Seven years of advanced and expensive training in the US has prepared me to be an attending in a few months. Particularly in my practice setting, expensive and complex interventions are the norm and sometimes benefit the patient. I’ve recognized throughout the years that the system that shaped me has some serious flaws. Health care access is often disparate, and we spend more time facing the computer than our patients. Futile care at the end of life and over-utilization of expensive interventions are common, and the bankrupting of patients occurs regularly (and beyond the view of doctors who contributed). I have sometimes felt my passion for this version of doctoring wane, and I came to ASRI seeking the holistic ideal of connecting with patients and improving the community with my practice.
My first impression seeing patients was a strong discomfort that I can’t see inside of you. Without all my usual tools I felt like patients’ problems were a mystery, augmented by my inability to gather a history in their native language. I felt the need to know patients’ renal function before prescribing an ACE inhibitor, get a TSH result for a patient with goiter and hyperthyroid symptoms, to see the pneumonia I was diagnosing on x-ray. I felt nervous that my digital-doctoring skills had replaced my human ones and that I was obsolete in this environment. Sometime during week two I made a diagnosis of heart failure, a diagnosis I’m very comfortable with given my extensive training on the subject. I thought, “Ah, I can see inside you!” Victorious, I began trusting my excellent training on the physical exam, and I was off and running.
The patient cases varied from routine to shocking, which is typical anywhere, but most striking to me was the result of the perpetual comparison of, “If this patient were in the US, we’d…”, since the answer was often a lifesaving intervention that wasn’t possible. A 63-year-old woman with a major heart attack would have been in the cath lab within the mandated 90 minutes at Stanford. Without that intervention her mortality rate doubled. Despite that, she improves each day and I smile encouragingly, hoping my eyes don’t betray me and say: “I’m worried, and I’m sorry I can’t offer more.” But it was also a lesson in the resilience of people; often times our insistence that a patient needs what we recommend and will suffer great harm otherwise got turned upside down. A pregnant patient with pyelonephritis declined antibiotic treatment after 3 days and we thought she would certainly become septic and possibly lose the baby (and told her as much). She returned a week later… and was perfectly fine! Perhaps she took a gamble and happened to win, but these situations were a great lesson in humility in medicine. An 89-year-old man came in with stroke symptoms and there were no diagnostics or interventions that we felt could help him, so the family decided quickly to take him home. Our ambulance driver drove all night to deliver the man to his home, to die. I was conflicted with the discomfort of not having a CT to really explain what happened, and not being able to admit him for at least some IV medications, speech, and PT. But on the other hand, I’m not sure all the expensive interventions would have amounted to anything but him dying somewhere other than home, leaving his family with insurmountable debt. It was yet another humbling moment for me as they drove off into the night.
I felt deep satisfaction in facing a patient, both of us barefoot, using hands, eyes, and ears to peel through layers of medical and human knowledge to craft a diagnosis and treatment plan that worked for the patient. I made a connection to the humanity of doctoring, which is what interested me in medicine in the first place, and that I hadn’t experienced so purely since I was a medical student in New Orleans (caring for only a few patients at a time). It’s not that the humanity is absent at home, it flickers in and out of my day like a ticker tape on the bottom of the perpetual computer screen of medical care. But here it was palpable around every patient, and reconnecting with that feeling was very powerful and timely as I set out to start my career.
The conservation model that ASRI employs was another incredible draw for me in pursing the Johnson & Johnson Global Health Scholars Program (J&J) in Borneo, and was even more impressive than I expected. I have been an environmentalist my entire life, with years of experience in wild animal rehabilitation and marine mammal training for conservation research. I loved attending Etty’s education seminar, where she skillfully drove home the critical connection between the health of humans and the natural world, and ASRI’s multi-pronged approach to these objectives. I spent a day with the Goats for Widows program and saw the gratitude of the families who benefit so greatly from the independence and financial security of the program. The reforestation program was of a scale I didn’t imagine, operating as a living-lab in addition to a conservation project. This was health care not just of people but of the earth, and has providing me with endless inspiration for working toward a better planet as a physician.
Clearly, I will take much more from my time in Borneo than I could ever give. For that, I will forever be indebted to those who ushered me on this journey. Huge thanks to ASRI, Health In Harmony, Nomi and Vita, J&J, Stanford, Yale, and Dr. Kinari for creating this reality and allowing me to share it, and to the patients on the treasured island of Borneo who made this experience so fulfilling. Till we meet again.
