Catatan Tommy Dharmawan

Selamat Datang di Dunia Tanpa Sinyal

Mon, 26 Dec 2011 18:40:00 +0700

Oleh: Tommy Dharmawan

Ini adalah cerita tentang pengalamanku mengikuti program tidak tetap atau disingkat PTT di kabupaten Halmahera Selatan (Halsel), Maluku Utara. Sebagai dokter umum yang baru saja lulus, aku berkeinginan membaktikan ilmu yang telah kuperoleh ke pelosok daerah terpencil di Indonesia. Bersama dengan ribuan dokter lainnya yang bertugas sebagai dokter PTT, aku berharap mendapatkan pengalaman yang tak ternilai harganya. Berbagai cerita dari para seniorku yang telah bertugas PTT sebelumnya telah menghiasi pikiranku. Legenda tentang dunia tanpa sinyal, cerita hantu, dan klenik bersemayam di ingatanku.

Pada akhir Januari 2009 aku pun berangkat meninggalkan gemerlapnya ibukota Jakarta menuju sebuah kabupaten di Maluku Utara. Halmahera Selatan namanya. Ya, Halmahera adalah pulau berbentuk huruf K yang terkenal sebagai penghasil cengkeh dan aneka rempah-rempah lainnya sejak zaman kolonial dahulu. Masa tugasku dimulai dengan orientasi di ibukota kabupaten. Labuha namanya. Masih ada sinyal, begitu ucapanku pertama kali pada keluargaku di ujung telepon. Selang seminggu, akhirnya saat-saat yang mendebarkan pun tiba juga. Aku harus berangkat ke Saketa di kecamatan Gane Barat yang terletak di seberang pulau Bacan. Satu jam di atas perahu motor di tengah lautan lepas, akhirnya sinyal di telepon selularku pun hilang sama sekali. Itulah awal perjalananku di dunia tanpa sinyal.

Selamat datang di dunia tanpa sinyal atau bahasa inggrisnya welcome to the world without cell phone reception. Itulah kata-kata sambutan pertama dari seorang sejawat dokter gigi di puskesmas tempatku bertugas, drg. Faisal namanya. Ia telah mengabdi 6 bulan lebih dahulu dari aku. Bersama dengannya aku pun berjuang menjadi satu-satunya dokter umum yang bertanggung jawab atas kesehatan lebih dari 9 ribu penduduk yang tersebar di 17 desa.

Suatu hari di akhir bulan ketika ombak mulai bertiup kencang, aku bersama motoris, sebutan untuk nahkoda motor boat kecil 20 PK milik puskesmas, bergegas menaiki kapal motor dari dermaga puskesmas untuk menuju ke kota pelabuhan di mana Rumah Sakit Umum Daerah (RSUD) kabupaten Halmahera Selatan berada. Di tengah perjalanan dalam gelapnya malam, ombak setinggi 6 meter menghadangku. Rasanya ingin cepat sampai, jika ada ombak menghadang, aku perintahkan motoris tetap melajukan kapal motor karena aku tak ingin kehilangan nyawa pasien yang kuantar dalam kapal motor ini. Ya benar, aku sedang merujuk pasienku yang membutuhkan pertolongan pisau bedah di RSUD kabupaten, 10 mil jarak tempuh lautnya dari pulauku. Asaku tinggi karena perjalanan panjang yang mendebarkan tersebut hanya memerlukan waktu satu setengah jam. Lebih cepat setengah jam dari waktu biasa. Walau kapal motor sering miring ekstrem dan nyaris terguling oleh ombak, namun karena kehebatan motorisku maka kami bisa sampai lebih cepat di dermaga Babang.

Dari dermaga, kami menempuh lagi dua puluh menit perjalanan darat dengan mobil puskesmas menuju RSUD Labuha di tengah hutan pulau Bacan. Namun sesampainya di sana, asaku langsung runtuh berkeping ketika mengetahui ternyata dokter bedah RSUD sedang cuti ke Pulau Jawa mengunjungi keluarganya. Aku langsung duduk bersimpuh lemas sambil memandang lemah ke arah pasien yang kuantar dan keluarganya. Kuberanikan diri menghampiri mereka dan memberitahukan bahwa dokter bedah sedang ke pulau Jawa dan satu-satunya cara menyelamatkan pasien adalah dengan membawa pasien ke Kota Ternate. Keluarga pasien tersebut setelah berunding akhirnya menolak, dengan alasan klasik, kekurangan biaya. Satu jam di RS tersebut, dengan pertolongan maksimal dengan fasilitas yang terbatas, kondisi pasien terus memburuk, dan akhirnya ia pun meninggal dunia. Dengan wajah tertunduk, aku kembali dini hari itu juga ke Saketa menaiki kapal motor yang sama, dengan pasien yang sama, tetapi sudah terbungkus kain jenazah.

Adapun kisah mendebarkan selanjutnya adalah saat aku mengantarkan ibu hamil dalam proses persalinan yang memerlukan operasi sesar segera. Ibu itu belum memasuki waktu persalinan yang diperkirakan, tetapi sudah terjadi kontraksi rahim dan air ketubannya sudah pecah. Tentunya, lagi-lagi aku harus secepat mungkin merujuknya ke RSUD kabupaten. Di tengah hujan deras ombak kami menempuh perjalanan berbahaya itu lagi dengan perahu motor kecil milik puskesmas. Setibanya di RSUD Labuha, kejadian serupa terulang. Dokter spesialis kebidanan sedang tidak berada di RSUD, melainkan sedang rapat dengan Kepala Dinas Kesehatan di kantornya. Untungnya, di Kota Labuha saat itu sudah ada sinyal, sehingga dengan mudah saya dapat berkomunikasi dengan dokter kebidanan dan memintanya untuk segera kembali ke rumah sakit untuk melakukan operasi sesar. Nyawa sang ibu beserta sang bayi pun berhasil diselamatkan.

Cerita lain yang tak bisa kulupakan adalah saat aku harus memberitahukan bahwa telah berjangkit wabah kolera di wilayah puskesmasku ke ibu kota kabupaten. Memang jelas ada peraturan dari kepala dinas bahwa jika terjadi wabah maka hal ini harus segera diberitahukan ke kabupaten. Wabah kolera di wilayah puskemasku baru kuketahui dua hari setelah kejadiannya. Hatiku miris memikirkan hal ini, padahal lokasi tempat tinggal pasien tersebut hanyalah berjarak hanya 5 mil ke puskesmas tempatku berada. Namun, sulitnya akses menuju puskesmas dan tidak adanya jalur komunikasi membuat berita tentang wabah kolera tersebut baru bisa disampaikan kepala desanya kepadaku pada hari berikutnya. Malam hari setelah kedatangan kepala desa ke daerahku, aku bersama motoris pun langsung berangkat ke tengah laut untuk mencari sinyal. Ketika akhirnya sinyal muncul di layar telepon genggamku, aku pun menghubungi kepala dinas kesehatan yang terkait. Mendengar suaranya di ujung telepon genggam hatiku terasa ingin tumpah dengan kebahagiaan, akhirnya aku berhasil menyampaikan berita penting mengenai wabah kolera ini. Sebagai tindak lanjutnya, pada hari berikutnya bantuan pun datang ke puskemasku dan bersama-sama kami menangani kejadian wabah agar tidak lebih lanjut membahayakan masyarakat.

Pengalamanku sebagai dokter PTT tidak lepas dari kesulitan utama yang kuhadapi, yaitu perubahan drastis dari dunia dengan ketersediaan sinyal telepon genggam yang berlimpah ke dunia tanpa sinyal sama sekali, tanpa jalur komunikasi yang berarti. Dunia terasa hampa, jauh dari keluarga dan tak mungkin menghubungi mereka walau rindu tak tertahankan. Sebelumnya tak terbayangkan bahwa susahnya mencari sinyal akan menjadi cobaan terberat bagiku selama masa PTT.

