Saturday, October 29, 2011

What makes Indonesian (not) healthy ? [part one]

Do you know if you were born in Japan you will probably live 40 years longer than somebody who were born in Afghanistan?*
*Life expectancy for Countries

And the fact that Indonesian people have life expectancy 12 years shorter compared to their neighboring country, Singapore !
This intriguing fact is something that I learned during my core course in Amsterdam about health determinant**.
**What determines health?

It has haunted my mind and spirit as medical doctor and public health practitioner.

Epidemiology and statistics, branch of study that talked about important numbers/indicators on population, used to be unpopular class when I was a student in medical school.

I remember how bored it was and demotivated most of us to really learn something from it, or put it into practice.

Few years after I finished my medical school, I realized how important it could be.

It does tell whether we're moving from one point to another (or not), make any good or bad progress as nation in terms of managing health.

Maternal mortality rate (MMR) in Indonesia is one of the highest in Southeast Asia, but if you stratified by region- some more developed region (West Java) has lower MMR (lower than Southeast Asia rate in average) while another region, Papua has MMR 3 times higher than national average!

Back to my main question, as a title: ' What makes Indonesian (not) healthy ?'

I would use the framework borrowed from Canadians :: Population Health.

This is actually looks like my assignment as master student in International Health program-
but in the name of knowledge, science, humanity and nationalism- I write this for you all who interested in this subject (as much as I do).

1. Income and social status

Pretty much makes sense for all of us, people who are poor would more likely have worse health status than those who are richer.

Specifically in countries like Indonesia whereas most of the health expenditure come from out-of pocket (user fees) expenses.

Those who are poor assumed would spend less money on health care (they would prioritize on something that are considered basic needs e.g. foods).

And this group would likely to come late (if they happen to be sick) to the doctors, they would collect money first, seek out alternative treatment etc- in this out-of-pocket systems.

Because here doctors/health care institutions are considered as something 'expensive' or luxurious need for the poor.

It's likely this could be the case: they (the poor) couldn't afford money to go to the doctors, they become even sicker. When they go to the doctor, their worsened conditions would make them pay ever more (more treatment, more medication) compare if they seek treatment earlier.

next on health determinants . . . .

2. Social support networks

3. Education and literacy

4. Employment / Working condition

5. Social environment

Friday, October 28, 2011

Public transport :: Never ending problems

I love public transport.

Here or moreover abroad.

I am people person, and even though I know I could take my own car, joined with others who have their own personal car and make traffic jam in the street altogether- there were times that I kept telling myself I should stay to my idealism and take public transport.

For me, taking a public transport means a more environmental-friendly approach than personal vehicle (of course). And being in a public transport with people, it's like sharing not just a car but also a life, their stories. Sometimes, it could be very VERY annoying when you're stuck with thoughtless people, who smokes regardless the car was already suffocated enough with 10 persons.
But also there were times it could be a rewarding moment, seeing interaction of people who help each other. Being a witness of such behaviour, I know it was not such a bad idea to stay on public transport.

I admit, though, public transport system in Indonesia is not the safest place in the earth.
In fact, it's one of the dangerous experience that you could have in your whole life.

Just recently, a minivan crashed at the place close to my hometown and few people died.
When I was a young doctor in a hospital, I saw too many cars/motorbikes accidents, some of them due to irrational behavior of the drivers.
It is a crazy and tough life on the streets here.

Back again during my study (or traveling) year in Europe (or elsewhere in Asia), I analyzed what make these developed countries build a success public transport system.
Is it a good system who drive users to oblige or start from capable users who drive the good public transport system?

I've come to the conclusion of: both.
It has to be driven simultaneously by systems (also environmental) and users.

For example, any Indonesian people who have been to Singapore, they know that they have to adhere to such strict regulation (not just transport, but also not to spit in public etc. Gosh).
Or any Germans (mostly they follow the rules) who have been to Indonesia they would find their way out from tricky traffic jams by doing exactly (or almost the same) like any Indonesian.
It's just their adaptation behavior to the systems, either it's good or bad.

Even in Europe, there's a huge difference between public systems in Denmark and in Italy.
My analysis: It's just because Danes have less emotional feelings on the street and stick to the regulation easily than Italians (and oh, I'm on the Italiano side :-)
Biking rules in Netherlands is very laid-back compare to Denmark.
So this is also applied to their personalities, I'd say.

