anesthesia was given. The clinic provides three types of anesthesia: the common pain reliever that affects brain function, a local anesthetic injected in the cervix, and verbal anesthesia. Verbal anesthesia was performed by a specialist nurse who was there just to talk with the patient during the procedure. They perform the procedure in under 15 minutes. It was safe, simple and fast.
I visited patients in the recovery room. Both patients with whom I talked said that they did not feel pain during the procedure. Pain management started when the women first entered the clinic. In addition to pain relief, the attitudes of the medical staff and the clinic’s athmosphere really helped the women to feel safe and secure. It was a women-friendly service.
I explained to one of the doctors that many of my clients in Indonesia told me that their doctor did not provide anesthesia because the cost was so expensive. ‘But here, with a very low charge you can provide three types of anesthesia. Don’t you lose money?’, I asked. The doctor answered: ‘It
depends on what your intent is. If money is the goal, then certainly you will lose money. If the intention is to help women, you don't lose anything but gain benefit for the woman herself.’
This answer brought home to me what a new experience it was to see this service in action. But it also made me reflect sadly on the situation in Indonesia, where the dramatisation of abortion, and all the secrecy and stigma that surrounds it, is a result of a conspiracy of ignorance and systemic failure and discrimination.

Respecting women

Abortion is a medical procedure that can save the lives of women. The process should be simple, fast and safe. If the information and medical technology are available and accessible, why should abortion be tragic and traumatic, as it so often is in Indonesia?
The answer is that Indonesia has its priorities wrong. The state should be prioritising provision of information and education about sexual and reproductive health, rather than criminalising women who have abortions. Lack of basic knowledge and skills about sexual and reproductive health is the root of the high number of unplanned pregnancies, sexually transmitted infections, and unsafe abortions, and of a lot of violence too. The state needs to be remedying this problem.
And when a woman decides she needs an abortion, the state should help her have one with safety, security and dignity. In the end, recognising the autonomy of women to make their own decisions about the issues that affect their lives is the central pillar of women's rights. And women’s rights are human rights, which the government of a democratic Indonesia should be dedicated to protecting.
Inna Hudaya (inna.hudaya@gmail.com) is the founder of, and senior counselor at, SAMSARA, an organisation dedicated to providing education and counseling on abortion issues in the context of sexuality, reproductive health and rights and gender equality. She also runs the ‘Ask Inna’ web page which provides information to women considering having an abortion and advocates on reproductive health issues.

Inside Indonesia 111: Jan-Mar 2013

Disease control in democratic Indonesia

Disease control in democratic Indonesia:

As infectious diseases spread, strategic governance becomes ever more important

Scott Naysmith

Caged birds ready to be transported in Lampung - Scott Naysmith
Indonesia is struggling to manage the burden of infectious diseases. In parts of Java there is a resurgence of diphtheria in children, stemming in large part from parents’ resistance to vaccinating their children. Public health officials across the archipelago are finding a greater than expected prevalence of lymphatic filariasis, commonly known as elephantiasis. Polio, once believed eradicated from the country, was reintroduced around 2005 by returning pilgrims infected while performing the haj in Mecca. Avian influenza has infected and killed more people in Indonesia than in any other country. These and other communicable diseases not only cause great suffering for those infected, but they also negatively impact on social and economic development and will increasingly compound the effects of non-communicable diseases, such as diabetes.
Controlling infectious diseases hinges upon a government’s ability to implement effective interventions. Since independence, Indonesia has experienced drastically different forms of government, ranging from centralised authoritarianism to decentralised multi-party democracy, each bringing unique constraints and opportunities to the task of containing infectious diseases. Whereas Suharto was able to employ coercive strategies for containing disease, the decentralised structure of government in contemporary Indonesia needs to pay more attention to providing incentives to local populations so that they participate in and comply with disease control programs.

Authoritarian responses to disease

In 1966, when the World Health Organization (WHO) formulated the global strategy for the intensified Smallpox Eradication Program, Indonesia was the second worst affected country after India. Smallpox programming was plagued by significant financial and logistical challenges. Historically, smallpox eradication was underfunded by the government and the international community. There was also a dearth of infrastructure and limited public health capacity to support vaccination and disease surveillance and reporting. Moreover, some parents believed that the vaccine harmed more than helped and consequently resisted vaccination for their children. And then there was the burden of geography: as one WHO observer noted in 1974, all you had to do was look at a map of Indonesia to realise the challenge of eradicating smallpox from every corner of the sprawling archipelago.
Despite these many barriers, doctors diagnosed the last case of smallpox in Indonesia in 1972 and then declared the country smallpox-free after a period of 18 months with no new infections. What accounts for the program’s success in the face of such serious challenges?
There are many factors that led to the eradication of smallpox in Indonesia, but a fundamental feature of the program was the commitment and strong-arm tactics exercised by Suharto’s New Order government. The New Order government understood that eradication would be successful only when every last case had been identified and contained. Through central government decree, Jakarta implemented an unwavering campaign, using soft coercive practices to ensure people complied with programming. The government employed all elements of the security forces, including the police, national armed forces, and hansip (local defense forces) to track unvaccinated persons, enforce quarantine and vaccination, and ensure cases were reported to government officials. Participation in smallpox eradication was not optional and there was little space for individuals or local authorities to resist or avoid the program. Later, the WHO pointed to Indonesia’s successful eradication of the virus as a positive example in the difficult final years of eradication programming in India and Bangladesh.

Decentralisation and disease

Shoppers handling live birds in a market in Lampung - Scott Naysmith
After Suharto’s government collapsed in 1998, Indonesia underwent a drastic and rapid reordering of political authority. Guided by international institutions like the World Bank and the International Monetary Fund, Jakarta relinquished much of the responsibility for health services to district level administrations. The results have been mixed.
To an extent, decentralisation has promoted local ownership of health priorities and created opportunities for tailor-made interventions suited to local contexts. At the same time, decentralisation has weakened rural health structures and created disincentives for preventative public health. With local officials now allocating funding and setting priorities, infectious disease containment has become more difficult. Infectious diseases are apolitical: such pathogens do not recognise political boundaries and readily travel on the backs of birds and in the lungs of people as they cross the country. As a result, controlling infectious diseases demands coordination at every level of government – a requirement at odds with the decentralised structure that currently defines Indonesian politics.
Nowhere is this more apparent than in recent attempts to contain avian influenza, commonly known as bird flu or the H5N1 virus. Live birds host H5N1 and since 2003 the virus has been found in every province. People who live and work intimately with poultry are considered the most at-risk for becoming infected – a particular problem considering that most Indonesians raise birds at home. The mortality rate for Indonesians infected with H5N1 is, incredibly, above 80 per cent.
Controlling the spread of the virus is difficult as millions of birds travel from farms to markets across district and provincial borders, loaded on trucks and along the sides of motorbikes, every day. Though some district officials actively seek and test poultry for avian influenza, such activities can be rendered null by both the movement of poultry and when neighbouring officials fail to take similar precautions.
Government officials are rarely aware of programming or disease outbreaks in nearby provinces. Aceh, for example, imports the vast majority of birds from Medan, a hub of commercial poultry farming that has experienced repeated outbreaks of avian influenza in both commercial and backyard poultry stocks. Yet Acehnese officials in charge of animal health in districts receiving thousands of birds a week from Medan have never met with their counterparts in North Sumatra. Such knowledge sharing is crucial to contain the disease.