About Jessie Kittle
Jessie recently completed her residency in Internal Medicine at the Stanford Medical Center and volunteered at the ASRI Clinic through the Yale/Stanford Johnson & Johnson Global Health Scholars Program in April of this year.]]>
1. “A Boon for Soil, and for the Environment” by Beth Gardiner at The New York Times
Typically, agriculture is thought of as a huge contributor to climate change, but this article points to the potential of soil to store immense amounts of carbon – if the farming is done right. In Indonesia and many places in the world, farmers traditionally use slash-and-burn techniques, where forests or woodlands are cleared to create fields for farming. This process depletes the soil of its nutrients, forcing the farmer to move to another plot of land and repeat the cycle. Our partner ASRI works to solve this problem by providing farmers and ex-loggers with training in sustainable farming (no chemicals, no burning, etc), which has lead to the formation of 16 farmers cooperatives. If climate-friendly farming practices are adopted worldwide, depleted soils could reabsorb 80 billion to 100 billion metric tons of carbon!
2. “The planet’s health is essential to prevent infectious disease” by Sonila Cook and Oren Ahoobim at The Guardian
For the past few years, we’ve been flooded with stories about the latest pandemic and how our health systems have failed to manage these outbreaks. This article wisely points out that we must must recognize that, “the conditions that allow for outbreak in the first place are rooted in environmental change.” Deforestation, for example, has made it easier for people to come in contact with zoonotic diseases, which is how many think Ebola was spread to humans. We’ve said it once and we’ll say it again, and again: when the health of our planet suffers, so do we. The article sums it up perfectly, “The connection between environmental change and human health is increasingly clear, but this big-picture view is not how we currently orient ourselves.” At Health In Harmony we hope that with you, we can lead the charge in the reorientation process.
3. VIDEO: Kevin Spacey is the Rain Forest
Just because we love the videos from Conservation International’s Nature Is Speaking campaign, here is Kevin Spacey as the rain forest. If you ask me, he makes a pretty compelling case for protecting the rain forest!]]>
Darya Minovi: In 2016, you became Health In Harmony’s Research Director. Can you tell us a little about how this position came about?
Bethany Kois: Yes! Of course. Over the past year, as you know, Darya, we’ve talked about how the social impact sector is becoming more and more focused, not just on actions, but on outcomes. Health In Harmony has paid attention to that shift. While it’s true that we have always considered how the actions we take on Borneo work to improve human and environmental health. In 2007 and in 2012, we created and implemented community surveys to evaluate the magnitude of our impact in the communities living around Gunung Palung National Park. We are now thinking about how we can ensure that our supporters can truly visualize – in detail – the impact of what we do. So, part of my job is to assist with that detail. To work with you in communicating our impact to our supporters.
We also haven’t considered how to communicate to our supporters the way in which we confidently and continually respond to the communities we serve. Our programs arise out of discussion with communities – talks about what problems they face and the obstacles they encounter when trying to solve those problems. We work really hard to collaboratively envision solutions that are workable and then assist our clients with gaining the resources and training they need to implement those solutions. But, it’s really hard to help our supporters understand – in a real way – how we do that and why it is so important. My job is also geared toward that end. Again, to work with you in helping to communicate what our service communities struggle with, how we listen to them, and what they say.
DM: What have you been working on since January?
BK: It’s been a whirlwind! I’d say I’ve worked first to understand what it means to innovate responsibly. New ideas and new projects are fantastic! Brainstorming about problems and solutions is absolutely exciting! But we need to be sure that innovations are also grounded in reality. We need some confirmation or justification that an exciting program idea has some proven element of effectiveness. That’s challenging! We want to keep learning from other organizations and from our service communities and testing their programs and trying their solutions. We want to take advantage of these amazing opportunities to improve and address problems in a unique way. But we also know that we have to be smart. We have limited resources and those resources must be used on programs that are workable.
I’ve also worked very hard to look at the programs we operate and consider whether they are having their desired effect. I think, how we, as an organization, respond to success and failure makes a huge difference in whether we are able to achieve our program goals. It’s about having a deep look at what is happening on the ground and being brave enough to make course corrections when things seem to be heading in the wrong direction. It can be scary to do that! But, it’s really important, right? Our supporters hope that every dollar they give will be used in a way that will make the biggest impact. We want that too!
DM: What next for you in this role?
BK: Well, right now have a few evaluation studies happening. I am pretty excited about each of them! We have a qualitative survey, using realist methodology, happening the ground right now in Sukadana that’s looking to identify and detail Health In Harmony’s theory of change. We expect that work to be completed around August of this year. We’ve also got an ongoing qualitative evaluation to explore the evolution of Health In Harmony and ASRI. That will likely be wrapped up by the end of the year. This summer, we’ll take a deeper look at whether and how radical listening works to empower community members. Lots more to come and lots more to share!
DM: Sounds like something our supporters need to hear about. Can I talk you into a monthly blog update on this work?
BK: Yes! That is a fantastic idea, Darya. Let’s start in June. Stay tuned!]]>
We were selling handmade tikar mats, which are a traditional form of art in Kalimantan. Since our partner ASRI accepts non-cash payment options to cover medical bills at the Clinic, patients handcraft these mats and use them as barter for health care. The mats are made from sustainably harvested nipa palm and are colored with natural and synthetic dyes. Each of these mats is an example of accessible health care!
