Our finest gifts

Merry Christmas everybody! From Jimmy, Hotlin & Jacky

Here in Indonesia, we're having a very different Christmas experience, but one that is rich and meaningful nonetheless.  In fact, being so far removed from familiarity,  it's hard not to find new meaning and truth in the season that transcends any geographic, linguistic, or cultural divide.

Despite what I've thought in the past, Christmas really is about gifts.  Beginning with a little baby in a manger, given to bring peace and demonstrate love, the core of the holiday is about making even the simplest of gestures to share goodwill with others.  In Sukadana and now as we travel through Indonesia, it is obvious that people here have it figured out.

I began thinking about this spirit of giving in a conversation with Kinari, ASRI's founder and director.  Her vision and determination to build this amazing organization all stems from the gesture of using her gifts to bring health to people and the forests of Borneo.  Her gifts are fine, indeed.  The top graduate of her class at Yale's medical school and a survivor of one of the most challenging and best residency programs in the country, she could have picked any specialty, picked a salary, and practiced anywhere.  Instead, she gave, and continues to give, her self in this incredible service.

Christmas in Pontianak's Mega-mall.  Jacquelyn & Etty

Gifts don't have to be wrapped up in discrete little packages.  Jacquelyn and I have received small, inconspicuous gifts in the form of friendship and generosity since we set foot in Sukadana.  People who are very new to us and in some ways very different have gone out of their way to make sure we are included, comfortable, having fun, and well fed.  None of these gifts were given with expectations or hopes of reciprocation.  Rather, they were given because these new friends see ways that they can use their local familiarity, their comforts, and their gifts to make little moments in life better for us.


Sometimes gifts are wrapped, and come in humongous packages.  We received one of these types of gifts two days ago, wrapped in a huge aluminum cylinder that arrived in Jakarta from Sydney and New Zealand before that.  Ashley Saunders and Tom Dickinson, on their delayed honeymoon, came to spend the holiday and explore Indonesia with us.  We've been friends since Sewanee and have lived closely in Chapel Hill over the past 10 years, sharing great times on Franklin Street and in the swamps and mountains of North Carolina.  It's an incredible gift for these two to come and, in a way, reconnect us with the wonderful life and friends we have back home.  It's also a wonderful gift to share stories face to face with them, to recount our adventures, and to create some new ones.

Lunch on Christmas Eve with a couple of cool cats.

So it is that even here on the other side of the world, we're celebrating Christmas with just as much cheer and good tidings, and surrounded by magnificent gifts.  I'm working now on my own gifts, wondering which are my finest and to whom I should give them.  I wonder how I can do more to make others more comfortable and content.  I also hope that I can pay tribute to the incredible life we have back home and to honor those special people and places.  This spirit of gift giving isn't one that needs to end today, and thoughts of how to do good with these gifts will last a lifetime.

No chestnuts, no open fire, but warm and cozy all the same.

 Right now, I need to get out on the beach, find a snorkeling mask, decide if we can get down to Kuta Lombock to surf for a few days before heading toward Komodo Island for New Years.  It's going to be a busy Christmas day.

'Tis the season... for planting a new rain forest

The klinik team, and a few of their seedlings

As halls are decked and stockings hung back home, the ASRI reforestation staff put up a few of their own trees this week - 26,000 of them, in fact.  Jacquelyn and I, along with most of the clinic staff, took a break from our usual Friday activities and visited the reforestation site to help finish the job.  Although our contribution was less than 1% of this total count, it was great to see the ‘other side’ of ASRI in action.

Planting all of these seedlings only took a week, but the ASRI reforestation team has worked hard in preparation throughout the past year.  They set up a research outpost and nursery at Laman Satang, a village just adjacent to Gunung Palung National Park, and chose a tract within one of the more heavily logged park sectors.  The better part of the year was spent growing the seedlings, sampling soil, and setting up experimental methods to share this work with other local and global reforestation efforts.  Since October, the reforestation team has added as many as 75 local workmen to help clear the tract and prepare it for planting.

Inspecting seedlings in the nursery.

ASRI’s tract is a tiny piece of the unfortunate landscape in much of Borneo, even within the national parks.  While government logging concessions destroyed over 50% of the virgin rain forest in West Kalimantan during the 1980’s and 90’s, illegal logging has increased more recently.  The global demand for timber, coupled with local economic deprivation and deficient resource protection make it too enticing and too easy to raze a few hectares.  Clear cut and then burned, the pristine lowland rain forest here and across the country is reduced to invasive grasses and shrubs, crowding out any chance for regrowth.

