Sunday, 20 December 2009

Health and wealth have missed me

Some good news for those in prison. The Jakarta Post reports on the signing of a memorandum of understanding (MoU) by the Minister of Justice/Human Rights and the Minister of Health. This makes prison inmates eligible for the government-run health insurance scheme for poor people, known as Jamkesmas.

In the past, it has frequently been difficult for prison staff to arrange free health care for inmates, since they often do not have valid identity cards and have difficulty proving that they are poor (within the meaning of the act). Now, all that will be needed to access hospital services is a recommendation from the prison warden.

Except for "inmates assumed to be rich, like drug abusers," the Post reports the Minister of Justice/Human Rights as saying. Since something like half of prisoners are there for drug offences, this would seem to place a severe limit on eligibility. A similar limitation previously in place in Jakarta excluded the inmates of the Cipinang Narcotics Penitentiary from accessing the free health care which at least in theory was available to other inmates.

The Director-general of Prisons appears to be unaware of this. He is quoted as noting that 90% of prisoners will be included in the scheme. Let's hope the wardens ignore the oft-held assumption that all drug users must be rich to afford their habit.


Saturday, 12 December 2009

Isolated with no before or after

A disturbing interview on NPR yesterday (Questions On Public-Private Prisons For Immigrants) confirmed my impression that the prison system in Indonesia could teach some others a thing or two. We heard about inhumane treatment in a prison in Texas (A Death in Texas). This prison in a remote part of the USA, with 3,700 inmates, has no infirmary! An epileptic prisoner was denied his medication, and locked up in an isolation cell (the "hole"} when he fell sick, because there was nowhere else to put him. He died in the cell.

Read the article. Listen to the program. And thank God that Indonesia is more enlightened.


Friday, 11 December 2009

All the little birds go tweet, tweet, tweet

Although I've been using the internet since 1995, I'm really not into social networking. Perhaps because I'm basically anti-social? I've never been good at old-fashioned chatting, let alone chatting on the internet. I've on occasion set up both Yahoo Messenger and Facebook accounts, but shut them down within minutes. And tweeting? They're all just not me!

But there's no doubt that Indonesians are really into these forms of social networking. It seems that almost everyone now has a Blackberry. A recent report on the Kompas Daily web site (Penetrasi Internet di Indonesia Naik Dua Kali Lipat) says that 17% of Indonesians are accessing the internet, with a rise of 700% in numbers of Facebook users and 3,700% in Twitter users over the last year. And it notes that most of the users are in the 15-39 year age range.

So what? Well, that age range is clearly that most affected by HIV. But many of those involved with AIDS planning are a bit (or in some cases, more than a bit!) older than that, and probably feel less than comfortable with these new developments.

Some examples: the Spiritia web site hot line received 109 anonymous questions last month. Since we started it in May last year, the Spiritia web site forum has attracted 427 members, who have posted close to 7000 messages. I guess Spiritia staff respond to an average of 3 SMS questions every day. And Spiritia is clearly not alone. An increasing number of NGOs are employing cyber-outreach, particularly for difficult-to-reach gays. Yet it sometimes seems that few program managers are aware of all this activity.

There is an increasing literature regarding AIDS outreach via SMS in Africa. Of course, internet coverage in Africa is currently much lower than in Indonesia. I would suspect there is a great opportunity for develop some cutting-edge ideas using these new tools. Perhaps it's time I re-established my Facebook page...


Wednesday, 9 December 2009

Grace under pressure

It's not only acronyms that lose their meaning. Take 'stigma and discrimination'. 'We' often refer to these without really thinking about what they really mean.

I remember back in 1996, when we were planning the first national Candlelight Memorial, we prepared a flier referring to the Indonesian term 'diskriminasi'. I guess that even if you don't understand Indonesian, you can guess what that means. Unless you are Indonesian. Very Kamil, then working with Lentera in Jogja, was in the meeting and asked the meaning of the term (I think he knew, but ...).

Although I'm not an etymologist, it always seems to me that, if a word for the concept does not exist in the language, chances are the concept does not exist in the country. After all, you need a word to describe the concept. And this is especially true for discrimination. In a feudal society (like that in many parts of Indonesia), you don't know you have rights, let alone what those rights are. So how can you talk of violations of rights?

Anyway, in the end we responded to Very's concern (as we still do) by adding in parentheses 'perlakuan yang tidak adil (unjust treatment)'.

Most HIV-infected people in Indonesia (and their families) have experienced discrimination. In my experience, it has usually been caused by lack of knowledge or understanding about HIV, and fear of infection resulting from lack of awareness of how HIV is transmitted (and not transmitted). Of course there are people who are just plain nasty, taking a moral (and often hypocritical) stance. But in my experience this is relatively rare in Indonesia. More often what is seen as discrimination against people with HIV in the health care settings is in fact the endemic discrimination faced by the poor. Those with money rarely face discrimination.

Stigma is more difficult. Again, there's no Indonesian translation, although we often refer to 'cap buruk (nasty mark)'. Actually 'cap' is perhaps more often understood to be the mark made by a rubber stamp (or a finger print). Indeed, recently infected people often feel like there is mark saying 'HIV' on their forehead. And this is indicative that self-stigmatization is at least a significant part of the problem.

All this came to mind at a meeting of the STOP TB Partnership Forum yesterday at which Care International presented outcomes of their TB program in parts of Banten (the province in Java west of Jakarta). In surveying community attitudes to TB, they changed the question on stigma to refer to 'social pressure'. I'm sure we could argue over the term for ever, but at least this caused me once again to think about what we really do mean by this term that we so often use without thinking.


Sunday, 6 December 2009

Grind in the prison house

"Don't worry about injecting drug use here. Indonesian kids wouldn't do that; they're good kids. And anyway, they're scared of needles." So went the conventional wisdom in the mid 90's, when I was working with the Pelita Ilmu Foundation. Pelita Ilmu started life doing outreach to schools, so they should know, right?

As we all now know, wrong! And I should have known better. When I used to hang out with kids in Jakarta in the early 70's, sometimes they'd say: "Watch out for him; he's a morphinist!" That was the 'in' term for a 'junkie' then, but they didn't actually use morphine. Dr. Erwin Widjojo, who set up the Drug Dependency Hospital (RSKO) in Jakarta around that time, tells me it was heroin they were using then. Not injecting; if they wanted an extra-fast high, they would slice the skin on their forearms with a razor, and rub the heroin into the wound. I still sometimes meet users from that period. Mostly they wear long-sleeved shirts to cover the scars.

Anyway, I bought that 'wisdom' right up to 1998, when by chance I sat in on a meeting at the Kusuma Buana Foundation. They were working with slum kids in Warakas in north Jakarta. The meeting was reviewing the program, assisted by Prof. Irwanto of the Atma Jaya University. I was shocked out of a reverie when Irwanto talked about some of the kids there injecting drugs. I visited the place, and found he was right. They apparently used the wasteland under the elevated toll road that borders the area. Dug some more, found out that there were others who were also concerned, such as George Loth of UNAIDS and of course David and Joyce Gordon.

To cut a long story short, several of us got together, with support from Project Concern International, to hold a seminar/workshop on responding to drug problems (but actually on harm reduction, although we hadn't started to use that term then). This five-day meeting in September 1999 involved several experts, including Nick Crofts, Dave Burrows, and Palani, who went on to help us build the foundations of the harm reduction response here.

Of course, a meeting of this nature cost a lot, and there was no funding available then for such controversial activities. So I was tasked to visit Australia to drum up some money. Obviously the prime target was AusAID, who was already running an HIV program here. In Canberra, I tried to persuade them that there was an urgent need to add drugs to this program. They were polite, but didn't seem to offer much hope. I talked to Nick in Melbourne; he put me in touch with Alex Wodak in Sydney, who put me in touch with a retired Australian ambassador to the region. I met him for coffee on a Saturday morning, the last day of my trip. He understood the need, partly because he'd already seen the effects, and also because (if memory serves me) he had a family member with a drug problem. He promised to use whatever contacts he still had in AusAID to lobby for support.

Those contacts must have been influential. On the following Monday morning, back in Indonesia, I received a call from the local AusAID head, telling me that Canberra had allocated 300,000 Australian dollars to the HIV program to be used for the response to drugs in Indonesia. Funding of our meeting was to be the first priority. As you can imagine, we were over the moon.

I'm reminded of this ten years later as I try to drum up interest in the health care challenges in the prisons here. The current AusAID-funded HIV program (HCPI) is doing a fantastic job responding to HIV in the prisons in Java and Bali, as did the earlier USAID-funded program. I'm sure the new Global Fund Round 8 and 9 programs will build upon this. But although HIV is a major problem in the prisons, the health care challenges are much broader and entrenched. Over-crowding, with many prisons at 300% over-capacity, limited funding (a health care budget of less than $50 per prisoner per year), poor sanitation, limited water supplies, a sporadic drug supply system, and limited human resources (some prisons are dependent upon doctors in local health centres) are only a few of the problems.

The prisons department, both at national level and locally, are clearly determined and striving to address this challenge. But they need much more help - and unlike some in Indonesia, they are very open to assistance from anyone who has the expertise and is willing to help. But who is willing to put up the cash? Any ideas? Do I need to make another trip to Australia with cap in hand?


Wednesday, 2 December 2009

Pore benighted 'eathen

It was back in September 1995 that I first learned that condoms have pores. The report in the Republika daily, that condoms have holes 1/10 micron in diameter (whereas HIV is only 1/600 micron) must be correct because it was written by a professor: Prof. DR H. Dadang Hawari. Even more so, since the byline noted that the article was a result of cooperation between the daily and the Indonesian Medical Association (IDI). Who could possibly doubt it?