Memang tak bisa dipungkiri lagi, komunikasi memudahkan segala hal dalam kehidupan kita sehari-hari, dari hal-hal kecil hingga urusan kesehatan yang menyangkut nyawa manusia. Pentingya komunikasi yang dapat diakses dengan mudah dan terjangkau murah di daerah terpencil tak hanya terkait dengan masalah ekonomi semata, tak hanya melibatkan masalah keuntungan bagi pemerintah ataupun perusahaan swasta. Sektor kesehatan juga sangat bergantung pada keterjangkauan sistem komunikasi. Pemerataan kualitas kesejahteraan masyarakat di segi kesehatan, seperti pemerataan jumlah dokter dan tenaga kesehatan lainnya di daerah-daerah, harus diimbangi dengan pemerataan teknologi komunikasi. Walaupun tersedia banyak dokter di daerah terpencil, bagaimana daerah itu bisa maju dan sehat, jika akses komunikasi untuk menangani hal-hal penting dan kasus gawat darurat tidak tersedia? Oleh karena itu, pemerintah dan sektor swasta, seperti perusahaan-perusahaan telepon seluler yang semakin giat melebarkan jaringannya, tak bisa lagi berjalan santai menjalankan pembangunan jaringannya yang lebih luas dan merata. Sesegera mungkin investasi dalam skala besar di sektor telekomunikasi selular harus dilakukan. Sesegera mungkin harus tersedia layanan jasa telekomunikasi untuk wilayah-wilayah pelosok di Indonesia, sebagai upaya untuk meningkatkan kualitas hidup masyarakat Indonesia secara menyeluruh.

Penulis bernama Tommy Dharmawan, seorang dokter, saat ini tinggal di Jakarta.

Blog URL: tommydharmawan.tumblr.com

Email: tommydharmawan@gmail.com

Immune system: Between friend and enemy

Tue, 13 Dec 2011 11:21:00 +0700

The Nobel Prize in medicine was announced on Oct. 3, 2011. Following the tradition of the prestigious award, medicine was the first prize announced by the Nobel committee. Ralph Steinmann, Jules Hoffmann and Bruce Beutler have been awarded the Nobel Prize for medicine this year for their roles in defining the pathway of the immune system.

The three scientists’ work regarding the immune system is crucial to developing the study of immunology and may become the basic foundation of vaccine technology to fight infections and cancer. Beutler and Hoffmann found a protein receptor that is the first line for human immunity in recognizing bacteria and other microorganisms. Meanwhile, Steinman’s work showed how important dendritic cells are to adaptive immunity.

Although the award came after Steinman died three days before the Nobel Prize announcement, his invention has brought a clearer pathway for identifying the immune system. Steinmann, one of the founders of the immunotherapy method of fighting cancer, died due to pancreatic cancer. Steinman was diagnosed with pancreatic cancer four years ago, and his life was prolonged by immunotherapy based on his own design using dendritic cells.

Immunology has been a favorite subject for Nobel Prize laureates since 1901, when Von Behring won the Nobel Prize for his achievements in discovering serum therapy, especially for its application against diphtheria. Immunology breakthroughs have garnered 20 Nobel Prizes.

From the time Edward Jenner found the smallpox vaccination in 1798, to when Steinmann found how dendritic cells work on adaptive immunity, there have been huge leaps in understanding the immune system. Each invention, from the 18th century until now, has filled in the puzzle of the immune system, though some pieces are still missing. There are questions as to why the immune system can be so helpful and sometimes can be so destructive to the human body.

The immune system is one of the body’s systems that is very hard to understand. On one side, it can be your friend and on the other side, it can ruin your health. We need our immune systems when there are viral or bacterial infections. When there is an infection, antigen cells will attach to the bacteria and start to invite the lymphocytes or the macrophages to destroy the invading organism.

Yet, right now many diseases are related to the immune system. This condition is called autoimmune disease. Many of these diseases are hard to cure and need lifelong treatment. This long term therapy is not without risks of complications. The therapy can also cause some severe manifestations.

Autoimmune diseases such as systemic lupus erythematosus (SLE) can become a nightmare those who suffer from it. SLE affects almost all the body’s organs including the heart (endocarditis), joints (joint pains), skin (butterfly rash), lungs (pleural effusions), blood vessels, liver, kidneys (lupus nephritis) and nervous system (neuropsychiatric syndrome).

The course of SLE is unpredictable with periods of illness called flares alternating with remissions. Another autoimmune disease is Guillan Barre syndrome. GBS is due to an autoimmune response to foreign antigens that targets the host nerve tissue. The end result is nerve damage leading to muscle paralysis.

Autoimmune diseases decrease patients’ quality of life, and therapy for it is very expensive. Two months ago, there was a story about two children being treated for GBS, Azka and Shafa. Their parents cannot afford treatment for GBS. Autoimmune diseases are complex and thus the treatment is expensive. Sadly, insurance companies cannot cover such autoimmune diseases.

Autoimmunity is the failure of an organism to recognize its own constituent parts, which allows an immune response against its own cells and tissues. Prominent examples include SLE, rheumatoid arthritis, idiopathic thrombocytopenic purpura and allergies. The concept that a body cannot recognize its own cells as part of itself has been known since the beginning of 20th century, when Paul Erlich proposed a hypothesis called horror autotoxicus.

One of the autoimmune hypotheses related to Steinmann’s work is dendritic cell apoptosis. Dendritic cells, as one of the immune system cells, present antigens to other active lymphocytes. Dendritic cells with faulty apoptosis can lead to inappropriate systemic lymphocyte activation and a consequent decline in self tolerance.

Many factors are recognized as being predispositions for autoimmune disease such as environmental factors, genes, sex and infection. There are some diseases more likely in females such as Graves’s disease, SLE and rheumatoid arthritis. Another factor is the environment.

There is a relationship between autoimmune diseases and pollution. According to Ritz the Journal of Medical Hypothesis, in 2009, said that pollution was one of the key factors for the rising occurrence of autoimmune disease. Another factor inducing autoimmune disease is cigarette smoking, which has been a major risk factor for rheumatoid arthritis as well.

There is also a relationship between viral or bacterial infections and autoimmune diseases. In GBS patients, there is a relationship between infection of Campylobacter jejuni and the influenza virus to elicitation of GBS. The supposed mechanism is that the parasite or bacterial infection stimulates the host’s immune response to protect itself.

Immunity is not only about self destruction. By knowing the application of immunology, scientists can discover vaccines that are very important to human life. In 2005, Ian Frazer, a well known scientist from Australia, discovered a vaccine to fight human papillomavirus (HPV) that has been related to cervical cancer.

Immunology is an interesting science, but we still don’t know much about it. If we know more we can understand how to overcome autoimmune diseases.

Is fasting during Ramadhan really a healthy ritual?

Tue, 13 Dec 2011 11:18:00 +0700

Every year, Muslims celebrate a whole month of fasting called Ramadhan. In Islam, a Muslim refrains from food, drink, sex and tobacco from pre-dawn (imsak) until dusk (maghrib). This period involves a shift in the pattern of intake from daytime to the hours of darkness.

Every adult man and woman should assume this ritual as a religious obligation, except for the sick, women who are menstruating, pregnant women, breastfeeding mothers and the elderly. Many Muslims also know that fasting is a healthy ritual, but how do they know?

If fasting is conducted like a calorie-restricted diet program, Muslims can acquire several advantages for their own health. Ruqian Wan, from the Laboratory of Neurosciences at the Gerontology Research Center, National Institute on Aging, Baltimore, stated that intermittent fasting improves glucose metabolism, as indicated by lower basal levels of circulating glucose and insulin, but maintains glucose and insulin responses to stress. Wan also concluded that improvements in cardiovascular risk factors and cardiovascular and neuroendocrine stress adaptation occur in response to intermittent fasting.

In term of hypertension, Alan Goldhamer said that almost 90 percent of subjects achieved blood pressure less than 140/90 mmHg (millimeters of mercury) by the end of the treatment program.

During this research, the average reduction in blood pressure was 37/13 mmHg, with the greatest decrease observed in subjects with the most severe hypertension.

Patients with stage 3 of hypertension (those with systolic blood pressure greater than 180 mmHg, diastolic blood pressure greater than 110 mmHg, or both) had an average reduction of 60/17 mmHg at the conclusion of treatment.

Fasting may boost the immune system in several ways, such as elevating macrophage activity; increasing cell-mediated immunity in the form of lymphocytes; increasing immunoglobulin levels; increasing neutrophil bactericidal activity; increasing the breakdown of monocytes and bacterial functions; and enhancing natural killer cell activity.For people who perform fasting for religious reasons, their stress and depression levels may well be reduced.

At the same time, their immune systems will be increased. And all this can be explained by the psycho-humoral-neuro-immunology paradigm.

A study published in the Journal of the American Medical Association, in March 2007, maintained that fasting also regulates insulin and glucose levels by lowering the concentration of insulin, and substances which are related to insulin, such as insulin-like growth factor 1 (IGF-1).

Plasma insulin concentration while fasting decreases by 65 percent and plasma glucose concentration also significantly declined among the calorie-restricted group.

Plasma insulin levels and plasma glucose levels — while fasting — are used as tests to predict diabetes. Researchers also found that excessive calorie restrictions cause malnutrition and can lead to anemia, muscle wasting, weakness, dizziness, lethargy, fatigue, nausea, diarrhea, constipation, gallstones, irritability and depression.