ASRI's 2010 reforestation tract, flanked by a few remaining trees

dr. Robin and one of his many new trees

 While the current rate of illegal logging will wipe out the remaining forest in West Kalimantan by mid-century, ASRI's work is a strong push in the opposite direction.  Now in their second year of planting, they have converted over 10 hectares of wasteland into a future forest that, with protection, will expand its borders and reconnect with patches of preserved forest.  What’s more, ASRI's work seems contagious.  The National Park Service has started their own reforestation program, and even hired a handful of staff that trained at ASRI last year.  By employing local people in the project, ASRI provides jobs in growing trees rather than cutting them.  Even more inspiring, it appears that ASRI is sharing its conservation ethic.   Earlier this year, local villagers gathered to stop a wildfire that approached last year’s reforested tract.  Such community action never occurs on any other uninhabited land.

Once again, Jacquelyn and I are in awe of the work being done here and the people who have the vision and dedication to make it happen.  As painful as it is to separate ourselves from friends and family over the holidays, it is quite a gift to be here.

Jimmy & Jacquelyn celebrating the final count, with dr. Hotlin and dr. Lucy.

Just Back from Kuching

A perfect city for a waterfront stroll.

 This week we traveled to Kuching, in Malaysian Borneo, to renew our visas (two more months!) and discovered a curious city with quite a feline temperament.  Wild and tame, lush and metropolitan, it's peculiarities left us feeling batted back and forth between pleasant surprises and a few frustrating, but ultimately laughable, disappointments.

Not a perfect city for a mouse.

    Kuching ("cat" in the local language) sits on the bank of the Sarawak River, about 10 km before it empties into the South China Sea, on the northwest coast of Borneo.  It's long been a commercial center, with Chinese, Indian, Arabic, and European traders setting up shop to trade with Malau locally and indegenous Dayak farther upstream.  It still carries the feel of a jumping-off point to the interior, which was once only penetrable by boat, was full of giant crocodiles, and where men measured their worth with their collection of heads.  Nowadays the many tour companies advertise with testimonials that boast of exotic adventures, and  also vouch for their clients' safe return.  

  

Our breakfast view.  Something for everyone.

  You wouldn't guess that deforestation is destroying human and environmental health upstream.  The city prizes its parks and waterfront, and massive, epiphyte-laden trees flank its high-rise hotels and banks and shopping malls.  Always a melting pot, white skin was even added to the mix in the 1800s when James Brooke was 'invited' to come be king of Sarawak, and help the Sultan of Brunei fend off the Dutch, Chinese, and pirates.  Now mosques (both Arabic and Indian), churches, and Buddhist temples harmoniously coexist among old English colonial buildings, business plazas and parks.

    

A fist-full of ATM rejections.

    Still, rafts of refuse in the river and the gaunt faces of boatmen suggest that the prosperity that pushed up the hotels hasn't spread equally.  Our own debacles with ATMs and inconsistencies between Eastern and Western banks hinted at underlying political differences.  And as amazed as we were with the diversity of cuisine, what we hoped to be our most fantastic meal was served with a good soaking of palm oil.  

    When the whirlwind trip came to an end, we were glad to return home to Sukadana.  With all the wonders that a new place can provide, the peculiarities and little annoyances made us ready to get back to familiarity.  It's nice to be back in a place where we've not only become intimately involved with the people, but where we can also participate in meaningful change.  

Saving Lives, Saving Rain Forests?

Our less-forested front yard, and Gunung Palung National Park rising across the street. (note the lawn service, in the foreground)

    I developed a cynical side at some point in my 33 years.  So when I opened Health in Harmony's redesigned website a few months ago and read its new tag line - "Saving Lives, Saving Rain Forest," I scoffed and considered it idealistic embellishment and maybe an extra reach for a little fund raising.  At that point in time, paperwork and politics in the US healthcare system left me with less and less time to spend with patients and with diminishing hope of helping to improve, much less save, anyone's life.   Lofty goals like saving forests that are thousands of miles away fell farther and farther on the priority list, even as it was becoming more and more obvious that weather and coastlines very close to home will increase their rate of change.