What about in Indonesia?

Here, taking a public transport it's like the option of poor people.
For those who can't afford their own personal motorbikes or cars.
It's very unreliable, chaotic, unsafe, dangerous (remember few weeks or months ago, about raping in public transport. It scares me and a lot of women too, I bet) and it's like risk taking every day when you don't have other choice.

And people, like me, who knows this experience, made a vow to themselves- as soon as I get more money I would buy my own bike/car so I won't stuck in this crazy situation everyday!

too many cars!now we have too many cars in the street!

But that's not a long term solution!

People are getting rich these days.
There will be more people who could afford their own personal vehicles.
There will be more motorbikes and cars in the street (it's already happened actually)
surely, there'll be more traffic jams here and there. We know it already!

At some point, every places in Indonesia, will be like Jakarta.
People are physically and mentally test every day in the streets due to its chaotic conditions.

The solution: We need more public transport, which is secure, reliable and cost-effective (we're not saying cheap, I'm sure a lot of people would rather to pay reasonable price as long it's worth).

We should shout it out loud to our government!
Or basically those who care, if the government burns out with too many task.
It could be public-private-shared organisation, I won't go into detail and it's not my expertise either. But we surely need this, now or later.

Tuesday, October 25, 2011

Conference addict :: Upcoming event on 2012

After my last scientific conference in Barcelona in the beginning of this month, I realized that I got addicted.

my poster presentation in Barcelona!my poster in International Health Conference, Barcelona
with Prisca, my co-supervisor from KIT, Ams

Being in the international conference was very inspiring for me. I was there for a poster presentation basically, but I could also learned so many things e.g. how to make better poster for presentation, attending seminars with experts, building networks with people all around the world.

One of the speakers that I found very inspiring for me was
Helen Rees. She brought a session about pre-exposure prophylaxis for HIV prevention, in a very practical manner. Also a stunning presentation!
One of the most impressive presentation (slides, also how she came up with the talks) that I've ever seen in my whole life as researcher (yeah I'm stil young researcher btw).

Then I googled her name and it turned out that she's indeed a very professional and dedicated person in her area (and she's part of WHO Advisory Committee).
Uh huh, no wonder why.

Now that I feel like I've learned so much from international conference, I got addicted to have some more !

Here's some of upcoming events (international scientific, clinical/ social conference) about HIV-AIDS in 2012 :

April 12-13, New South Wales (AU)
Silence & Articulation

May 23-25, Marseille (FR)
"Searching for Cure" - ISHED

July 22-27, Washington DC (US)
Turning the Tide Together

So for those who are interested, don't forget to submit your abstract and hopefully I'll see you there !

Monday, October 24, 2011

NG :: 7 Billion Population in 2011

THis is an example of nice public health message from National Geographic.

It's about demographic, the world will reach 7 billion population by 31 Oct 2011.

Enjoy !

Sunday, October 23, 2011

Health Promotion :: The Power of Information

When I was abroad, I talked to several friends that I know how did they get source of information about sexual reproductive health.

It was quite common in Europe, that young people know about their sexual and reproductive rights since very early age. Either they get the source information from school or mass media.

I asked a friend of mine, she's Indonesians but has been living in one of the state in Europe for years. She said that she never heard anything before this kinda information when she stayed in Indonesia. Then when she lived abroad, it's clearly such information were commonly spread in public.

Also information about HIV.
HIV in Indonesia is actually not involving a big number.
In general population the prevalence (only) 0.2 % but among at risk population it ranges from less than 5% (among sex workers) to more than 50% (among people who inject drugs).

While it's pretty common in developed countries, where they put every one (especially young people, who presumably sexually active groups) at risk - public health professionals put the message that 'preventive is important'.
Its implication: (Hopefully) Every young people know that they should use condom with a new sexual partner (to protect from STI) or use another form of contraceptive, if they long term partner (as birth control).

These days, information plays a major role in our life.
And it's really fast in our globalization era. Just hours ago Simoncelli had an accident in Sepang, Malaysia and it was spreading whole around the globes in one click away (if you have internet connection).
We all connected through invisible bonding, thanks to internet and mass media.

And we all may received also wrong or invalid information from media.