Two very prominent theories of aging are the free radical theory and the glycation theory, both of which can explain how calorie restrictions can work. With high amounts of energy available, mitochondria do not operate very efficiently and generate more superoxide.

With a calorie restriction program on fasting, energy is conserved and there is less free radical generation.

A calorie restricted organism will have less fat and require less energy to support weight, which also means there does not need to be as much glucose in the bloodstream.

Less blood glucose means less glycation of adjacent proteins and less fat to oxidize in the bloodstream that can cause sticky blockages resulting in atherosclerosis.

Type 2 diabetics are people with insulin insensitivities caused by long-term exposure to high blood glucose. Obesity leads to type 2 diabetes. Type 2 diabetes and uncontrolled type 1 diabetes behave in much the same way as “accelerated aging”, due to the above effects. There may even be a continuum between calorie restrictions and the metabolic syndrome.

A small-scale study in the US, at the Washington University’s School of Medicine in St. Louis, studied the effects following a calorie-restricted diet of 10-25 percent less calorie intake than the average western diet. Body mass index (BMI) was significantly lower in the calorie-restricted group when compared with the control group.

It was found that the calorie-restricted group had remarkably low triglyceride levels. In fact, they were as low as the lowest 5 percent of Americans in their 20s. This is more remarkable when it is noted that the calorie-restricted individuals were actually aged between 35 and 82 years of age.

It was also found that the average total cholesterol and LDL (bad) cholesterol levels for calorie-restricted individuals were the equivalent of those found in the lowest 10 percent of normal people in their age group, while the average HDL (good) cholesterol levels for calorie-restricted individuals were very high — in the 85th to 90th percentile range for normal middle-aged US men.

A 2009 research paper showed that a calorie restricted diet can improve memory function in normal to overweight elderly people. The diet also resulted in decreased insulin levels and reduced signs of inflammation. Scientists believe memory improvement during that experiment was caused by the lower insulin levels, because high insulin levels are usually associated with reduced memory and cognitive functions.

However, that relation seems to be age specific since in another study, when analyzing people older than 65, those who were underweight had a higher dementia risk than normal or overweight people, while the latter group had a lower risk regarding the other two conditions.

Fasting can be dangerous, however, when the body is not able to perform gluconeogenesis (the production of glucose). If the body is not in ketosis (burning fat for energy), then the brain and vital organs (which can burn either glucose or ketones), need 800 calories a day to obtain ample glucose.

If fewer than 800 calories a day are consumed, the brain and vital organs are deprived of the necessary glucose, which can cause damage and, in some cases, death. Ideally these diets should be supervised by healthcare practitioners who are experienced with therapeutic fasts.

So, do fasting with careful calorie restrictions, and stay healthy.

Welcoming a medical education law

Tue, 13 Dec 2011 11:16:00 +0700

Ihsan was a promising student from South Halmahera, North Maluku, who once dreamt of becoming a doctor.

It was a noble wish given that almost 80 percent of general practitioners in South Halmahera were contract doctors and the local government relied on this program every year.

However, Ihsan failed to pass the admission test for a state medical school. To study medicine at a private university is very expensive; his family could not afford to pay his tuition.

The financial constraints facing Ihsan are one reason why Indonesia produces few doctors. The Constitution ensures that every citizen has the right to good healthcare but the perennial problem facing us is a lack of access to doctors due to their unequal distribution in Indonesia.

This would not happen if there was easy access to medical education in every region in the country.

Every province that falls short in general practitioners should be allowed to open its own medical school to fill the gap. Of course there will be a lot of questions regarding budgets, lecturers, curricula and availability of teaching hospitals.

Therefore, the House of Representatives made a good decision when it proposed a medical education bill to balance the distribution of doctors and provide equal access to healthcare for all.

The low quality of the country’s healthcare sector reflects the poor quality of its medical education and deficit of doctors.

Indonesia’s population is currently 238 million. Indonesia needs 95,000 general practitioners; it is 23,000 general practitioners short of that goal. With only 5,000 new doctors graduating a year, Indonesia will only be able to meet its current demand in five years.

There is also an uneven distribution of doctors between Java and the rest of Indonesia. Over 80 percent of the nation’s general practitioners reside in Java.

Over 70 percent of Indonesia’s medical schools are located on the country’s most populous island. Sadly, there is no longer a regulation that requires recently graduated doctors to serve in remote areas.

To address the shortage, some regional governments have provided scholarships to medical students who sign a contract to serve in the region after graduation.

Another solution is to build a school of medicine in every province. Under the medical education bill, the central government would allocate money to build a medical school in each region that is underserved by doctors.

At the same time the National Education Ministry could provide scholarships to recently graduated GPs to pursue specialist studies to entice them to teach at local medical schools. Or else local governments could offer good salaries to graduating doctors.

The government can play its part by forcing state universities who have an A accreditation to support the opening of new medical schools, which might in turn ask local government hospitals to serve as teaching hospitals. Those hospitals would be accredited as part of a network of teaching hospitals.

For a long time there has been no clarity about whether teaching hospitals fall under the supervision of the National Education Ministry or the Health Ministry.

The fact is most teaching hospitals do not function properly as they are not managed by medical schools. The government must put an end to this uncertainty and allocate more money for teaching hospitals to improve their quality.

We know that most teaching hospitals in Indonesia serve the poor only, reducing their status to second-class, and hence poor quality, hospitals. In contrast, most of the best hospitals in the United States are teaching hospitals.

In terms of quality, however, medical school graduates are facing a serious problem of a lack of recognition overseas. Indonesian doctors find it difficult to pursue specialist programs outside the country.

The problem rests with the curriculum here, which is old fashioned. Indonesian medical schools have to cooperate with the world’s top universities to improve their curriculum and secure international acknowledgement.

Another obstacle to promoting medical education is money. According to Rohmani a legislator on the House of Representative’s Commission X overseeing education, the cost of a medical education ranges from Rp 300 million (US$35,000) to Rp 400 million, which certainly is elusive for students from lower income families.

A solution lies perhaps in differentiating the medical education fees. The “have” students can pay in full, while those from lower income families can have their tuition paid for by the central or local governments under contract or scholarship schemes.

Now what is the government’s responsibility in medical education? We know that medical education is classified as a public good that falls under the government’s auspices. The government cannot just give half of the burden to private sector because medical education is not a subject of privatization.

The high cost of a medical education will result in expensive healthcare services, therefore limiting access. The medical education bill should address this long-standing issue.

Innovation to fight TB

Tue, 13 Dec 2011 11:14:00 +0700

World Tuberculosis (TB) Day was celebrated on March 24, 2011. The theme of world TB day this year was “On the move against tuberculosis” and the goal was to inspire innovation in TB research such as developing rapid TB tests, faster treatment regimens and effective vaccines.

The theme also inspires us to generate public health programs about how to improve TB case findings, modernize diagnostic laboratories and adopt the revolutionary TB tests that have recently become available. The impact will be the reduced prevalence, morbidity and mortality of TB patients.

The elimination of TB can only be achieved if current TB management can be changed by using novel technologies that can help with prevention and provide optimal diagnoses and treatment for all forms of TB in people of all ages, including those living with HIV.

In Indonesia and other developing countries, such tools must deliver quicker results and be affordable for the poor.

Sometimes a newly developed diagnostic kit is very expensive, so developing, evaluating and implementing effective technologies requires not only large-scale investment but also coordination from
all TB research stakeholders such as scientists, donor organizations, governments, pharmaceutical companies, doctors, health workers, tuberculosis patients and their families.

Recently, the World Health Organization (WHO) endorsed a novel rapid test for TB. The test can give an accurate diagnosis in about 100 minutes compared to current tests that can take up to three months for results. “This new test represents a major milestone for global TB diagnosis and care.

It also represents new hope for the millions of people who are at the highest risk of TB and drug-resistant disease,” said Mario Raviglione, Director of the WHO’s Stop TB Department.

The WHO’s endorsement of the rapid test, which is a fully automated nucleic acid amplification test (NAAT), follows 18 months of rigorous assessment of its field effectiveness in the early diagnosis of TB, as well as multidrug-resistant TB (MDR-TB) and TB complicated by HIV infection, which are more difficult to diagnose.

The WHO says that implementation of this rapid test could increase more than three-fold the diagnosis of patients with drug-resistant TB and give a doubling in the number of HIV-associated TB cases. Many countries such as Indonesia still principally rely on sputum smear microscopy, a diagnostic method that was developed over a century ago.