Of course, since then I have learned that Prof Dadang is typical example of our faith-based, rather than evidence-based, academics. And even IDI felt it must respond. So they arranged a debate on condoms, exactly 14 years ago today. This was held in the medical faculty of the prestigious University of Indonesia, and I was there. Prof Dadang was due to speak, presumably on the 'side of the angels.' However, he pulled out at the last moment, as he as always done when called upon to defend his position. So the debate went ahead, one-sided, without him. As I recall, it was one of my first experiences of us preaching to the choir.

The challenge of 'pored' condoms has since come up, it seems, at least once a year. On each occasion, 'we' tell each other 'we' must do something, that 'we' must address this once and for all. But since 'we' usually means 'someone else', nothing changes.

At least that was until this year. Now it's just gotten worse! I've just read in the Jakarta Post (Students told to nip bad habits in the bud) about a young high-school student who has become 'one of the 92 ambassadors of the Jakarta Stop AIDS campaign.' At 15 schools he has visited, he has told fellow students that "there is still a risk of contracting AIDS through the use of condoms because they have pores through which the virus can pass,” He says he learned what the Post rightly calls this 'scaremongering information' at a workshop organized by Unilever and Yayasan Cinta Anak Bangsa (an NGO doing outreach on drugs to youth), and 'based on material from the National AIDS Commission.'

The one bit of good news is that the Post knows better, "According to the WHO, laboratory studies have found that viruses (including HIV) do not pass through intact latex condoms even when they are stretched or stressed," it states. At least we've made a little progress with some of members of the mass media.


Sunday, 29 November 2009

Walk...toward the unknown region

Pace ASEAN, I've always found the idea that there is some essential similarity between the Khmer and the Acehnese, or between the Karen and the Moro, somewhat questionable. It's like the concept of 'Asian values', which is often adduced but rarely defined. And if there is really little in common between all of the countries of Southeast Asia, how much less among the Asia-Pacific?

I therefore tend to question the value of regional groupings and responses. Almost every month we get requests to identify candidates to attend regional trainings, seminars, and workshops, for some reason almost always held in Bangkok. Since the medium of instruction is always English, the prime qualification is a degree of fluency in that language, a skill which is quite rare in Indonesia, and (I imagine) in several other countries in the region. In contrast to some others, at least Indonesia uses a Roman script.

In addition, the instructors or presenters usually come from outside the region, often with little understanding of the situation in the various countries, and speaking in a way that may be difficult for even those relatively accomplished in English to understand.

This has been brought to mind recently by a UNAIDS-organized "Joint capacity building workshop on TB/HIV and advocacy for networks of people who use drugs and their support organization", for injecting drug users from the region. This two-day workshop was recently held in Bangkok, and one of my colleagues has just returned from it. There appeared to be a huge gap between the level of knowledge of TB among participants from different countries. Most of the first day was apparently spent in reviewing the basics of TB. Although this was clearly needed by participants from some countries, for those from Indonesia this was 'old hat, since all had already attended training on this at home. In addition, I wonder how much similarity there is between advocacy in Indonesia and (say) Vietnam?

In the early days of Spiritia, we organised trainings and meetings at a national level. But as the number of those affected increased, we identified that this was not a cost effective approach. Arranging a national training for 20 people costs around $12,000, but with that amount we can arrange around six local trainings covering a total of more than 100 people. No doubt there are some networking benefits from a national meeting, but I think these are often over-stated.

Surely it is time for a similar approach to be applied to these regional meetings. For the same amount of money, it would probably be possible to arrange a series of similar meetings in each country in the region. And rather than "importing' speakers, these could use local trainers, people who understand local conditions and speak the local language. In this way we could choose participants based upon there real qualifications, not primarily on their English skills.


Saturday, 28 November 2009

Hope for the best...

...and trust in God?

As I've noted before, we're all waiting (with more or less patience) for a cure. But is that realistic? We're often told that Islam teaches that God will provide a cure for any sickness that He inflicts upon us. Leaving open the question of why He would so inflict us, I think this statement requires a large dose of faith. There's a whole bunch of 'old' conditions for which there is still no cure.

I am often asked how long it will be before there is a cure for HIV infection. How should I respond? My 'hero'. Prof. Joel Gallant of Johns-Hopkins, often gets taken to task for the realism of his responses to such questions - see Cure. I myself believe that it is highly unlikely that I will see a cure, but then I'm quite elderly. Should I respond so directly, or offer what I see as unrealistic hope?

Dr. Fauci, head of the National Institute of Allergy and Infectious Diseases (NAID) maintains that we already have a 'functional cure', in that currently available therapy can offer HIV-infected people the hope of dying of old age (or more likely other conditions, given the less than healthy lifestyle of many such people here). Is that enough? Not really, since it still requires taking potentially toxic drugs for life, and does not guarantee non-infectiousness.

The search for a cure is still needed. But like the search for a vaccine, our hope must be tempered by realism...


Friday, 27 November 2009

Preaching to the converted

When I was a lad attending Tech College in Chelmsford, in Essex in eastern England, I lodged at a hostel right next to a church. I still remember how my Sunday morning hung-over sleep was interrupted by the peel of the bells from the church, calling the faithful to prayer. I was reminded of that as I was on my morning walk today, this time around the Lubang Buaya monument to the generals slain in 1965 during the so-called communist uprising. (The paths on my preferred walk would be very muddy following heavy rain yesterday.) It being Idul Adha (the Muslim Festival of the Sacrifice), the many mosques in the area were at full blast, and my ears were assaulted from all sides.

The letters pages of the Jakarta Post have long been bombarded by complaints about this, with comments reaching a crescendo after the reports that Cairo is taking steps to address this babel (One voice for Cairo's call to prayer). What seems to be clear is that several mosques appear to compete on the volume, rather than the quality, of their muezzin's call. The result is an often ear-splitting cacophony, which almost certainly exceeds the limit that can cause lasting ear damage.

Why do I bring this up? Because we in the AIDS community tend to act in the same way. We compete with each other on the volume of our shouts, rather than on their quality. We preach to the converted, just like the mosques, particularly in our increasingly shrill exchanges in our mail lists and forums. And, like the mosques, it all rises to a peak on specific days. At this time of year, our fax machine runs out of paper with all the invitations to events. If we attend, we'll find the participants are primarily 'same old, same old.' And many organizers will also be asking for us to arrange a 'rent-a-PLHIV' to present 'testimony' at the event. (My friend Wahyu says that his price for testimony is three million rupiah, but he's free if invited as a speaker.)

Happy World AIDS Day!


Thursday, 26 November 2009

and I don't care

I'm sure we all frequently use acronyms and abbreviations without thought as to their underlying meaning. One example that always sticks in my craw is 'WTS' (wanita tunasusila, or women without morals), a euphemism for sex workers. While some are quite likely 'amoral', no more than members of the general population, and many that I have met are more moral than me (OK, not saying much!). It's an extremely judgmental, inappropriate and unempowering term. Yet it's still used by the Social Welfare Ministry, where there is a subdirectorate providing social rehabilitation service for those without morals (Subdit Yanrehsos Tuna Susila). Sadly I can't tell you much more about it, because the web page for this subdirectorate only displays 'Lorem ipsum dolor sit amet, consectetur...". But I have refused to attend activities of the Ministry until they change the name.

Today, another example came my way, although raising very different concerns. 'CST' is increasingly used for Care Support and Treatment (mainly for HIV-infected people or PLHIV) and this English abbreviation is often used even in Indonesian. In fact, the report I was listening to, while frequently referring to CST, in fact focused almost exclusively on treatment, with little concern for care and support.

We have frequently emphasised that provision of antiretroviral therapy (ART), while important, is by no means the only need of PLHIV. For example, we have still made little progress in retaining PLHIV in care, especially those who have yet to meet the criteria for starting ART. The result is that, even if we manage to identify infections at an earlier stage, the PLHIV concerned will rarely return for follow-up until he or she falls sick with a serious opportunistic infection, and with an immune system that is already shot. In addition, as Dr. Chavelit pointed out in the meeting, we almost totally ignore palliative care.

Fact is, as my colleague Dr. Hendra recently pointed out to me, while we've made a degree of progress in provision of treatment, and Spiritia and partners are doing a reasonable job of support, we've made almost no progress on care. Those who are normally the main providers of care, nurses, are often viewed as skivvies (a menial for those from the ex-colonies), and frequently lack caring skills.

Clearly changing this requires a very long-term effort, but at least we could start to acknowledge the need, and avoid lumping this important activity with the other two.


PS A Happy Thanksgiving to all (two?) of my US readers. As you probably know, the English celebrate thanksgiving on 4th July (grin!)

Saturday, 21 November 2009

Water buffaloes, neurasthenic

Dr Ronald's report predicting five million cases of HIV infection next year (Figures don't lie... (cont)) referred (as many such reports do) to the iceberg phenomenon. We often used to hear that for every case found, 'the WHO calculated' that there were 100 or 1000 (choose your figure) others that made up the unseen part of the iceberg under the water. I'm doubtful the WHO ever made such an assertion, but it became an urban myth.

Ignoring the figures (and the fact that icebergs are quite rare in the tropics), the metaphor of the tip and the submerged part is in fact totally inappropriate. The problem with it is that the full size of an iceberg never becomes apparent. As the ice melts, the iceberg gets smaller (never larger, like an epidemic), but the ratio of tip to submerged part remains the same. Thus the metaphor suggests that, as more and more cases are identified, so there are more and more cases unidentified.