Incentives not enforcement

The main strategy for containing avian influenza is depopulation – culling – of suspected infected poultry. This requires encouraging bird owners to report suspected infection in their flocks and then watch as their birds are killed. District and provincial governments have been inconsistent in their application of this tactic since 2003. Compensation for culled birds is extremely rare, and if money is disbursed it is paid at below market value. Some bird owners have taken to hiding their flocks from government officials to avoid loss of livelihood. Many farmers in Aceh, Banten, and Lampung report that they sell their birds promptly at the first sign of sickness. In short, there is both an inability to enforce culling coherently and insufficient compensation to encourage wide-scale reporting of sick poultry.
In the absence of a strong centralised system to track, report, and enforce disease control programs, all levels of government – central, provincial, and district – must ask what levers of political power exist to contain infectious diseases that readily spill across provincial and district borders?
While top-down methods preferred by the New Order government are relegated to history, the central government still has a significant role to play in containing infectious diseases. Jakarta must support the provinces and districts with financial and political commitments, and assist in brokering interventions sponsored by bilateral and multilateral donors. Provincial and district governments must commit financial and human resources to long-term programming extending beyond the tenure of their elected officials. The central government can and should provide a forum for better cooperation across political boundaries. Ultimately, however, understanding what economic and social incentives exist for local populations to participate in and comply with infectious disease control programs will determine the success of these interventions in decentralised Indonesia.
Scott Naysmith (scottnaysmith@gmail.com) is a doctoral candidate in the Social Policy Department at the London School of Economics and Political Science and a Trudeau Doctoral Scholar, supported by the Pierre Elliott Trudeau Foundation.

Inside Indonesia 111: Jan-Mar 2013

Where there’s smoke, there’s politics

Where there’s smoke, there’s politics:

Campaigns against smoking are finally gaining ground, but the tobacco lobby is fighting back

Andrew Rosser

Smoking is a major killer in Indonesia - Jimmy Walsh
‘Support Smoke Free Jakarta’ reads a sign posted at the front entrance of the Century Park Hotel, an international class hotel in Jakarta’s Senayan area. When I first stayed at this hotel a few years ago, it offered rooms on designated smoking and non-smoking floors. But now it is almost completely smoke free; the only part of the hotel where smoking is permitted is the outside bar area. By contrast, many other top hotels in Jakarta still have dedicated smoking floors.
The Century Park’s decision to go smoke-free and advocate a smoke free Jakarta doubtless reflects a commercial judgment by its owners and managers. But it also reflects increasing activism on the part of anti-smoking groups following the country’s transition to democracy. This activism has led to increasing concern about the popularity of smoking in Indonesia and its negative effects on people’s health and welfare.

A nation of smokers

More than one-third of Indonesians aged over 10 years smoke according to Ministry of Health figures. And the number is rising. Between 1995 and 2010 the proportion of men who smoke rose from 53 per cent to 66 per cent while the proportion of women rose from 1.7 per cent to 4.2 per cent. With such a large number of smokers, passive smoking – that is, the involuntary inhalation of smoke from other people’s cigarettes – is also extremely widespread. An extraordinary 78 per cent of adult Indonesians are exposed to passive smoke at home according to the 2011 Global Adult Tobacco Survey.
At the same time, smokers are getting hooked at ever younger ages. Between 2001 and 2010, Ministry of Health figures suggest that the number of people who started smoking between the ages of 10 and 14 rose by 80 per cent, while the number who started between five and nine years of age quadrupled. In 2010, two-year old toddler Ardi Rizal became an internet sensation when video footage of him puffing away on cigarettes went viral on YouTube. Severely obese, he was reportedly consuming 40 cigarettes a day until he did a deal with his parents to quit smoking in exchange for new toys. His case, the many similar ones that have since been reported in the mass media, and the widespread nature of passive smoking illustrate graphically that Indonesia’s smoking problem affects people of all ages.
The health and welfare effects of this epidemic are immense. According to one recent study published by the International Union Against Tuberculosis and Lung Disease, smoking kills at least 200,000 Indonesians each year while also contributing to lower economic productivity through reductions in physical functioning, lung capacity, and more frequent illness. It also reduces welfare – particularly in poor households – to the extent that cigarette purchases often displace spending on necessities such as food, clean water, health care and education.

Anti-tobacco activism

Driven by concerns about these issues, anti-smoking organisations – the most prominent of which are the National Commission on Tobacco Control, the National Commission for Children’s Protection, the Anti-Corruption Coalition on the Tobacco Clause, and the Indonesian Women Without Tobacco Association – have lobbied actively in recent years to persuade Indonesia’s political leaders to introduce stronger controls on the advertising, sale and consumption of tobacco. And with the support of some figures in government, such as the late Health Minister Dr. Endang Rahayu Sedyaningsih (who ironically died from lung cancer in early 2012), they have had some success.
In 2009, Indonesia’s national parliament enacted a new Health Law that included tobacco in its list of addictive substances and provided for the establishment of dedicated Smoke Free Zones in public places. In August 2011, President Susilo Bambang Yudhoyono said that he would support a proposed government regulation on tobacco control that, among other things, requires cigarette producers to provide pictorial as well as written warnings on cigarette packets and prohibits children from buying, selling and consuming cigarettes (although this regulation has still not been issued). Finally, many regional governments have moved to implement the 2009 Health Law’s requirement for Smoke Free Zones in their respective regions: in December, Vice Minister for Health, Ali Ghufron Mukti, announced that 58 district-level governments and three provincial governments (Jakarta, Bali and West Sumatra) had passed regional regulations providing for such spaces.

Tobacco fights back

Anti-smoking groups have not had things all their own way, however. The country’s smoking lobby – the key elements of which are major cigarette producers such as Gudang Garam, Djarum, British American Tobacco, and Philip Morris; groups representing tobacco farmers; and smokers’ rights groups – has actively resisted efforts to impose controls on tobacco at virtually every stage. Cigarette barons have good political connections and enormous financial resources at their disposal – they are among Indonesia’s wealthiest people according to rankings published by magazines such as Forbes and GlobeAsia – and tobacco farmers are well organised and arrange effective public protests. Together they have had the capacity to frustrate, if not completely stop, anti-smoking groups’ efforts to promote reform.
For instance, it is widely believed that major cigarette companies persuaded President Yudhoyono against appointing Nila Djuwita Anfasa Moeloek, the wife of a well-known anti-smoking campaigner, as Health Minister in 2009. It is also believed that they successfully bribed legislators in the national parliament to remove articles in the 2009 Health Law referring to tobacco as an addictive substance before it was signed by the President (although, once the changes to the law were publically exposed, Yudhoyono subsequently insisted that the missing articles be reinserted into the law).
Members of the smoking lobby have also challenged parts of the Health Law through the Constitutional Court, winning a case last year that forced the Jakarta city administration to annul a 2010 regulation prohibiting smoking in workplaces and public places. The ruling makes it compulsory for government and privately-owned buildings to provide dedicated smoking areas.
Finally, over the past year tobacco farmer groups have actively lobbied against the proposed government regulation on tobacco control, threatening to vote informal at the next national elections if it is enacted. This political challenge has clearly swayed the views of some politicians and appears to be the main reason why the proposed government regulation on tobacco control has not been issued so far.
How this contest between pro and anti-smoking groups will play out in the future remains to be seen. But what is clear is that the issue is not as straightforward as perhaps it should be. The politics surrounding the issue means that there is a real prospect that the health of millions of Indonesians, including many children, will be sacrificed to serve the narrow interests of powerful cigarette companies and tobacco farmers. For politicians, the issue is, and will continue to be, a major test of political will.
Andrew Rosser (andrew.rosser@adelaide.edu.au) is associate professor of development studies and an Australian Research Council Future Fellow at Adelaide University.

