Saving Rainforests with a Stethoscope

by Health in Harmony
Vetted

Seven years of advanced and expensive training in the US has prepared me to be an attending in a few months. Particularly in my practice setting, expensive and complex interventions are the norm and sometimes benefit the patient. I’ve recognized throughout the years that the system that shaped me has some serious flaws. Health care access is often disparate, and we spend more time facing the computer than our patients. Futile care at the end of life and over-utilization of expensive interventions are common, and the bankrupting of patients occurs regularly (and beyond the view of doctors who contributed). I have sometimes felt my passion for this version of doctoring wane, and I came to ASRI seeking the holistic ideal of connecting with patients and improving the community with my practice.

Jessie Kittle-April 2016-Patient x-ray

Barefoot doctors checking out a patient’s x-ray

My first impression seeing patients was a strong discomfort that I can’t see inside of you. Without all my usual tools I felt like patients’ problems were a mystery, augmented by my inability to gather a history in their native language. I felt the need to know patients’ renal function before prescribing an ACE inhibitor, get a TSH result for a patient with goiter and hyperthyroid symptoms, to see the pneumonia I was diagnosing on x-ray. I felt nervous that my digital-doctoring skills had replaced my human ones and that I was obsolete in this environment. Sometime during week two I made a diagnosis of heart failure, a diagnosis I’m very comfortable with given my extensive training on the subject. I thought, “Ah, I can see inside you!” Victorious, I began trusting my excellent training on the physical exam, and I was off and running.

Jessie Kittle-April 2016-Jessie with patient

Jessie and a patient at the ASRI clinic

The patient cases varied from routine to shocking, which is typical anywhere, but most striking to me was the result of the perpetual comparison of, “If this patient were in the US, we’d…”, since the answer was often a lifesaving intervention that wasn’t possible. A 63-year-old woman with a major heart attack would have been in the cath lab within the mandated 90 minutes at Stanford. Without that intervention, her mortality rate doubled. Despite that, she improves each day and I smile encouragingly, hoping my eyes don’t betray me and say: “I’m worried, and I’m sorry I can’t offer more.” But it was also a lesson in the resilience of people; often times our insistence that a patient needs what we recommend and will suffer great harm otherwise got turned upside down. A pregnant patient with pyelonephritis declined antibiotic treatment after 3 days and we thought she would certainly become septic and possibly lose the baby (and told her as much). She returned a week later… and was perfectly fine! Perhaps she took a gamble and happened to win, but these situations were a great lesson in humility in medicine. An 89-year-old man came in with stroke symptoms and there were no diagnostics or interventions that we felt could help him, so the family decided quickly to take him home. Our ambulance driver drove all night to deliver the man to his home, to die. I was conflicted with the discomfort of not having a CT to really explain what happened, and not being able to admit him for at least some IV medications, speech, and PT. But on the other hand, I’m not sure all the expensive interventions would have amounted to anything but him dying somewhere other than home, leaving his family with insurmountable debt. It was yet another humbling moment for me as they drove off into the night.

Jessie Kittle-April 2016-Jessie and Nomi

Jessie and Nomi reviewing a patient’s file together

I felt deep satisfaction in facing a patient, both of us barefoot, using hands, eyes, and ears to peel through layers of medical and human knowledge to craft a diagnosis and treatment plan that worked for the patient. I made a connection to the humanity of doctoring, which is what interested me in medicine in the first place, and that I hadn’t experienced so purely since I was a medical student in New Orleans (caring for only a few patients at a time). It’s not that the humanity is absent at home, it flickers in and out of my day like a ticker tape on the bottom of the perpetual computer screen of medical care. But here it was palpable around every patient, and reconnecting with that feeling was very powerful and timely as I set out to start my career.

The conservation model that ASRI employs was another incredible draw for me in pursuing the Johnson & Johnson Global Health Scholars Program (J&J) in Borneo, and was even more impressive than I expected. I have been an environmentalist my entire life, with years of experience in wild animal rehabilitation and marine mammal training for conservation research. I loved attending Etty’s education seminar, where she skillfully drove home the critical connection between the health of humans and the natural world, and ASRI’s multi-pronged approach to these objectives. I spent a day with the Goats for Widows program and saw the gratitude of the families who benefit so greatly from the independence and financial security of the program. The reforestation program was of a scale I didn’t imagine, operating as a living-lab in addition to a conservation project. This was health care not just of people but of the earth, and has provided me with endless inspiration for working toward a better planet as a physician.