With improved surveillance (active or passive), the proportion of unidentified cases is reduced. Epidemiologists then say that the size of the submerged portion decreases compared to the tip (see iceberg phenomenon). This is clearly wrong-headed, since such can never happen to an iceberg. And this wrong-headedness leads the press (and activists who should know better) to scream about an exploding epidemic each time the number of identified cases goes up.

I was reminded of this during my morning walk around the small farms at the back of the Halim airbase (the Sunter Valley is not quite as attractive as the Thames Valley, but this morning's walk was pleasant, with clear views of Mount Gede and Mount Salak to the south). I pass a number of muddy pools, and as usual this morning, several water buffaloes were enjoying their morning bath.

Some time ago, Doc Suharto (late of the Education Department and the National AIDS Commission) proposed this as a replacement metaphor for the AIDS epidemic in Indonesia. We first see only the buffalo's snout above the water, and we have no idea if it is a small baby or a large adult. But slowly the beast raises itself out of the mud, and its size starts to become apparent, until finally we can see its full extent.

This clearly provides a much more appropriate metaphor, besides being easier for people here to understand. At the start of the epidemic. the buffalo is small, but as time passes grows larger. But as surveillance improves, the buffalo heaves itself out of the mud, and we begin to appreciate its full extent.

Wonder if there's any hope of getting epidemiologists to change their metaphor?


Wednesday, 18 November 2009

Figures don't lie... (cont)

How many HIV-infected people are there in Indonesia? The general consensus among the experts is around 300,000. I have noted before that Malaysia, with one tenth of the population of Indonesia, had identified around 70,000 cases of HIV infection. It thus seems reasonable to guess (as a non-expert) that Indonesia had at least 350,000 cases.

Now we have another expert, our friend Dr. Ronald Jonathan, quoted suggesting that by next year, there will be five million (yes, six zeros!) cases by next year, in only 300 of the almost 500 districts in Indonesia (Five million HIV/AIDS cases in Indonesia by 2010). Interestingly, only an English-language version of the report appears on the Antara web site.

I've just talked to Dr. Ronald. He tells me that he was presenting figures of worst-case scenarios from several years back. He was not at the time aware that the Antara reporter was present, but when he was later interviewed, he corrected the reporter's mis-impression, and requested that it not be published. Seems Antara ignored this, and the report was picked up and published in the Jakarta Post yesterday.

On the other hand, at a meeting a few days back, I heard that a new 'official' estimate is being prepared, which may end up suggesting even an even lower figure than the 300,000. Sadly, the surveillance efforts here are very limited, very infrequent, and with questionable samples. So the fact is that we have little idea if it's 200,000 or two million.


Sunday, 15 November 2009

My actions are my ministers

The furore over the appointment of Endang R. Sedyaningsih as Minister of Health seems to have died down a little. I think that to most of us in the AIDS world her appointment is very welcome news. Five years of a xenophobic minister, who declined to talk of harm reduction at a cabinet meeting on AIDS apparently because she didn't know what it was, have done little to enhance the response to HIV in Indonesia.

Mbak Endang was one of the earliest Indonesian AIDS activists. Back in 1996, she collaborated with Pandu Riono to set up the first Indonesian-language AIDS mail list, AIDS-INA. I ran into her at many meetings in the late 90's, and she was always pressing for a broad-based response.

Many have probably forgotten that Ibu Endang was among the earliest supporters of the concept of harm reduction. It was back in December 1999 that she published an op-ed article "AIDS di Indonesia: Ke Mana (AIDS in Indonesia: Going Where?)" on this in the Kompas Daily. In the article, she noted:

One group with high risk behaviour is injecting drug users (IDU), whose numbers continue to increase. Anecdotal data that we are starting to collect indicate a yellow signal to the developing spread of HIV/AIDS in this group (three HIV positive from 35 young people in a rehab program, 3% of the total of drug users under treatment). Sharing needles is customary among this group. Actually this behaviour is a very effective way to spread HIV. As a result, we expect that the number of cases of HIV/AIDS among IDU will jump exponentially in the near future. In anticipation of this, perhaps it is time to consider unconventional efforts to reduce risk, such as providing sterile needles and teaching sterilization of needles (my translation).
Remember, this was ten years ago, when even the WHO was doubtful that an IDU-driven epidemic in Indonesia was likely, when the concept of harm reduction was far from acceptance even among the experts, and needle exchange was a taboo subject in most of the world.

Welcome, Ibu Endang!


Saturday, 14 November 2009

Powerful amidst peers

I think I've mentioned before that I've been working with the AusAID-funded HIV Cooperation Program for Indonesia (HCPI) on the response to HIV in the prison system in Java and Bali. One focus has been to support the 2005-2009 National Strategy on HIV in Prisons in Indonesia, which (among other elements) called for "Creating peer network as form of support and care for HIV positive among prisoners/detainee."

Dhayan, one of my colleagues in Spiritia (and an HIV-infected ex-prisoner), has been working with me on this. Together we have visited ten prisons, meeting with staff and prisoners, including many who know that they are HIV-infected. The aim has been to look into how peer support groups can be formed and developed in this environment, and to prepare a manual to assist in this process. In fact, we found that support groups had already been formed in around half of the prisons we visited. This helped us to validate our ideas, and provided useful input.

At one of the prisons, Banceuy Narcotics Prison in Bandung, we found the process was very well advanced. Partly this was due to the very strong support from the prison governor, Pak Ilham, who earlier got his 'baptism' in responding to HIV as governor of the Kerobokan prison in Bali. This prison was one of the first in Indonesia to identity HIV as a problem. Pak Ilham has now used this experience to nurture a really supportive and caring regime in Banceuy.

During our last visit to Banceuy, aimed at reviewing the draft manual, we noted that much of what was being achieved in responding to HIV in Indonesian prisons was not well appreciated, even in Indonesia, let alone among the international community. We suggested to Pak Ilham that he might encourage reporting by the media, particularly referring to the Jakarta Post, the foremost English-language daily in Indonesia.

Don't know if this was the cause, but a few days back, we were very pleased to see an article 'Penitentiary to establish peer group for inmates' in the Post. The name of the support group there is 'Banodis', standing for 'Banceuy No Discrimination', and members of the group do indeed report that discrimination is extremely rare in that prison.

I've noted before, that despite facing huge challenges, the Indonesian prison authorities are dedicated to developing cutting-edge solutions. Peer support is only one of these.


Friday, 13 November 2009

Sweet retired solitude

Some of you may be aware that, since 30th September, I've given up full-time work with Spiritia. I'm still doing occasional work as a volunteer, particularly to maintain the web site. I'm also continuing to work for with the AusAID-funded HIV Cooperation Program for Indonesia (HCPI) as a consultant, at least until the end of the year. Hopefully there will opportunities to continue this next year.

However, I do intend to spend more time in the UK. I had a really enjoyable couple of weeks there in September, partly staying with my sister between Reading and Newbury, but also spending four days hiking in Exmoor. During that time, I hardly saw a soul all day - a very pleasant change from the wall-to-wall people here. There's so much of the British Isles I've always wanted to visit, so I plan to start to address this starting next Spring.

Meanwhile, I'm spending much of my time with the prisons. I'll write more about this tomorrow. There's still plenty of time for more adventures. And hopefully I'll have more time to write...


Thursday, 12 November 2009

Good bye, Uncle Bob!

Sadly another loss to report, this time not directly caused by HIV. Bob Monkhouse, known to his friends and many, many 'children' as Uncle Bob, died early this week in Bali.

Bob had been in Indonesia since at least the mid 1970's. At some stage he opened a bar (I think it was the Pink Panther) in Kuta. I'm sure he'll forgive me for noting that, like many in that situation, he became too fond of his own wares. The upshot was that he formed an Alcoholics Anonymous group in Bali. This group continues to meet.

In the late 90's, it was natural that he should feel drawn to respond more directly to addiction. His first approach was to form the Bali Health Foundation (Yayasan Kesehatan Bali, or Yakeba as it soon became known). Yakeba set up a rehab centre for addicts in Denpasar. With growing demand, this was moved to some cottages in a lovely spot in the Balien valley, near Tabanan. Rosy, one of the early residents, remembers it as being very free, with no doors. Uncle Bob was always quick to forgive the inevitable thieves.

As news of HIV among drug users started to spread, Bob decided this demanded action. But like most of us at that time, he was no well informed about HIV, and felt the best approach was to get all the eighteen residents at the rehab centre tested. The results arrived on New Year's Day 2001: eight were positive! Rosy was one of those who received this terrible New Year's present; she recalls that they all had no idea what that meant, just that they would probably die within days or weeks.

Bob searched for help in responding. Fortunately, he quickly contacted the AusAID-funded HIV program (IHPCP) in Bali. At that stage, the extent of the HIV epidemic among injecting drug users (IDU) in Indonesia was only just beginning to become apparent, but the news from Yakeba was a real shock. By chance, I happened to be visiting the IHPCP office on 3rd January 2001, and was invited into a meeting with Bob (I think Rosy was also there), to try to decide what to do. One upshot was to arrange for them to meet with Suzana Murni, the founder of Spiritia. Meeting with a 'peer' who had been living with HIV since 1995, greatly assisted them to come to terms with their infection.

As a result, it was natural that the eight should form a peer support group in Yakeba. This group, now known as Hidup ('life', but also playing on the abbreviation IDU) still continues to support many people infected with HIV through drug use in Bali.

As the extent of the drug-driven HIV epidemic in Bali became more apparent, Bob expanded Yakeba's activities. Surveillance in the Kerobokan prison identified a huge problem there, so outreach to addicts in that prison was an early activity. As a result of these efforts by Yakeba and other groups, stigma and discrimination against those with HIV in that prison was pretty much eradicated by mid 2004.