Inside Indonesia 111: Jan-Mar 2013

Medicine for a sick system

Medicine for a sick system:

Healthcare in Indonesia suffers from many chronic problems that only healthier politics can cure

Elizabeth Pisani

A young girl helps her mother at a medicine stall in a market in Bowae, Flores. Inappropriate self-treatment has led to very high levels of antibiotic resistance in Indonesia - Elizabeth Pisani
A community meeting in the Papuan highland district of Paniai, mid 2012. People have come to talk to the district head (the bupati) and the head of the health department about service provision. Except the bupati is not there; he’s gone walkabout in Jakarta and is being represented by the (Javanese) second assistant district secretary. And the head of health isn’t there either; he has something better to do, and has sent the (Torajan) secretary for health.
The crowd rounds on the secretaries: ‘What’s the point of regional autonomy if all the service providers are from outside, and all the money goes to buying flash cars for functionaries from other islands?’, asks one gentleman. ‘We want to be seen by [health staff from] our own people!’ There was a lot more in the same vein: people are clearly cross that decentralisation (and in this case, Papuan regional autonomy) is not delivering what it promised: health services that are better suited to local needs.
The secretary for health heard them out. Then, quietly: ‘There are five Papuans in Paniai trained as midwives. Five. And not one of them wants to work with patients.’ He went on to explain, with an unprecedented frankness clearly born of frustration, that because these five are the only locals with any health qualifications, every single one of them has lobbied to run a puskesmas, or primary health clinic.
He reminded the crowd, too, that the department has given 30 motorbikes to puskesmas throughout the district to use in outreach and service delivery. ‘After just a couple of months, you don’t see them anymore, lost, maybe, broken maybe, who can say?’ Seven out of seven speedboats given to puskesmas to serve the populations around Paniai’s lakes had also evaporated or rusted into disuse, he said.

The logic of dysfunction

The case of Papua is extreme; trained health staff are in exceptionally short supply there and new districts (kabupaten) and municipalities (kotamadya) have been budding off with great virulence – there are now 38 kabupaten/kota across two provinces where there used to be just eight grouped in a single province. But it highlights what ails Indonesia’s health system as a whole. The motorbikes and speedboats, for example: they may just have been stolen, but it is just as likely that that have failed because of poor maintenance, or simply run out of petrol. The situation is a lot worse with medical equipment, which generally requires trained staff and reagents or other supplies to keep it running, besides needing to be professionally maintained.
I have several times seen expensive equipment still sitting in its wrapping because no-one knew how to use it. In an office in the Ministry of Health in Jakarta, I once found two computers unused because they had three-pin square plugs on them instead of the Indonesian standard two-pin round. Rather than spend a few pennies on adaptors, the division had requested funding for two new computers from a foreign donor. Absurd though this seems, it’s quite rational. The incentives in the health system are stacked heavily in favour of capital spending: it allows politicians and their flunkies to show off concrete investments and to take kickbacks; recurrent spending, including maintenance, is harder to turn to the advantage of functionaries.
This logic was present even in a more centralised system; it has been aggravated by decentralisation because directly-elected local government heads are especially keen to be photographed with high-profile, capital-intensive services: the new hospital building, the MRI scanner, whether or not they are needed. In many cases, they are not. Districts with small populations don’t need equipment to diagnose rare conditions – they’d be better off sending people to a reference hospital elsewhere. That’s fine if there’s a provincial hospital handy. But Indonesia is hamstrung by its administrative structure as well as its geography.
On the island of Lirang, in Southwest Maluku, I watched a frail old woman being hauled up from a fishing boat to the deck of a cargo boat (there is no functioning port). She needed to go to hospital, but of course there is no hospital in Lirang, nor should there be: only 8,000 people live in Lirang and the four other islands in the sub-district of Wetar combined. In pain but remarkably resigned, this woman sat next to me on the deck of the boat for three days and three nights before arriving at Saumlaki. That gave us lots of time to chat. Why, I asked, did she not go in the other direction to Kupang, a much bigger city with better facilities only a day and a half from Lirang? Because, she replied, Kupang is in NTT (East Nusa Tenggara), a different province.
As a resident of Maluku, this woman could not use her health insurance in NTT. Saumlaki would be difficult enough, because it is no longer in the same district as Lirang. Health services in Saumlaki, Southeast Maluku, are no longer funded to care for patients from the newly excised Southwest Maluku. ‘But if you know people from the old days, you can usually fix it with a bit of this,’ the lady rubbed forefinger and thumb together. The administratively correct alternative would be for this sick 70-something year-old to travel another three days to the provincial capital of Ambon.

Missing in action

Petty political jealousies and funding arrangements often undermine cooperation between new districts and those from which they have been split, the mother district or kabupaten induk. Hospitals and doctors are concentrated in larger towns and cities. When a town gets promoted to become a municipality, or kotamadya, the rump district is left with few facilities. Often they build health facilities – that photo-op for the district head again – but then have trouble staffing them. To give just one example from a recent World Bank expenditure analysis in South Sulawesi, there are an average of 2.2 health facilities per 10,000 people in the municipalities in that province, with 41 qualified medics for the same number of people in those municipalities. The rural kabupaten have rather more facilities: 3.2 per 10,000 people, but those 10,000 are served by just 13 trained health staff.
A neglected community health centre (puskesmas) in Lombok. Incentives for capital spending mean a new puskesmans has been built 10 kilometres away. This facility now languishes in the care of a single midwife - Elizabeth Pisani
Indonesia’s ratio of health providers to population is among the lowest for a country of its income level. So I was surprised, in well-funded Aceh, to run in to an Acehnese graduate from a nursing college in Jakarta who had been working on an ad-hoc basis in a private clinic for the last two years. ‘I can’t afford to get a job in the puskesmas,’ he said. The going rate to get a prized job as a civil servant nurse in East Aceh is 60 million rupiah, paid under the table to some individual in a local government that will then provide a salary of around three million a month.
Health staff often repay the debts they incur getting a job by operating private practices after hours. On the Maluku island of Banda Naira, I stopped for a coffee in a road-side kiosk directly opposite the local puskesmas. The owner was cradling his sick child. Why didn’t he take the kid across the road? I asked. The puskesmas appeared to be open, and even staffed. ‘I’m waiting until evening, when you get the strong medicines. In the daytime you just get the over-the-counter stuff (obat warung).’
People appear to believe that the often free healthcare provided by a growing number of provincial and district governments is not worth having; they would rather pay to see the same doctor at home after hours. Two thirds of doctors at puskesmas run private clinics, and the proportion is highest in rural areas. They don’t seem to be short-changing the people who they see at the puskesmas in terms of diagnosis, at least (how they distribute the drugs the government supplies is less well studied, though there are some eye-popping examples of abuse in the drug supply system: see for example Michael Buehler’s article on HIV drugs in Inside Indonesia). Evidence from the Indonesian Family Life Survey suggests that health staff in public facilities are as good or better at following diagnostic procedures as those in the private sector. When they turn up for work, that is.
Staff absenteeism is a huge problem in the public sector. In a 2006 study published in The Journal of Economic Perspectives, researchers did spot checks on puskesmas in 10 provinces and found that 40 per cent of staff were not at work; doctors were more likely to be missing than nurses or midwives. The government has tried to address this problem by obliging recent graduates from medical school to do at least six months on a relatively well-paid temporary contract in a remote area, but this scheme creates other headaches associated with uncertainty and high turnover. Allowing doctors on state salaries to run parallel private practices is one way of trying to keep them in remote islands and rural areas. And if it doesn’t increase absenteeism too significantly, a shift to private practitioners by wealthier patients might free up more resources in the public system for poorer families.
Another step Indonesia is taking to address low staffing ratios in the health system is to increase medical education. A growing number of nursing and midwife schools are now pumping out more than 10,000 new midwives and 34,000 nurses each year, even though it’s really not clear what they are being taught. There are efforts underway to get some kind of an accreditation system in place, but there are currently no agreed standards for medical education and no real quality control. In medical schools, the huge number of applicants has created wonderful money-making opportunities. It is an open secret that securing a place at medical school will cost a minimum of 10 million rupiah for students with good grades, ranging up to 250 million for those who don’t have even the basic qualifications. Exam results are for sale too.
Not surprisingly, then, health staff have not increased in quality as much as they have in quantity. According to a 2006 World Bank study on the provision of health services in Indonesia, while the number of doctors jumped by 26 per cent and the number of midwives by 12 per cent in the 10 years to 2006, their score for diagnostic performance barely budged in that time. It remains worryingly low; when last measured, only two thirds of health workers in the public sector were correctly diagnosing common illnesses in kids. In adults, they followed correct procedures little better than half the time. But there’s no clear system for holding providers to agreed quality standards even in the public sector; the private sector is almost totally unregulated.