Although this method is still reliable, there are some disadvantages, such as the need for trained laboratory technicians and that the test is time consuming and requires some stain to smear, as well as the inconvenience for TB patients who have to expel sputum.

Meanwhile, the new rapid test incorporates modern DNA technology that can be used outside of conventional laboratories. Other benefits are that it is fully automated, easy and safe to use.

The WHO has now included the NAAT to be rolled out as part of plans for TB and MDR-TB care and control. Indonesia needs to develop policy and operational guidance regarding this new diagnostic technique.

Indonesia has the third largest TB prevalence in the world. The problems with the TB elimination program in Indonesia are not just about issuing TB rapid diagnostic tests but also the surround the implementation of Tuberculosis Directly Observed Short-course (DOTS) programs in remote regions.

With most of our country consisting of islands and mountainous villages, the implementation of TB programs must be accompanied by good regulations in local government health policies. So, cooperation between the central and local governments is a must to organize a good TB elimination program in Indonesia. Besides that, more funding and political commitment are important.

Since foreign aid is more than 70 percent of Indonesia’s TB elimination budget, central and local governments must increase their budgets for TB programs so Indonesia does not depend on foreign aid as much.

We don’t want our TB prevalence and our case detection rates to increase just because there are no foreign funds.

In summary, although there have been major improvements in TB care and control, tuberculosis killed an estimated 1.7 million people in 2009 and 9.4 million people developed active TB in 2008 worldwide. In Indonesia, there are still a lot of problems that hamper people, not only in remote places but also in urban areas.

The government should take several additional approaches to increase the accessibility of TB care. We want to see innovation and direct action from health workers to help people with TB, and we want the community to think outside the box and get involved in TB eradication.

Stigmatization hinders fight against HIV

Tue, 13 Dec 2011 11:12:00 +0700

A national report estimated that there were 227,700 people living with HIV/AIDS in Indonesia in 2007.

According to the Health Ministry, the number increased by at least 21,770 in 2010, despite the United Nations-sanctioned Millennium Development Goals (MDG) that calls for efforts to substantially curb the spread of the virus by 2015.

Studies have highlighted actions to significantly reduce the spread of HIV, such as sufficient political and financial support from the government; better coordination and cooperation between government agencies, strength alliances with community-based organizations and participation of people living with HIV and AIDS in designing, implementing and evaluating the programs.

Yet in addition to the problem of how to halt the virus, there is also the problem of addressing the stigma toward people with HIV/AIDS.

Secrecy and denial pose a great problem for HIV/AIDS control in Indonesia. People are worried they will be banned from social activities because they are living with HIV/AIDS. Husbands are afraid to let their wives know about their HIV status because they are afraid they will be abandoned. Wives are worried they cannot get pregnant if they are HIV positive.

These are some examples of stigma facing people with the virus in Indonesia. Stigma and hopelessness always seem to accompany people with HIV/AIDS.

HIV/AIDS stigma is considered a major barrier to effective responses to the HIV epidemic. Link and Phelan’s theory states that stigma is the convergence of labeling, stereotyping, separation, and discrimination by the perpetrators of stigmas who have access to social, political and economic power.

Stigma absolutely limits the coverage of critical services, such as voluntary counseling, testing and antiretroviral therapy.

In a study of 112 patients receiving antiretroviral therapy in Botswana, 69 percent of patients did not reveal their HIV status to their family, and a majority of those who reported delaying testing for HIV did so due for fear of the HIV/AIDS stigma. Without questioning that an HIV/AIDS stigma exists and needs redress, some argue that the profound lack of access to antiretroviral therapy in resource-limited countries, rather than stigma, is the real driver of poor uptake of testing and treatment services.

Individuals with advanced HIV/AIDS, who exhibit visible signs of disease and are no longer able to work, experience severe stigma.

According to Mahajan, the majority of HIV/AIDS specific interventions are designed to reduce stigma at the community level by increasing the tolerance of people living with HIV/AIDS (PLHA) among the general population. Strategies underlying these interventions are education of factual information about HIV/AIDS, increasing the willingness of healthcare providers to treat PLHAs and developing coping skills among PLHA.

One of the strategies is via mass-media campaigns. These campaigns can disseminate facts about HIV/AIDS and could potentially reduce the HIV/AIDS stigma.

One of the key means of reducing the stigma is providing factual information to health workers about HIV/AIDS. Butt stated in June 2010 that some healthcare workers in Papua who have received training for voluntary counseling and testing agree with statements that PLHA are dirty, should be shunned and should receive punishment.

Most health workers agreed with more subtly stigmatizing statements, such as PLHA having to accept limits on their behavior, or assume that PLHA feel ashamed of their status.

Violations of confidentiality affect the willingness of Papuans to go for HIV testing. Many respondents said they were afraid healthcare workers (both indigenous and migrant) would not respect their privacy. Secrecy is the PLHA’s primary concern, but confidentiality is routinely violated at health service centers in Papua.

We also know that there are many doctors in Indonesia who still recommend misleading suggestions to PLHA, including sterilization programs for women who are infected with HIV. The government or NGOs can provide training for doctors or nurses on how to handle HIV and AIDS cases properly.

Religious leaders also need to take part in reducing the stigma. We are glad to hear the Vatican statement that using a condom is a lesser evil than transmitting HIV to a sexual partner.

The government should support good access for PLHA to antiretroviral therapy. Both the government and NGOs can build clinics that can provide holistic therapy. PLHA can arrange appointments with health workers trained on methods for coping with HIV/AIDS status. They can also seek voluntary testing to understand their HIV status.

Proper antiretroviral therapy will enable PLHA to return to productive lives and motivate others to take tests and seek treatment.

Theoretically, a widespread increase of testing and treatment access may turn HIV into a treatable, rather than a deadly disease, and thereby ultimately reduce the HIV/AIDS stigma.

The government must also promote policies that could reduce the stigma and discrimination of people who live with HIV/AIDS. Current laws and policies in many countries directly contribute to stigma and discrimination associated with at-risk groups. Governments should stop policies that criminalize PLHA or require proof of residency status to access antiretroviral therapy.

Finally, approaches to reducing stigma must be viewed as a long path that requires cooperation between the government and society. The society should give empathy to people living with HIV/AIDS and help them cope with the stigma and discrimination.

Society should also build community-based interventions that are designed to mobilize PLHA, help leaders to address maladaptive self-stigmatizing behaviors and advocate against discrimination in the wider community.

Road safety, a concern for all

Tue, 13 Dec 2011 11:10:00 +0700

A 2004 WHO report estimated that 1.27 million people die and between 20 million and 50 million were injured annually in road accidents.

In Asia and the Pacific, road accidents are a major public health problem, with some 10 million people severely injured or killed annually on the region’s roads, the World Health Organization (WHO) has warned.

The Asia-Pacific region accounts for about 60 percent of global road deaths, despite having only 16 percent of the world’s vehicles.

Road deaths jumped by nearly 40 percent in Asia between 1987 and 1995 — while in developed nations, the number fell by about 10 percent because of better safety measures.

WHO estimates that if current trends continue, road accidents will be the third global cause of disease or injury by 2020 after heart disease and depression.

In high-income countries, most of those killed or injured in road accidents are drivers of four-wheeled vehicles. But in low- and medium-income countries, “vulnerable road users” — pedestrians, cyclists and motorcyclists, and users of public transportation — make up a larger proportion of those injured or killed.

In low- and medium-income countries, a motorcycle is a family vehicle, with children routinely transported as passengers and helmets rarely used.

Road accidents are a huge economic drain. It is estimated that every year, road traffic accidents cost US$518 billion globally.

The cost of road crashes on country economies is often as high as 2 to 3 percent of GNP — more than the total annual amount received in development aid.

Many victims are the bread winners and, when injured or killed, their families are left without economic support. In addition, those who survive often need immediate hospital care and many require long-term support.

These injuries impose substantial economic burdens on developing nations. As a result, there is a direct link between road safety improvement and poverty reduction.

Problems associated with injuries and violence include insufficient awareness and understanding of the magnitude of the problem; a lack of national policies and plans on injury prevention; and a limited national capacity to collect and analyze injury data and design interventions.

Governments need to develop and implement national policies, programs and legislation on injury prevention; to promote public awareness and political commitment; and to strengthen national capacities in surveillance, intervention and monitoring.

Simple measures can be taken to make people safer on the roads. The measures, WHO said, include setting and enforcing appropriate speed limits; setting and enforcing blood alcohol limits; introducing and enforcing mandatory seat belt, helmet and child restraint laws; providing safer routes for pedestrians and cyclists, constructing speed bumps, separating different types of traffic; and improving the emergency services from the crash scene to the health facility and beyond.