This was followed by outreach to schools, and the initiation of a harm reduction program in 2003. When the methadone program trial was started in the Sanglah hospital, Yakeba took on the task of finding the first clients. Later, Yakeba also started a program of outreach to gays in Kuta.

Rosy remembers Uncle Bob as having a kind heart, willing to help anybody. While not being 'religious', he had strong spiritual convictions, with a deep trust in God.

"Uncle was our father," Rosy told me yesterday. "He gave us dignity."

Uncle Bob, you deserve your rest. Give us strength to carry on your legacy.


PS. Please respond if you have your own memories of Uncle Bob, or corrections to my fading memories.

PPS. There is an obit of Bob on the BaliDiscovery web site <Bob Monkhouse, 1941-2009> which provides a little more history.

Sunday, 7 June 2009

Pedestaled in triumph

Some of you may have followed the story of the young (nursing) mother who was remanded in prison on the charge of defaming a private hospital in the Jakarta area. A test at the hospital lab had indicated she had very low platelets, and as a result she was diagnosed with dengue and was admitted and infused. But the next day, it appeared that her platelets were in fact normal, and the diagnosis was incorrect.

She moved to another hospital and was correctly diagnosed and treated. Following this, she apparently tried to view her medical record at the original hospital, but this was allegedly refused. She then sent a private E-mail to a friend, indicating that she felt that she had been treated badly. This E-mail was then forwarded to a mail list, resulting in wide distribution. As a result, the hospital took legal action, and she was arrested by the police and locked up.

A number of things about this case have upset many in Indonesia. First, how could the doctors in the hospital concerned allow such a thing to happen? Should they not have put pressure on the hospital management to be more compassionate - do we not expect all our doctors to show that quality? Second, the Minister of Health washed her hands of the problem, saying she has no control over private hospitals.

Although the law on Doctors' Practice (no. 29/2004) very clearly states that patients own the contents of their medical records, and that they are entitled to a second opinion, requests for both in Indonesia are routinely effectively denied.

As the BMJ pointed out several years back, Doctors will get off their pedestals when patients get off their knees. One of our efforts is indeed aimed at trying to get HIV-infected people to get up off their knees and become empowered patients. But actions like this will set back the whole process.


Saturday, 6 June 2009

All sorts and conditions of men

My friend and colleague, Theo Smart, has embarrassed me into returning to this task. Theo edits the HATIP (HIV/AIDS Treatment in Practice) newsletter for NAM (don't ask what that means; it used to be National AIDS Manual, but now like BP it's just an acronym). For several years (almost since its inception) I've been one of the review panel for HATIP, among a very distinguished list of clinicians, including Graeme Meintjes from South Africa, and Anthony Harries, formerly from Malawi.

Frequently HATIP's topics are above my head and outside my experience (such as 'Managing meningitis in people with HIV in resource-limited settings'), but sometimes Theo comes up with a topic which I can contribute to. Last week he circulated some initial thoughts on an article about services for men who have sex with men (MSM). It became clear that (as is so often), although the term MSM was coined to be more inclusive and not just limited to those who identify as gay. the focus was mainly towards gays and bisexuals, with little emphasis on transsexuals.

I have been involved with the waria (transsexual) community in Indonesia since 1995, when I first met up with Gaya Celebes in Makassar, a group doing outreach to this community. Coincidentally, at the same time I met with Tom Boellstorff (almost the only person to comment on my blogs; thanks Tom!). Although based in the US, Tom has had deep involvement with waria in Indonesia since the early 90's, and his recent book 'The Gay Archipelago: Sexuality and Nation in Indonesia" is the first to explore the lives of gay men in Indonesia.

From Tom and the dedicated volunteers at Gaya Celebes, together with contact with waria groups throughout the country, I have also been lucky enough to get some insight into the challenges faced by waria in Indonesia. For obvious reasons, they are extremely vulnerable to HIV infection, and as I have noted previously, in many groups they are 'queuing up to die.' So as I say, Theo hit my hot-button, and I responded by describing some of my experience with waria, and asking him not to ignore transsexuals when discussing MSM. Theo has just posted this to the HATIP blog ('Reaching the Waria of Indonesia'), at the same time kindly promoting this blog. So I must make a renewed effort to keep up with the news here.


Friday, 8 May 2009

Selamat Jalan, Indri

Yet another sad loss. Yesterday we heard that Indri Morizette had been taken from us. Indri, was one of the most beautiful and talented waria (transsexual) that I have ever met. In April 2002, she co-founded 'Saribattangku', a peer support group for HIV-infected waria in Makassar, South Sulawesi. that quickly became a model for similar groups around the country.

We take activists like Indri for granted. I've never taken the trouble to find out about her background or to write down what I did know of her. I recall that she was chosen as Queen in at least one beauty contest. I also remember that she address at least one international congress, the ICAAP in Kobe in 2005 - perhaps others can provide more details.

I'd hoped we were moving away from the situation where 'waria are queuing up to die', as the leader of the Surabaya waria group put it so bluntly several years back. But it seems that we've still a ways to go. And the loss of Indri won't make it easier.


Sunday, 12 April 2009

Long choosing, and beginning late

So how can we do a better job of getting people onto life-saving antiretroviral therapy (ART) sooner, before they fall sick, and risk death as a result? I do have one or two ideas, Tom, if not solutions.

Clearly the first challenge is to identify people infected with HIV earlier. Certainly easier said than done, and as I've discussed before our current 'voluntary counselling and testing (VCT)' program is totally failing in this regard. Effectively passive, it's really provider initiated in most cases, detecting people only after they have to be admitted to hospital with AIDS-related conditions. But from the many questions I get (but rarely answer), it does seem many people are more ready to go to the ubiquitous private labs (Prodia is the best known) for testing, often very soon after their risky activity. Sadly they are usually poorly counselled and rarely referred from such labs.

As far as I know, these labs are not included in the national AIDS action plan. Would it not make sense to recognise their role, and provide guidelines and even accreditation to assist them to do a better job?

Once identified, how do we get them into treatment - and retain them? Clearly we need a better referral system. But if we get them into care soon after they are infected, we know that it may be five years or more before they need ART - based upon the current criteria. It's clearly extremely difficult to expect them to return for regular follow-up - more so since (as I have noted) they'd prefer to forget that they are living with HIV.

The solution is simple - and now increasingly urged: start ART immediately. Hardly a day goes by now, but some study does not report the benefits of much earlier start, and the risks of delaying. Prof. Joel Gallant from Johns-Hopkins, one of my HIV care heroes, was asked recently, if he became infected, when would he start ART. His answer? "Immediately" (Suppose that you were positive). And this is even more important for people with co-infections such as viral hepatitis.

Studies by WHO experts have shown that starting ART immediately would save money in the long term. The challenge of course is in the short term. Even the WHO shows no signs of 'putting its money where its mouth is.'

Other approaches? I am convinced that one barrier to starting ART is that people are doubtful that they will be able to adhere to the every 12-hour schedule of current first line regimens. But in fact the current standard first line regimen in the rich world is much easier: one pill once a day before going to bed. Most people go to bed every day, so they don't need complex reminders, or concern about being late. Clinton Foundation can buy such a pill for little more than US$300 per patient per year - less than the government pays Kimia Farma for the current standard first line regimen. And of course this one-pill-once-a-day ART solves the problem of taking ART during the fasting month.

I've never been a strong supporter of the concept of 'case managers' here. But since we have them, why don't we require them to play a more active role in retaining people in care, especially those do not yet need ART? Get help from peer support groups if they lose contact. Of course they should be doing this already for those on ART, but...

We can - and should - do all we can to make sure that no more Fredy's die from starting treatment late...


Friday, 10 April 2009

The dark world will submit to its present treatment

Surprise, surprise! As I forecast. there's confusion over where to put the drug users 'sentenced' to rehab. The Department of Social Affairs has admitted that they are totally unprepared to accept even a small proportion of them. They have only 33 such centres on their books, with total capacity for 1000 addicts, Their spokesperson admits that there may be others that don't "meet our minimum standards." I'd hate to see what those look like - although I think I've already seen several.

Those are the ones that they monitor. The mental hospitals (many of which have turned addiction into a lucrative business) add some more places, and one assumes that these are properly monitored by the Health Department (or not as the case may be). Of course, as I noted a few days back, they'll shortly all be full of failed parliamentary candidates.

Then there are the 'faith-based' ones (to use the 'in' term); I guess they are monitored by the Religious Department (yes, there is one here!). Among these are the centres located in cool hilly areas that wake residents up at 2 a.m. for a dunking in a cold bath. You need extremely strong faith to survive that!

Since no doubt the judges will obey the Supreme Court ruling (I'm sure that they always do what they are told), supply will respond to demand. Prepare for a mushrooming of rehabs that fail to meet the low minimum standards of the Social Department.

In some ways, the sad thing is that, as I noted in my report on a prisons workshop, the prisons are finally getting their act together, and treating (in both senses of the word) prisoners with HIV better. While still very limited, they have the staff, the facilities, and the increasing will to respond. Is there any chance that even the rehabs that meet the minimum standards will provide such services? Fergetit!


Thursday, 9 April 2009

Delays breed dangers

Sadly, another heavy loss this week. Fredy Malik, Indonesian Drug User Activist since 2002, died of AIDS. I did not know him well, but it is clear that he had played a crucial role in the development of harm reduction in Indonesia, in Asia, and probably more widely. It is due to people like Fredy that Indonesia is among the leaders in this field.