After a successful evening, the Cargo staff generously offered to let us continue selling the mats in their store. Even more, they would give us 100% of the proceeds from mat sales – which gets donated right back to ASRI! Almost a year later, they’re still selling our mats, and continue to be grateful for their kindness and support. Today, I had the chance to chat with Patty Merrill, Cargo’s owner, to learn more about this unique shop
Darya Minovi: Cargo is definitely a favorite in the Portland community, how’d it get started?
Patty Merrill: I started Cargo 20 years ago. I was originally working in middle-management at a bookstore on Hawthorne, but I was always interested in ethnic art and traveling. So, it was my passion that drove the business!
DM: Cargo features an array of imported goods from all over the world – many from Asia. Have you had the opportunity to travel to Indonesia?
PM: Indonesia was one of the places I started – 19 years ago was my first trip. We started in Mexico and Indonesia and then expanded to China, India, Vietnam, Thailand, Laos, and Guatemala.
Our paper bags are made out of recycled newspaper. We are able to support an entire village in Java, where they make the bags for us. I’ve been working with the same families in Indonesia for the last 18 years, I’ve seen children take over the businesses – it’s a remarkable experience to be part of a global family.
DM: Are you supporting local artisans?
PM: We are a small business, so we really only work with small businesses. On my last trip, I met some of the most amazing female entrepreneurs. They create products, collect handicrafts, and foster female artisans. Throughout the years, our partnership with artisans have gotten stronger, so we have a whole new Rolodex of female entrepreneurs around Asia.
DM: In addition to supporting international entrepreneurs, you’ve also shown a commitment to supporting local organizations in Portland. Why did you decide to support Health In Harmony?
PM: We believe in you, and are happy to support you. We know how much of an impact your program has on the lives of families in Indonesia.
DM: Is Cargo doing anything special for Mother’s Day?
PM: A lot of us are mothers, so we’re just celebrating ourselves and everyone who comes through our doors! We’ve got an open heart for mothers, and we’re supporting a community of them around the world.
With Mother’s Day around the corner, we encourage you to explore Cargo for the perfect gift. Don’t forget that you can also buy one of our tikars, which are great for picnics, camping, or a day at the beach! By purchasing one, you are supporting a unique work of art that saved a life.
Cargo is located at 81 SE Yamhill and is open 11am-6pm every day.]]>
Darya Minovi: How did you hear about Health In Harmony?
Jeff Wyatt: I first heard about Health In Harmony from our amazing docents at the Seneca Park Zoo. They had seen Hotlin’s presentation at the ZACC conference that year and she made an amazing impression on them. Our docents were super motivated to advance the conservation programming at Seneca Park, so they said to me, “We as a zoo MUST support Health In Harmony.” And our docents are always right.
DM: How did your initial support turn into a full on commitment to the program?
JW: In 2012, we decided that our zoo needed to play a bigger role in international conservation programming, so I determined that we should prioritize Health In Harmony since we are the only zoo in New York that has orangutans. That December, I visited Sukadana and Gunung Palung National Park for the first time. On this trip, we realized that there was an opportunity to further the program in a sustainable way.
So we developed a plan to create a herd health mentoring program. Andrew Winterborn (a vet from Queen’s University in Canada) and I went to Sukadana in November 2013 and with assistance from Etty and Erica held two 1-day workshops to radically listen to farmers and widows. We wanted to know what their priorities were for advancing herd health. Together, we generated a list and identified anemia and overgrown hooves as major problems. One of the best parts about this was that we learned from the widows and farmers, particularly the herbal treatments they were employing to treat the animals. It was a two-way learning experience!
After the training, we brought Jili and Ibu Setiawati in to show them how to collect data on anemia, body condition, and hoof health. We also helped them implement program changes like hoof trimming, having more fresh water available, and exercise for the livestock.
DM: So, what were the results after all this training?
JW: Well, in February 2015 we came back and helped Ibu Setiawati and Jili do another herd health assessment. We were so impressed with the improvements in body condition and blood parameters – just through very simple husbandry changes. We also invited the ASRI clinic staff and volunteers to join us. At the University of Rochester, our focus is “One Medicine-One Health” which looks at the intersection between human health, habitat health, and animal health. Having the clinic staff with us helped open their horizons to this connection.
DM: Now that you’ve just returned from your 4th trip, how were the goats doing this time around?
JW: This time, we found that all the goats were reaching well beyond one year of age. We also calculated that widows and farmers are generating $180 in revenue per goat! We kept asking everyone, are your goats in good condition? The answer was a unanimous yes, which was not the case on our previous trips.
