Healthcare to Heal the Planet Health In Harmony and the Future of ASRI Health Clinic Sukadana, West Kalimantan, Indonesia
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Why Us, Why Now? Eighteen years ago, an undergraduate biology
major named Kinari Webb set off into the forests of Indonesia’s Gunung Palung National Park to study orangutans. Stunned both by the incomparable beauty and biodiversity of these forests, and the threat that illegal logging posed to the ecosystem and its poverty-stricken human communities, she emerged with a clear vision: Poverty drives the destruction of invaluable rainforest habitat. Human health is tied inextricably to the health of these forests. And time is running out for the conservation of this precious resource. She envisioned a comprehensive program that would both serve human needs and preserve rainforest habitat – and, in 2007, returned to Indonesia as a physician to make that vision into reality. Three years later, the tiny clinic that opened in 2007 is struggling to find space for the thousands of patients that desperately need its services, and the conservation programs that empower local villages to care for the forest are poised for tremendous success. It is time for the vision to grow.
Indonesia
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Partners in Healthcare to Heal the Planet Using healthcare initiatives to help loggers become rainforest guardians Alam Sehat Lestari (ASRI) is the Indonesian non-profit foundation established by Dr. Kinari Webb to meet the urgent medical and conservation needs of the communities around Gunung Palung National Park. Gunung Palung is a vast tract of diverse habitat that harbors one of the world’s last remaining populations of wild orangutans, as well as many other rare and endangered species. The park also serves as a watershed, providing clean water for more than 60,000 people. Despite the importance of the park, and its protected status, illegal logging – driven by the poverty of surrounding communities – threatens the park’s forests. Rainforest destruction, in turn, threatens the health of local communities by increasing disease and flooding in agricultural areas. Alam Sehat Lestari means ‘healthy nature, everlasting.’ ASRI, its acronym, means ‘harmoniously balanced.’ Project ASRI strikes a balance between multiple aims — saving lives, alleviating poverty, saving rainforest, and building the capacity of the Indonesian medical community. Through a creative non-cash payment system at the clinic, ASRI links together initiatives to improve the health of both the local community members and their ecosystem. An incentive program provides additional healthcare benefits to communities that protect the rainforest from illegal logging. New reforestation efforts provide the promise of conservation-related alternative livelihoods. And through the clinic’s daily practice, Indonesian medical practitioners increase their skill, strengthening local capacity.
Nurturing the links between human health & environmental health Health In Harmony was founded to support the vision inherent in the ASRI model. Health In Harmony operates on the principle that human health and environmental health are tightly linked, and that the key to protecting global health is safeguarding and promoting the bonds between the two at the local level. Health In Harmony provides fundraising support to Project ASRI, recruits volunteers and coordinates equipment donations to the project.
We are on our way to building a green hospital and need your help The tiny ASRI clinic has accommodated more than 15,000 patients since it opened its doors in July, 2007, and the number of villagers seeking services increases daily. On the busiest days, the clinic’s beds are full, and waiting room benches serve as temporary beds for those AWACSaiting care. Project ASRI’s incentive program has engaged 20 of the 22 counties around the park in agreements to protect the forest, and education and outreach to surrounding communities continues. ASRI’s reforestation effort has planted 15,000 seedlings across nearly ten acres of formerly logged areas within Gunung Palung National Park, and the project’s organic farm training program is helping to curb slash-and-burn agricultural methods while strengthening communities’ economic capacity.
A new ASRI hospital will provide inpatient capacity and an operating theater that will meet some of the serious needs that the current clinic cannot address, including life-saving C-sections that are simply not available to most local women. A new hospital will also expand Project ASRI’s training capacity, pairing Indonesian and Western doctors to learn side-by-side, exchanging knowledge and gaining the inspiration and skill necessary to replicate this work around the world. There are few, if any, proven sustainable environmental conservation programs that are building effective long-term solutions for both local economic development and environmental protection. Health In Harmony supports ASRI’s innovative, smart approach with its proven track record of success — and the ASRI hospital is a critical part of sharing this model with other parts of the world. Read the stories in the following pages that illustrate ASRI’s successes and its unique approach — and join us in taking the vision of a new ASRI hospital from concept to concrete.
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Health In Harmony: Linking Human Health and Environmental Protection with Local Sustainable Food Production
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Project ASRI integrates sustainable agriculture and affordable healthcare, through pay-through-labor options that allow patients or family members to work in ASRI’s organic garden in exchange for healthcare at the clinic.