James Blogg from the AusAID-funded HIV Cooperation Program for Indonesia (HCPI), who I ran into earlier this week, noted how sad it is that many Indonesian drug users with HIV leave it until very late to start antiretroviral therapy (ART). This was apparently the case with Fredy. Seems that this has been a challenge in Bali since the start. In around 2003, the Bali provincial AIDS Commission agreed to provide funds for ten activists to start treatment. But almost a year after the launch, only two or three people had taken up the offer, even though many clearly needed it. In meetings with HIV-positive people, it became clear that they were extremely worried about the reported side effects, to the extent that they were scared to start therapy.

Part of the problem is the not infrequent cases of what is called Immune Reconstitution Inflammatory Syndrome or IRIS. Many symptoms of infections, for example fever, are a result of the response by the body's immune system to the infection. But when the immune system is severely damaged, it is unable to mount a response, and thus people with advanced HIV infection frequently appear quite well, with no serious symptoms. However once they start ART, the immune system starts to recover, and quickly responds to these 'masked' infections. The paradoxical (and very distressing) result is that within weeks or months of starting ART, many people who start late experience a worsening of their health, sometimes some really nasty symptoms (such as loss of sight), and not a few die.

The solution is to start (as recommended) before the immune system becomes so badly damaged. For many, this is not an option, since they are only diagnosed HIV-infected in this condition. But many, such as Fredy, have been long aware of their infection, but have delayed starting. To many this seems amazing; why would they be so loathe to start life-saving therapy, especially when it is free? It's a no-brainer, no?

Actually, we often underestimate the psychological barriers to starting ART, especially for those who have lived several years without any health problems caused by HIV. Starting ART can seem like capitulating to the disease, accepting that HIV has won and the journey to AIDS is near its end. Not only that, but we must accept that HIV is now going to control our lives. ART: don't leave home without it. Be reminded that we have HIV twice a day when we open our pillbox. Face unpleasant side effects, both short and medium term (and worry about long term ones which have yet to appear). Agonize over whether we can really develop the discipline to take the meds exactly as prescribed every twelve hours without ever forgetting. Worry about sustainability of supply of ARVs, by a system which has demonstrated a clear inability to guarantee availability. And face the ever present threat of treatment failure, causing the development of resistance and the need to change to a more complex and expensive regimen. No, we should not underestimate the challenges of starting therapy.

In fact, in this regard those diagnosed late may be better off. They aren't given time to think about it. 'You need to start ART in a couple of weeks if you want to survive.' Still a decision, but more easily reached.

What can we do to help the Fredy's to start earlier? This post has gone on long enough. I'll return to this point later.


PS: Yvonne A. Sibuea, General Coordinator, PERFORMA, has posted 'In Remembrance of Fredy Malik.' on a mail list. I cannot link to this, but if anyone would like me to send them a copy, please let me know.

Monday, 6 April 2009

One half the nation is mad

Mental hospitals are on standby! Emergency cases expected! No, not an explosion of drug use, or even an emptying of the prisons as a result of the Supreme Court decision that convicted drug users should not be incarcerated in prison, just incarcerated in (probably less humane) 'rehab centres' (see Iron bars a cage).

No, this is for the parliamentary candidates who don't get elected. Although some might feel that they should have considered this as an alternative to becoming candidates, there is fear that a significant proportion will require mental treatment as a result of losing everything in their effort to represent their community. Many have hocked all they own to raise money for their campaigns, and clearly are unqualified for any form of productive employment.

I forget how many candidates there are from the more than 30 parties for around 500 assemblies (nation, provincial and district/municipal), but it runs to more than a hundred thousand. If only one percent 'go mad', that's a lot of candidates for the asylums - someone estimated it far exceeds their overall capacity. So it'll not just be the prisons that'll be overcrowded! And most of the mental hospitals are also rehab centres for drug users!


Friday, 27 March 2009

When mistrust comes in, love goes out

She's at it again. Our beloved Minister of Health is now questioning the validity of vaccination for "meningitis, mumps and some other diseases," according to the Jakarta Post (Minister wants to review vaccinations). She is apparently once again accusing foreign drug companies of using Indonesia as a testing ground.

The Minister is reported to want scientific proof that immunization against pneumonia, chicken pox, flu, rubella and typhoid are beneficial. At least we can be thankful that she apparently still believes in immunization against measles, polio, tetanus, hepatitis B and TB, but perhaps that's only a matter of time.

I doubt she'll get around to proposing beetroot as treatment for AIDS, as did her erstwhile South African counterpart - I've very rarely seen beetroot in Indonesia. But it could be 'buah merah' (the Papuan red fruit which is still touted as a cure for AIDS) or perhaps the 'Green Cocktail" promoted for its ability to 'control HIV/AIDS' by the State Islamic University (UIN) - I'm sure that would appeal to her.

The Post also reports that UNICEF will wait until the immunization policy is officially changed before commenting. It is perhaps understandable that they don't want to get into a shouting match with the Minister, but one would have thought that they might have felt able to provide the scientific proof she needs - I assume it exists?


Thursday, 26 March 2009

Supply and demand in strawberries and motor-cars

We can now access our Health Minister's statement to the recent meeting of the Commission on Narcotic Drugs. The achievements she claims are all in the field of supply and demand reduction. Among them, she lists the dubious achievement of a 'slight decline' in drug offence-related cases in 2008 after a massive 300% increase between 2003 and 2008. She does note that "in the area pf demand reduction, Indonesia's efforts focus on integrated comprehensive strategies as a continuum of care," whatever that means.

She notes that the economic cost of drug abuse in Indonesia was estimated to be US$32.9 billion in 2008, which she says in one-tenth of the value of global drug trade. I wonder how much of that goes to domestic corruption. Some time back someone estimated that the profits from drug dealing in Indonesia exceed the total budget of the police force. Plenty of room for a little 'lubrication.'

We should not be surprised that she does not mention harm reduction. At a cabinet meeting on AIDS a couple of years back, it is related that she omitted to deliver the parts of the statement prepared for her that referred to harm reduction. It transpired that she was uncomfortable to address this because she didn't know what harm reduction is.


Tuesday, 24 March 2009

Consumption brought him down to the grave

It's exactly ten years since I wrote my first article in the Jakarta Post about World TB Day - which falls today. I'd been fascinated by TB since I'd first got involved with HIV. It did seem like there was a connection, but I found it difficult to understand. How did TB suddenly become active and cause all the damage? Why do people seem so much more vulnerable to active TB in the first couple of years after they are infected with HIV, even thought their immune system is still relatively healthy? Perhaps all this is beyond the grasp of a simple engineer!

But it was clear to me even then that there was a real connection between the two diseases. Indeed, as a press release from UNAIDS on World TB day in 1998 (sadly no archived on their site) noted, "TB is the biggest killer of AIDS patients worldwide." The release also noted:
"A comprehensive response to the dual TB/HIV epidemic has not yet been implemented," Dr. Peter Piot, UNAIDS Executive Director commented. "Only a dual strategy of TB control and HIV prevention can reduce the TB/HIV burden." Dr. Piot believes that this strategy must be implemented worldwide "...if we are to break the lethal combination of HIV and TB, a partnership which is adding to the suffering of millions of people with HIV, shortening their lives and helping spread TB to alarming levels."
Sadly, Piot and UNAIDS then seemed to forget all about TB. Indeed, a search of their web site finds no pages on TB and HIV until May 2006, prior to the Special Summit of African Union on HIV/AIDS, Tuberculosis and Malaria. Even then, there is little effort made to connect the epidemics. As I think I have noted before, when I visited South Africa in 2004, for a pan-African workshop on Treatment Literacy, Treatment Action Campaign couldn't find anyone to speak on HIV and TB.

I attended a meeting of activists at the TB Conference in Paris in October 2005. Amazingly, that meeting focused strongly on HIV (when will an AIDS conference ever focus on TB?). Everyone was there. Except no one from UNAIDS! So we got together and drafted a letter to Peter Piot requesting action. Happily this triggered a response. The HIV-TB guru from WHO, Alistair Reid was moved to UNAIDS to take responsibility for a co-infection program.

The recent emergence of extensively drug resistant TB (XDR-TB) has demonstrated once again the fatal nexus between HIV and TB. I concluded my first article in the Post by noting that the best policies "...simply cannot have a widespread impact on the disease without political commitment. Clearly to develop and maintain such commitment in Indonesia at present represents a major challenge." Ten years on, this remains the challenge...


Monday, 23 March 2009

Full alchemized, and free

Psychiatrists reject pharmaceutical industy funding! 'Bout time! I heard this quite by chance on NPR news, and googled to get details. Found it The Carlat Psychiatry Blog - "Supporting the search for honesty in medical education." Wow! What a concept!

The article, APA Votes to Phase out Industry-Funded CME, gives some the details, although I can't find anything about it on the APA web site - or indeed on any other sites.

The NPR report noted that there are an increasing number of studies which indicate that these free lunches do impact on prescribing habits, and that they have greatest impact on those doctors who swear blind that they are not affected.

Now all we need is for this to spread to other medical disciplines - and then to Indonesia.


Sunday, 22 March 2009

Iron bars a cage

No more prison for drug users, Supreme Court tells judges - a headline in yesterday's Jakarta Post. The 1997 narcotics law provides for the option of rehabilitation rather than prison for drug addicts, but this sentence is rarely offered.

Sounds like good news. But where are the rehab centres for the 100,000 or so drug addicts currently incarcerated? And who will pay? If history is a guide, there will be a mushrooming of 'commercial' rehab centres; anyone with a largish house will cram four or five three-high bunk beds into a bedroom, put bars on the windows, and charge as much as Rp 5 million ($400+) a month for 'rehabilitation'. This happened a decade ago, when parents looked for any way to 'get the junkies out of the house.' Several centres chained up the addicts (I personally saw a teenage girl in leg shackles in a rehab centre in North Sumatra). Many feed them 'legal' drugs to keep them sedated, adding another level of addiction.