Jessie Kittle-April 2016-Jessie with ASRI doctors

Jessie with the ASRI clinic doctors, Etty, and Monica

Clearly, I will take much more from my time in Borneo than I could ever give. For that, I will forever be indebted to those who ushered me on this journey. Huge thanks to ASRI, Health In Harmony, Nomi and Vita, J&J, Stanford, Yale, and Dr. Kinari for creating this reality and allowing me to share it, and to the patients on the treasured island of Borneo who made this experience so fulfilling. Till we meet again.

About Jessie Kittle

Jessie recently completed her residency in Internal Medicine at the Stanford Medical Center and volunteered at the ASRI Clinic through the Yale/Stanford Johnson & Johnson Global Health Scholars Program in April of this year.

I remember the first time I ever saw a patient pay for medical care with tree seedlings at the ASRI Clinic. Pak Hamsu, a patient from the village of Laman Satong where our main reforestation site is located, had amassed medical bills totaling over $375 at the ASRI Clinic after he had a severe stroke in April 2013. When he finally died, his family did not have enough money to repay the debt. So his nephew Jhony repaid the debt the only way he knew how: raising tree seedlings, grown from the seeds collected in the nearby forest that his village has protected for generations.

That got us all thinking. It is a terrible feeling to ask a poor patient’s family to settle outstanding medical bills after the patient has died. But we also have to cover costs to keep our clinic’s doors open so that we can keep treating patients. What if we starting attacking the debt problem more creatively, by making it easier for patients to repay debt with tree seedlings that we could later plant in degraded areas of Gunung Palung?

Laman Satong_Patient Seedlings 3_compressed

Seedlings at the Laman Satong reforestation site

Fun Fact: If you just remove one letter from the word for “debt” in Indonesian – hutang –you get the word for forest – hutan. It’s like it was meant to be easy to turn debt into forest.

So we discussed this idea with our community partners, especially the Forest Guardians. They were totally enthusiastic – but they also reminded us that being in debt is a huge social stigma and a shameful condition that people will go to great lengths to hide. To remove the association between tree seedlings and debt, they suggested another option – why not prevent debt in the first place by allowing patients to create “savings accounts” with seedlings?

Again, this was totally brilliant. Our goal at ASRI is to make sure that the sudden, unexpected cost of a health emergency does not bankrupt families or bankrupt the forest. Banking seedlings in advance could also help chronically ill patients or pregnant women who need routine medical checkups.

Since we started offering this option, over 50 patients have banked 4,256 seedlings representing 28 species and worth a total of Rp. 25 million (about $1,900). We hear reports that there are thousands more seedlings in the pipeline from villagers setting up their own “savings accounts” at ASRI.

The “seedling banking” option has been wildly popular in the villages where ASRI runs the mobile clinic. These places are rich in natural resources but do not operate on the basis of a cash economy because few people have cash-paying jobs. Our Reforestation Coordinator Pak Frans just went to the village of Pangkalan Jihing last week to pick up2,000 tree seedlings (and it took him 8 hours to get there because the road is flooded and practically impassable). Because there is no medical care there, the villagers depend on ASRI’s mobile clinic and with the seedling payment option they literally depend on the forest to be able to pay for medical care.

Community members giving seedlings to the mobile clinic for their savings account

Community members giving seedlings to the mobile clinic for their savings account

From an ecologist’s perspective, this system has been fabulous for increasing genetic diversity within the site. Rather than planting thousands of red meranti seedlings from the same parent tree, we are getting meranti seedlings from parent trees throughout the landscape. This increases the site’s resilience to disease and helps re-create the biodiverse richness of the natural forest that we are trying to restore.

This system is also helping to build our stock of hard-to-obtain tree species, like belian or Bornean Ironwood. One of the first patients to create a savings account last year, Pak Saifal paid with 213 ironwood seeds collected from his family’s own traditional tree garden (you may have read about him in Health In Harmony’s year-end mailing in 2015). This was a rare gift – Ironwood trees are one of the slow-growing giants of the rainforests of Borneo – their timber is prized for construction and boat building, and they are undoubtedly the most highly targeted species for illegal logging in Gunung Palung (which means it is almost impossible to get seedlings!). Every time I visit the nursery, I notice a new belian seed has sprouted even after almost a year of lying dormant, and I feel thrilled that we will be able to plant healthy ironwood seedlings to replace the stumps of the forest giants that remind us of the forest the site used to be before it was logged.