The garden not only provides healthy food for
clinic staff and patients, but offers a model of sustainable agriculture to local communities: the garden inspired villages all around Gunung Palung National Park to ask for further training and education in organic farming techniques. Project ASRI founder Dr. Kinari Webb shared this recent story about the power of organic farming in park communities: Pak Mustafarudin came to our organic farm training last week. After about an hour he stood up and almost passed out. We caught him and discovered he had a high fever. We brought him back to the clinic and heard an almost unbelievable story. Twelve years ago, Pak Mustafarudin had fallen 15 meters from the top of a coconut tree. The crash to the ground broke his back, leaving him incontinent and unable to walk for a year. It also tore into his foot where a bad infection set in. Somehow he triumphed on his own, and, as he said, “I forced myself to learn to walk again.” He now walks relatively well — but, if you can believe it, his foot has remained infected for all these years since the infection had penetrated into the bone. Last week the infection had poisoned his blood, making him very sick. Pak Mustafarudin agreed to have a long course of antibiotics and to pay for it by working in the organic garden. Bone infections are hard to treat and we didn’t know how successful we would be, but after one week of daily injections his foot is visibly healing. Imagine 12 years of pain and after just one week of antibiotics he is already better! We will still continue to treat him with antibiotics for a while yet, but already he looks so much healthier.
However, last week we really had a hard time with him because he refused to stay in bed during the day — he wanted so badly to join the organic farm training. And why did he want to join? Because at the last training he learned how to make organic compost, and that one skill has transformed his life. He now has a large organic garden and is selling over $30 in vegetables per month (the average income in these communities is $13 per month). He says that with one dollar of manure he can fertilize his whole garden. The same amount of chemical fertilizer would have cost $26. That prohibitively expensive start-up cost had prevented him from having a garden. Not only that, but he and all the other participants say that the results are also better with the organic compost. One participant said to me, “We all want to stop illegal logging, so please don’t stop this program. We are learning so much and now don’t have to do illegal logging because we can make more money growing vegetables.” That’s just one of the remarkable cases we’ve treated recently — and simultaneously. Among the others have been a small baby with severe pneumonia, a young woman with lupus and a massive breast abscess, and a 12-year old girl with such severe asthma that she had stopped breathing twice — clinic staff The need saved her life by “breathing” for her with a hand-ventilation to grow bag. These patients all pulled and build through with careful treatment, but the temporal coincidence of these serious cases put a major strain on ASRI’s facilities. We have only one inpatient bed in the clinic, reserved for overnight cases; we resorted to using most of our exam beds for these critical patients and transformed our dental chair into an examination bench! My resourceful staff pulled the ambulance around to the side of the building to function as a temporary exam room. The picture is clear: we are in serious need of a bigger building to house more patients and meet their critical health needs.
Left: Participants in one of ASRI’s organic farm training sessions learn new farming techniques for better health and better profits.
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Health In Harmony: The Economic Wisdom of Conservation
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Project ASRI provides access to affordable, high quality health care as an incentive for conservation of the rainforest. A free ambulance ride is linked to prevention of illegal logging and the lives of a mother and her baby are saved.
Another story from Project ASRI’s clinic staff: Just yesterday, our ambulance helped save the life of a lovely 22-year old woman named Siti, as she was rushed the two hours to the city for an emergency C-section. Both she and the baby are safe and well, thanks to Health In Harmony’s donors who made the ambulance purchase possible. That ambulance is an important part of the ASRI conservation program. Since August 2007, Project ASRI has been working with communities around Gunung Palung National Park to identify health-promoting services that could act as powerful incentives for local people to protect this important conservation area. The ASRI team learned the needs of local communities through a series of participatory workshops that involved representatives from every community around the park. The outcome: villagers around Gunung Palung National Park wanted (1) an efficient and affordable ambulance service; (2) a mobile clinic that brings healthcare services to distant and isolated villages; (3) discounts at the ASRI clinic in Sukadana, and (4) training in organic farming. They are willing to prevent logging on the borders of the national park in exchange for these services. Supporters in the United States raised the $15,000 for the ambulance in 2008, and in 2009 the ambulance served all of the villages around the national park. Patients from communities with a “green,” or non-logging, conservation status pay only the cost of the fuel needed for the ambulance pick-up. Communities with a “red” conservation status — indicating that there is logging in their sections of the park — must also pay a service fee. Mobile clinics now serve “green” communities at a discounted rate. Each month, the mobile clinic
team visits all of the villages participating in the incentive program. When villages belonging to the same group (i.e., having the same mobile clinic location) work together to be “green” — that is, if all members of the group protect their borders with the national park — the group will receive discounted mobile clinic service. Members of the conservation and organic farming team join the medical team to provide conservation education and training in organic farming. Villages with a “red” conservation status receive mobile clinic visits, but pay full price for services until they achieve “green” status. The discount system is also now in place at the ASRI clinic for patients from “green” communities. Nobody who comes to the clinic is ever refused healthcare services, but patients from communities helping to protect Gunung Palung are given services and medicines for about half the price (or half the number of work hours, if they choose to pay through the non-cash payment program) that “red” communities pay. Already, 20 of the 22 counties around the park have signed the agreement to work toward being “green” in order to receive the healthcare incentives. These incentives The incentive program will be strengthened is our way of saying immeasurably by the construction of “thank you” to local an ASRI hospital, communities. By where expanded care building the ASRI — and life-saving services — will be hospital, we are saying available for all of “thank you for saving ASRI’s patients. Patients like Siti our global health by and her daughter, saving this rainforest.” who survived only because the ambulance was able to help them reach the care they needed. Patients who, until ASRI opened its doors, had to make the hard choice between food for their children or medicine for a sick relative. Patients who choose to protect the forest in exchange for affordable healthcare. This is the economic wisdom of conservation.
