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.