Just $2.00 buys a seedling and pay for a patient’s health care and cover the cost of planting, watering and maintaining the seedling for a year. And 12 seedlings is the average amount a patient barters for a typical visit.

Your support of Health In Harmony turns debt into forest everyday.

An open invitation to the villages calling all loggers for hire for construction on ASRI’s new Community Hospital Training Center (CHTC) is taking sustainable construction to the next level.

Well before ASRI broke ground on the CHTC, the staff had made sure to include a clause stating they will hire 40% of local labor during the duration of construction. The labor was defined as low-skill labor to people without construction training for work under the supervision and direction of the CHTC contractor. The jobs include excavation, block laying, and construction of temporary form work to support concrete.

Former logger, Pak Usuf now works as a security guard on ASRI's hospital construction site.

Former logger, Pak Usuf now works as a security guard on ASRI’s hospital construction site.

ASRI has been committed to saving the rain forest by offering more options for illegal loggers to be trained in alternative livelihoods for the last 8 years. A common refrain heard from illegal loggers is, “We are ready to stop logging – but we still have to feed our families. Can you offer us other work?”

So when ASRI’s Hospital Construction Manager Edy was practicing “radical listening” with ASRI’s conservation team to learn how the hospital’s construction could support conservation – the team replied, “Please hire loggers.”

The construction team listened. They offered an open invitation to illegal loggers in the area to join the CHTC construction team. The local labor recruitment follows a three-tier system, which prioritizes loggers (Tier 1) before moving on to recruit area from the neighborhoods surrounding the hospital (Tier 2) or from the broader community (Tier 3).

Currently, there are 17 former loggers working on the hospital, and about 3-4 positions are being added every week as the construction progresses in phases. Positions will come and go, offering about 200 different jobs throughout CHTC construction; even though the call for hire has long been closed, not a week goes by without more community members registering their interest to join the construction team. The hospital construction labor force is constantly changing with phases of the complexity, and sometimes more technical work requires trained qualified individuals. In between phases, ASRI will provide as many jobs to loggers as possible. The low-skilled labor will take loggers out of their current work and provide them with new hard skill learning opportunities.

However, the transition from logging to construction has not been easy. One logger almost resigned on his first day – because he found the construction site to be brutally hot compared to the cool, shady environment of the forest. “I could hardly breathe because there was no wind entering the site at all,” he recalled. “But we have to do the best we can in the course we have chosen.” Other loggers agreed that the learning curve has been steep for them, but they have expressed determination to overcome all the physical and intellectual obstacles posed to them to succeed in this new line of work.

Interestingly, the recruitment process has provided many fascinating insights into the rationale of why loggers choose (or do not choose) to quit logging. These insights are helping the ASRI conservation team to re-tool each individual program to better target behavior change in illegal loggers.

For example, ASRI tracks the number of active illegal loggers in village surrounding the Park through its routine monitoring efforts to determine which villages are awarded the “red” and “green” status. However, after the CHTC call for hire ASRI discovered the numbers were higher than formerly documented. 63 active loggers have registered to join the construction team, many of which originated from villages where ASRI had previously counted only a handful of loggers. This new data has provided ASRI with a more accurate picture of the seasonal dynamics around logging – many of the individuals recruited for the hospital are not “full-time” loggers; they log in-between odd jobs, between crop harvests, and other times when they struggle to meet day-to-day needs.

This helps to make sure that all the villages receive a fair “red”, “yellow”, or “green” discount based on logging activities.

Following the completion of the CHTC, all the local laborers will be provided with certificates that certify the skills and expertise they have obtained during the construction phase. ASRI believes that this certificate will help the former loggers to secure further work with construction jobs – ensuring that they never need to pick up their chainsaws again once the hospital opens its doors.

In a recent interview with some of the ex-loggers in the community, ASRI found that all of them had some understanding on the negative impacts of logging the forests. Many of them acknowledged the trees bring water, and need water to live and to farm.