Left: Patients at a mobile clinic visit pay for their healthcare by trading seedlings to be used in ASRI’s reforestation program.
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Health In Harmony: Linking local Human Health and Environmental Health through Public Education Leads to Global Health for All
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Project ASRI uses the distribution of antimalaria mosquito nets as an opportunity for meaningful community education and direct environmental action. In every village, people learn about the link between logging, increased malaria and climate change through story telling and workshops. Families in the village donate 10 seedlings for each bed net, and the seedlings are used to replant illegally logged areas of the forest. Now individuals in the developed world can offset their carbon from the new forests being planted, and the funds from carbon offsetting will pay to plant more trees. This is another strong link made for our global health.
A broad diversity of players teamed up last year to help Project ASRI deliver 4,000 mosquito nets to the communities around Gunung Palung National Park. These players included the British nonprofit Against Malaria Foundation, St. Stephen’s Episcopal Church in Durham, North Carolina, the Phoenix Zoo, the Jakarta Lion’s Club, the Kayung Utara Department of Health, and many individual donors.
Each family receiving a net gave ten tree seedlings to ASRI, used in reforestation efforts started in January 2010. In return for the protection from malaria, the recipients are helping to protect the health of people around the world through rainforest restoration. Why ask villagers to exchange tree seedlings for mosquito nets? The answer lies in the chain of consequences linking the destruction of the natural environment and human health. On the small scale, deforestation can increase malaria — bite rates of malaria-carrying mosquitoes are as much as 278 times higher in logged areas than in primary forest. On the global scale, forest destruction brings climate change that impacts global air quality and threatens human health everywhere. Etty Rahmawati, of ASRI’s conservation team, recently
explained these links in a community meeting where 500 nets were distributed. To the rapt audience at the meeting, Etty told the story of Pak Bujang. Bujang’s family lived adjacent to an area of Gunung Palung National Park that was being logged illegally. The logging led to more breeding ponds for mosquitoes. Pak Bujang’s family did not have mosquito nets to protect them while they slept, and his daughter contracted a case of malaria — a case that was fatal because she did not have access to healthcare. After she told the story, Etty talked through the chain of consequences, pointing out how, by working with the community, ASRI is working to break each link by providing treated mosquito nets, reforesting degraded areas of the park, decreasing illegal logging, and providing access to high quality, affordable healthcare. For more and more of us — in the developed world and in communities like those around Gunung Palung National Park — it is becoming clear that our global health depends on saving the world’s rainforests.
Time is running out Building a teaching hospital for Project for the conservation of ASRI will help ASRI the world’s rainforests. expand its successes in empowering loggers Our global health to become rainforest depends on our action guardians; ASRI will reach more patients now. Please join us in with life-changing care; supporting Healthcare villagers will grow vegetables to meet to Heal the Planet. their economic needs instead of logging the forests of Gunung Palung; more communities will go “green” for healthcare rewards. And western doctors and Indonesian doctors will train side-by side. By seeing and learning first hand how to link local community human and environmental health together, hundreds of young doctors will become inspired and educated to replicate this work around the world. Left: Etty Rahmawati, of ASRI’s conservation team, explains the chain of consequences that links the destruction of the natural environment and human health.