There were 24 additional widows added to the program since last year and there was more evidence of widows managing a breeding herd of goats, with oversight from Ibu Setiawati. Some widows has as many as nine goats! We also saw two homes that had beautiful new roofs that were paid for by selling a goat.
On this trip, it was clear that we are “irrelevant” now. Ibu Setiawati and Jili are collecting data, well-equipped, and are now training others. My personal goal was to ensure that this program is sustainable, which it clearly is.
DM: It sounds like your work here is done! Do you plan on going back?
JW: We are definitely going back, but I love the idea that we aren’t that necessary anymore. Moving forward, we will be focusing on assisting instead of mentoring. What we are looking at now is instead of using medicine for deworming goats, we’ve reviewed the literature and have seen that papaya seeds are effective. Otherwise, I hope we can replicate this program to another area or significantly expand the herd health program to a larger area around Sukadana.
DM: Aside from your contributions at ASRI, how are you supporting these projects from the US?
JW: At the University of Rochester, we send one physician per year to volunteer at ASRI. This year, we held a fundraiser to buy urgently needed medical supplies for the ASRI Clinic. Health Partners International of Canada puts together boxes of medical supplies targeted for the tropics. The boxes are worth $7,000, but it cost us $400 to buy. So, the medical students sold “Orangutan Orange” tulips to fundraise, and we sold out within an hour!
DM: You also recently joined our Board of Directors! What do you hope to bring to the organization now that you’re more directly involved?
JW: What I plan to bring to the Board is expanded financial opportunities be engaging additional conservation partners, specifically from zoos and aquariums that are more committed than ever to save animals from extinction. I’m also doing a presentation at AZA and it’s all about Health In Harmony. People usually hear about conservationists going into a community, changing something, then leaving. But this holistic approach: looking at a community, environment, people, and the habitat is a story that captures the attention of zoo and aquarium guests and leadership.
DM: And how would you like to see Health In Harmony grow?
JW: I would like to see us scale-up this program. I think it’s very important that we demonstrate by example so that other programs can replicate our work in other parts of the world. One thing we are doing is publishing the results from our herd health mentoring program to reach other vets.
I also want to replicate what we’ve learned in Sukadana in my own community. I love the mantra of radical listening, and in Rochester there is a lot of poverty. One of the projects I’m working on is the sturgeon reintroduction program, so we’ll be working with a refugee population near our fish release site. We hope to have them involved in the program and also raise awareness about health concerns around eating fish from the Great Lakes each day.
DM: From volunteering at ASRI to fundraising in Rochester, you are truly involved in every aspect of this organization. What draws you to Health In Harmony?
JW: I see this program as an effective way of saving orangutans from extinctions. I know the orangutans at our zoo – I’ve even known one for 30 years! These orangutans play an incredibly important role in connecting our guests with this organization. And as far as vets go, orangutans really like me! I care so much about their future as a species, and I see Health In Harmony as a very effective way to serve the greater good for orangutans, humans, and the forest.
DM: Any last thoughts?
JW: My last night at ASRI, we had a celebration recognizing all of the volunteers and staff. It felt like a family celebrating goats and each other. I think that was a wonderful grand finale, we had a sunset party at the hotel. It was a beautiful experience that really emphasized to me what a great family of colleagues supporting this collective mission is.
About Jeff Wyatt, DVM, MPH, DACLAM
Jeff is a Professor and Chair of the Department of Comparative Medicine at the University of Rochester and is the Director of Wildlife Health and Conservation at Seneca Park Zoo. He has been to ASRI four times through his herd-health mentorship program and now serves on Health In Harmony’s Board of Directors.]]>
This is a story where I try to trace what left me squatting in a dark bathroom full of large spiders, in a house without electricity, on the edge of the rainforest, after an evening meal in a Dayak household (an ethnic group who are the native people of Borneo). **Note: I will star every time I consumed something questionable.
I sat crossed-legged on a dusty mat, covering a worn wooden floor. Plastic bowls of rice, bamboo shoots, and wild pig sat in front of me, illuminated under a tall sloping roof of ceramic shingles by a single old light bulb. A bottle of air putih (literally “white water” referring to clean drinking water) joined the bowls. Everyone watched intently as I scooped rice first, then bamboo and wild pig, into my bowl. The faces were curious and apprehensive. I took a little rice and a piece of wild pig from my bowl with a spoon. Eyes narrowed around me. I opened my mouth, deposited the spoon, closed my mouth, and brought the spoon back out empty**. The watching pupils dilated. I chewed slowly, not to savor the taste but because the tough meat and gristle demanded it. “Enak?” (“Delicious?”), several voices around the table asked in unison. Each face smiled earnestly now. “Enak”, I said dutifully through a mouth still full of spicy juices and tough meat.