Drinking and driving is one of the main causes of road crashes worldwide. In high-income countries about 20 percent of fatally injured drivers have excess alcohol in their blood, while in some low- and middle-income countries these figures may be up to 69 percent.

Effective drinking and driving programs have the potential to save thousands of lives.

Wearing a motorcycle helmet can cut the risk of death by almost 40 percent, and the risk of severe injury by 72 percent.

Light-colored helmets were found to be associated with a lower risk of a crash. A study concluded that 18 percent of crashes could be avoided if non-white helmets were eliminated.

Child restraints (infant and child seats and booster seats) reduce the death rate in car accidents by 71 percent among infants and by 54 percent among young children. Seat belts have saved more lives in accidents than any other road safety measures.

“Road deaths have increased with a nation’s economic growth, but governments can incorporate safety strategies now to avoid this pattern.”

Wearing a seatbelt belt reduces the risk of bring ejected from a vehicle and suffering serious or fatal injury by 40 to 65 percent.

Teenage drivers have more than five times the risk of a fatal crash compared with drivers aged 30 years and above, at every level of blood alcohol content.

In many countries, a high proportion of injured pedestrians who have consumed alcohol fall in the 16-19 year age group.

Speed is the main factor contributing to road traffic injuries in most countries. Reducing average speed by 1 km/hour has been shown to lead to a 4 to 5 percent decrease in fatal accidents.

Research shows that a 5 percent increase in average speed leads to approximately a 10 percent increase in all injury crashes and a 20 percent increase in fatal crashes.

Creating and enforcing laws that require seat belts and helmets and punish drunken driving is a proven, cost-effective injury prevention strategy, said Dr. Kelly Henning, director of global health programs at Bloomberg Philanthropies. For every person dying as a result of injury, there are hundreds more that sustain non-fatal injuries and other health consequences.

Although the ultimate goal must be to prevent injuries from happening in the first place, much can be done to minimize the disability and ill-health arising from the injuries that do occur despite the best prevention efforts.

Providing quality support and care services to victims is therefore an essential component of any response to intentional and unintentional injuries. Appropriate services for victims of non-fatal injuries can prevent future fatalities, reduce the amount of short-term and long-term disability, and help those affected to cope with the impact of the injury on their lives.

Historically, road deaths have increased with a nation’s economic growth, but governments can incorporate safety strategies into transportation and infrastructure plans now to avoid this pattern, said Tony Bliss, lead road safety specialist at the World Bank.

If we could successfully turn this around, it would be one of the great 21st-century public health achievements.

Climate change affects health in Indonesia

Tue, 13 Dec 2011 11:06:00 +0700

Climate change is responsible for 2.4 percent of all cases of diarrhea worldwide and for 2 percent of all cases of malaria, according to the WHO.

Moreover, an estimated 150,000 deaths and 5.5 million “disability-adjusted life years” were recorded in 2000 due to climate change. “There is growing evidence that changes in global climate will have profound effects on the health and well-being of citizens in countries throughout the world.

One of the affects of climate change is global warming. In Europe this past summer, for example, an estimated 20,000 people died due to extremely hot temperatures.

Climate change automatically has an impact on the spread of disease in Indonesia — as seen in a malaria epidemic in Papua and pestilence epidemic in Pasuruan, East Java, in 1997 and dengue fever outbreaks in almost every Indonesian province in 1998 due to the El Niño/La Niña-Southern Oscillation.

Scientist Amin Subandrio estimated that 35 new infectious diseases have appeared due to climate change. He also said that climate change has made humans more vulnerable to disease and also increased the incidence of airborne and waterborne disease. Degenerative and infectious diseases are more likely to afflict not only babies and the elderly, but also people who are undernourished and live in unhealthy environments.

In addition, WHO stated that global warming has also triggered allergic and respiratory diseases.

“Heatwaves increase particles and dust in the air, while increases in sea water levels can cause flooding and abrasions, especially in coastal areas, and pollute hygienic water sources,” it said. The other effect is an increase of cholera and malaria, especially in poor countries.

Potential risks to human health from climate change arise from increased exposure to thermal extremes (cardiovascular and respiratory mortality) and from increases in weather disasters (including deaths and injuries associated with disaster).

Other risks may arise because of the changing dynamics of disease vectors such as malaria and dengue fever, including the seasonality and incidence of various food-related and waterborne infections; a reduction in crop yields; an increase in plant and livestock pests and pathogens; increased salinization of coastal lands and freshwater supplies resulting from rising sea-levels; climatically related production of photochemical air pollutants, spores and pollens; and the risk of conflict over depleted natural resources.

The effects of climate change on human health can be expected to be mediated by complex interactions of physical, ecological and social factors. These effects will undoubtedly have a greater impact on societies or individuals with scarce resources, where technology is lacking and where infrastructure and institutions such as the health sector are least able to adapt.

For this reason, a better understanding of the role of the socioeconomic and technological factors that shape and mitigate these impacts is essential. Because of this complexity, current estimates of the potential health impacts of climate change are based on models with considerable uncertainty.

Adverse health outcomes are associated with the ingestion of unsafe water, lack of access to water (linked to inadequate hygiene), lack of access to sanitation, contact with unsafe water, and inadequate management of water resources and systems, including in agriculture. Infectious diarrhea makes the largest single contribution to the burden of disease associated with unsafe water, sanitation and hygiene.

Global warming seriously affects human health. The government, especially the Health Ministry, must take action to anticipate the effects of climate change on health because it directly affects the transmission of diseases. The challenge today is to handle the effects that have already appeared while taking measures to prevent more severe climate change effects in the future.

Efforts should include the dissemination of regulations on energy consumption and environmental conservation as well as preparing action plans to prevent epidemics. Of equal importance is the promotion of a healthy environment and disease control management. Indonesia can begin by taking measures to improve its health system regulations in provinces and by simplifying coordination between central and provincial governments.

In the short term, the government must strengthen collaboration between agencies related to climate change impact mitigation and also strive to increase public awareness about climate change effect to human’s health.

In long term, the government needs to do research for the sake of climate monitoring, develop a climate change response plan and develop a surveillance capacity that spans health and environment issues. It is time for Indonesia to take action to face climate change and move towards a green and healthy Indonesia.

Does Ramadan really change ones’ performance, emotion?

Tue, 13 Dec 2011 11:05:00 +0700

Many individuals undergo periodic fasting for health, religious or cultural reasons. In Ramadan, Muslims abstain from food, drink, sex and tobacco from early in the dawn (imsak) until dusk (maghrib).

This period involves a shift in the pattern of intake from day time to the hours of darkness. According to R.J. Maughan of the School of Sports, Exercise, and Health Sciences, Loughborough University, fasting is characterized by a coordinated set of metabolic changes designed to spare carbohydrates and increase reliance on fat as a substrate for energy supply.

As well as sparing the limited endogenous carbohydrate, and increased rate of gluconeogenesis, glucose production from amino acids, glycerol and ketone bodies, help maintain the supply of carbohydrates. There seems to be little effect on overall daily dietary intake and only small metabolic effects, but there may be implications for both physical and cognitive function.

The limited evidence suggests that effects of Ramadan-style fasting on exercise performance are generally small. It is better not to stop exercise in Ramadan. The best time for Muslims to exercise during Ramadan is just before maghrib. But it is also okay to work out two or three hours after breaking the fast.

The study from Abdul Rashid Aziz from Singapore Sports Institute this year examines the effects of Ramadan fasting on endurance performance. A method using a crossover design, 10 moderately trained, active Muslim men performed 60 minutes runs on a treadmill in the fasted (Ramadan, RAM) and non-fasted (Control, CON) states on two separate counterbalanced occasions.

After familiarization, four subjects performed their CON trial one week before Ramadan, while the other six subjects performed their CON trial one week after Ramadan. The subjects’ last meals were standardized before their exercise trials.

The results: Blood glucose concentration was significantly lower and urine specific gravity was significantly higher at the start of exercise in the RAM condition than in CON.

Physiological responses during the 30-minute run (mean heart rate, blood lactate and ratings of perceived exertion) were, however, not significantly different between the two conditions.

There were also no significant difference in the subjects’ daytime sleepiness or mood profile between the RAM and CON conditions. At the conclusion of this study, Ramadan fasting has a small yet significant negative impact on endurance running performance, although the impact varies across individuals.

The study from A. Michaelsen, et al, from Kliniken Essen Mitte, Germany, stated that it was commonly reported that short-term fasting leads to mood enhancement and emotional harmonization.

