Sunday, November 28, 2010

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.

Saturday, November 20, 2010

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.

Wednesday, November 17, 2010

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.

Sunday, November 14, 2010

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.
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