This was actually the second time this exact sequence of events played out. The first was about a month earlier when I made my first trip to the village of Laman Satong, the location of ASRI’s most remote reforestation site. It is about a two-hour drive southeast of Sukadana, depending on how treacherous the road is that day. Laman Satong is a village populated mostly by Dayak people. They are also mostly Catholic (unlike the country’s Muslim majority), and for them, wild pig is a staple food and something they love to share with guests.
“Minum?” (“Drink?”) Ibu Ismanto asked. She is the matriarch of the household and also the chief of the food that was – in fact – delicious. She poured water from the cloudy bottle into glasses as the rest of the assembly served their own food. I took a sip of the water**. The cast of characters that sat around me were: Pak Ismanto and his wife, their two daughters, Pak Jul, the Reforestation Coordinator at Laman Satong, and his young daughter Bella. Pak Jul and Pak Ismanto both have teenage sons who were distantly present, although most of their attention was on painting the motorbike that hung from the rafters of the front porch.
We ate and talked fast. I tried to follow the conversation and got lost often. Many questions were thrown in my direction and my confused answers were almost always followed by laughter. My most common answer was “Tidak tahu” (I don’t know), which was always mimicked by Pak Ismanto’s oldest daughter. “Tidak tahhhhuuuu” she would say, and the rest would shriek with laughter. Weeks later I found out that the word “tahu” has two meanings. When pronounced without an “h” sound it means “to know”, when the “h” sound is pronounced “tahu” means tofu. Being the precise student of Indonesian that I am, I was not about to leave out an “h” sound from the word; therefore, my answer to most of my hosts’ questions was: “I don’t tofu”.
On this night, hundreds of large cicadas were swarming the lights around the front of the house and the light above our dinner. When asked if I liked to eat them, a sarcastic “ya” was my foolhardy response. Unfortunately, sarcasm does not translate well when you are learning a language, and what followed was very much in the same spirit as my mom’s favorite dessert at home: popcorn and wine…except the popcorn was deep-fried cicadas and the wine was arak, a traditional alcoholic drink made by the next-door neighbors.
I was directed by Pak Ismanto’s oldest daughter in how to prepare the cicadas for our dessert. We sat on the floor near the entrance of the house and pulled off all of the cicadas’ legs and wings before throwing them in a bowl between us. Pak Ismanto and Bella kept us supplied with fresh cicadas by snatching them from the air around the lights. The conversation was light, considering the screams that were coming from the bowl that was slowly being filled.
Part of the conversation was a story told by Pak Jul, with his tank top folded up exposing his potbelly. Pak Jul is a small man with a mischievous smile, teasing eyes, and a cute, mischievous giggle. Many of the adventures I have had in Laman Satong are a result of his vast sense of adventure and rebellion. The story he told is one of these adventures. I could not follow the story word-for-word, but because I am one of the main characters I know the story well and I will try to convey it with the same enthusiasm he does.
We rode Pak Jul’s motorbike out a long narrow trail. We came to a river after driving through several kilometers of grassland beyond which the grassland ended and the forest began. We stopped, stripped to our underwear, and started barefoot up the stream, surrounded by trees and screaming cicadas. After a kilometer of scrambling along the bank and wading through the river, we made it to our destination, a steep slope of rapids with five stages of small waterfalls. We proceeded to climb up.
This is the part of the story where Pak Jul gets really animated, so here is my best translation of what he says. “I climbed to the top of the rock above the fourth waterfall and looked back, David was about half way up the slippery section above the waterfall. I smiled, giggled, and waved. As David raised his hand to return the wave his foot slipped and he fell into the pool at the bottom. He came up blowing water from his nose. I yelled David are you okay?! He looked up dazed, and his sunglasses were missing from where they had been on his head.”
Everyone sitting around the screaming bowl burst into laughter, it was at least the third time most of them had heard the same story. Pak Jul then pulled out his camera and showed everyone the numerous pictures he had taken of me struggling up the waterfall in my underwear. I think most everyone around the screaming bowl, excluding the toddler, has hiked to the top of this waterfall without incident.
The cicadas were then fried and eaten, their screams finally subsiding. They were surprisingly delicious with a little garlic powder sprinkled on top after I came to terms with the meaty texture of their heads**. They tasted of some combination of shrimp and fried crickets. The arak came in plastic sandwich bags and we drank it from small tin mugs** that were later filled with coffee and condensed milk as a capper to the night**. Soon after, we waved goodbye to Pak Ismanto and his family from our motorbikes. Then we set out through the newly falling rain toward the reforestation site.
Later that night in the dark bathroom of the small ASRI-owned house that sits on the edge of the reforestation site, suffering through the backlash of my enthusiasm to immerse myself in a new culture, I had a lot of time to think. First, I thought about how Pak Jul and Pak Ismanto like many men from Laman Satong are ex-loggers. Then I thought about how they eat lots of bush meat, and harvest fruits and vegetables from the forest. I thought about how toward the end of the night I was scolded for calling in ghosts from the forests with my whistling. They are people whose identity is ingrained in the forest.