That's why leaders (community leaders, religious leaders) used to be and still nowadays, play essential role-- because they may be the source of information, like it or not.
Especially for uneducated people, when they can't be critical (for they concern about only their primary needs).

Unfortunately we can see in our mass media (yes I am talking about Indonesian TV channels) we have limited room for public health messages that can educated people.

I didn't watch TV (in Indonesia) that much because sometimes it could make me sick.
But I also noticed some channels consistently put nice public messages to inform viewers.

I know that every one has their own agenda, whether it's profit (and I believe cheesy movie/ infotainment could bring a lot of profit) or better motives.

Just few weeks ago I came back from Europe, then I started to notice few commercials break in TV. There's this nice public commercial talked about food substitute for rice (because in Indonesia we have so many food staples beside rice, yet they less popular).

I wish for more public health message like this. If I have people who work in media, I would like to contribute my idea to develop public health message.

We are in great need of this message e.g. how to overcome traffic jam (driving behavior), also safety in the street (also for pedestrians), or talking about healthy eating habit.

And it should be regulated in the Ministerial level!

I think for every junk food advertisement (McDonalds, KFC, etc) should be certain percentage aside for health eating habit advertisement !

It's a pity, too many young people with unhealthy eating habit were considered as 'normal' because it represent the sign of 'success' or 'wealthy'.

Then again, smoking prohibition in public space.

Ah yeah, I should have mentioned first, that tobaccos are a big deal in Indonesia.
And it's so cheap ... even kids underage could afford it.

Compare with Europe, for example, you only could buy cigarettes if you're over 18 years old.
I've noticed in some countries e.g. French, Italy, Spain I saw people from younger age also smoke cigarettes. But they have concern that if they smoke, that doesn't mean other people have to smoke too (at least better than here).

And because it's so cheap (cigarettes in Europe also very expensive because they put higher taxes) there are so many poor people that could not afford buy food, they will buy cigarette instead. That's tragic !

I think only rich people that should buy cigarettes, because when they got sick (due to respiratory problems) at least they could afford their medical care.

Maybe it sounds too cynical. But to be very practical, I would put higher tax on cigarettes -- then relocate the budget for health care --
And this works to stop people from smoking too, I believe.
I know many Indonesian friends who stop smoking when they lived in Europe for some while (because it's too expensive to buy cigarettes there).

We've seen so many innovative and impressive advertisement from this tobacco companies in Indonesia. We should also asked them to be balance by provide the information of how harmful cigarettes could be for our health.
Then again, it will be conflict of interest for them!

So, who should provide such information then?
I would say, us, community, public health professional, clinicians, if not government in general (only if they interest in the health state of their citizens).

Friday, October 14, 2011

Sexual Reproductive Health :: It's not your own business

My mother always told me to mind my own business.

Everytime I'm babbling around about this world could be a better if only people would do their task responsibly, she stopped me to talk further. For her, we could only done our part and let the rest do their own business.

But I can't !

I am a medical doctor, and what I always do is actually taking care others business.
I do care about other people's health, also about their financial insecurity, sometimes about their sex life's too.

It is so ridiculous everytime I heard people being so individualized and not really care about other people business.
Cause we know that we actually care!
And that's why we LOVE gossips so much.
Just look at the television where they talked about nonsense, these celebrities doing this and that (And oh how public adore them, for their shallow attitudes).

They (the celebrities) don't even care if you're injured and couldn't afford your hospital bills, but still it's so commercialized (and uneducated) that we're people thought it's normal for daily consumption.

I really think, if Indonesia people really like to mind other people business, they should do it in the right way.

There are so many rooms for help people, and yet we know that we're Indonesian good about it.

Remember Prita case?

Her case was so famous because it moved hundred thousands people to actually help her by donating small moneys.

It is in our blood. We're moved by social injustice. We could not see others people suffer.

So why we could not do it in a better way?

Talking about sex life. Hmmm... Yeah, it's always an interesting topic.

But why am I bring up this topic is because Indonesia, with 237 million of population, we're facing a problem of overpopulated country.

It's not as bad as India or China. But I'm sure we're getting there.
It's just a matter of time.

So why not propose something to stop this exploding number of citizens?

I would propose 3 things:
(a lesson learned from my scientific writing, only 3 points max.)

