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...


Sunday, 15 February 2009

Spread my dreams

Residents and visitors to Jakarta will be aware of the Busway saga. There are currently seven corridors in operation, although a lack of buses means that the frequency is well below the five minutes required to make any real impact on the Jakarta traffic. But despite all the challenges (several buses have burst into flames, and the busway lanes are taken over in the rush hours by other vehicles, causing delays to the buses), it was decided to go ahead with another three (or was it four?) corridors.

The new corridors were constructed at great expense, together with foot bridges (the busway lanes are in the centre of the road) and shelters. This infrastructure was completed almost on schedule a year ago. Only problem: someone apparently forgot to order the buses. These have still not arrived - I rather doubt they've even been ordered. So the return on that huge investment has been ... negative.

Now, perhaps because of rising complaints, or increasing embarrassment, or just because an election is coming, the governor has put his foot down. One of the new corridors will start operation on 13th February. Err, 20th February. If it can be made ready. Where will the buses come from? Moved from the other under-served corridors of course. So the service on those will further decrease, while the service on the new corridor will be around every 20 minutes. More people will get to see the buses, even if no more people actually get to ride them. The shelters and the buses will of course get even more crowded - and dangerous.

What has this to do with HIV? Well, just that it is symptomatic. I remember when I was a lad, butter was rationed in England; one pat per person per week. So we had to spread it real thin. This is the policy here: spread it thinner and thinner. Like busway corridors, new hospitals (or new wings in existing hospitals) have been built, but not occupied. Why? No staff. So spread the current man- (and women-) power more thinly. Oh, and the funding too.

Dr. Nurlan, commenting on the HATIP article on problems retaining healthcare workers, noted that in one hospital in Jakarta, qualified nurses are receiving a salary of Rp 1.5 million, well below $150, per month. A little in excess of the minimum wage for labourers here. Below what many household maids get. Not much left over after paying for their (probable) 3-4 hours travel every day (no busway!). The hospital is apparently confused why there is high turnover - and low morale.

The Ministry of Health planned to have 400 ART referral hospitals in operation by the end of 2008. How many now? Still only 150, less than planned for 2006. Why? Shortage of staff, inadequate training, and hospital management that would prefer to refer AIDS patients to other hospitals.

Indonesia is buying a submarine from Russia. Great idea! One submarine to cover the huge expanse of sea that is Indonesia. Spread it thinly, lads...
But I, being poor, have only my dreams;
I have spread my dreams under your feet;
Tread softly because you tread on my dreams.


Friday, 13 February 2009

A victim without murmuring

I've written before about the Denver Principles, proclaimed by a group of HIV-positive activists in 1983 at the first AIDS conference. I noted then the preamble to the declaration, which noted:
We condemn attempts to label us as ‘victims,’ a term which implies defeat...
Yet 25 years later, some of us are quite happy to be given that label - at least the Indonesian language equivalent, "korban' (which also means 'sacrifice' as in a religious offering). A year or so back, a group of people living with HIV demonstrated at the Hotel Indonesia circus in Jakarta (the favourite place for such activities) wearing T-shirts proclaiming themselves to be 'AIDS victims'.

I personally feel even more strongly than those early activists that the term is totally inappropriate - and almost dangerous. Because it suggests that we have no control over what happens to us, that it is all the fault of someone else. Perhaps for some (clearly for babies), this may be true, but does it help to spend the rest of your life blaming others?

It sort of raises the question: for how long is an 'accident victim' a victim? For life? Even if they suffer disability, surely there must be a limit to how long they consider themselves victims? Most are able to get over it and get on with their lives; why not people with HIV?

Is this different for drug users? They have formed the Indonesian Drug Victims Network. Partly this is to avoid being considered criminals; the law is thought to treat victims more humanely. But does that mean they have to be victims all their lives?

There must be a 'statute of limitations' for victims...


Wednesday, 11 February 2009

A bridge too far

Are the antiretrovirals (ARV) produced in Indonesia equal to the imported ones? This question is often asked in the various forums and during meetings with people with HIV here. I have usually answered that the generic drugs industry in Indonesia is said to have a good reputation, that the Indonesian Food and Drug Administration (BPOM) is said to do a good job of monitoring the industry, and anyway, 'the proof of the pudding is in the eating': my friend Yuni has been on locally-produced ARVs for almost seven years now, with a CD4 rise from 17 to more than 800, and a consistently undetectable viral load. In addition, it seems that all of the ingredients are imported from standard sources (in China?), and are only assembled and packaged here.