Michaelsen investigated psychosocial well-being and the neuroendocrine response, assessed by nightly urinary excretion of cortisol and catecholamines hormones, in 28 inpatients with chronic pain syndromes during and after a one-week modified fast.

Twenty-two of the patients participated in a seven-day fasting with daily intake of 300 kcal/day, six control patients received a vegetarian-based diet. With fasting, significant increases of the urinary concentration of noradrenaline, adrenaline and cortisol were observed, whereas controls showed no significant endocrine changes.

The neuroendocrine response to fasting was pronounced in younger subjects (age <50 years) and in the presence of a BMI (Body Mass Index) >25 kg/m2, moreover the increase in cortisol excretion was significantly higher in subjects with lower baseline cortisol levels.

Mood and well-being increased non-significantly in both groups. Fasting was well tolerated, and regarded as beneficial by most fasting patients. Our results show that short-term fasting leads to neuroendocrine activation and may suggest that the extent of this response is dependent on the individual metabolic and endocrine state at baseline.

“Good diet and modifications to sleep and work timetables may minimize or even eliminate any
effects on performance.”

Good fasting has both spiritual and health benefits. Studies have shown that fasting can induce a healthy condition to our body and reduce the amount of cholesterol in the blood.

Too much cholesterol in the blood causes plaque to build up on the walls of arteries and veins, which could lead to clotting and a stroke. Fasting is also said to boost the immune system and the metabolism, thus promoting healing.

Restricting caloric intake also slows down the production of free radicals in the body, which can help prevent degenerative diseases. A recent study carried out in Indonesia has concluded that fasting can reduce the amount of free radicals in the body by about 90 percent and increase the antioxidant level by around 12 percent. Fasting also can decrease body weight. Nutritionist Ali Khomsan said many Muslims lost 5 percent of their body weight in Ramadan.

To maintain a healthy and active lifestyle, it is necessary to have a diet that is balanced enough. The principles of good nutrition hold true for anyone who is fasting. It is best to avoid too much fat, sugar, salt and caffeine and to always choose fresh non-processed food. It is important to drink at least seven glasses of water a day — three in the morning at sahur and four in the evening.

Fifty percent of food consumed should be at the time when you break your fast, 10 percent after the tarawih prayer and 40 percent at sahur time. It is best to break the fast with foods such as dates or bananas that will quickly release glucose into the bloodstream.

Let the stomach rest for one hour after that before eating rice or anything more substantial. It is a good idea to choose food from each of the major food groups: the grain group, the fruit and vegetable group and the meat and dairy groups. The meat group includes vegetarian options such as nuts and beans.

Finally, it is true that in the first week of fasting we feel tired. This is normal and indicates the body needs time to adapt. Avoid strenuous activity in the fasting month but do not allow yourself to get lazy.

Increases in subjective sensations of fatigue may be the result of loss of sleep or disruption of normal sleep patterns. Good diet and modifications to sleep and work timetables may minimize or even eliminate any effects on performance. So, fasting has been found to be really healthy and does not decrease our performance.

Healthcare condition in Indonesian remote places

Tue, 13 Dec 2011 11:03:00 +0700

I never imagined before that I would work in a remote island called Saketa in South Halmahera, North Maluku province. I worked as a medical doctor there upon graduation from medical school three years ago. I was on the island as part of the government’s program for young doctors in the province.

Saketa was totally different from big cities such as Jakarta, where I used to live. Cell phone reception, electricity, fresh water and petroleum were precious things on the island. The South Halmahera district covers 17 islands with a population of around 9,000.

I was the only doctor for the district at the time. In the health center I worked at, I could check up to 46 patients with various illnesses in one day. The health center was very crowded with patients and their families, not only in the clinic, but also in the ward.

As a doctor, I met many patients and also many problems. For instance, there were no simple health facilities such as blood-test and radiology equipment, at the health center. Most times, people did not have a health insurance system fully covered by the local government.

There was one incident that I am still not happy with. One night I was called to a house of a 30-year-old man, located 100-meter away from the health center. He complained of pain with his distended abdomen. When I arrived, I saw him almost in a delirious state. His abdomen was swollen, his respiratory rate was abnormal at 30 times a minute, his body temperature was high and his radial pulse was weak. He surely needed an operation.

But to take the patient to the district hospital was not easy as normally it takes two hours by boat from Saketa. I then took him to the health center where I inserted an infuse set and a modified nasogastric tube from his nose through his stomach to decompensate his distended belly as emergency treatment before I decided to take him to the district hospital.

With 5-meter wave and rain that night, I managed to get the patient to the district hospital one hour longer than the normal journey. But, the long and risky journey was useless as the hospital surgeon was having time off to visit his children in Java. The man died in hospital without further medical care. I was in a complete shock and could not believe what had happened.

Yet, the problem is not only in the health facility, but also the health system. The health system in Indonesia is not built to handle new emerging degenerative diseases such as cardiovascular diseases, cancer and diabetes. It only works for infectious diseases.

Furthermore, the Indonesian health budget only constitutes 4 percent of the total national budget, which is too small to cover expenditures for all infectious diseases, let alone degenerative diseases.

Moreover, life expectancy of Indonesians is more than 65 years nowadays. As a consequence, the number of patients with degenerative disease is staggering.

Another problem is in the quantity of health workers. In the district hospital that I mentioned above, there is no permanent surgeon, pediatrician and internist, while the entire wards and emergency rooms are only covered by one general physician and two nurses.

The problem is apparently not specific to Saketa, but nationwide, as the overall number of doctors in Indonesia is not compatible with the population.

There is no formal data from the government or other source of the number of doctors in Indonesia, but former chairman of the Indonesian Doctors Association (IDI) Fahmi Idris once said there were 70,000 doctors — 50,000 are general physicians and the remaining 20,000 are specialists. That number is definitely not enough to cover a healthcare program in Indonesia.

According to Fahmi, the right ratio should be one doctor to 2,500 people. So Indonesia should have more than 90,000 doctors.

There are two solutions to increase the quantity of doctors. First, the government can enhance private universities to open medical schools, without neglecting the quality of their graduates. Second, the government can invite foreign doctors to work in Indonesia.

Besides quantity, the government, however, should also care for fair distribution of doctors in all regions in Indonesia. According to former director for medical care at the Health Ministry, Farid Husain, beside low quantity of doctors, their distribution is also unequal, with 64 percent of Indonesian doctors still concentrated in Java.

Another solution to the poor health program implementation is by establishing good health regulations and policies for regional governments to cater to the need for health services in the regions.

In the autonomy era, local authorities sometimes are blamed by the central government for poor healthcare, while citing the minimum accessible healthcare data available in some provinces.

In addition, lots of reports of health cases from the regions had failed to be treated properly as they were late reaching the Health Ministry that the illnesses had become severe and difficult to handle — thus taking a lot of victims.

In this case, cooperation between the central and local governments is vital in setting up a good health system in Indonesia.

In summary, there are still lots of healthcare problems, particularly in remote places across the country.

It is the government’s responsibility to increase the accessibility of healthcare services for them.

Indonesian doctors’ attitude

Tue, 13 Dec 2011 11:01:00 +0700

According to the Health Ministry, in 2007 more than 100,000 Indonesians went abroad to seek medical assistance. Indonesians have especially visited Singapore, Malaysia and China over the last 10 years.

Approximately, Indonesian patients have contributed more than US$600 million to those countries every year since 2003.

Moreover, former Indonesian Medical Association president Fahmi Idris in 2008 stated that in 2010 Singapore would gain $2 million from Indonesian patients’ pocket. There are several reasons why more Indonesian citizens travel abroad for medical care.

One answer is hospitals in foreign countries provide the best medical service and professionalism. Patients can receive proper medical care in a short time.

In one day, patients can know the result of an examination. The length of stay for patients depends on their condition, not by a hospital’s financial motive.

Furthermore, the workload of doctors is also different. Doctors in other countries only work in one hospital or health center. In Indonesia the doctor works in many.

In addition, in foreign countries, patients are free to ask anything about their diseases, the examination and therapy process.

Doctors will answer it clearly. Patients may question the competence of doctors without worrying about offending them.

On the contrary, there are stories on how hospitals in Indonesia may be cutting edge high rise buildings, but their medical services are below average. Patients in the hospital for several days are referred to another hospital due to lack of facilities. As another example, patients are prescribed medicine without knowing why. Patients stay longer than usual in hospital.

There are many Indonesian doctors who practice late into the night with many patients. Moreover, the gap between Indonesian doctors and their patients is wide. Doctors still think that their position is higher than their patients, so they do not care about their patients’ needs or privacy; this problem affects communication between doctors and their patients.