Then I thought about how the overarching goal of reforestation is to make the world a better place to live. I also thought about how, in reforestation, we often think of large-scale issues like climate change and species extinction to justify our actions, sometimes forgetting that there are people living in these areas whose lives can also be improved by our projects. These people and their values for the forest cannot be overlooked because their cooperation is needed to create and maintain healthy forests.
From the conversation that night, the stories told, and the meal itself, I learned some of the many values that the forest has for my hosts. It is a place for recreation, and it is a source of culture and spirituality. It also provides many resources they can use to make a living. It is both loved and feared. In order for the reforestation project to be successful at Laman Satong, it has to cater to these values. ASRI recognizes this issue and tackles it with the unique variety of conservation and health programs that they offer. While still squatting in the dark, I momentarily forgot my discomfort and was filled with pride and appreciation for the opportunity I had been given to learn from this incredible organization and the people it influences.
So, where did I go wrong? What was the substance that led to my sickness? I have an idea of what I think it might have been, but I will let you decide on your own.
About David Woodbury
David is from Washington and recently graduated with a degree in Environmental Science and Terrestrial Resource Management. He is currently volunteering at ASRI’s reforestation site and recently extended his stay.
To read previous Volunteer Voice reflections, click here.
As a result, a few months ago the ASRI staff approached 14 loggers in the villages of Pangkalan Buton and Sutera to see if they’d be willing to participate in a program that would help transition them to an alternative livelihood. After hours of chatting over sweet tea, the ASRI team better understood the challenges faced by this particular group of loggers. From the 10 loggers who expressed interest in the program, a baseline socioeconomic survey was conducted, showing several key findings:
When you look at these numbers, it is easier to understand why many of them turn to logging. For many, their monthly expenditures are higher than their income. When it comes to health care, which drives up household expenditures (up to $5,000 per month for some), it’s no wonder why they turn to logging for fast cash to support their families.
The survey had another interesting finding: 82% of the loggers already had side jobs that had the potential to be improved and scaled-up. As such, ASRI launched a family entrepreneurship training to focus on micro-enterprise development for the 10 loggers and their wives.
Entrepreneurship experts from Jogjakarta led a 5-day training that included the development of business plans for each household and distribution of start-up funds of roughly $330 to each household. With these funds, the households have invested in their new enterprises, which include poultry husbandry, restaurants, grocery shop owners, traditional snack stands, barber shops, fishing, and carpentry.
The results from the first-round of “entrepreneurs” is encouraging: 60% of the participants have stopped logging entirely. 40% of participants still log occasionally while they wait for their businesses to become profitable.
One individual managed to match his previous level of income from logging with his chicken farming business, saying; “It has been a whole year since I climbed the mountain to log. Now I make almost 5 million rupiah (~$370) each month from my chicken business. I feel good that I was able to stop because I know it is bad for the whole community.”
For those who are still logging, they face social pressure from the community. One logger’s wife says that she feels confident in convincing her husband not to log because she feels he no longer has an excuse to do so after receiving funding from ASRI. And with fewer loggers in the forest, the remaining loggers don’t have a network of informants to rely on, making the risk of getting arrested too high for some.
This initial success of ASRI’s Family Entrepreneurship Program is a testament to the importance of “radical listening” – creating a space where programs are developed and led by the communities affected by them. With this approach, ASRI predicts that the holdout loggers will cease going into the forest by the end of this year.
*Results are based on a survey completed in late 2015 and are approximate estimations.]]>
Millions of seedlings need to be planted to bring back the forests in Indonesia. This job takes a lot of time and work to do. People are needed to plant seedlings in deserted areas.
Planting trees isn’t the most difficult part of reforestation; it’s keeping them alive that is hard.
Reforestation is needed because people cut down the trees or set them on fire to clear the areas. It’s crucial that we work to build awareness of the effects these practices have on the overall health of the local environment. The only way to ensure trees make it to maturity is to make sure they are taken care of by people who want to save the planet.
Forest fires are a yearly problem due to slash-and-burn land clearing. Reforestation sites are vulnerable to farmers and palm oil plantations as well, which is why we’ve developed a fire prevention and mitigation plan.
The fire prevention and mitigation plan involves having ASRI workers monitor reforestation sites for fires and dig firebreaks if a fire starts. If that doesn’t keep the fire from destroying the forest, workers spray water with pesticide sprayers on the fire for hours until it is controlled.
While it may be impossible to stop a fire from starting, it is possible to keep it from destroying an entire reforestation project, as long as there are people available to take action. Additional teams are needed now to keep more forests from being destroyed.
Involve the Community
Community involvement is crucial. Reforestation cannot succeed without the help of people who want to dedicate their lives to tropical rain forest conservation.