But now I'm not so sure. The headline in today's Jakarta Post says it all: "Consumers warned of ‘substandard’ generic drugs." The article even specifically refers to Kimia Farma (KF, the producer of the generic ARVs here) - although it is not clear that there is any specific concern with that company.

Actually. a presentation "Generics: access, efficacy and quality" by Andrew Hill from Liverpool University at the recent HIVNAT Symposium in Bangkok has already raised worries in my mind. Andrew raised the concept of "PK bridging", which is used to "prove" that generics are in every way equivalent to the original drug. There is a 'gold standard PK bridge' (picture of the Golden Gate), that is employed by reputable companies. There are 'other forms of PK bridging" (picture of rickety footbridge) that are 'much less stable." Several elements of this bridge should raise red flags. For example, unpublished trials - I have yet to see any data about trials by KF. And why are they not WHO approved - do KF practices meet the standards? Where can we get answers to these questions?

Sometimes I'm scared to dig too deep...


Monday, 9 February 2009

A distant voice in the darkness

I have on several occasions referred to the longer-term threats to survival which face many people with AIDS in Indonesia. Perhaps the greatest threat will be caused by the high prevalence of viral hepatitis co-infection among those with HIV in Indonesia - probably as high as 50%. The effects of this co-infection will start to be felt early in the next decade, given the longer 'latency' of viral hepatitis.

Whereas there is an increasing number of treatments for HIV, treatment for hepatitis C seems to be stuck in a time warp, with still only two drugs available, both of which must used together, at unaffordable cost, with excruciating side effects, and having a very low success rate - less than 30% among co-infected people. But without this treatment, they will start to suffer liver failure, which (without liver transplants - again rarely accessible) will be fatal. It'll be like we're back in the 90's.

There are estimated to be more than 170 million people with chronic hepatitis C infection around the world, significantly more than the number living with HIV. So why do we only have two awful drugs to treat a curable disease, while we have more than 20 for HIV? Part of the reason is that the hepatitis C virus was identified several years after HIV.

But it is difficult not to draw the conclusion that there hasn't been the pressure. Prof Joep Lange, in his closing presentation at the recent HIV-NAT Symposium, made the point that we were very lucky that the HIV epidemic first became apparent among gays in America. If it had appeared as an affliction of poor black people in Africa, would there have been the same pressure to discover new drugs, to determine the cause. Surely, not! The parallel with hepatitis C is obvious.

Of course, there is a significant number of people with hepatitis C in the West. But they are not a homogenous group; indeed, many of them are 'junkies' (since hepatitis C spreads among injecting drug users in the same way as HIV, just ten times more easily - 90% of such drug users in Indonesia have hepatitis C). But also people are not (yet) dropping dead with the disease, and particularly not at such an early age as they did in the early 80's with HIV.

The message is clear: we need much, much more activism to press for development of new drugs - and a vaccine - for hepatitis C infection. Sadly the voices are very muted.


Sunday, 8 February 2009

The test of any man lies in action

I've written before - and I'm sure I'll write again - about the figures, So often we read the reports, we see that figures, but we don't think much about what the figures mean. We all know that 'mortality' means real people dying, but in reports it can become just another statistic.

I've just been working on the final draft of our annual report. Among others, we generally comment on the fact that only a small proportion of people with HIV infection in Indonesia are aware of it. There seems to be agreement that the total number of people living with HIV in Indonesia is around 270,000 - I think that's a low estimate, but let's accept it for the moment. The last annual statistics from the Ministry of Health note that less than 5,500 new cases of HIV infection were reported last year. So I did a little calculation: at that rate, it'll take us 50 years to identify all the current cases. Of course, most of them will have died by then, but...

OK, the reported case numbers are notoriously low. Figures from the provinces are usually at least twice those reported nationally (ask why?). But even if we assume we're finding 10,000 cases a year, it'll still take us more than 25 years to find them all.

There's been priority given to scaling up voluntary counselling and testing (VCT) over the last couple of years, with massive injection of Global Fund money. So what have we achieved? A 30% increased in case detection over the last two years! Gee!

'We' regularly discuss (or argue about) introducing provider initiated counselling and testing (PICT), with opt-out. 'We' are not sure what that means, but are scared that it will violate human rights. Fact is that probably a majority of the 5,500 cases reported last year were identified among in-patients in hospitals; the symptoms suggested AIDS-related infection, the history suggested possible risk, the doctor (finally) connected the dots, and the patient was referred to the VCT clinic. That sounds to me like provider initiated testing, no? So what's the problem?

