How does a remote medical clinic, in West Kalimantan, come up with ideas like “payment in kind”, a non-cash exchange for medicine and life-saving treatments? What is behind their successful health project that has decreased illegal logging households by 68 percent in just first five years of operation, and how did they turn illegal loggers into organic farmers? Stephanie Brookes talks with local hero Kinari Webb.
The US non-profit Health in Harmony supports the ASRI medical clinic in Sukadana, West Kalimantan. Its aim is to improve the health of poor villages, and also to work with various programmes to help save the forests in the surrounding Gunung Palung National Park from illegal logging.
When did the ASRI clinic open and how did it get started?
We first opened the ASRI clinic in July of 2007. The ASRI health and conservation programme was the culmination of a dream that began in 1993 when I first came to Indonesia to study orangutans. I realised then that it might be possible to find solutions where both humans and the natural environment benefited, so that rain forests could be saved, while at the same time, human well being could be improved. Luckily, I found a wonderful team of like-minded people in Indonesia and the US, who shared this vision, and together we began the combined health and conservation program.
What attracted you to work in West Kalimantan?
When I first returned to Indonesia to do this work, after finishing medical school and residency, I first spent a year travelling all over Indonesia looking for the right place for this programme. I was looking for a place that had rainforest that was threatened but could still be saved, communities in need of health care, and a receptive local government. The first was sadly hard to find, the second sadly too easy to find, and the third variable. After evaluating over 13 provinces, I ended up choosing the place where I first studied orangutans: the Gunung Palung National Park in West Kalimantan.
What are some of the health issues facing the local villagers? Why can they not seek help from the closest hospital? How many patients do you treat at ASRI?
When we first began working, we found there were common infections and diseases, like malaria, tuberculosis, and pneumonia in addition to the standard medical problems one finds anywhere in the world: diabetes, health disease, lung disease, high blood pressure, anxiety, etc. After distributing 4,000 mosquito nets, we now almost never encounter malaria cases from our area, and we have seen dramatic decline in tuberculosis. Our community health workers are also making sure that patients with tuberculosis finish their course of treatment so that drug-resistance is not created. Last year we had an amazingly low dropout rate of only 0.6 percent.
In total, we have had over 39,000 patient visits in the first seven years of the programme, with about 17,000 individual patients.
Tell me about some of the medical successes of the clinic.
One of the joys of working in the clinic is that nearly every day we get to save someone’s life, but that is also one of the sad things: how desperately necessary our clinic is. We care for a huge range of cases but unfortunately, we still can’t provide surgical care. We are planning on expanding and with our new facility, we hope to close that gap. Still “miraculous” cases are pretty standard fare in our clinic—from saving children with diarrhoea and pneumonia, to healing patients who have been paralysed from tuberculosis of the spine. We have given the gift of sight to hundreds of blind patients through cataract surgeries as well. But sometimes for me, it is just the joy of being able to lovingly care for and explain to a patient what is wrong with them. That is the most fun.
Tell me about the “payment in kind” system. How did this idea come about? How does it work? What makes it successful and sustainable?
David Werner, who wrote, “Where There
is no Doctor,” told me about this system that was invented by a group of villages
in Mexico. I was looking for a solution where everyone would always have access to care, no matter how poor, but where people’s dignity would also be valued,
and sustainability of the programme
would be possible. This seemed like the perfect solution and indeed it has worked amazingly well. Payment in kind means paying for services without cash, e.g. paying with seedlings, manure, woven mats, etc.
What is a green village? Tell me more about this concept.
We believe strongly that long-term human well being is only possible if we also protect natural ecosystems. I was not surprised to find in our baseline survey of over 1,300 households that the communities around Gunung Palung National Park felt similarly with 95 percent of the people wanting to protect the park. But despite this number, logging was rampant. So we asked people in over 400 hours of community meetings during our first year what kind of “thank yous” they would need from the world community for protecting the rain forest and stopping logging. They were very clear: access to high quality, affordable health care and organic farming training.
The reasons for these two things were that health care is something that one must have cash for and it can’t wait. Logging was one of the few ways to get cash quickly or to be able to service a debt that had been incurred. In these meetings we were told the villages wanted organic farming training because the traditional method of farming is slash and burn, which worked well back then, when there was a lot of forest and not very many people. They had heard there was a way to plant in one place without expensive chemical fertilizers but they didn’t know what it was.
The local communities loved the idea that they had something valuable to trade with the world community—protecting precious rain forest and that the world community could provide assistance with the things that they needed to be able to stop the logging.
Thus, the “red-green” system was born. Villages that totally stop logging (green) get a 75 percent discount off the actual price of care. Individuals and organizations that care about protecting orangutans and rain forest cover the difference. “Red” villages—or those still logging—get a 25 percent discount simply for working with us and trying to decrease the logging. Some of our patients come from the city, which is two hours away, because of the high- quality care we provide. They pay a slight premium. No one is ever denied care and everyone can always choose to pay with non-cash options.
How did you convince the local villages to stop illegally logging when it provided much needed income?
If we were trying to convince them I doubt we would have been successful. When we started, a survey found that 100 percent of loggers would prefer other work. They wanted to stop but they just couldn’t, until they had the things they were missing: health care and knowledge about sustainable agricultural methods.
And indeed after five years there was a 68 percent decline in illegal logging and the number of green villages had now increased from 10 percent in 2010 to 47 percent. The head of one of the villages at our fifth year anniversary party said that he felt the big difference was that now loggers could become farmers, without the start-up money required for expensive chemical fertilizers.
As your model has been so successful are there plans to replicate what you have created in other communities around Indonesia?
Yes! The next spot we have our eye on is Raja Ampat in Eastern Indonesian, which is the area with the highest marine biodiversity in the world. The local communities there are often forced into extreme overfishing, coral reef bombing, or logging in order to pay for even one medical emergency which can cost the equivalent of an entire year’s income.
For example it can take 400 pounds of dried sea cucumbers to pay just for the transportation to care.
What has been the most moving experience for you and what message would you like to give others?
For me the most amazing part of this work has been to see the principle that true win- win solutions really are possible. In fact, I believe that not only can both humans and the environment simultaneously benefit, but that, in fact, that is necessary if we are to survive as a species on this planet.
ASRI needs donations to keep operating. Here is the web link to donate: https://www.z2systems.com/np/clients/hih/donation.jsp ASRI Information: www.healthinharmony.org
Contact: KKU District Government Tourism to arrange ASRI visits plus Karimata Islands and eco-friendly tour options Contact: Rachel at +6285252555678 Email: email@example.com
Contact: Canopy Indonesia can also arrange a visit to ASRI, plus design a tailor-made programme to include trekking in the Gunung Palung National Park, an overnight stay in a forest cabin, a tree-planting activity with the local forest rangers in a designated orangutan corridor, a boat trip out to the beautiful Karimata Island Group and a tour of Karimata Island by motorbike. www.canopyindonesia.com Contact: Deny +62 813 4530 2228 Veni: +62 813 526 19136