According to the director general of medical care at the Health Ministry, Farid W. Husain, there are
three factors that a good hospital should possess; hospitality, high-end technology and professional human resources.

There is something that enables Singapore and other countries’ medical services to provide better quality aid than Indonesian medical services. Maybe the problem is not in health technology, because the health technology in Indonesia is the same as other Southeast Asian countries. Maybe there are problems with Indonesian doctors’ hospitality and professionalism.

But that is not the point, the real point is Indonesian doctors do not trust their people. Healthcare
specialists are like any other professionals, this job needs the trust from its client. Indonesian doctors should change their attitude so clients trust them.

Furthermore, the Asian Free Trade Area is a reality, and many foreign doctors will work in Indonesia. It is the time for Indonesian doctors to change.

A doctor is not perceived as a king or God, a doctor is a professional who must provide the best services to his or her patients. This is a challenge that must be answered to prevent Indonesian doctors’ dignity shattering into pieces.

Since 2008, Indonesia implemented a new medical practice act. Our country already has a council that regulates, watches, and maintains the quality of Indonesian doctors. In 2009, this council, known as the Indonesian Medical Council, stipulated that every doctor should have a standard level of competence before they practice.

Besides that, communication and empathy skills are now being introduced in the Indonesian medical school curriculum. We should see the result in the following years.

In addition, there should be a reform in our medical structure. Nowadays, there are 50,000 doctors in Indonesia’s health system. Doctors are not alone in the health system, there are 2.4 million nurses, 232,000 pharmacists, 294,000 laboratory technicians, 121,000 paramedics, and 85,000 dietitians.

Almost 70 percent of people in Indonesia do not have health insurance. They must pay for medical services. The doctors must be thorough when determining what medication is suitable within the patient’s budget. In the health insurance plan, people must first see their GPs before they are referred to a specialist.

The salary for general physicians will be paid by the government from the health insurance budget. Doctors are trying to encourage people to live healthier lives to cut medical treatment costs and focus on health insurance plans.

This will also prevent doctors cheating the pharmacy industry to get bonuses by prescribing their drugs. The patients will also receive proper medicine.

Indonesian doctors should change their attitude and improve their competence to make more people trust in their quality service. On the other hand, Indonesian people should also trust their doctors.

Affordable medicines, affordable justice

Tue, 13 Dec 2011 10:58:00 +0700

Oct. 6, 2009. It was 3 a.m. when the phone rang at the home of Elizabeth H. Blackburn. Blackburn received the phone call from the Nobel Prize committee. Blackburn, along with her colleagues, Carol W. Greider and Jack W. Szostak, had just been named the recipient of the 2009 Nobel Prize for Medicine.

They never expected their work would receive the Nobel Prize.

“When we started the work, of course, we were really just interested in the very basic question about DNA replication, how the ends of chromosomes are maintained,” Szostak said in an interview with the Associated Press.

“At the time, we had no idea there would be all these later implications.”

The trio solved the mystery of how chromosomes, the rod-like structures that carry DNA, protect themselves from degrading when cells divide. The Nobel citation said the laureates found the solution in the ends of the chromosomes - features called telomeres that are often compared to the plastic tips at the ends of shoe laces that keep the laces from unraveling. It was the mechanism by which it adds DNA to the tips of chromosomes to replace genetic material that has eroded away.

Their research triggered many more on cancer drugs, driven by their discovery of telomeres. Szostak says telomerase is very active in many cancer cells, “and if you turn it off or destroy the cells which have this high activity, you could be able to treat cancer”.

The Nobel committee says there is a lot of work yet to do to develop therapies for blood, skin and lung disease based on the winners’ breakthroughs.

Later on, many pharmaceutical companies began to investigate new cancer drugs based on telomere research. Many new cancer drugs came to the market and many doctors began to prescribe the drugs. But can all patients really afford to buy the new cancer drugs, since the development of new drugs needs a lot of research, and research needs a lot of money?

Who benefits from the science, from the research by Blackburn and her colleagues? Who benefits from the development of cancer research? Is it only the rich who can use it? Is it people from developed countries, or people all around the world, irrespective of their origin, who can benefit from the scientific developments? It is a big question for us to answer it.

In Indonesia, there have been a lot of advertisements for new vaccines for the human papillomavirus. HPV can cause cervical cancer. The development of the HPV vaccine was also triggered by Blackburn and her colleague’s research on telomeres. It seems a miracle that a tiny HPV vaccine can save many lives. But did you know that only a small percentage of Indonesian people can afford it? The price for one HPV vaccine is almost US$100. Only the rich can afford it.

The commerce of science creates a disparity between those who can afford new developments and those who cannot, especially in health science. Pharmaceutical companies race to make the newest and best treatment against all diseases.

When they get a result, they must sell the new therapy at no cheap price. It is not their fault, because to make the new drugs takes a lot of money.

The other reason for the disparity is the lack of agreement between countries to make equal and fair agreements about science and technology transfer. For example, avian flu is a problem in developing countries, which agree to send the virus specimen to developed countries.

Then pharmaceutical companies from developed countries make a vaccine for it. But the irony is the companies sell them at expensive prices to developing countries. It is unfair. Developing countries are supposed to have the right to benefit equally from virus specimens that they have shared.

Affordable new medicines for everyone are what we need, to make a just, prosperous, sustainable world for all, because all people have the right to benefit from scientific development.

The government can subsidize the production costs for new drugs that are not cheap. Developed countries that have the technology to create new drugs can agree to transfer their technology and expertise to developing countries. The United Nations also can support the fund to develop new affordable drugs for all countries.

When they get a result, they must sell the new therapy at no cheap price. It is not their fault, because to make the new drugs takes a lot of money.

Affordable new medicines for everyone are what we need, to make a just, prosperous, sustainable world for all, because all people have the right to benefit from scientific development.

Govt (still) has no commitment to tobacco, smoking control

Tue, 13 Dec 2011 10:54:00 +0700

In May 2003, member countries of the World Health Organization (WHO) adopted an historic tobacco control treaty, the Framework Convention on Tobacco Control (FCTC), which has the potential to reduce the terrible health toll of smoking.

To date, Indonesia — which ranks among the five major consumers of cigarettes in the world and has a booming tobacco industry — has not yet ratified the FCTC. This means the government does not have any regulation on tobacco control and smoking to educate their citizens on the dangers of smoking.

In comparison, almost all developing countries in Asia now have strict tobacco/smoking regulations about tobacco control and smoking.

This condition could be interpreted to mean that the government has no commitment to protecting and ensuring the health of the Indonesian people.

Analysts have pointed to a few reasons why the government has not yet ratified the FCTC: One, a strict tobacco/smoking regulation might incur a loss in tax revenue from the tobacco industry; two, such a regulation might cause massive lay-offs in the industry and add to national unemployment; and three, it could negatively impact tobacco farmers, particularly small-medium producers, who depend on the industry to make their living.

Are the analysts correct?

It is true that the cigarette industry plays important role in the country’s economy. More than 600,000 workers are employed directly by 3,000 cigarette producers and related businesses across Indonesia, and about 10 million indirectly work in the industry.

On the other hand, in developing countries the tobacco industry contributes only a small percentage to the job market. In terms of the living standards of workers, no significant increase has been seen, even though the industry makes a huge annual profit from cigarette sales.

The majority of industry workers are hired on a contract basis, even if they have worked more than 10 years at a single company. The same holds true for tobacco farmers: A survey by a non-governmental organization in East Java shows that a majority of tobacco farmers still live below the poverty line.

In terms of tax, the tobacco/cigarette industry generates much in annual tax revenue for the government. In 2006, this figure reached almost Rp 38.53 trillion; for 2007, the government has estimated a revenue of almost Rp 42.03 from cigarette tax.

However, World Bank data in 1990 show that the health budget used for the curative treatment of diseases related to smoking is almost six times the cigarette tax income. The data shows annual revenues from cigarette tax at Rp 2.6 trillion and economic losses related to smoking at Rp 14.5 trillion.

The health budget is estimated at Rp 1.7 trillion, which means that the short fall must be borne by the public.

The government should tackle smoking because it is unprofitable in terms of both physical and economical health.

According to WHO data, tobacco kills almost five million people each year. If current trends continue, it is projected to kill 10 million people annually by 2020, with 70 percent of those deaths occurring in developing countries.

Tobacco also causes an enormous toll in health care costs, lost productivity and of course, the intangible costs of the pain and suffering born by smokers, passive smokers and their families.