Whose job is it anyway?

In theory, the Ministry of Health in Jakarta calls the shots on standards, not just in medical education but in service provision too. It creates national guidelines for all manner of things, from lab procedures to treatment of individual diseases. But the system which used to funnel these guidelines from the centre through the provinces to the service providers in the public sector has broken down. So has the system which used to funnel data on disease distribution from the districts to the centre. That’s critical, because viruses and cancers do not recognise district boundaries.
In health intelligence as in military intelligence, someone with a national overview has to be planning to prevent threats and distribute troops rationally across the whole country. Now the epidemiological Big Picture has been lost because districts no longer routinely report data to the provinces, as they are meant to. ‘Part of my function is supposed to be to map health needs against the population, then take that to the bupatis and the district planning boards and argue for the rational distribution of funds,’ the head of one provincial health department told me. ‘But the money goes straight from Jakarta to the districts, who can do whatever they want with it. All we can do is sit at the side of the road and watch.’
The role of the standards setters and quality assurers is restricted in another important way. The single most important health facility, the district hospital, does not answer to the district health department. The head of the hospital is a political appointee, answering directly to his or her patron, the bupati. This is sometimes a strength: visionary hospital heads can choose to cooperate with puskesmas and other actors to lift the performance of the whole district health system. But not all hospital heads are visionary, or even qualified; the health department has no leverage over them at all.
The Ministry of Health in Jakarta continues to hold a few trump cards. It does a lot of the hiring and deployment of doctors who have civil servant status. And it still controls the too-many programs which focus on single diseases or issues: HIV, TB and malaria are current favourites. Many of these programs reflect the institutional priorities of various donors and the current fashion in ‘global health’ more than they reflect Indonesia’s needs. But they are well-funded, and provide the centre with an important source of both income and patronage. These vertical programs greatly distort priorities at both the national and the local level.
The most egregious example is probably the area in which I worked for many years, HIV. In 2010, Indonesia spent US$ 69.2 million preventing HIV infections and AIDS deaths. Sixty per cent of that was taken out of the wallets of taxpayers in other countries. A chunk of it went to establishing and supporting district and provincial AIDS Control Commissions even in places with no real epidemic, lots more went to programs aimed at keeping ‘innocent’ women and children (already at close to zero risk for HIV in most of Indonesia) at no risk. Only five per cent of it was spent on preventing infections among those who really are at risk – drug injectors, gay men, sex workers of all genders and their clients. But only 8,000 Indonesians have died of AIDS ever, and fewer than 200,000 are believed to be living with HIV nationwide right now. That compares with around 32,000 deaths and 320,000 life-altering injuries in road accidents in the last year alone. The dedicated budget for prevention of death and injury on the roads: zero.

The solutions are political

This imbalance highlights another shortcoming of the Indonesian health system (one that it shares with many other countries): the incentives are stacked very heavily in favour of curative care and away from the basic public health work that would make curative care less necessary.
A vendor uses anatomical models to explain the benefits of herbal medicines in a market in Bowae, Flores - Elizabeth Pisani
This may change in years to come, because the state is increasingly picking up the cost of people’s illnesses. One of the great achievements of recent years is the expansion of health insurance, especially for poorer Indonesians. According to another recent World Bank study, the national scheme, Jamkesmas, increased health insurance coverage for the poorest 30 per cent of Indonesians from 17 to 43 per cent in the five years to 2009. If consumers can negotiate their way through a confusing thicket of schemes, there are also many provincial and district-funded schemes, as well as free care for priority conditions such as TB and pregnancy. This has increased service use in some areas (‘Now people come to hospital every time they have a headache,’ complained a doctor in Aceh, one of the first provinces to provide a generous package of free healthcare), though not in others: pregnant women covered by Jamkesmas were no more likely to have medically skilled help at their birth than women with no insurance at all.
It’s not yet clear whether greater consumption of health services is translating into better health. Infant mortality fell to 34 dead kids per 1,000 live births in 2007 from 46 a decade earlier, according to Demographic and Health Survey data. For adults, though, things are less rosy. Adult survival, measured as the likelihood of a 15 year-old surviving until they are 60, appears to have fallen in Indonesia in recent years, possibly because of changes in lifestyle and diet. More healthcare won’t change that, unless it is also good quality healthcare that addresses the needs of the local population rather than the whims of a planner in Jakarta, Geneva or Washington.
Publicly funded health programs are likely to expand further: a promise of free healthcare always goes down well with the electorate (see article by Edward Aspinall and Eve Warburton in this edition). Such promises also increase expectations; one of the reasons that health providers get away with such poor performance is that consumers, traumatised by years of repeat visits to health centres that are locked or crowded with people waiting hours for high-handed service, have such low expectations.
Indeed even with the new health insurance schemes, two thirds of Indonesians questioned in the 2009 Susenas survey didn’t bother to use any health service at all last time they were sick. They either did nothing, or took one of the potions on offer at the local market. At one market I visited recently in rural Flores, the selection ranged from antibiotics past their sell-by date to slices of ants’ nest, by way of the bitter herb sambiloto and a concoction of roots and lava known as raja gunung, the king of the mountain. Irrational drugs policies fostered by a cosy alliance of pharmaceutical firms and senior health ministry officials mean that these remedies may be as effective as those on offer in the health system. Indonesia’s national HIV program went on treating sex workers with drugs we knew didn’t work for four years before the national guidelines were changed and service providers were allowed to switch to more effective medicines, now provided by a favoured local producer.
As people’s expectations rise, they might begin to hold their politicians to higher standards. And that in turn might reduce the distortions, inefficiencies, rent-seeking and outright corruption in government offices, private hospitals, pharmaceutical company warehouses and medical schools alike. It is curing these political ills, rather than more training programs for midwives, that is the key to improving healthcare in Indonesia.
Elizabeth Pisani (pisaniATternyata.org), the author of The Wisdom of Whores, is taking a break from her day job as an epidemiologist to work on a book about Indonesia, to be published by Granta and WW Norton in early 2014. Contacts and commentary at http://portraitindonesia.com.

Inside Indonesia 111: Jan-Mar 2013

The politics of health

The politics of health:
Eve Warburton and Edward Aspinall

Indonesians deserve a better healthcare system than the fragmented and dysfunctional one they’ve got

If you are rich in Indonesia, you can get top notch healthcare, though you might have to go to Singapore or Malaysia to get it. For poor Indonesians, and even for many in the middle classes, the options are not so good.