1. Family planning access for all reproductive ages people (women or men, married or not)
2. Sexual reproductive health information for all (esp teenagers, youth, adolescents, even kids).
3. Female education
[ Not necessarily in order, but those things are very essential ]

I was actually about to mention 'access to safe abortion' (if needed).
But I recognize this topic could be highly sensitive and leading to many discussions/debates, also touching religion/ belief perspective.
So I will set aside this topic after top 3 priorities that I've mentioned.

The first 2 priorities seem obvious and make sense to point out.
Therefore, I would start with my last point : Female education.

Why is it so important in sexual reproductive health program.

Because I believe the core of the problem in my developing countries (with overpopulated problem) is somehow interrelated with the (inequality) woman's position in society.

I will show this correlation with simple manner:

Uneducated female -> early marriage, lower wages in employment sector, low bargain power in intimate relationship, lower position in society -> (limited?) access to health service -> worse health outcome (for herself and her children).

Maybe not as simple as that.
In above calculation, there's always assumptions (and theories) applied e.g.
uneducated female less to have access to health service because she doesn't know how to find it (not informed) or doesn't know that she actually need the service (health seek behavior).

Anyway, I'm not the expert of such theories as well.
May the social scientists explain such behaviour.

What I'm concern is, how serious the government (yes they should) and also other sector (including religious sector) put effort to female education, if not gender equality in this country.

Why female?

Because I am woman and I know how care we (women) toward our family (esp children).
I believe if a woman well-raised, she could also able to raise a healthy child (or children) and taking care her family well. And hopefully the final outcome is a healthy nation.

Women are more likely to sacrifice for the sake of their kids and family.
We all know the story about women who struggle of her financial crises so that her children could have better life. And women would invest more on her child's need (men, even if he has kid, would spend more on gadget or his own pleasure!).

It is so common sense, right?

Another example is street kids. I've seen many of them without their parents in the street.
Some are altogether with the mother asking small money in the street.

Mothers are always to blame in this case. We're gonna say (in our heart, or loudly), 'How come the mother dare to do this to their children?'

Maybe they do dare for the money (it is a strong motivation though, as strong as many corruptors steal money from the government),
maybe it's the only way they know how to get money.

Female education though is not a simple remedy for gender inequality.

There's another aspect e.g. male education (likewise we educate female, our society indeed need smarter men, too. Just look at our public figures these days and we're realized they could be as ignorant as uneducated people as well).

In my area of intervention, if we educate the women about HIV and contraceptives- we should not forget to inform the couple (likely men) as well. Otherwise, the men would think it's ONLY WOMEN responsibility to take charge of family planning program, while it should be BOTH.

Also religious sector, could influence the acceptance of contraceptive options (or basically many aspect besides contraceptive).
It is a country with biggest number of moslem population anyway ...

And oh, also talking about abortion.

Yes, I do believe God and I do worship Him, and I believe there is heaven and hell.

But it doesn't make me against abortion, because I believe safe abortion could be an option sometimes.
I could not imagine the woman who got raped and have no access to safe abortion had to carrying fetus for 9 months unwillingly in her womb!

pregnant belly
And if we're pretty good at access to family planning to those who need it, we're actually don't have to face abortion issue at all.

Now, remember Ariel case ?
Ariel is a famous lead vocalist from famous (cheesy) boyband from my hometown.

And he got prosecuted for having sex in his own place, because somebody publicized his videotape (?!???)

It is really confusing case. It's his own (sex) business, he's not even stealing government money like corruptors !

I'm not on his side at all. (I'm not taking side in this case).
I'm just upset how people could care wrongly about this sexual case, while they should more care rightly about other issue.

So my conclusion is, if we're so care about other people's business especially sex life, why not doing it in a right way?
Why not transparently educated our people about sexual and reproductive health facts-
instead of tell them what to do.

I believe when people well-informed enough, s/he could weighed decision what's best for her/him. It's time to take our responsible to our body !

Thursday, October 13, 2011

Why Public Health :: Matter of Life

Why Public Health ? Why International Health ?

That question appeared in my mind. And also in minds of others people; friends, colleagues, families, who has questioned my decision. Why am I taking interest of this subject and even pursued my master on this subject.

I would say: Because it's really important (especially in developing country, where I came from).

It's a simple answer, yet defines so many things that we're (Indonesia) lack of.