We then asked which government entity is responsible for registering and monitoring such rehab centres. No one seemed to know.

My understanding is that this is the policy in Malaysia, which has set up 'boot camps' as rehab centres for addicts. Reports I have heard suggest that the regime there is worse than in prison.

There is ample evidence that rehab at best 'cures' 10% of voluntary 'patients', and little more than 0% of those who are forced. Even those who become 'clean' usually relapse within months. So we need a revolving door. Or we apply the option only to first time offenders (I think that is indeed the intent of the law), and lock up recidivists. Same difference!

This policy might empty the prisons, but will (I fear) do nothing to solve the problem. Indeed, I fear it make exacerbate human rights violations. Like it or not, legalization of drugs is the only solution.


Saturday, 21 March 2009

With tired backs we bring you gifts

She's at it again. Our revered Minster of Health is again lashing out at the foreigners, according to the Jakarta Globe (Minister Wary of Foreign ‘Attack’, although the print version has the headline 'Minister Attacks Foreign Funding', with the subhead "Paranoia? 'World will use our viruses or DNA do attack us'").

As I have noted before, her decree banning export of viruses and DNA samples has put the kibosh on the offer by Australia to detect HIV in babies within weeks of birth using dried blood spots. It is increasingly clear that very early diagnosis and immediate treatment can have a major effect on survival of babies born with HIV. The reported 'policy' of the Ministry of Health is to support early testing, but as yet no concrete steps have been taken to implement it. So you could say that the Minister's ban is costing lives - of babies. What a great record for a Minister of Health! She and Manto are a right pair! Except that Manto is no more Health Minister in South Africa. We'll have to wait until October to get a replacement.

Paranoia it may be, but this is also evidence of an increasing xenophobia. If I was alone in this feeling, perhaps I'd put it down to cantankerous old age. But none other than Endy Bayuni. Chief Editor of the Jakarta Post (and someone I particularly respect), referred to it exactly three years ago to the day, following the Jogjakarta earthquake (What's with this post-disaster xenophobia?).

One reported comment by the Minister is telling: "Trust me on this one, there is no such thing as free help. When people offer big money to help you, they undoubtedly expect to benefit from it," Supari said. This reflects a trait that I notice here; If someone offers help, it is assumed to be for their own benefit, and thus thanks are not required. Quite the reverse: the donor should be offering thanks if the gift is accepted. I wonder what she thinks the Global Fund will demand...


Monday, 16 March 2009

Always at the infectious disease roulette table

Those days before AIDS. I've written about them before, but this time from a different perspective. I'm currently in Singapore on another visa run, and something took my mind back more than 40 years to when I was with the British Army about 100km north of here, at Kluang in Johore State. I was then working for the Army Air Corps (AAC), and the base in Kluang was used for 'theatre conversion.' This involved young lads who had gone through basic helicopter flying training at the AAC base in Middle Wallop (yes, that's really the name of a village in Southern England), but we're still wet behind the ears - "a year ago I couldn't even spell 'Heliocopter Pilot' and now I are one."

Of course, flying over Salisbury Plain is a tad different from flying over a tropical jungle, so they had to learn about this - hence theatre conversion (theatre of war, not other forms of drama). So these kids, most of whom had never been out of Europe before, spent a month or so flying all day over the local jungle. Of course in the evenings they were ready for anything.

But Kluang didn't offer much in the way of exotic entertainment. So we used to bundle them into our cars of an evening, and drive for about an hour over to the west coast, to a small town called Batu Pahat. In theory this was out of bounds, but since there was no garrison near, that was never a problem. We'd always end up at the Hawai Kedai Kopi (Coffee Shop), a dingy place with the floor covered with peanut shells - and 'waitresses' who would do what I think now is called 'lap-dancing.' After a few minutes of this came the offer: 'ten dollars, upstair, you come?' Of course, our intrepid helicopter drivers, having imbibed more than a few cans of Tiger, were ready for anything.

Next morning, over the hangover breakfast in the Mess, we'd start talking about the local prevalence of pox and other nasties, and tell them that we were sure they'd used condoms last night - of course they hadn't. The fact that our mess was shared with the local military hospital, so usually there were one or two doctors present, added spice to the discussion. I never heard that any actually picked up any disease, but they were sure worried for a couple of days.

One certainly wouldn't want to play that form of Russian Roulette today...


Sunday, 15 March 2009

Hell that tests my youth

My posting yesterday reminded me that the age of consent is a continuing problem here. There is no clear definition of this age here, since a number of different laws provide different ages. I think there seems to be a consensus that in general it's 18 years for a woman and 21 for a man. But this applies to marriage (I think) and not clearly to medical decisions.

Many health care providers assume someone is 'under-age' if they are still dependent upon their parents - and if the parents are paying, this means the patient is still dependent. I recall meeting with a 27 year old woman together with her father and mother. She had been HIV-tested and was starting antiretroviral therapy - and had taken no part at all in making the decisions around this. Because the parents were paying.

I'm always amazed that 'we' continually urge that HIV-testing is dependent upon informed consent, yet we ignore the 'elephant in the corner', the fact that many of those who should be tested are considered unable to consent, because they are under age. "Want to get tested for HIV (or a sexually transmitted infection)? Go get your parents consent first." Duh!

At the last count, almost 500 of the 16,000 people reported as infected with HIV in Indonesia were aged 15-19. How many more would test if they were offered friendly and hassle-free services? Certainly their lack must have an impact.

The Thais have recently woken up to this, as recently reported in the Bangkok Post. But even they acknowledge that they need many new clinics to provide this service.

Why do we continue to turn a blind eye to this problem?


Saturday, 14 March 2009

The medium is the massage

While on my way to the office (a journey of an hour at best), I (try to) do the Sudoko and crossword puzzles in the Jakarta Post. On the rare occasions that I finish both, I often turn to the Classifieds. The section headed Massage; it rarely has less than 20 small ads, offering massage by females and males in about equal quantities.

There used to be one or two that are offering a 'real' massage, but these clearly didn't do much business. The females now are almost all 'models', offering 'fantasy special massage for expats.' with 'sensational females to your hotel' - 'One Look & You're Hooked' - sounds like a real hooker!

The males increasingly describe themselves as 'boys' (although I'm sure the Post would not abet under-age sex - not so difficult since the definition of 'under-age' here is anything but clear!). Several have taken to adding 'See website Utopia' - you don't have to look very long at the result of Googling that keyword to find that it refers to a gay and lesbian site - I doubt it's referring to the Utopia Bathroom Furniture Group.

All good clean fun, I'm sure. But having worked for a large Mid-Western multinational company (Caterpillar), I know how frequently 'wet-behind-the-ears' visiting 'firemen' are sent by such companies on brief visits to this part of the world. What would not play in Peoria can easily happen in Jakarta. First night in the hotel, there's a knock, and they are offered service by someone who looks a lot more attractive than their spouse. But most of these 'kids' (and they're not only men) have never even seen a condom and would have no idea where to find one in Jakarta even if they had. I often wonder how many take back an 'oleh-oleh (souvenir).'

Before they leave the US, they are provided with a medicine box, including meds for diarrhoea and the like. I once asked my boss here (who is now the top man in Caterpillar) if the box included condoms. 'No,' he said. 'Should it?' I asked. 'Probably.' 'Could it?' 'No way' was his answer.


Wednesday, 11 March 2009

God screens us evermore

There's been much uninformed discussion regarding Provider-Initiated Testing and Counselling (PITC - or is it PICT?) here. Nobody seems willing to come up with a clear definition of what we mean by this, let alone achieving a consensus on how it might be implemented. But it is abundantly clear (as I have written before) that the current practice of VCT will take more than 25 years to identify those who are infected today.

It's clear as well that most of the HIV testing taking place in hospitals in effectively provider-initiated. A sick patient is admitted; the doctor (finally) suspects an opportunistic infection, the patient admits previous risk behaviour, so the patient gets referred for VCT, perhaps getting counselling, perhaps just having blood taken in the same way as for other tests. So effectively we wait until the person falls sick, often with a badly damaged immune system, before we diagnose the underlying condition.

Several WHO experts have proposed annual universal testing of all people over the age of 15 years for HIV. This is clearly not yet feasible, and thus has often been rejected. But the fact is that we must find a better way to identify the 95% of people infected with HIV here before they fall sick with very nasty conditions.

The military have it easier, A report on the Indonesian armed forces web site recently described mass testing of a Marine unit. Unfortunately the article is peppered with so many military acronyms, it's a little difficult to understand, but this photo helps. The article refers to 'early detection through Blood Screening Tests', but it does appear that it is not 'unlinked-anonymous' - as if that would be possible in the military! It also reports that the 'marines welcomed the blood-letting enthusiastically, proved by the attendance of all ranks of the unit.' Does that mean it was not in fact compulsory? Only obligatory, perhaps.

Let's hope that those diagnosed with HIV remain enthusiastic. The military is now trying to come to grips with HIV, and total isolation inflicted on 16 members of the peacekeeping force returning Cambodia with HIV in the 90's is hopefully a thing of the past. But HIV-positive soldiers are still often removed from active service, generally posted to the medical corps, where they while away their days. But at least they now get treatment.

The Marines say their top brass now give great attention to HIV, including with 'Peer Leader HIV Training'. So far no reports of formation of peer support groups for marines known to be HIV-positive. Maybe we need to take more initiative...