Well, the problem is that the doctor in his office does not connect the dots - how can he (or she) in five minutes consultation? Thus the whole argument seems moot to me: PICT is already happening in hospitals and is not feasible in out-patient practice.

So do we just wait 25 years? With people are getting infected MUCH faster than we're identifying them...


Saturday, 7 February 2009

...sick and full of burning

One of the ever-present side-effects of working in the AIDS field is burn-out. I guess we've all experienced it, to a greater or lesser extent. Of course it hits the health care workers most heavily, as Theo Smart of aidsmap has identified in a recent issue of the HATIP (HIV/AIDS Treatment in Practice) newsletter, Caring for the caregivers in the face of HIV and TB. As Theo notes, there is a conception that things have become easier now we have antiretroviral therapy (ART). In theory this means that the hopelessness and helplessness has reduced, and people are not dying in the same numbers. As I've mentioned before, we've certainly seen that here, but... People are still presenting at a very late stage, when even the 'Lazarus' effect of ART cannot be guaranteed. And with the increase in shear numbers of those infected, while the percentage of deaths has fallen dramatically, the absolute numbers still remain awful.

In addition, for those who benefit from the Lazarus effect, there is the ever-present fear of what is called Immune Constitution Inflammatory Syndrome (IRIS), or what the TB old-timers called the Paradoxical Reaction. This appears as a sudden worsening of symptoms in someone who has started ART with a very damaged immune system. In that situation, the immune system has lost its ability to generate a reaction to infection. We often see people with CD4 counts (which measure the state of the immune system) in the single figures who are still apparently relatively healthy.

But after they start therapy, the immune system starts to recover, and often immediately starts to react to the 'hidden' infections. You may imagine the trauma when someone who feels relatively fine starts treatment and goes blind. Yes, that happens; I've seen it twice, a result of a hidden CMV infection which wrecks the retina.

No, ART has not solved all the problems, and has certainly not removed all the stresses which are faced by health care staff and community supporters.

We've just be translating that article by Theo. The first problem we faced is that there really is no translation for 'burn out.' The usual term used, 'jenuh', has more of a connotation of 'worn out', even though the dictionary does say it means 'sick and tired'. Theo also reports a doctor saying that nurses are unable to share their fears with their partners, ‘because they freak out completely’, A serious problem, but at least we had some laughs trying to translate that term!

Even in English, I think the term 'burn out' has become devalued. Back when, we used to talk of a nervous breakdown; I guess that term is no longer politically correct, but it certainly seems to fit what I felt at one stage, and what one of my close friends seems to be experiencing right now. And I guess if we go back a bit further (before my time, Dear!), the shell-shock experienced in the trenches in the First World War had a similar cause.

As Theo notes, "Clearly much more needs to be done to keep our healthcare workers healthy, happy and productive members of the health system." And the same is true of the community members working as buddies, counsellors and case managers, who often lack even the meager institutional support that the nurses get.


Wednesday, 4 February 2009

Money is like muck, not good except it be spread

Probably all of you have seen Lucy Williamson's report Tackling Indonesia's HIV spread on the BBC web site. Lucy has been doing a lot of research for her articles about HIV here, including meeting with us collectively at Spiritia, and separate meetings with several of us - thanks for the lunch, Lucy!

Lucy refers to 72 districts. I assume that is the number that will be supported by the new Global Fund project. But there are in fact more than 450 districts and municipalities in 33 provinces in Indonesia. Most provinces are as big as a country elsewhere. But the big problem with the decentralization that Lucy refers to is that it didn't devolve autonomy to the provinces, but directly two levels down to the districts. This leaves the provinces with a less than clear role. Worse, it often seems to add an insulating layer between the national policies and the local implementation.

Some districts are indeed acting as role models. For instance, Jembrana in the north-west of Bali (off the tourist - and tourist dollar - track) has managed to provide free health and education to all. It has also set up an amazing computer network, to which all government offices and services are connected. If Jembrana can do it, why not others?

As the article notes, the huge Global Fund grant will support responses in less than half of the provinces, and less than a quarter of the districts. Yes, it covers the notorious 'hot-spots', and (as Bob Magnani of FHI notes) that focus is essential for effective prevention. But for treatment? How do we tell people with HIV in the other provinces, sorry, you'll be looked after when (if) the next Global Fund Round clicks in. In the meantime, well, be patient - and try to survive. I fear we are further extending the inequities that already exist - clearly urban dwellers with HIV are better served than those in the villages.

I agree that the resources are spread very thinly. But I still do not understand why countries like Malawi can scale-up access to antiretroviral therapy so much more successfully than Indonesia.