Conservation Manager Erica gives Guardian awards
Conservation Manager Erica gives Guardian awards

On September 21st, 32 of 34* ASRI’s Forest Guardians gathered for an all-day workshop hosted by the ASRI Reforestation team. Forest Guardians are respected community representatives from each village surrounding Gunung Palung National Park and represent powerful bridges by which ASRI can communicate with and help villagers improve their health and livelihoods, and protect their watershed. Each Forest Guardian is recruited based on their commitment to conservation and their potential to act as leaders within their communities. They are responsible for monitoring all illegal logging activity in their villages, representing ASRI among their village, and helping to disseminate ASRI’s message of healthy forest, healthy lives — or as they say in Bahasa Indonesia, “Hutan terjaga, masyarakat sejahtera” — Protected forest, prosperous community.

Throughout the day, the Forest Guardians discussed their experiences over the past year, and ideas for raising local awareness of ASRI’s health care discount. Hendriadi, the Forest Guardian program coordinator, presented data on logging trends over the last year. Pak Frans, the Reforestation Coordinator, introduced the seedling health savings program to the Forest Guardians, who were given seedling polybags to distribute to their community members to build “savings accounts” at the clinic by donating seedlings for use at the reforestation sites.

Many Guardians reflected on successes and stories of the past year. One Forest Guardian boasted about the reduction of 60 illegal loggers down to 4 during the past four years. Another told a story about confiscating a logger’s chainsaw, because the logger had cut down a fruit tree in the Park that “belonged” to another family, according to local tradition.

To close the event, ASRI staff distributed awards for distinguished Guardians. One award category for “above and beyond call of duty” went to a Forest Guardian who created a personal health savings account of $70 (by donating 88 seedlings) over the course of the year. One day his neighbor fell ill and the Forest Guardian graciously paid for his neighbor’s medical care at the ASRI Clinic with his own health savings account.

In October, we profiled other Forest Guardians on our Facebook page, including:

Pak Wawan who went to every logger in his village to encourage them to apply for jobs at the hospital instead of cutting down trees.

Pak Amir who won the Best Forest Guardian award this year for being dedicated to his job in addition to other full-time work, bravely standing up to hunters, and helping his village earn a 'yellow' logging status and 50% discount in the clinic.

Pak Samsu who has long loved the forest, takes personal responsibility for protecting it, and helped his village go 'green', which means there is no logging happening and villagers receive 70% off their medical bills.

Pak Ridwan who is from one of the villages most entrenched in logging, but doggedly pursues an end to the practice by engaging his community members in regular radical listening meetings.

All of the Forest Guardians are a vital part of the ASRI program. We are incredibly grateful for all of their work protecting the rain forest and caring for the needs of their community members.

 

*Two forest guardians were not able to attend because they had been asked to represent their communities at government meetings — a sign that they have become trusted leaders within their villages.

Forest Guardians workshop
Forest Guardians workshop
Pak Amir
Pak Amir
Pak Ridwan
Pak Ridwan
Pak Samsu
Pak Samsu
Pak Wawan
Pak Wawan

Links:

Dr. Yuli, the staff, and members of the community
Dr. Yuli, the staff, and members of the community

The ASRI Clinic has a lot of programs, and one of them is the Mobile Clinic. We do the Mobile Clinic twice a month and visit the Pangkalan Jihing and Matan villages, which take 7 hours and 9 hours to reach by car, respectively.

Since February 2015, we've also visited the Jago village, an hour away from Matan. The first time we went to Jago, we came across a truck that got stuck in the mud. We stopped, and with the help of everyone around, we helped pull it out, and then continued our trip.

When we first arrived in Jago, people would come and see what we were up to, but did not want to be seen by a doctor. They assumed that they would have to pay a bill of 300,000 rupiah ($22) for a doctor's visit, a cost too high for the residents of the rural village. We then explained our payment system. At ASRI, patients can pay for health care with cash, or non-cash options -- which include manure, handricrafts such as mats, baskets, and bracelets, or offering their labor with the Clinic or conservation programs. After our explanation, everyone was enthusiastic and wanted to be seen by the doctor! One patient was surprised when the bill she paid was one tenth of the price she expected.

In Indonesia there is a quote, "Poor people should not get sick." This quote is actually a satire to criticize the government's policy. People expect accessible health facilities and affordable bills. ASRI, a non-profit organization, tries to reach especially unreachable people. We give the best service to them and every time we do the Mobile Clinic, we meet grateful people. Happy people are our pleasure.

Truck stuck in the mud
Truck stuck in the mud

Links:

 

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Organization Information

Health in Harmony

Location: Portland, OR - USA
Website: http:/​/​www.healthinharmony.org
Project Leader:
Trina Jones
Portland, OR United States

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