A health worker vaccinates a toddler against measles - UNICEF/Josh Estey
Political change is a double-edged sword for healthcare. Some of the big challenges affecting the sector, as well as some of the sources of dynamism, arise from decentralisation. Since the fall of Suharto’s authoritarian government in 1998, political and fiscal decentralisation has produced a complex set of challenges for health programming. On the one hand, decentralisation of health services creates opportunities for visionary local leaders to develop targeted healthcare programs for their electorates. But it has also made the system vulnerable to local power politics and unchecked corruption, and perpetuates the divide between rich and poor regions.
Inaccurate or late diagnoses, inadequate facilities and treatment, costs that are beyond reach: all of this is part of the daily experience of healthcare for millions of Indonesians. As a result, every year, countless citizens of the country die from conditions that should have been prevented or cured. This special edition of Inside Indonesialooks at the problems that beset healthcare, and searches for signs of hope amidst the political changes that are remaking Indonesia as a more democratic society.
Our articles explore the social and political forces that have generated such uneven outcomes for Indonesia’s health sector during the nation’s transition to democracy. While Indonesia’s economy is growing fast, the government continues to spend less on healthcare per capita than its neighbours with a similar economic profile; key health indicators – like the ratio of health providers to population – are also lagging. All the articles in this edition address the complex question of ‘what is holding Indonesia back?’ What motivates elected officials, health professionals and consumers to make the decisions they make? And what are the outcomes for Indonesia’s most vulnerable communities?
The lead article by Elisabeth Pisani, an epidemiologist and long-time observer of Indonesia’s health system, describes the varieties of dysfunction that plague the sector: from absenteeism in health clinics to the breakdown in critical information sharing between districts and the centre. Pisani blames skewed political incentives for much of this dysfunction. For example, elected local officials invest in expensive and conspicuous health infrastructure to boost their political profiles, rather than addressing more complex healthcare needs. But the democratic transition has also brought positive change. Pisani points to how direct elections put pressure on local politicians to answer their constituents’ demands for better health services. As people’s expectations rise, she hopes, so too will the quality of care.
Edward Aspinall and Eve Warburton analyse the relationship between electoral politics and the rise of local healthcare schemes. Populist campaigns that promise free healthcare are now commonplace in district and provincial elections around the country. This trend reveals how local politicians are engaging with the demands of their electorates in new and progressive ways. Even if the costs of healthcare are coming down for many people, however, this does not always mean that quality is improving.
Reproductive health activist, Inna Hudaya, offers insight into the plight of young women experiencing unplanned pregnancies. She explains how social stigma and discriminatory laws force women into the dangerous, traumatising and sometimes fatal world of illicit abortion. In this case, too, politics plays a role, but it is a politics of social conservatism that denies women control over their bodies. Thankfully, new organisations run by people like Inna are struggling to change discriminatory laws and to help women find the information and services they need.
Andrew Rosser provides an analysis of the political war between anti-tobacco activists and Indonesia’s powerful tobacco lobby. Health laws are slowly changing in response to a strong campaign by the anti-smoking movement, but the tobacco lobby has money and, consequently, friends in high places. It is launching a counter-attack, but a growing number of Indonesians are becoming aware of the huge toll that smoking exacts every year.
Medical anthropologists Byron Good, Mary-Jo DelVecchio Good, and Jesse Hession Grayman present a detailed account of one of the most neglected areas of healthcare in the country: mental health services. Though the situation is in many respects terrible, their experience working on mental health programming in post-conflict and post-disaster Aceh gives hope that a new model of care is emerging.
Still in Aceh, Catherine Smith explores the world of medical tourism in her piece about Acehnese who travel abroad to Malaysia in search of better quality care. The trend not only points to the limitations of local health services, but also reveals how many Acehnese deeply distrust the Indonesian medical system as a whole.
Finally, in a close examination of the problems posed for disease control by political decentralisation, Scott Naysmith looks at the challenges of managing the spread of avian influenza in a context of fragmented governance. Indonesia cannot return to the days of top-down, authoritarian disease eradication, as was practised during the smallpox eradication program under Suharto. Even so, his analysis shows there is an urgent need for more cooperation between districts, provincial administrations and the central government.
Politics is reshaping healthcare in Indonesia. Often it seems that most of the changes are for the worse. Each of our stories, however, provides at least some signs of hope, if only by pointing to how members of the public, health workers and activists are making new demands for better healthcare in the context of democratic politics. One thing is clear: Indonesians deserve much better.
Eve Warburton (evewarburton@gmail.com) is a research assistant at the Department of Political and Social Change, Australian National University, and administrator of the Sydney Southeast Asia Centre, University of Sydney. Edward Aspinall (edward.aspinall@anu.edu.au) researches Indonesian politics at Australian National University and is an editor of Inside Indonesia.

Inside Indonesia 111: Jan-Mar 2013

A new model for mental health care?

A new model for mental health care?:

Mental health services have been seriously neglected in Indonesia, but emergency responses to the Aceh tsunami and conflict have led to new ways of thinking

Byron Good, Mary-Jo DelVecchio Good, and Jesse Hession Grayman

Conducting the Psychosocial Needs Assessment in one of Aceh’s post-conflict villages - Byron Good
Natural disasters, bombings, and political violence during the past decade have brought issues of trauma and mental health clearly into Indonesia’s national consciousness. Psychosocial programs and mental health services have been key elements in national and international responses to disaster. However, efforts to develop sustainable services for persons with mental health problems have come face to face with the limitations of the country’s mental health system. Indonesia has among the smallest number of psychiatrists and mental health specialists, as well as psychiatric beds, per population of any country in Southeast Asia, ranking only ahead of Papua New Guinea, Cambodia and Laos.
Physicians and other health professionals who work in general medical services often lack training in how to diagnose and treat mental health problems, and the country lacks community mental health services. As a result, the burden of caring for people with serious mental health problems falls almost exclusively on families. Most persons with severe depression or anxiety disorders, as well as children and youth with mental health problems, are largely untreated.
Despite growing awareness about the importance of mental health among national policymakers, less than one per cent of all health care funds are spent on mental health services, and mental health is not listed as a priority for the country’s network of primary health care centres (puskesmas). Indonesia is not unique; mental health goals remain a glaring omission from the millennium goals, and mental health care remains tragically under-funded in most low and middle income societies. It is striking that in Indonesia the vast majority of persons with even the most severe mental disorders do not receive basic medications, and that the number of persons locked in back rooms or constrained by traditional wooden stocks (pasung) continues to be an embarrassment to the country.
Ironically, some signs of positive change have come out of Indonesia’s worst experiences in recent times. With the violence at the end of the Suharto era, successive bombings in Bali and Jakarta, and momentous natural disasters, including the tsunami in Aceh and numerous earthquakes, ‘trauma’ has entered the national vocabulary, along with the awareness of the importance of providing mental health care to those most severely affected. A number of Indonesian professional networks and specialised NGOs – such as Yayasan Pulih in Jakarta and Yayasan Kanaivasu in Bali – have developed model programs of trauma treatment. Policymakers have become increasingly aware of the importance of such programs.
Though the use of the words ‘stress’ and ‘trauma’ in Indonesian often differs significantly from that in English, these shared words serve to bridge local understandings of the personal effects of violence and disaster and the rising interest of many NGOs and intergovernmental organisations in providing psychosocial and mental health services in response to disaster. Out of this fusion, new approaches for treating mental illnesses have begun to emerge.