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We ’re Ready to Build I
n the spring of 2009, an interdisciplinary team of graduate students from the College of Architecture at Georgia Institute of Technology and Health Systems Institute were presented with a remarkable opportunity to bring quality healthcare to the impoverished region of West Kalimantan, Indonesia. Over the course of two semesters, the workshop grew from a powerful idea into a design for a full-fledged facility that is both culturally sensitive and locally appropriate.
Deep consideration was given to traditional building methods and materials, community needs, sustainable practice and the latest in evidencebased design. The design articulates principles of evidence-based design, passive cooling systems, breathing walls, and lessons from local architecture. Incorporating views of nature, gardens, and courtyards maximizes natural ventilation, natural light, and promotes patient healing.
(CONCEPT ONLY. PREPAR PART OF AN ACADEMIC (c) 2010,Georgia Tech Re
Concept Only. Prepared by Georgia Tech students as part of an academic exercise. Not for construction. Š 2010 Georgia Tech Research Corporation. All Rights Reserved.
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Fundraising: Five Year Goal
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$5,000,000
Annual Support for first five years
$2,500,000
Hospital Construction
$1,100,000
Campaign Costs
$500,000
Green Energy Supply
$400,000
Sustainability Fund
$250,000
Medical Equipment and Supplies
$200,000
International Medical Training Program
Annual Support (for first five years) ASRI Salaries
$50,000
$160,000 - $350,000 $50,000 - $80,000
Equipment, Materials & Maintenance
$20,000 - $40,000
Meetings, Insurance, Admin, Taxes, and Misc. Expenses
Annual Total
Hospital Construction
$500,000
Salaries
$375,000
Travel
$50,000
Website and Database Upgrade
$30,000
Materials & Other Expenses
$15,000
Green Energy Supply
$400,000
Solar Power
$400,000
Sustainability Fund
$250,000
Endowment
$250,000
Medical Equipment and Supplies
$200,000
$2,500,000
Supplies, Materials & Program Expenses Travel & Local Transportation
Campaign Costs
$10,000 $60,000 - $100,000 $500,000
$1,100,000
Lab & Pharmacy Equipment
$40,000
X-Ray Equipment
$12,000
Emergency & Trauma
$11,000
Operating Equipment
$10,000
Dental Equipment
$10,000
Mother-Baby Equipment
$5,000
Pharmacy
$2,000
Ultrasound
$2,000
Other Equipment & Supplies
$108,000
Outpatient
$300,000
Inpatient
$240,000
Power, Water, & Sewage
$240,000
OR, Trama, Lab, & Radiology
$170,000
International Medical Training Program
$50,000
Administrative & Community Space
$140,000
Coordinator and Instructor Salaries
$40,000
Print & Online Materials
$10,000
Landscaping & Finishing
$10,000
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Fundraising: Naming Opportunities
What people are saying
In all cases in which donors contribute $10,000 or more to one of the priorities of the campaign or make a gift of $100,000 or more to the Sustainability Fund, Health In Harmony would be pleased to provide naming opportunities where appropriate and desired.
We really need a new hospital with complete facilities so that we don’t have to go so far away to Ketapang.
We especially need surgical and radiology facilities. We love that the new building will be built on the organic farm land so that the patients can see the work as ‘asri’ (meaning “harmoniously balanced”).
Reza
Medical Staff Member Teluk Melano Government Health Clinic, Borneo, Indonesia Lobby & Family Reception
$150,000
X-ray
$25,000
Operating Room/Trauma
$150,000
Ultrasound
$25,000
Outpatient Exam Rooms
$150,000
Obstetrics
$25,000
($10,000 ea)
Nursery
$25,000
Laboratory
$100,000
Inpatient Room 1
$25,000
Inpatient Room 2
$25,000
($10,000 ea)
Inpatient Room 3
$25,000
Meeting Space/Community Education
$30,000
Inpatient Room 4
$25,000
Dental Office
$25,000
Inpatient Room 5
$25,000
Pharmacy
$25,000
Inpatient Room 6
$25,000
Kitchen
$25,000
Inpatient Room 7
$25,000
Prayer Room 1
$25,000
Inpatient Room 8
$25,000
Prayer Room 2
$25,000
DOTS Room
$10,000
(10 total spaces)
(15 total spaces)
(9 total spaces)
Offices/Other (7 total spaces)
($15,000 ea)
($11,000 ea)
$70,000
Health In Harmony’s vision for attaching care of the person to care of the earth is forward thinking and
inspiring. We want Yale medical students to learn all that Dr. Kinari Webb and her colleagues have to offer. Currently we have one medical student working with Kinari and another will go in the spring of 2010. It is a great collaboration that we hope to foster and grow once the Medical Hospital is built.