Communities around reforestation sites must unite to plant seedlings, ensure there is enough water, and protect them from environmental hazards until they don’t need as much care. With millions of hectares of land available in Indonesia for reforestation, the work in planting and nurturing trees is plentiful.
Fire prevention is another activity needing community involvement. Reforestation sites need 24/7 monitoring and a team of workers to dig the firebreaks in case of a fire.
Health in Harmony cannot do this alone. We need everyone’s help.
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The second reflection in our Volunteer Appreciation Month series! Stay tuned for a new post from volunteers each week in April.
On my last day in Borneo, I awake at 6:30 as usual, I spend the first hour of my day meditating and reading while roosters crow in the dawn. Then, an invigorating morning mandi (bath). Though I can barely communicate with her and haven’t said anything, Ma Unggal knows I’m leaving and made sure that my clothes were swiftly washed and pressed. Last week, I stopped by the house during work to find her humming in my room, folding clothes I had thrown hastily in my armoir after returning from a weekend at Tanjung Puting. I’m going to miss her care.
At the Clinic, we rounded on our in-patient, a woman in her late 30s with chronic weight loss and vomiting. She is gravely thin, her son and husband at her bedside. We fear cancer or TB at worst, a severe ulcer at best. She really needs to get an endoscopy at the hospital in Ketapang, two hours away. Even though she is covered by the new government health insurance, she can’t afford to travel and stay in Ketapang for the procedure. In the meantime, we see if anything shows up on an abdominal ultrasound. First, Dr. Nomi scanned through the liver: normal. Dan, the new Emergency Medicine resident from the University of Rochester scans the stomach. Strangely, it was full of some semi-solid material, stretched all the way across to her right side, and with little peristalsis or gas. The pylorus appeared to be narrow with little flow through. We talk through ways that we could possibly remove some of it to ease her symptoms, ultimately deciding (by Dan’s creativity) that in lieu of an orogastric tube that Coca Cola would be our best bet for dissolving the material and getting her some calories. He ran to buy some next door as a gift before the family left. I wished I was here longer with Dan and Jessie (Internal Medicine resident from Stanford) to learn more from them. We all wished the patient could save enough money to go to Ketapang for more definitive treatment before it was too late.
Our next patient, a young mechanic, came from a village outside of Ketapang after getting a shard of steel in his eye; he’s the second patient with this issue in a week. Dr. Nomi donned jeweler’s glasses and removed the piece with a small needle, followed by applause from her audience. We then saw a woman seeking advice on contraception, a typical primary care visit for once. Then, the ASRI ambulance pulled up with a man who had gone to the government clinic for a lump under his chin and ended up with seven teeth pulled, now with continued pain, swelling, and drainage. He recently had several lumps on his neck that were incised by a surgeon in Ketapang. Dental x-rays he brought in confirmed our suspicion that the problem had nothing to do with his teeth and was more likely an infection of his lymph nodes (Similarly, someone came in last week with Bell’s Palsy and had his wisdom teeth removed as the treatment). Removal of the bandages on his neck revealed oozing at 4 or 5 small incisions in his neck and over his sternum. Jessie thought it might be scrofula, TB of the neck. We anxiously waited for the lab techs to mount and stain some of the fluid on a slide to see what organisms were present. We all looked at the slides, nothing but pus. Perhaps the antibiotics he had started 3 days ago were starting to work. Later in the afternoon Dan and Jessie gave a great impromptu lecture on myocardial infarction (heart attack) management to the group of visiting health profession students, some of which ASRI is hoping to recruit as future staff members. I was grateful for an action-packed last day at the Clinic.
I head to our after-work meet-up spot at Pak Amat’s cafe next door where friends were already waiting and wondering what I wanted to do for my last evening: sunset and kelapas (coconuts) at the beach of course, followed by karaoke–a traditional volunteer send-off. On the bike ride to the beach, I took a last look out to the sunrays shining on the mountains of Gunung Palung National Park, my companions from ASRI riding close by. I never have words on this stretch except to exclaim the perfection of the scenery, simplicity, and community of Sukadana, my riding companion kindly agreeing and humoring me. Voices of children yelling “hello mister!” emerge from the roadside houses. As we near the beach, teenagers eye us, some also yelling hellos, as they ride around. Motorcycle rides are their chance to embrace in public.
Sunset papaya juice, sweet and smooth with susu (condensed milk) and ice. I again marvel at the rawness of the forest-crested brown beach while the sun turns the trees into silhouettes and the first stars poke out. Jokes cut through heavy feelings left by those recently-departed volunteers with whom we shared songs (Forever Young, Toxic, Leaving on a Jet Plane) and laughter. The reality of my dwindling hours in Sukadana now setting in.