The Aceh effect

The province of Aceh has been critically important for the development of new models of mental health care. The Great Indian Ocean Tsunami of 26 December 2004, which had such profound effects on the coastal communities of Aceh, led to one of the greatest outpourings of humanitarian response in history, with more than 300 international organisations and Indonesian NGOs flowing into Aceh. When the Government of Indonesia and the Free Aceh Movement (GAM) signed a peace deal on 15 August 2005, the humanitarian response, already underway, was widened to include post-conflict communities, particularly those up in the hills. Humanitarian organisations recognised the enormous personal and psychological suffering associated with the disaster and the years of conflict. They used the term ‘trauma’ to legitimise the search for funds to provide psychosocial and mental health services to both post-tsunami and post-conflict communities. Aceh thus became a global laboratory for the development of post-disaster and post-conflict psychosocial and mental health responses.
The programs in Aceh had several characteristics. First, they were widely dispersed and enormously varied in the nature of services and populations targeted. Some focused on training, developing short courses for doctors, nurses, and teachers on how to recognise and respond to the effects of traumatic experiences. Other programs provided direct services such as recreational activities, schooling, and play groups for children and youth, particularly those displaced by the tsunami and living in the barracks. Some organisations developed community-based psychosocial programs, focusing on reconciliation among (perceived) conflicting groups in communities or on reintegration of former combatants into their home communities. Others focused explicitly on providing ‘trauma treatment’, via special ‘trauma clinics’ or group therapy programs for villagers in conflict-affected districts. Some programs provided direct services, while ignoring government agencies and even regulations; others closely coordinated with provincial and district offices of the Ministry of Health or led efforts to develop a provincial mental health policy.
While extremely important services were provided, the second over-riding characteristic of these programs was that they were largely undocumented and with few exceptions not formally evaluated. If Aceh was a laboratory, it was one which carried out experiments but did not record results systematically nor provide scientific analysis of what was done or what worked successfully and what did not. Almost no agencies provided genuine accounting of benefits and costs that could be used by policy makers to determine where and how funds should be invested in psychosocial and mental health programs across Aceh and throughout Indonesia. A great opportunity was lost to learn from this experience.

One program with documented success

IOM’s mental health mobile clinic in a village - MaryJo D. Good
Our work with the International Organization for Migration (IOM) was one exception to the general failure to evaluate programs and policies. As part of its role in the administration of the peace process, IOM Indonesia sought funds to provide services not only to former prisoners and combatants, but also to families and communities most affected by the conflict. IOM made the unusual decision to contract with the Department of Global Health and Social Medicine at Harvard Medical School to support the development and evaluation of programs in the area of post-conflict mental health care. This unique arrangement led to an intensive collaboration over five years, which included the design and implementation of a major ‘psychosocial needs assessment’, followed by a pilot intervention program using mobile teams to provide mental health care to 25 highly conflict-affected villages, and later extended to 50 more villages. Formal documentation and evaluation of these services and their outcomes, as well as training and supervision of health care workers and close collaboration with district health offices, was central to this program.
The ‘psychosocial needs assessment’ was designed in late 2005 to help guide the development of the IOM program. Our goal was to evaluate levels of traumatic events associated with the conflict, levels of psychological and psychiatric symptoms, levels of disability associated with mental health conditions, and desire for particular kinds of services. Working with teams from IOM and Aceh’s Syiah Kuala University, surveys were conducted to provide representative data of adults in villages in high conflict subdistricts first in three districts on Aceh’s north coast, then in 11 more districts around Aceh. (On-line copies of the IOM reports that resulted can be found here and here.)
The surveys found shockingly high levels of conflict-related traumatic experiences, particularly in Aceh’s north, east and southwest regions. In those areas, 78-80 per cent of adults experienced combat; 48-66 per cent of men reported being beaten, and 24-25 per cent of men reported being tortured. The surveys also documented extraordinarily high rates of psychological symptoms, comparable to those in war zones such as Bosnia. The survey and associated interviews documented that villagers had a strong desire for mental health services, as well as for other forms of support, but that powerful memories of the surveillance of the health care system by the military were preventing them from seeking treatment.
The challenges of providing mental health services were enormous. Aceh had not only usual forms of mental illnesses (standard epidemiological figures suggest rates of over one per cent of adults with major psychotic illnesses alone – over 20,000 persons in Aceh), but also high levels of mental health problems from the terrible losses associated with the tsunami and years of conflict.
Acehnese are resilient, and many recovered over time without medical forms of mental health care. However, many continued to show signs of classic PTSD – of reliving terrible events they had witnessed or experienced, with associated nightmares, panic attacks, and anxiety – as well as elevated rates of depression, sleep disorders, and disabling anxiety (see ‘No nightmares in Aceh’, Jesse Grayman’s analysis of how trauma was expressed through dreams, based upon this same research). To respond to these problems, Aceh had only four full-time psychiatrists for a population of over 4 million people at the time of the tsunami, one psychiatric hospital, and no psychiatric units in district hospitals. By contrast, Australia, with 13 psychiatrists per 100,000 population, would have approximately 420 psychiatrists for a province of equivalent size, along with community mental health clinics, acute wards, specialised services for children and adolescents, and an even greater number of psychologists, psychiatric nurses, and psychiatric social workers.

Treatment in the villages

Providing prescribed medications - Jesse H. Grayman
Given these limitations, we worked closely with IOM to develop a model that could provide services to particularly high conflict and relatively isolated villages on an emergency basis, while building capacity within the primary health care system. A small group of dedicated Acehnese general practitioners and nurses were given short, specialised training and close supervision by an Acehnese psychiatrist. They formed mobile mental health outreach teams, who along with nurses from the primary health care centres, went into villages, provided general medical care, sought out persons with mental health problems, and provided treatment – including diagnosis and medication, counseling and family visits, the formation of village level support groups, and in a subset of villages, ‘livelihood’ support. Nearly 2100 people in 75 villages were treated over a period of three years.
The evaluation research provided strong evidence for the benefits of this model of mental health services. First, it demonstrated that competent mental health care could be provided by GPs and nurses making monthly visits to villages, and that such services would be strongly supported by local communities. Teams treated approximately six per cent of village members. Of these, only a small number suffered psychotic illnesses or organic brain disorders; the vast majority were treated for depression, anxiety, and post-trauma mental health problems.
Second, the research demonstrated that overall, rates of recovery were remarkably high, for men and women. Of 1077 persons in the treatment study sample, 83 per cent reported some to great improvement in their symptoms. The per cent of persons with the highest levels of anxiety symptoms dropped from 43 per cent before treatment to 11 per cent after treatment; those with high levels of PTSD symptoms from 26 per cent to eight per cent.
Third, the project demonstrated that common mental health disorders are terribly disabling, and that treatment is extremely powerful in returning individuals to regular work and social functioning. When individuals entered treatment, they reported that before they became ill, they were able to work on average 28 hours per week (even though limited by the conflict); when they fell ill, this was reduced to 10 hours per week. At the end of treatment, individuals reported that they could now work an average 41 hours per week!
The IOM project showed that a model of training and supporting general practitioners and nurses to deliver full-time mental health care, providing them good supervision and access to referral, and using mobile mental health teams is extremely effective for providing services to a population with high levels of mental illnesses in a region with extremely limited mental health resources – and virtually no psychiatrists. This model of care, however, requires financial and administrative support beyond what Indonesia currently invests in mental health.
At the same time, the IOM project was like many other psychosocial and mental health projects developed by humanitarian organisations. It was focused on responding to an acute situation, not on the long-term. By 2010 IOM, along with nearly all other organisations, had stopped supporting mental health programs in Aceh. The international community provided critical services in the four or five years following the tsunami and the peace deal. Important investments were made in rebuilding hospitals and primary health care centres, critical services were provided, and many professionals were trained in trauma-related mental health problems.
However, nearly all humanitarian agencies worked with an ‘exit strategy’ in mind, which included phasing out funding, developing ‘sustainability’ plans, and turning services over to local government and non-government agencies. While these plans sounded promising on paper, ‘sustainability’ was most often little more than a slogan.