Tuesday, 10 March 2009

First do no harm

There's been a lot of traffic among the chattering classes here as a result of the news that Indonesia was among 13 countries that voted against the inclusion of the words 'harm reduction' in a footnote to the draft Political Declaration from the 52nd Session of the Commission on Narcotics Drugs (CND) in Vienna. As a result, apparently harm reduction is not mentioned in the draft political declaration, not even in a footnote.

This has confused everyone, because as I noted in my recent prisons report, the policy of the Indonesian government (as usual, whoever that is?) strongly supports harm reduction. Indeed, Michel Sidibe, the new Executive Director of UNAIDS in a speech to a donor conference on harm reduction on 28th January, praised Indonesia for its support: "It is extremely heartening that countries with huge populations like Indonesia and China are seriously embracing the harm reduction challenge, at the full scale. Indonesia for example is aiming to ensure that needle and syringe exchange covers 70% of injecting drug users by 2010, up from the baseline of only 10%, and that methadone treatment reaches 30% of users." He must be feeling like the rug has been pulled out from under him!

Ibu Naf, the AIDS Commission Secretary quickly confirmed that this does not reflect a change in policy: "Don't worry. We're still working in accordance with the ruling of the Coordinating Minister of Peoples' Welfare [he's also the chair of the AIDS Commission]. We can continue to use the term, and continue, indeed increase, our efforts as laid out in the national work plan for AIDS."

But activists are wondering if they may still use the term 'harm reduction.' Of course, that raises the question why we use an English term for this. When we translated the Asia Harm Reduction Manual ten years ago, we went to great efforts to achieve a consensus on the Indonesian translation of 'harm reduction'. A very late final agreement meant we had to make many last moment changes only a couple of days before we went to the printers.

Pandu Riono notes that the Coordinating Minister's ruling clearly has not reached all those concerned, particularly in Vienna. We need to do a much better job of communicating, he says. Prof. Wirawan wondered if the Indonesian delegation in Vienna was aware of this ruling, but Ibu Naf confirmed that they knew. But she notes that the CND is primarily made up of law enforcers and diplomats. They would refer to the narcotics law, which does not mention harm reduction.

Actually they are in good company. As the international activists have only just noticed, back last November, Antonio Costa, the head of UN body concerned with drugs (and a UNAIDS co-sponsor), claimed harm reduction has been appropriated by "a vocal minority. This kind of harm reduction can prevent the spread of blood-borne diseases. But it does not solve the underlying problem, and can even perpetuate drug use."

It seems we all need to do a better job of communicating...


Monday, 9 March 2009

Truth suppressed by friends is the enemy's readiest weapon

The younger members of the community, or perhaps those with shorter memories, tend to forget the AIDS is only the latest spectre affecting the sex scene. Although the cure for syphilis emerged in the 1940's, at the time I was coming out in the 50's, there was still a huge fear of this venereal disease (VD as we all knew it then). And rightly so. Prior to the arrival of penicillin, syphilis infection was just as much a death sentence as HIV used to be. And in a nasty way. Death from neurosyphilis was said to be pretty awful - I recall a description of someone dying of the pox in one of James Clavell's early books - Tai Pan, I think it was.

Penicillin - and Stonewall (although I was not aware of it then) changed all that, as Gabriel Rotello recounts in Sexual Ecology. But wait! There was another one before AIDS. Yes, herpes. When I was living in Singapore in the early 80's. we heard rumours of this incurable disease. Of course it soon became apparent that it was by no means like the pox, but incurable and recurring really worried us.

I'm reminded of this by the fact that the most common search term on our web site every month is herpes. It ain't gone away, and many think it's often the entry point for HIV infection. We thought we could lick that; treat herpes and we'd reduce HIV incidence. Seemed too easy only a couple of years back when I listened to Connie Celum propose it. So go our dreams!

As I say, AIDS is only the latest in this series. There's a successor girding its loins right now. Is it one of the HTLV family? Sexual and particularly Injecting Ecology mean viruses that previously only mutated once a generation when transmitted from mother-to-child now get the opportunity to mutate and combine continuously as they move directly from bloodstream to bloodstream by shared needles.

Rotello's 1997 book deserves a re-read...


Sunday, 8 March 2009

Law embodies the story of a nation's development

My brain (that box that sits beside my keyboard) reminds me that I planned to write more about laws addressing HIV in Indonesia. As I mentioned, there is no national law on HIV, and this in theory presents a challenge for provincial legislators. This is because a local by-law must refer to a higher level law (those paragraphs starting 'Mindful of' and 'Paying attention to'). Without that higher authority (so I'm informed) they are not fully valid.

It's not only by-laws on HIV that are of questionable validity. But since the central government seems to have no wish to take on the local administrations. and perhaps because many of the national laws appear to be just as unconstituional, nothing is done. Of course, few laws are actually implemented - or even have the required implementing regulations, so everyone is 'fat, dumb and happy,' as one of my mid-West colleagues used to say.

Back to the topic. Another of my more recent colleagues, Bang Syaiful, has carried out a review of 21 of the 22 provincial by-laws on HIV that have so far been enacted. He reports that without exception they place their main emphasis on morals. In doing so, as he says, they encourage stigma and discrimination.

For example, he notes, several prioritise the role of 'faith and piety' in HIV prevention. This despite the mountains of evidence that it is no more effective now than it was almost 25 years ago, when in 1985 the then Minister of Health replied to a journalist's question that "with faith in God, we don't need to worry about contracting AIDS." So much for pious hopes!

The by-laws also refer to 'healthy living' (the NGO I first worked for here in support of people living with the virus had the slogan "healthy living prevents AIDS"; I had quite a job explaining that to my 'clients', for whom this suggested that they had been living unhealthily. But then, who can claim to live a healthy life now?).

The other favourite cliche in the by-laws is 'family solidarity'. As Bang Syaiful notes, they are effectively saying that HIV-infected people are not pious, have no faith (in God), live unhealthy lives and come from broken families. Good excuses?

And as a result, Bang Syaiful notes, a member of the staff of the provincial AIDS Commission in Aceh told him and other journalists firmly and repeatedly that AIDS control in Aceh would in no way include reference to condoms. As he says, surely use of a condom is part of healthy living?


Saturday, 7 March 2009

Things you do not hope happen

Yesterday, I mentioned that the second half of my week was taken up with prisons. Actually, I was lucky enough to attend a workshop on scaling up the response to HIV in prisons in Java and Bali. The workshop was organized by the Department of Justice and Human Rights (Depkumham in its Indonesian acronym; a combination which often causes a snigger, but in my experience makes good sense). Invited were some 50 prison governors plus the heads of the provincial offices in charge of prisons in each of the seven provinces of Java and Bali.

The meeting started with a review of the Master Plan for Strengthening and Providing Clinical Services Related to HIV and AIDS in Prisons 2007-2010. This provides for 22 prisons in Java and Bali to offer basic HIV counselling and treatment, while a further seven will provide comprehensive HIV services, including provision of antiretroviral therapy, effectively to become provincial centres of excellence on treatment of HIV-infected detainees. And a further eight prisons will also provide methadone, adding to the existing eight, with intention to further increase this number.

I find the provision of methadone in prisons interesting. It seems to me that the only justification for this 'harm reduction' activity is to reduce the risk of HIV infection from sharing needles. Thus it is an implicit admission that this continues to occur in the prisons - a remarkably refreshing fact in my view.

On the other hand, as I pointed out (to deathly silence!), there has been little if any progress on provision of condoms in the prisons, even though this is 'blessed' by the national strategy. At one prison I visited some time back, the warden (with a very straight face) responded to a question on condoms by saying that there were no women detainees, so there was no need for condoms (I really can't believe he was really that naive!).

Nevertheless, I find it amazing and cause from hope that the prison governors are clearly convinced of the need to respond to HIV, including providing methadone (I wonder how many countries have moved that far?).

The dark side of all this is the admitted high rate of mortality in the prisons, rising to 893 deaths in custody in 2007. It seems there has been a slight improvement in 2008, but perhaps what was heartening was that everyone seemed to accept that this rate was totally unacceptable, and must be addressed - hence the Master Plan.

Adding to this is the chronic overcrowding in these prisons. We were told that nationally, occupancy in the prisons is 30-40% over the 88,000 capacity. But this average figure conceals the reality in Java. For example, the juvenile prison in Tangerang has around 950 kids aged 15-18 years incarcerated (almost all for drug offences), against a capacity of less than 250. I heard similar stories about many other prisons, including those for women. Prisoners sleeping eight to a room intended for three. People sleeping in front of the bathroom door. One can only imagine what will happen when TB hits them.

And there also lies a challenge. Sadly this AusAID-supported scaling-up is limited to HIV; there was little talk of integration of TB services. A number of prisons have apparently been provided with lab equipment (including microscopes) by the Global Fund, but there has been no authorization of lab technicians, so the equipment remains in the boxes. Some have tried to make arrangements for technicians from the local community health centre to moonlight in the prison clinic, but this doesn't seem to be a feasible solution.

But I came away heartened. The prison governors are beginning to understand the challenges and seemed determined to come to grips with them. The perplexity that we met even a year ago, the feeling of helplessness in the face of all the problems of HIV and drugs, seems to be clearing. And although the prisons directorate must take much of the kudos, there is no doubt that Dr. Nurlan's team in the AusAID-funded HIV Cooperation Program for Indonesia have quietly stimulated and nurtured this response, and also deserve to take a good part of the credit.