We have (currently) huge problems in mass transportation, infrastructure, community health, waste managements and sanitation, human capacity, emergency/ disaster preparedness, development problems... Just name it and you could find it here, in Indonesia, the biggest archipelago with 237 millions of population.

homeless, Braga corner
It does really sound fantastic to have such big number for population. It also describe our problem to organize the system (politic, economy, health) that would fit enormous number of citizens, spreading in more than thousands islands, with different needs and characteristics.

But I would limited my theme just into Public Health.
The area that I interested the most.

Back to my question in the first sentences,
' Why Public Health ? '

When I was doing my governmental duty, post graduated from my medical school (I was so proud that I had finally graduated from a long and suffering yet impressive medical study. I was ready to save people's life and also the whole world). I was located in Sumbawa, an island next to east of Lombok. Why I was there is part of my plan, a bit of accident also coincidence.
I was there only about 9 months. But it was enough for me to decide I could not save the world just by saving people's life one at a time.
It was just TOO frustrated.

Basically what I did, I was saving this patient from one disease but then he would died by something else. He would died because he even couldn't get the money to come into the nearest health facility to get treatment in time. He would died due to lack of nutrition. He would died cause his ignorance that simple medication would actually could cure his symptoms.

Another patient that I treated, would just keep coming back for the same issue.
Malaria is highly prevalent in the area, and just medications to cure the symptoms not really actually treat the environmental cause of Malaria.

In the end, I decided that if I really want to save this people, or this nation (in terms of health issue) I have to do something bigger.
And it has nothing to do with being a clinician.

Somebody has to do something. I want to do my part. It's my calling.

So I took a master program in International Health. It took 3 years (I sent my application 3 times, in 3 consecutive years) to get what I want. My whole 1 year entire program was funded by European Union (I got Erasmus Mundus scholarships) and I studied in 2 different universities in Europe; Royal Tropical Institute, Amsterdam and University of Copenhagen, Denmark.
It was a fantastic year and I learned a lot (still a bit from what I should know) about health systems, managements, and policies.
And I am sure this is my passion, this is what I would like to do further in my career path.

Before I got enrolled in my master program, I also had a chance to work as a researcher in the field of HIV. Most of the time I was doing social studies that related to people living with HIV.

Doing this as clinician, (if it's not one's calling) it's even more frustrated.

If only we're clinicians could treat all the symptomatic people with HIV, it still will not eliminate the problem (because far more people with asymptomatic actually need intervention as well).

Most of the time, these people not even aware that they actually AT RISK.
Or those who already aware that they at risk are AFRAID of SEEK further treatment (sex workers and transgenders are highly stigmatized, they hardly seek treatment if they get sexually transmitted infections. Self treatment are pretty common for them).
Or those who already reached the health care facilities, sometimes get DISCOURAGED by the unfriendly approach of health care workers.

This is a chronic disease (and also infectious disease). And it has so many social aspect apart from merely the clinical aspect. It touches issue of gender relation, sexual behaviour, addiction, adherence, stigma and discrimination & so forth.

It's a very interesting subject (for researcher) but also complex and confusing in its intervention.

And it was not easy because it cannot be intervene by only clinical intervention.

You have to talk with religious leaders, political officers, sex workers and their pimps (also the owner of pubs/ karaoke bars), local governments (of course) to really target the cause of social problem of HIV.

As you can see, public health could be indeed a very important and essential aspect in Indonesia- by giving example of HIV epidemic (my interest).

There's also a whole aspect of public health need to target.

Just take a stroll in the streets of Bandung- my hometown- and see how many street kids on the red light asking for small money.

Does it bother you people?

I guess we all know about this fact, yet don't know what to do.
(Or don't care about it anyway).
It was so hopeless and we BLAME to the government how come they let this happen.

Of course we should blame someone when something wrong happen.
But it doesn't solve the problem.

This street kids represents (common) social issues in Indonesia: lack of social insurance, huge social inequality (riches get everything, poor left with nothing), public ignorance etc.

I was so annoyed by this fact!

And I felt it long before I got the chance to study to Europe to see how this wealthier nations managed their health systems and managements.

I would like to do the same for my country! Because this is my country (many expats or international donors would help Indonesia, but few of Indonesian themselves feel the same calling).

I know I could do it in so many ways.

For now, I am writing it down as a promise to myself.