    The past week has brought more experiences that have quieted that cynical side and are restoring my capacity for hope.  On Wednesday a man came in with two infected fingers after getting them stuck a week prior in a diesel engine.  A bone fragment remained, swelling had increased, and sensation was disappearing even after two encounters at other health facilities.  We removed the bone fragment, cleaned the wound, started an IV antibiotic, and asked him to return the next day.  On Thursday, it was obvious that the infection had taken the life from his distal middle finger was climbing up the bone.  After some quick and thorough reading and a call to a hand surgeon in the US, we turned one of the clinic rooms into an operating room and removed the infected part.  Yesterday both fingers continued to improve without any sign of further infection.

    Earlier in the week, ASRI hosted a meeting of stakeholders involved in and affected by the illegal logging trade, which is the greatest local threat to the surrounding rain forest.  It would have been unheard of just a few years ago for villagers, many of whom are loggers or benefit from the industry, to come together with town officials and police, national park administrators, and local and international conservation organizations to discuss the present and future state of Gunung Palung's forests.  But under ASRI's facilitation and community-based approach, these meetings are common and carrying greater strength.  A number of attendees who spoke up were former loggers, who realized the harm they were causing to their land and their families, and warned others of the fate that awaited them once the forest disappeared.  The government has reported now that no more logging contracts will be approved, that the current concessions will expire within a year, and that any logging thereafter will be obviously illegal and more easily enforceable.

    So it is that my cynical side is silenced, and each day I walk home from clinic in awe of the accomplishments being made here.  Long-term, sustainable solutions for quality health care and rainf orest conservation will not, and should not, come overnight.  A lot of listening and a lot of learning must happen for development to proceed in a healthy, harmonious manner.  In the meantime, it's good to have a place like Sukadana and an organization like ASRI that are doing this work on a small scale, seeing daily success, and demonstrating that lives and rain forests can indeed be saved.

 

Good Times on Thanksgiving

Twas the night before Thanksgiving and...power's out, insects in eyeballs, can't read the box, but dammit, we WILL make cake.

Meet Jimmy, master chef

Dessert's here, party time!

Will leading the Indonesian Idol sing-a-long

More pie?

Happy buleh (whitie)

Happy Thanksgiving!

Hopefully all of you in the US had a lovely Thanksgiving. Here in Sukadana, we had a very unique and memorable Thanksgiving dinner. Jimmy, myself, and a couple of other Americans cooked a feast for our Indonesian friends and co-workers. It was pretty incredible to watch many people eat their first Western-style roasted chicken, stuffing, gravy, mashed potatoes, greens, and apple pie. I now understand what I must look like trying a new Indonesian dish! The whole evening was a precious moment branded on our hearts that we will never forget.

One week of really good medicine

    I wasn't expecting to be so enthralled by the work here in Sukadana. Several media celebrities and a handful of academic physicians whom I admire have all spoken highly of this project, but I've been most impressed by the work I've witnessed over the past week in clinic. The director's vision was forged over 15 years ago as she researched orangutans in the nearby Gunung Palung National Park. Overwhelmed with the poor access to health care in the area, she returned to the States, became a family medicine doctor, and returned to create this organization, which provides high-quality, low-cost health care to local villages, additionally focuses on education and nutrition, and actively promotes conservation of the surrounding rainforest.

    In doing so, she has brought together a staff of over 20 men and women from nearby communities and from across Indonesia, who are just as passionate about linking and promoting the health of people with the health of the environment. The program is based on an initial assessment of the health status and interests that were voiced by local communities themselves, and continues to operate with their direction. Each project within the organization, ranging from organic agriculture and reforestation to emergent medical care, focuses just as much on building local capacity as it does on doing the work.

    I spent most of my time this week learning the ins and outs of the clinic, shadowing Indonesian physicians and becoming familiar with the medical records, laboratory, and pharmacy systems. We had a broad range of patients. A man in his 80s stayed a few nights with what is probably a peri-appendiceal abscess, receiving IV antibiotics and improving very well.  We enrolled another older man in our directly-observed therapy program to treat tuberculosis, with reasonable fear that previous treatment elsewhere was inadequate and is leading to a worse recurrence.  A young woman came to us in the midst of a first psychotic break, and we’ve begun visiting her at home where she can rest with her family. Another woman came in, 37 weeks pregnant, with her baby in breech position, which we’ll watch weekly and send 2 hours to Ketapang if it hasn’t turned when labor begins. Another gentleman will become very familiar to me over the next few months, as we debride an enormous ulcer on his foot and try to get his diabetes under better control. In each of these cases, significant morbidity, if not death, would have resulted if this clinic were not here.