According to the WHO’s The Tobacco Atlas, smoking is the etiology for almost 90 percent of lung cancer cases, 75 percent for cases of chronic obstructive pulmonary disease (COPD), and 25 percent for heart attacks.

Nowadays, smoking is not restricted to men as more and more women are becoming active smokers. Consequently, cases of smoking-related cancers in women are also increasing.

Aside from lung cancer, smoking has been connected to many forms of cancer, including gynecologic cancers. Smoking can increase the risk of developing gynecologic cancers by fivefold.

Data from the 2001 National Economy Survey by the Central Statistics Agency (BPS) revealed a disturbing trend that people below the poverty line sacrificed their family budgets to buy cigarettes. From the hundreds of billions of cigarettes produced in a year, more than 220 billion cigarettes are consumed by those of the lower economic bracket.

These statistics indicate the declining quality of health among Indonesians — but the same phenomena has also been recorded in other developing countries.

World No Tobacco Day, which falls on May 31, was established in 1987 by WHO member countries. In Indonesia, every year this day is commemorated with anti-tobacco campaigns and much newspaper and television coverage of the issue.

Nevertheless, no clear government regulations exist on tobacco control.

To minimize the negative health and economic impacts of smoking, the government must act by first ratifying and implementing the FCTC along with supporting tobacco/smoking control regulations.

In the economic sector, a progressive tax on cigarettes can be levied — up to 50-70 percent as in developed countries. This way, national revenues from cigarette tax will remain high while the cigarette consumer rate will fall.

Another solution is to implement more stringent regulations on the media promotion of cigarettes, particularly in advertisement, could be put in place as part of a national anti-smoking campaign. Furthermore, the government can educate citizens about the dangers of smoking to both the economy and an individual’s health by involving public participation.

But this is not just the government’s responsibility. Citizens must also recognize the negative impacts of smoking and, instead of waiting passively for a regulation to be enacted and enforced, we should move to protect ourselves and our family.

With the death and disease that smoking causes, smokers will be the burden of the country, which is still combating infectious diseases.

This year, May 31 could be a new start for the Indonesian government to show the world that it cares for the health of its citizens.

Urging cervical cancer prevention program in RI

Tue, 13 Dec 2011 10:51:00 +0700

Imagine that globally, a woman dies of cervical cancer every two minutes.

According to one research from Ferlay et al, almost 500,000 new cases of this cancer is identified each year. Eighty percent of these cases occur in developing countries, where at least 200,000 women die of the disease each year.

These facts rank cervical cancer as the second most prevalent form of female cancer in the world.

Today, cervical cancer is becoming the number one female cancer in Indonesia. It accounts for 34 percent of female cancers and at present, 48 million Indonesian women are at risk.

According to 1998 data from Central Jakarta’s Cipto Mangunkusumo General Hospital, cervical cancer was the leading cancer among the 10 most prevalent primary female cancers it recorded.

Meanwhile, research conducted in August 2006 by the Female Cancer Programme Foundation — a non-governmental organization funded by the Netherlands government and the Europeaid cooperation office — shows that the prevalence of cervical cancer in Indonesia numbers approximately 100 cases per 100,000 people. In comparison, the Netherlands records a prevalence of only 9 cases per 100,000 people.

Indonesia is thus facing a new era of disease: On the one hand we are still combating infectious diseases such as tuberculosis and avian flu, and on the other, we must face degenerative and malignant diseases such as cervical cancer.

The main reason this cancer has a high mortality rate is because patients come to medical attention in the late stages of cancerous growth; around 65 percent of patients are diagnosed in the late stages — that is, beyond stage IIB.

One of the causes of this late diagnosis is due to the fact that 90 percent of cervical cancer cases in the early stage are asymptomatic, so the patient is not aware of the disease. In addition, patients — particularly in Indonesia — go in for a check-up only after they have experienced spontaneous vaginal bleeding. But this symptom might indicate that the cervical cancer is already in the late stages of development.

Another problem in combating cervical cancer in Indonesia is the very low screening coverage for this cancer.

Screening is one way to detect precancerous lesions and cancers in the early stages, but Indonesia records less than 5 percent screening coverage for cervical cancer; the ideal coverage is about 80 percent. As a result, 70 percent of cervical cancer patients are diagnosed in the late stages.

Such conditions make for a low survival rate and thus a high mortality rate for the patient. The problem is compounded because the government does not have a formal cervical cancer mass screening program, a national registry of cervical cancer cases, or data on screening results.

This is an irony, because early diagnosis (screening) and treatment is easily accessible to cervical cancer, which can drastically reduce the mortality rate. More importantly, cervical cancer is to a large extent a preventable disease.

Cervical cancer develops in an area of the cervix known as the transformational zone. This zone is more prone to the loss of cellular differentiation and can develop precancerous changes that may turn into cancer, depending on the presence of cervical cancer risk factors.

Some of these risk factors are: multiple sexual partners, a male partner who has had multiple sexual partners, multiparity (having more than four full-term pregnancies), early age of first intercourse, immunosuppressant usage, genital infections, imbalance of free radicals and antioxidants, smoking and low social economy.

A major risk factor is Human Papilloma Virus (HPV) infection. Cervical cancer can develop up to 10 years after an HPV infection. Further, an HIV infection increases the risk of an HPV infection by up to 10 times because of the decline in immunity.

The clinical manifestations of cervical cancer are: vaginal discharge, bleeding between menstrual cycles, postmenopausal bleeding, spontaneous vaginal bleeding, vaginal bleeding during defecation, pain during sexual intercourse and bleeding after intercourse.

Several strategies exist to lower the prevalence of this cancer.

The first method is primary prevention, which includes educational programs to reduce high-risk sexual behavior, measures to reduce or avoid exposure to sexually transmitted diseases including HPV, avoiding or minimizing other risk factors like early marriage (under 20 years old), early child bearing (teenage pregnancy) and smoking.

The HPV vaccine also falls under primary prevention methods.

According to the 2006 De Boer research, the virus — particularly types 16 and 18 — was detected in 95 percent of cervical cancer cases. This research also found that HPV type 18 is more dominant in Indonesia; the dominant virus in other Asian countries such as India and Korea is HPV type 16.

Thus, HPV vaccination is one solution in a cervical cancer prevention program, as the HPV vaccine widely used by doctors — such as the quadrivalent and bivalent vaccines — can be used against both HPV types.

But costs for mass vaccination remain high, so another strategy is needed against cervical cancer in Indonesia, namely secondary prevention methods.

Secondary prevention includes detection and treatment of precancerous lesions, which are simple, easy to administer and effective. The key to secondary prevention is a mass screening program to detect precancerous lesions. Indonesia needs a good screening test that is effective, safe, practical, affordable and readily available.

Some methods of early detection are the pap smear and visual inspection acetic acid (VIA).

The pap smear is the gold standard, and all women should have pap smears from an age before the onset of sexual activity until 65 years of age. If undertaken annually, and consecutive results from 2 to 3 smears are negative, then the pap smears can be undertaken at intervals of 3 to 5 years.

While pap smears are widely used as a screening test for cervical cancer, it has its limitations. In Indonesia, one such limitation is the availability of trained human resources that can conduct the test.

Another method of early detection is the VIA, which can differentiate between a normal and abnormal cervix. Although this type of screening is not new — it was introduced by Hinselman in 1925 — the technique fits with conditions in Indonesia: it is the most affordable, cost-efficient and fastest method (PATH, 2000) of identifying precancerous cervical lesions.

VIA is a visual cervical examination conducted by swabbing acetic acid (3-5 percent concentration) on the cervix and observing the effect over 20 to 30 seconds. Precancerous lesions temporarily appear white after staining with acetic acid.

VIA can be implemented in a wide range of settings, as no laboratory processing is required, the results are immediate, and treatment can be provided on the same visit.

In this case, one thing the government must do is provide VIA training for health workers, especially in rural areas.

A final strategy is tertiary prevention, or cancer treatment, such as surgery and radiation therapy, depending on the stage of cancer.

It must be stressed that a strategic approach to cervical cancer prevention in Indonesia — triangulating between women, the health services and technology — should be developed urgently.

According to the World Health Organization’s 2002 prevention program development, the steps involved are to: confirm political commitment, engage high-level stakeholders, conduct a situation analysis, develop policy and maximize access to health care providers.

The focus of the cervical cancer prevention program should be to maximize coverage of screening and treatment services, as the overall mortality rate will decrease if more patients are diagnosed in the early stages of the disease.

Prevention — rather than curative methods — remains the best way to take this opportunity to protect women from this dreadful disease, and to stop the rapid growth of cervical cancer cases in Indonesia.