On my way home from the beach, I can’t help but feel the island is giving me a gift for my last evening as a blanket of bright stars emerged despite the rainy season. Last Ma Unggal dinner: boiled vegetables, chile-marinated boiled eggs, tempeh, and white rice. As a small gift for her care, David and I bought Ma Unggal a turquoise hijab for her en route to karaoke. Our main event opened with a heartfelt rendering of I Will Always Love You, the words resonant with my feelings toward those I would leave after tomorrow’s morning meeting. The heart-sob-sweat-bath carried on until late.
Back at the beach, David (fellow volunteer), Tiar (engineer), and I earned a Boy Scout badge for building a blazing fire with wet wood. Clouds now hiding the moon and stars, and the tide fully in, made for the brightest night of bioluminescence yet. Blue-green light flashing around our bodies in the waist-high waters, sparkles shimmering as water moved across. Bright lightening in the distance and thunder. An elderly man emerges from a nearby house bringing uneasy laughter. He puts some wet logs over the fire, leaves. It’s 2 am, our swimsuits almost dry. We three fall asleep on sheets around the fire. We’re awakened by the sounds of the call to prayer, gibbons in the distance, and crowing roosters.
Last morning, surmounting insecurities, I wrote a postcard to my girlfriend’s father so he could collect a stamp from Borneo, then finished my farewell speech. I had it translated by the new Indonesian doctor over breakfast as he wooed David and I with small hints of brilliance. At the morning meeting, I fumbled through my going away speech to an expectant crowd. My 6 weeks ended with tearful goodbyes, me too choked up to talk, too tired to hold it together.
Smooth waters on the boat to Pontianak made for a relaxing nap. Of the many topics, John (ASRI visitor) and I reflect on how much easier it can be to relax when traveling and away from city life and how we want to live in the woods. We are shocked by the luxury of Santika hotel and excess of having a jacuzzi and an ice bath. For dinner, we find a vegetarian Chinese restaurant with Indonesian staples so Jonty (fellow volunteer) and I could try bakso (meatball soup), but the herbal seaweed ginger soup with mock chicken is the winner. Bubble teas (mine gritty with fresh carrot) and banana fritters for dessert. A feast for under $3 each. Back at Santika, we capped the last month together with four 32 oz Bintang. Welcome back to American prices and the goodbye to the innocence and simplicity of laughter without the influence.
Even in Pontianak there’s some air of celebrity and extra friendliness, but now in the airport eyes flicker away, people cut lines, all but step on your toes. Blazers, jewelry, polished leather shoes, eyes glued to newspapers or screens–none of the things associated with the bliss of rural life where the simple pleasures (bucket mandis, rooms decorated only by the drape of mosquito nets over the bed) remind you that happiness needs nothing but the breath, simple food and shelter, good friends, nature, and purposeful work.
About Alex Domingo
Alex is a Yale medical student, pursuing a residency in Internal Medicine. He volunteered at ASRI from Jan-March 2016.
To read previous Volunteer Voice reflections, click here.]]>
Over the ensuing years, I’ve been honored by and grateful for friendships with many of you and privileged to do this work with Health In Harmony’s founder, Dr. Kinari Webb, my esteemed Board of Directors, and my most valued Health In Harmony and ASRI work tribe. Friendships and connections I never imagined have been made possible because of the work we do together: engaging community-led solutions for human health and the health of our planet.
Now, it is with the greatest of respect and love for each of you, and all of Health In Harmony and ASRI, that I have asked and your Board of Directors has accepted my resignation as Executive Director. I am leaving at this time because my work, the very best work I do, is done. It has been a most amazing journey, going on 5 years. I still recall the day well, December 1, 2011, when I accepted the job with Health In Harmony. Borneo wasn’t even on my bucket list but I was thrilled and I remain so thankful for what has been a personally and professionally transformative journey with each of you. It is important to me that you know I am retiring with a little “r” and choosing to take a 6-month personal sabbatical to explore what’s calling.
This is an exciting transition. Every non-profit organization has its seasons and there is a leader unique to every season. In my season here, the greatest gift I have given Health In Harmony has been my steadfast leadership and vow to work in and with integrity on the foundations for an effective, passionate, accountable organization. Today, it is one that is even more capable of greatness and I believe the time has arrived as Health In Harmony embraces its next decade, for Health In Harmony to embrace new, savvy, dynamic executive leadership.
In closing, I go back to what I wrote in February 2012, Reflections on Gratitude (April 2012): “Crossing the tarmac at Ketapang’s outpost airport, I am momentarily caught in a gulp of sadness…. because I know in the deep well of my heart that I’ve stepped across an invisible threshold and will never be the same again even though I know I don’t completely know how so — yet.” In so many ways, none of us will ever be the same again whether we’ve donated, worked, volunteered or served Health In Harmony or ASRI in any way. I know I will have left a piece of my heart and soul in Health In Harmony and at ASRI.