    I’m glad that I’m here, even if the Indonesian physicians have it all under control. My clinical role will be strictly teaching, although the exchange will certainly be mutual.  I’m thankful for my training in family medicine, and the skills to care for each of these very different patients. Most of my initial work will be in improving clinic systems, in which I was also well trained during residency. Next week I’ll venture off with at least two mobile clinics, and look forward to visiting the more remote communities around Gunung Palung.

Idul Adha in Sukadana

As most Americans prepare for the Thanksgiving holiday next week, Jimmy and I are taking part in our first Indonesian holiday. Today is Idul Adha, or the feast of sacrifice, in Indonesia. Yesterday marked the beginning of this Muslim holiday with offices closing early, fireworks sounding across the evening sky, and a general sense of excitement in the air. As Jimmy and I biked around town yesterday afternoon, we were met with a greater than usual number of “Hello misters!” from kids running around. People were excited. This morning, lengthy prayers emanating from mosque loudspeakers marked the beginning of the holiday. Fireworks soon followed. At 6 am. Early morning takes on a whole new meaning here.

We were graciously invited to share a mid-morning meal at the home of our “ibu,” named Ma’ngal. Ma’ngal is basically our lifeline. She buys our food, cooks, cleans, washes our clothes, and is teaching me many Indonesian words. On top of all that, she is one of the most kind, generous, and open hearted people I have ever met. When you look into her eyes, all you see is kindness and generosity shining back. She’s truly a gem.

True to form, Ma’ngal invited us to share a holiday meal with family and friends at her house this morning. Ma’ngal is an excellent cook, so we were delighted to share in quite a spread. Because part of Idul Adha involves animal sacrifice and sharing meat, there is quite a bit of meat to be eaten around town right now, which for many people only happens once a year. Ma’ngal treated us to delicious and savory meat and chicken dishes, stewed jackfruit, fried pisang (bananas), sticky rice with a rich coconut sauce, and many other cakes and treats.

Much like in America, the meal ended with women and babies chatting over remaining food and empty dishes, while the men retreated to the living room (and eventually to a more interesting activity—cruising on motorbikes). For the rest of the day, people here will visit friends and relatives, share food, and rumor has it that a local band may play at the pantai (beach). Indonesia is a unique and lovely country; I feel fortunate to be participating in its traditions.

Kami Sudah Datang - we have arrived!

Sukadana Bay - the more crowded, 'public' beach

A speedboat dropped us off on the dock in 'downtown' Sukadana three days ago. It was a quite a journey to get here, regardless of where we mark the beginning. The boat trip itself, down the Sungai Punggur Kecil, through mangrove estuaries, past logging outposts and stilted river villages and then across Sukadana Bay, took a little over four hours.  We needed every bit of the past month to cross the ocean and equator and transition from the cool climate and glaciated peaks of the Pacific Northwest.  And after three months, I'm finally catching up on the sleep and reconnecting with pieces of my self that I neglected during the past three years of 80-hour work weeks and 30-hour inpatient shifts.

I'm most excited to have arrived at the end of a seven-year journey through medical education, which was a roller-coaster ride with many joys, but that often distanced me from my roots in community organizing and public health.  It was a struggle for me to focus narrowly on biomedical maladies when so much of my patients' diseases resulted from social, economic, and political environments.  I'm thankful for excellent training in family medicine, that will enable me to care for all ages and genders of patients, and that also prepared me to make clinic systems work better for underserved patients.  But now, I have an amazing opportunity to apply these skills in a community setting, with direction from the local community, and with inclusion of environmental and social interventions.  I've disembarked from this seven year journey into a place where I can bring it all together.

Here in Sukadana, on the west coast of Indonesian Borneo, we have found a community health program that answers local people's requests for medical care and disease prevention AND supports projects to decrease illegal logging, promote rainforest conservation, to ultimately preserve one of the few remaining natural habitats for orang-utan (people of the forest).  Once we settle, I'll begin working alongside Indonesian doctors in the health center and mobile clinics, and begin exploring their public health programs that range from DOTS therapy for tuberculosis to delivery of goats to villages' widows.  Jacquelyn has already started work in the organic garden and this week will accompany the environmental education coordinator to stakeholder meetings to address land use around the nearby national park.

Right now, I'm enjoying a cool midday breeze coming off the bay, truly relishing a breakfast of powdered milk, corn flakes and perfectly ripe local bananas, devouring a Nestle-crunch ice cream bar that a new best friend just bought me off the back of a motorbike that plays music just like the trucks in the states, and looking forward to diving into all the action tomorrow morning.