BTW, following up on my post of a couple of days back (Stand by to crash), I had good news. Radnet managed to recover all the data from the failed hard disk, and our web site was back up yesterday afternoon, without any effort by me (other than pulling what remains of my hair out!). Now to ensure that proper backups are done...


Tuesday, 3 February 2009

We cannot escape history

How important is history? There has been a debate about this over the last few days. On our web site, we have included a History of AIDS in Indonesia, based on the History pages on the Avert web site (which we have also translated).

In Indonesia, our report says that the history starts in 1983. It was then that Dr. Zubairi returned from post-graduate training in Paris where he worked under Prof. Mathe at the Institute of Cancer and Immunogenetics at the Paul Brosse Hospital. His task there was to learn about the immune system, and specifically about the sub-population of lymphocytes (white blood cells). This clearly awakened his interest in the newly identified syndrome just renamed AIDS. So on his return, he sought out any evidence that AIDS might have entered Indonesia.

Some may recall that the syndrome had first been identified in 1981 among gays in the US, although at that time the cause was not known. It was surmised that it was in some way connected with sex between men and men, so it was initially called Gay-related Immune Deficiency, or GRID, It was only in mid-1982 that it became apparent that it affected other groups, and so the name AIDS was coined. However, it was still seen as predominantly a disease of men who have sex with men (MSM).

So it was perhaps natural that Dr. Zubairi should search out a group of waria to test. Among MSM, waria were perhaps the easiest to find in Jakarta; the gay life was not particularly well-defined then. So he collected a group of 30 waria from Taman Lawang in Jakarta, still (I believe) their favourite stomping ground (if that's the right term!). He examined blood samples from the 30 in the lab at the central hospital. On the basis of symptoms and their low CD4 counts, he deduced that two of them had AIDS. Of course, at that time a definitive test was not yet available,

Were those the first identified cases of HIV infection in Indonesia? Clearly the Ministry of Health don't agree, since they always refer to the First Case as the 'notorious' Dutch tourist who died in Bali in 1987. But Dr. Zubairi is pretty convinced, although of course he cannot prove it.

This has just become an 'issue' (as things do in Indonesia) because a representative of a gay group has implicitly criticised Dr. Zubairi for picking on a group of waria, considering it to be discrimination. Why, he asks, didn't he pick on other groups? Clearly he was not aware of the history.

In responding, Dr. Zubairi made the point that what is more important now is to discuss how we can work together to address the challenges of HIV and AIDS in Indonesia. While I agree to a certain extent, I always remember the axiom in the subject...


Monday, 2 February 2009

Stand by to crash

It's been a bad computer day! This morning, when I tried to open the Spiritia web site, I got an error. Not particularly unusual: recently they've had problems with a service called DNS, which works like a telephone directory, to convert '' into an address a computer can understand. The frustrating thing is that is only affects people logging in form the Radnet domain (Radnet host our site), but does not affect people logging in from other domains, which have their own directories.

Normally this problem is sorted out in minutes, but this time it was taking longer. Finally I was informed that the hard disk on the Radnet server had crashed, and they were restoring from a back-up. This always means we lose some data, because the back up is always made some time (normally at most, a week) previously. However, when the site came back up, it looked like they had used a backup from last August! They are now trying to do better, but I fear I may have to re-upload a lot of data tomorrow! Oh well!

Then, our office assistant brought me her notebook computer, which 'was not working right'. A virus, or multiple viruses. Tried to recover it, but in the end, had to repair Windows. After that, everything was OK, except that the WiFi wouldn't work. Gave up on that at 5 p.m. I think Acer may have to sort that out.

This morning, because of the rain , the papers weren't delivered when I left for the office. Just been scanning the Jakarta Post. Monday's computer day, and Jeremy Wagstaff's column is always interesting. Today, he is Getting lost the forest of insecurity, having discovered a hole in Indonesia's banking system. It seems that anyone using internet banking here can find out details of anyone else's phone bill, including their name and amount. I guess I should have guessed this, since I use internet banking to pay my phone bill, and all I have to do is enter the number, and the details appear, even though the telephone is still in the name of my long diseased partner - and his name comes up! Haven't tried entering other numbers, but I'm sure Jeremy is right!

So much for confidentiality in Indonesia. I regularly get questions from people who are worried whether they can trust the hospitals to keep their details secret. I wish I was more confident about the answers I give. Usually I say that the policy is to maintain confidentiality, but the biggest risk is human errors. But I'm sure an increasing number of hospitals are maintaining records on computers. Could they be hacked? Need you ask?