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!

Babé

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?

Babé

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...

Babé

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...

Babé