A model for the future?

Patient recovery leads to revitalised household economies - MaryJo D. Good
What has developed by 2013? Despite the problems outlined above, the post-tsunami and post-conflict programs in Aceh left important legacies. A number of young Acehnese physicians have gone on to advanced training in psychiatry and returned to practice in local communities. Today there are 16 psychiatrists working in the province: still a tiny number for a population of over 4 million, but a major improvement nonetheless. Several district hospitals have developed psychiatric services, meaning families of acute patients no longer have to take them to Banda Aceh. Nurses in many primary health care centres have received basic training as community mental health nurses, and spend part of their time traveling to villages to provide basic care for those with the most severe mental illnesses.
Aceh’s previous governor, Irwandi Yusuf, launched a ‘bebas pasung’ (stock free) program, which supported identifying individuals in physical constraints and bringing them to the hospital in Banda Aceh for free treatment, before returning them home. In addition, young, activist physicians, including psychiatrists, are developing small but important programs of community-based care and rehabilitation services in specific, local communities.
A broad model has evolved as government policy in Aceh – in part growing out of meetings of stakeholders organised during the post-tsunami period. In this model, the primary health care centres (puskesmas) should be the centre of mental health care. GPs in these centres should receive mental health training and administer medications, and each centre should have several trained specialist mental health nurses who provide outreach care.
In the villages, where families remain the primary unit of mental health care, specialised village cadres – volunteer health workers – should be trained to link those with mental illness and their families to the puskesmas. Referrals should go upward to a psychiatric unit in district hospitals, staffed by a psychiatrist, and these should refer upward to the provincial mental health hospital.
This broad model expands well beyond the old model, inherited from Dutch colonial times, that focused exclusively on building and staffing provincial psychiatric hospitals for those with chronic psychotic illnesses. It is emerging as a de facto policy of what may one day constitute an integrated mental health system in Indonesia. However, the model is not far advanced in implementation. Most community mental health nurses, where they exist, have only been provided basic courses, while the work they are expected to do requires more advanced training. Physicians cycle through the primary health care system, and new physicians are often not provided mental health training. Funds for mental health care remain woefully inadequate.
The politics of mental health are too often a politics of neglect. Activists, journalists and the general public often give their attention to the politics of commission. The politics of structural violence and omission – of the neglect of the human rights of those with highly treatable mental illnesses – are, however, often as devastating as acts of overt violence. Unfortunately, such politics are global. Thankfully, there are at least signs now in Indonesia of the beginnings of a realistic model for mental health care, one that respects the human rights of people with mental illness and provides competent and humane services for those in need. We should not be unrealistic about what has been achieved, but there is a growing space for hope and optimism.
Byron Good (byron_good@hms.harvard.edu) is a professor of medical anthropology and Mary-Jo DelVecchio Good (maryjo_good@hms.harvard.edu) is a professor of social medicine, both at Harvard Medical School. Jesse Hession Grayman (jgrayman@gmail.com) recently completed his PhD in the Department of Anthropology at the Harvard Graduate School of Arts and Sciences.

Inside Indonesia 111: Jan-Mar 2013

Rain Stoppers

Rain Stoppers:
By Bodrek Arsana



May to October is Indonesia’s dry season. By the end of October, though, the rains are approaching and the pressure mounts. Last year in Bali, the sun stung our skin and the night-time heat was oppressive. Although it’s hard to remember when we’re drenched now, people say that Bali’s getting hotter every year.

By Murat Subatli

Nyoman Wargita came out of his house in Jalan Katrangan, Denpasar, his face wet with perspiration. Bare-chested and wearing only a sarong, he carried a crying child in his arms: “Kleng… it’s so hot,” he said, “My child keeps crying and can’t sleep because of the heat. The Denpasar climate feels like a desert.”
May to October is Indonesia’s dry season. By the end of October, though, the rains are approaching and the pressure mounts. Last year in Bali, the sun stung our skin and the night-time heat was oppressive. Although it’s hard to remember when we’re drenched in January, people say that Bali’s getting hotter every year: “Before, the dry season wasn’t like this. The days used to be warm enough, but the nights were cool. But now, day and night are just as hot as each other,” said Ketut Setiawati, Wargita’s wife.
Still sweating, Wargita offered an explanation: “This is because there are so many trade expos being held in Bali. They’re using special lasers to chase away the clouds, so the rains don’t come.”
Scorching sun? Expos? Lasers? What’s this about? The trend for setting up public trade and industry expos took off in the last decade. All sorts of things are sold at expos: household items, furniture, clothing, electronic goods and food products. There are stands selling motorbikes, bicycles, children’s toys and even real estate. They’re really the place to see and be seen these days. Some of the stalls are located outside, while others are under cover. Either way, the organisers favour clear weather. Rain clouds chase away customers. So expos usually have a generator connected to a laser machine, which send rotating beams high into the clouds. At night, the laser-beams can be seen from far away and they have become a feature of urban Bali’s sky at night.

Anti-rain laser

Bali’s most famous expo used to be located on Jalan Gunung Agung, in the far west of Denpasar, but years ago the site was moved to Jalan Hayam Wuruk, in the east of the city. Expos are also held in Sesetan and Kuta. They are hugely popular and are now being staged outside the capital as well. “Just think—there are all these expos now, all using the lasers. No wonder the weather has been so hot,” said Wargita.
Made Armaya, a friend of Wargita’s who works at the municipal office in Denpasar, said that the mayor, Anak Agung Puspayoga, banned the all-night use of lasers at expos, limiting their usage from 7pm to 10pm. “Many people complained that the weather was getting hotter because of all the lasers. I heard that Pak Puspayoga was also suffering from the heat in his house.”
Darmawan, a neighbour who goes to a private university in Denpasar, gave me this analysis of how the lasers work: “The lasers are filled with ions that can sweep away the other ion particles in the rain clouds. Because the beams are directed up to the sky, the clouds get pushed further away. That’s how the rain clouds get cleaned.” He said he learned this in his high school physics class.
Gede Ardana, Darmawan’s friend, thinks this hypothesis has been proven: “I always go to expos with my wife and children. Sometimes, if I have money, we buy something, but usually we just walk around and enjoy the cheap and cheerful atmosphere. To start with, I didn’t believe Darmawan’s story about the laser beams repelling clouds and stopping the rain. But now I’ve seen the proof; one rainy day I went to an expo and on the way there, it was pouring, but the area around the expo site was completely dry. So there you are.”
Although Ardana agrees that the anti-rain lasers are effective, he also worries about their impact. And it’s not just that the lasers make the weather hotter. He is concerned that his grandfather, who is a professional rain-stopper (pawang hujan), isn’t getting much business these days: “Before, my grandfather was often asked to stop the rain before the opening of outdoor events—things like trade expos, religious ceremonies and open-air music concerts. He was once asked to stop the rain for a concert given by Sheila on 7, that famous band from Jogjakarta. But now people rely on the lasers.”