Dr. Nancy Angoff
Associate Dean for Student Affairs Yale University School of Medicine
I have followed the growth and evolution of the Health In Harmony program in Borneo since its inception in
2006. What sets this remarkable initiative apart from many others is its holistic approach: the empowering, participatory way it integrates the primary health needs of a local population with environmental needs at both the local and global levels. As such HIH is an exemplary model for facing the challenges of the 21st Century. To this end, the proposed addition of a comprehensive community hospital, designed to more fully meet the goal of Health for All, will be a big, much needed step forward within this groundbreaking venture.
DavidWerner
Co-director of HealthWrights Author, “Where There Is No Doctor”
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Officers and Advisory Board Officers Alison Norris, MD, PhD Ellertson Postdoctoral Fellow Department of Population, Family and Reproductive Health Johns Hopkins School of Public Health Zanzibar, Tanzania Health In Harmony Board President Ann Lockhart, MD Professor, Contra Costa Regional Medical Center Family Medicine Residency Health In Harmony Board Treasurer Martinez, CA Christina E. Fitch, DO, MPH Primary Care Internal Medicine Dartmouth-Hitchcock Medical Center Lebanon, NH Health In Harmony Board Secretary Julia Riseman, MBA Mentor/Consultant Grinspoon Institute for Jewish Philanthropy Northampton, MA Health In Harmony Board Clerk Nancy Angoff, MD Associate Dean for Student Affairs and Associate Professor of Internal Medicine Yale University School of Medicine New Haven, CT Thomas Duffy, MD Professor and Director of the Program for Humanities in Medicine at Yale Yale University School of Medicine New Haven, CT Antonia Gorog, PhD Ecologist and conservationist with focus on Indonesia; PhD research done at Gunung Palung National Park Conservation Director, Alam Sehat Lestari West Kalimantan and Bogor, Indonesia Anna Hallemeier, MD Double-board certified in Medicine and Pediatrics Yale University School of Medicine Cotuit, MA Kim Johnson Retired Executive Assistant Kensington, MD Peter Mayland, MD Psychiatrist Redwood Valley, CA
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Contact Us
Kristin Rinehart-Totten, JD Attorney Kalamazoo, MI Mark Totten, JD, PhD Ethics Professor, Michigan State University College of Law Kalamazoo, MI Tim Waters, JD Partner in the law firm of McDermott, Will & Emery Washington, DC Kinari Webb, MD Family Medicine Specialist Program Director, Alam Sehat Lestari West Kalimantan, Indonesia Advisory Board Michele Barry, MD, FACP Senior Associate Dean of Global Health and Director of Global Health Programs in Medicine Stanford University Palo Alto, CA Margaret Bourdeaux, MD Double Board-Certified in Pediatrics and Internal Medicine Harvard University Boston, MA Luc Janssens, PhD Artist, vintner and founder of the Lao Rehabilitation Foundation Napa Valley, CA Mimi Plumley Philanthropist The Chapin Foundation, Inc Arlington, VA Preetha Rajaram, PhD Epidemiologist Johns Hopkins University Baltimore, MD Laszlo Tamas, MD Neurosurgeon Pittsfield, MA Chris Todd, MD Physician specializing in care in remote areas Fairbanks, AK Cam Webb, PhD Ecologist specializing in Bornean rain forest trees Harvard University and Center for Tropical Forest Science Affiliated with Lembaga Ilmu Pengetahuan Indonesia (LIPI) Bogor, Indonesia
If you would like to learn more about Health In Harmony (HIH) and the Alam Sehat Lestari (ASRI) program, please contact us or visit our website.
Health In Harmony 4110 SE Hawthorne Blvd #246 Portland, OR 97214 Office phone: 503.422.8517 Brita Johnson - brita@healthinharmony.org Health In Harmony Executive Director Julia Riseman - jriseman@mac.com Development Committee Chair Health In Harmony Board Member www.healthinharmony.org
Health In Harmony: Integrating high quality, affordable healthcare with strategies to protect the threatened rainforest. Global health for all depends on linking human and environmental health at the local level.
Photographs courtesy of Nicole See (www.undertoldstories.org) and Ted Ullrich (www.tomorrow-lab.com) Document design courtesy of Ted Ullrich