Friday, 6 March 2009

Everyone confesses in the abstract

It's been a hectic week! We were asked by UNAIDS here to run three courses on preparing and submitting abstracts to the 9th International Congress on AIDS in Asia and the Pacific (ICAAP). Actually, UNAIDS is only funding; the ICAAP Local Organising Committee (LOC) is responsible for selection of the 150 participants, drawn from seven key groups: drug users; gay, lesbian, bisex and transex (LGBT); women; inter-faith; PLHIV; youth; and sex workers.

Monday and Tuesday we ran the first course. Unfortunately, it quickly became clear that the selection had not been over successful in eliminating candidates who had really had very little of interest or value to present at the Congress. With only four mentors, it was quite a task to help and encourage all the participants to think of an interesting topic and commit it to paper. And of course, few were capable finally to translate the result into English, even more within the 200 word limitation. Google Translate came to our rescue for that; although the result is far from perfect (and sometimes quite amusing!), several of us found it did save time in preparing a first draft.

We heard a lot of stories, some of which I may report here later. Some were indeed only confessions or sharing. But in the end, the majority were able to submit their abstracts on-line (what a change this has made!), and although I suspect some will confuse the reviewers, others will definitely offer a broader community view. I guess if perhaps three quarters of the participants benefit, and half of those have abstracts accepted, it'll have been useful.

The next course, also in Jakarta, is planned for next week, although we still don't have a final list of participants. I'm always amazed at our ability to arrange flights for a large number of people from all over the country at very short notice; pity our poor travel agent!

The rest of the week was spent on prisons; more on that tomorrow...


Friday, 27 February 2009

The way of the pioneer is always rough

More sad news, I fear. We've lost one of the very earliest of our activists. Sulasi was always open about her status, so I don't think I need to hide her name. She was identified as HIV-positive in 1991, in Surabaya. Like our late friend in Makassar, her case became a sensation.

As one of the very first, she was 'monitored' by the local health department. When she decided to get married a couple of years later, this was forbidden. But Sulasi was always 'her own woman', and went ahead with the wedding anyway. Her husband was (and is) HIV-negative. Given a fait-accompli, the health people said, 'OK, but no children.' Again, Sulasi made her own decisions, and gave birth to two lovely kids, neither infected.

The family returned to her home village about an hour by bus and motorcycle taxi from Malang in East Java. But it got out that she was living with HIV, and she was expelled from the community. She moved to another village, but happily after some time, her original neighbours accepted her back, and she returned to the village with her family to plant coffee. I was lucky enough to meet her and the family in her home in 2002, in a lovely area in the hills to the east of Malang.

It was not until around 2003 that she needed antiretroviral therapy (ART). She started with the standard regimen, supported by Susan Paxton's ARV fund. Unfortunately, she experienced bad side effects from the nevirapine, and at that time, there was no alternative available, so she had to downgrade to dual therapy, Then she suffered from anaemia, and had to change the AZT with d4T. Of course, at that time, there were very few doctors who understood ART, and she again she played a pioneer role.

As I said, she was one of the early activists. She was one of only 16 who attended the first national meeting of PLHIV in Bali in 1998, and she also joined the second meeting, also in Bali, in 2001, where I first met her. In the early 2000's, she was active with the positive community, always being willing to invited to take part. She was one of the first to join in our 'local strengthening visits', as a member of the team with Suzana and I (and Ariel, Suzana's adopted son), on a visit to Makassar in early 2002.

A couple of years later, when UNICEF planned to shoot an Indonesian version of its training video 'With Help and Hope' about the lives of people with HIV, Sulasi was an obvious choice. Do take a look at her story.

In the last few years, we rather lost touch. But we heard from her faithful supporter from the early days, Dr, Kamboji, that she had been admitted to hospital, and he just rang Yuni to tell her the sad news.

We've 'used' Sulasi as an example of one who can survive for more than ten years without ART and progress well again after starting treatment. So apart from all else, we've lost a role model.


Thursday, 26 February 2009

The injustice of discrimination

Activists here frequently press for a law on HIV. The current legislation does not mention HIV specifically, and there is fear that the law on contagious diseases (which allows for quarantining of those infected) might be applied to HIV infection. We all know that HIV is not contagious, but the difference is not clear in Indonesian.

There is also hope that a law on HIV would outlaw discrimination. In fact discrimination in the health care sector is prohibited by the 1945 Constitution. This should be enough, but although one of the most prominent lawyers here, Todung Mulya Lubis, over ten years ago offered to take any cases of discrimination against people with HIV to court for free, no one has yet to take him up on that offer. Why? Perhaps because the law here is unpredictable. And certainly it would be impossible to guarantee anonymity - in fact almost certainly the plaintiff would become famous!

But most discrimination occurs because of fear, caused by lack of understanding, caused by lack of information. As I raised many years ago in a case involving Dr. Samsu, is it appropriate to take people to court for ignorance? Yes, I know 'ignorance of the law is no excuse', but surely the first approach must be to inform people. Of course there are 'bad' people who enjoy exercising their prejudices, but in my experience that's fairly rare here, at least among the medical profession.

But back to a law on HIV. I've always opposed this for a number of reasons. Firstly, would it not be seen as further exceptionalising AIDS? If we need a law on HIV, don't we also need one on hepatitis? And what will happen when the successor to AIDS appears - as it inevitably will? Will we have to wait years again for a specific law covering it? In my view, much better we develop a more general law which can apply to all infectious (but not contagious) diseases now and in the future.

The second reason is that it is easy to start a movement for a new law. But it is impossible to predict how it will develop. I am very scared that, particularly given the moralising by members of parliament which was characterised by the pornography law, we could end up with a law which does more harm than good. I'll return to this topic in a future post.

I have suggested that we should work to get HIV and other infectious diseases covered more generally in existing laws, particularly Law No, 23 from 1983 on Health and/or Law No. 4 of 1984 on Contagious Diseases. In fact, I was involved in work that started some time back with the Parliament to develop amendments to these laws. However this effort expired as the life of that Parliament ended.

Fact is that the Parliament has a huge backlog of draft laws, so there's not much hope of anything effective happening soon. I guess we're left with current advocacy approaches, which may in fact be more appropriate.


Saturday, 21 February 2009

Use any language you choose

An E-mail from Ken in Australia reminded me that it was time I put a bit of effort into the English language part of the Spiritia web site. Naturally our first priority is to providing clear information for people in Indonesia in their own language. But a secondary objective, similar to the primary one of this blog, is to provide a picture of the state of the HIV epidemic in Indonesia for outsiders who don't speak Indonesian. In addition, sadly there are those working in the AIDS or associated field here whose knowledge of Indonesian (to put it politely) is somewhat limited. We hoped also to help them.

But it's been some time since I had any feedback on the English part, so, well, out of sight, out of mind. I'd even forgotten what information was offered. But Ken, who has an Indonesian partner, and works as an HIV clinical nurse specialist in Sydney, reported that he had been working with an Indonesian student with HIV and TB. This guy is due to return to Indonesia next year, and Ken was trying to find out about treatment options here. And he couldn't find anything useful on our site.

He was right. As those of you who have (perhaps) visited the site will have seen, we'd provided a general article on AIDS in Indonesia, but nothing specific on care, support and treatment (CST). And this information is certainly needed to support our objective of informing outsiders about the situation here.

So this morning, I sat down and wrote this up. I've just uploaded the result Care, Support & Treatment for PLHIV in Indonesia. If you have time and inclination, do take a look and let me know if I've left anything out. It is naturally a bit subjective, but I hope it is reasonably balanced.

Now what else do we need? I'm thinking that there ought to be an article on peer support in Indonesia: how it developed, and where it now stands. I think we've pioneered some interesting approaches, which might be of interest to others. Any other ideas?


Thursday, 19 February 2009

High thoughts must have high language

I have written before about the trials and tribulations around translating articles into Indonesian. My old friend Dr Erwin Widjono (the founder of the Jakarta Drugs Dependency Hospital or RSKO back in the 70's - but that's another story!) always complained that Indonesian is a very impoverished language. It's very difficult to express shades of feeling in the language. He told me that he first translates to Javanese, which he says is a richer language, and then back to Indonesian.

There's been a lot of correspondence on this recently in the Jakarta Post. It seemed to me that much of it was wide of the mark, But I do think that a language reflects the culture. For example, the fact that there is no word for 'accountable' (at least to differentiate it from 'responsible') seems to me to give some insight into the challenges Indonesia faces in combating corruption. If you get caught, give the money back and all will be well!

Our job has been a little simplified with recent launching of the fourth edition of THE Indonesian dictionary, Kamus Besar Bahasa Indonesia, "The Great Dictionary of the Indonesian Language." The Dutch Ambassador to Indonesia, Dr. Nikolaos van Dam, has just written a very learned but interesting mini-review of this in the Jakarta Post that is worth reading. He notes a number of shortcomings - and he has clearly spent a lot of time with the book - but he notes that it is a very welcome release. As with any language, there are a number of inconsistencies, but it does appear that these are slowly being addressed, as each new edition appears. He notes that the first edition only made it to the shelves in 1988, with only 62,000 entries. The second edition, which is the one I have at home, very dog-eared, was published in 1991 with 72,000 entries. The current edition takes this up to 90,000. I suppose it is unfair to compare this with English - many pocket dictionaries contain more entries than that - but this relatively low number (including, according to His Excellency, 20,000 'loan words', many from his own language) does reflect a degree of poverty.

Of course, English also has its shortcomings. Talking of 'responsibility', we face difficulties when we discuss what is now often called 'positive prevention' - the idea that HIV-positive people should also be involved in breaking the chain of transmission of HIV. A very sensitive topic, partly because they do want to be seen to be 'responsible' people, but clearly don't want to be held 'responsible' for the spread of the epidemic.

Sometimes language can be a barrier to clear communication...