Sapu lidi

Intrigued by Ardana’s story, I visited his house in Batubulan. There were a number of people in pakaian adat (traditional Balinese costume) waiting to request the services of Pak Likés, Ardana’s grandfather, to ensure good weather for their child’s marriage ceremony. To begin the ceremony, he checked that the offerings were correct and started to sing a special rain-stopping mantra. Then he lit a kerosene lamp and readied a sapu lidi (broom made from the spines of palm fronds) by sticking chillies on the ends of its spines. After completing the mantra, he hit the ground several times with the sapu lidi.

By Juriah Mosin

What was the connection between the lamp, thumping the chilli-speckled broom and controlling the weather? Pak Likés just told me that it has always been that way. “The lamp has to be guarded to make sure it stays alight for the duration of the ceremony. If it goes out, it will rain,” he explained.
Knowledge of how to stop the rain has been passed down from generation to generation. Balinese people, with the frequency of their outdoor ceremonies, have appreciated this skill for just as long. But recently, requests to influence the weather are thin on the ground. Pak Likés accepts this with good humour: “My grandchild tells me that there are new machines to stop the rain now. They say that they are made in Japan. Rain stoppers like me can’t challenge Japanese technology, just like Indonesia can’t compete with making motorbikes and cars.”
But when the monsoon comes, it comes. Neither lasers nor sapu lidi can hold back the rains forever.

(First published in Latitudes Magazine)

Bali’s Sashimi Tuna Journey to the World’s Biggest Fish Market

Bali’s Sashimi Tuna Journey to the World’s Biggest Fish Market:
By: Seamus McElroy

Five local Indonesian wooden longline vessels enter Benoa harbour within the space of two hours. They have been fishing for yellowfin and bigeye tuna in the Indian Ocean for the past week and will offload today to a simple processing facility beside the quay, TFK, for export overnight to Tokyo, Japan. It is the third day of the New Year, and the world’s biggest fish market, the Tsukiji wholesale market in Tokyo, Japan, will open again on Saturday, 5th of January 2013, two days time. The captain and crew of the boat know that this is jackpotday, the day the highest price will be paid for a bluefin tuna, and are hoping that their fish will also get a good price. And their surprise catch of this trip is a 150 kg Southern Bluefin tuna which, given its size, will have a high fat content and so be very valuable.

On any night of the year there is so much longline laid out by the world’s tuna fishing fleets that it circumvents the world five times – that’s 200,000 km of longline. The last batch of fish from the latest vessel to unload this day comes ashore at 17.45. Each fish is inspected for freshness and toro (fat) content. Fish are rejected or approved at this stage, and if approved will be sent by plane to Tokyo tonight. Each fish which is approved is weighed and packed into standard-sized cardboard “coffins”.  These are then transferred to a waiting refrigerated truck, which shortly after is speeding on its way to Ngurah Rai international airport where its cargo is set for loading onto the 00.35 Garuda flight to Tokyo, arriving in Narita at 08.45 the following morning.

Benoa

During this day in Japan, the tuna shipment passes through customs and health checks, is then held in a large chilled storage room, which incidentally handles more tuna than any other facility in the world, before being transferred by road to the Tsukiji wholesale market, Tokyo’s main wholesale market for fruit, vegetables and fish. The market opens every morning at 03.00, the trucks unload, and an hour before the auction starts the tuna fish are placed on the floor for inspection by the buyers. The auction gets under way at 05.20.
The fish being sold from Bali are now between three to 10 days since being hauled from the warm tropical waters of the Indian Ocean. Before this day is out, it will be on the lunchtime or evening plate of a customer at a Tokyo sushi or sashimi diner.
Back in Benoa, Bali, the crew are nearing the end of their two rest days and are  preparing to head out tomorrow early morning to search for and land fresh sashimi-quality tuna again in about seven to 10 days’ time. There are over 850 such tuna longline vessels based at Benoa.
This is the height of the Southern Bluefin tuna breeding season with their spawning grounds located to the South of Java. Though these fish range between the southern half of the Atlantic, Indian and Pacific Oceans, this is their only known breeding ground.

Japanese

Southern Bluefin tuna is one of three bluefin tuna species which span the oceans of the world. They are valuable, highly migratory pelagic fish. They are all long-lived, have a lengthy pre-maturity period of from 5 to 12 years and virtually life-long exposure to fishing pressure; each stock is slow to recover from depletion relative to other shorter-lived species, including most other species of tuna.
Japanese and Australian fishermen have targeted SBT commercially since the 1950s. In 1961, a peak catch of 81,000 tonnes of SBT was landed by these two nations. The species was initially sold to tuna canneries, but the development of the fresh tuna market for sashimi and sushi in Japan over the past four decades has seen a major shift in the fishing and marketing of SBT and today it is primarily sold into this market.
Despite the global catch of the SBT species being regulated since the mid-1980s, high levels of fishing have caused serious depletion of the adult stock. Scientific studies suggest that the spawning biomass may now be between 3% and 8% of its unfished level, and as a result the species is considered to be “critically endangered” by the International Union for the Conservation of Nature (IUCN).




10,949 tonnes

In 2010, the body which manages only this resource, the Commission for the Conservation of SBT, for the first time in its twenty six year history, unanimously adopted a formal rebuilding strategy to allow SBT to recover to sustainable levels with its members committing themselves to recovering the SBT stock to an interim target of 20% of its unfished level by 2035, with new annual national allocations being adopted in 2011 for the fishing seasons 2012 through 2014. The increase in the global total allowable catch (TAC) was 2,000 tonnes over this three year period. The TAC for 2009 to 2011 at 9,449 tonnes was its lowest ever. Clearly, the managers of this valuable fish resource, primarily Australia, Japan and New Zealand, had consistently failed in their duty to conserve this resource for nearly 30 years. The global TAC for 2013 is 10,949 tonnes, of which Indonesia gets 707 tonnes (6.5%).
Tokyo’s Tsukiji Market is the biggest wholesale fish and seafood market in the world and also one of the largest wholesale food markets of any kind. It has been called the fish market at the centre of the world given its importance in setting global prices for a range of fisheries products. Tsukiji market is listed as the number one attraction for foreign visitors to visit in Tokyo by Time Magazine.
This Tokyo market handles more than 400 different types of seafood, weighing more than 700,000 tonnes with a total value in excess of Yen 600 billion/year (US$ 7 billion/year) – equivalent to over $20 million/day. Registered employees varies from 60,000 to 65,000, including wholesalers, accountants, auctioneers, company officials, and distributors.

Bluefin

Tsukiji market holds the record for the most expensive fish sold. For each of the past five years, a bluefin tuna has sold for a new world record price on the first day the market opens after the New Year. 2013 was no exception. “Bluefin tuna sells for record £1 million” – British Newspaper The Telegraph’s banner headline screamed. On 5th of January this year, a Pacific bluefin tuna was sold for a record 155.4 million yen (£1.09 million or US$1.82 million equal to over US$10,600/kg of fillet) – nearly three times the previous high set last year. The record sale comes as environmentalists warn that stocks of the majestic, speedy fish are being depleted worldwide amid strong demand for sushi.
Japanese eat 80 percent of the bluefin tuna caught worldwide, and much of the global catch is shipped to Japan for consumption. Stocks of all three bluefin species, Pacific, Southern and Atlantic bluefin, have fallen dramatically over the past 20 years amid widespread unreported, unregulated and illegal overfishing including fleets from EU countries and Japan.
“Everything we’re hearing is that there’s no good news for the Pacific Bluefin tuna also,” said Amanda Nickson, Director of the Washington-based Pew Environmental Group’s global tuna conservation campaign. “We’re seeing a very high value fish continue to be overfished . . . these poor species are being hit from every angle.”
(First published in Bali Expat)

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