In late 2011, epidemiologist, writer and adventurer Elizabeth Pisani granted herself a sabbatical from the day job and set off to rediscover Indonesia, a country she has wandered, loved and been baffled by for decades. She was on the road and the high seas for a year, covering dozens of islands in 27 provinces. This site records photos and musings from that journey and beyond. See more about the project
The failure was highlighted in the new UNAIDS report on the state of the epidemic. They estimate that the rate of new HIV infections in 2011 was more than 25% higher in Indonesia than it had been a decade earlier. That raises some questions for me: is an increase of more than 25% in HIV incidence (i.e. new infections) over 10 years really so shocking? Is the rate of new infections in Indonesia still increasing today? How do we know?
1) How shocking is an increase of 25%?
It rather depends on what the original rate was. The fact is, Indonesia had virtually no HIV epidemic in 2001, except in drug injectors and waria sex workers. In other words, the baseline rate of new infections in the largest risk populations (female and male sex workers, their regular clients, and gay men) was extremely low. If you go from four new cases a year to five new cases a year you increase by 25% but add only one new infection. If a high prevalence country goes from 10,000 incident cases to 11,000 cases, it has increased by just ten percent but added 1000 new cases. Which is the bigger prevention failure? I’m not saying that HIV prevention in Indonesia is a great success story; quite the reverse (see below). I’m just reminding people to beware of relative measures.
2) and 3) Is the rate of new infections in Indonesia still increasing now? How do we know?
The fact is, we don’t. Indonesia, which in the early 2000s built up quite a strong surveillance system, has seen that system break down rather badly, in part because of the effects of decentralisation and in-fighting between government departments which means that people who should be running the system are busy squabbling over project funding, and in part because of the small-mindedness of some of the donor-funded NGOs, who cared more about measuring their own little efforts and sucking up to their own pet partners in government than about supporting strong and transparent national systems. We can’t measure new infections directly, so incidence estimates are based on models that use information about overall infection rates (prevalence) from several years for several different population groups, together with information on risk behaviour, in some case. I’m frankly surprised that UNAIDS even published an incidence estimate for Indonesia, given the shockingly poor quality of the data available in the last 5 years. I note that the shied away from giving estimates for many of the other large countries with similarly diverse epidemics and patchy data: Brazil, China and Russia.
That HIV prevention failed in Indonesia is indisputable. The failure was totally unnecessary, but sadly inevitable given the choices the country and its “development partners” made. When infection rates were still low we measured very high levels of risk behaviour in key groups. We did very little about it, and what we did was more often driven by institutional needs and development fashion than by the needs of the people at risk. We kept measuring risk and infection and saw that risk was not falling and infection was rising. We spent lots of time and energy getting more money, then threw the money at the same failed approaches (including, in the most iniquitous example, treating people’s STIs with drugs we knew didn’t work because the Ministry of Health, the WHO, the drug companies and their various cronies couldn’t get their shit together to change the outdated national guidelines on treatment).
If what data we have are to be even remotely believed, there does appear to have been some success reducing new infection rates among drug injectors. But by 2009, three years into Nafsiah Mboi’s tenure as head of the KPA, Indonesia had sucked 60 million dollars into its HIV coffers, for that year alone. How much of that was spent on HIV prevention for gay men, a sizeable group in whom infection rates had rocketed from under 3% in Jakarta when I did the first study in 2002 to over 8% in 2007? A princely US$ 23,000. It’s not at all shocking that HIV prevention doesn’t work if you are simply not doing it. Or if you are doing the kind of thing Indonesia is mostly doing, pictured above. The poster reads: “Don’t ruin your life for just a moment’s pleasure. HIV/AIDS. You can get it, you can prevent it.” Does it tell you HOW you can get it, HOW you can prevent it? No. And there are even worse examples out there.
Here’s something that I found shocking: UNAIDS chief Michel Sidebe was in Jakarta just a couple of months ago. What did he talk about? Not the gay men, junkies, waria, rent boys and clients of hookers that make up four fifths of the Indonesian epidemic (the majority of other cases being in female sex wokers). Or at least not according to newspaper reports of his visit. No, he talked about the importance of protecting innocent women and babies through sexual education for young people, most of whom are at practically zero risk. (Reminder, you can’t get HIV by having sex, even unprotected sex. You can only get HIV by having unprotected sex with an infected person. As long as they stay away from the trade, most young heterosexuals in Indonesia can have as much sex as they like without risk of HIV infection.)
The highest UN official for HIV comes to Indonesia and stresses the importance of prevention for people who are not at risk, and Ibu Naf wonders why infections continue to rise in the groups that are at risk. Please deh! Someone should write a book about this.
As part of the Makassar Writers’ Festival, I’ve been asked to give a talk about HIV in Indonesia at the faculty of public health at Hasanuddin University. I’m reluctant. I’ve been wandering Indonesia without any thought of focusing on HIV for over eight months now. In that time I’ve met a surprising number of widows, orphans and middle-aged couples who have lost a child. Only one of those deaths has been HIV related. The rest are all in traffic accidents, mostly involving motorbikes.
That’s not entirely surprising. Bike ownership in Indonesia is booming, with 8.1 million new motorcycles crowding on to the country’s shockingly bad (and already crowded) roads last year. It’s perfectly common to see primary school kids driving motorbikes; it’s very rare to see a primary school kid in a helmet. And the industry is not exactly doing a lot to promote norms of safe driving. Here’s how Suzuki was pimping its new (quite girly, automatic transmission) model in Bau Bau, Southeast Sulawesi, last weekend.
Reporting of road accident related deaths is even worse than reporting of AIDS deaths in Indonesia. But working on best estimates, death contracted on the roads far outstrips death contracted in bed or while shooting up. Some 32,000 people died because of road accidents in Indonesia last year alone, a quarter of them teen-aged boys, and 60% of them on motorbikes. Ten times as many were injured badly enough to alter their daily lives. That compares with just over 5,000 Indonesians reported as having died of AIDS, ever. Let me repeat that. Over 30,000 road deaths a year, versus 5,000 or so AIDS deaths over the last 25 years. And yet Indonesia spent US$ 69.2 million preventing HIV infections and AIDS deaths last year, 60% of it taken out of the wallets of taxpayers in other countries, much of it spent very badly indeed. Indonesia does have a national road safety action plan, but, according to the Director of Road Safety in the Ministry of Transport, it has no dedicated budget to cut death on the roads. If I didn’t know better, I might console myself that HIV is not much of a problem in Indonesia precisely because of the prevention spending. Sadly, that’s not true. I also recognise, of course, that death tolls are not the only basis on which to make public health decisions. But it doesn’t take a very sophisticated observer to see that HIV programmes in Indonesia are grossly over-financed relative to other important killers and maimers, notably road death. (Then there’s smoking, but that’s a whole nother post…)
It doesn’t seem like this problem is likely to evaporate. Though the motorbike industry is wringing its hands over the effect that a perfectly sensible new restriction on credit will have, I’m not seeing it in the field. The Suzuki mob were offering new bikes for a downpayment of just 350,000 rupiah (about US$ 38.00). If that meets the 25% deposit requirement of the regulations, which came into effect this month, then it is a VERY good value bike, despite being girly. Even by the most pessimistic estimates, there will probably be another 6.5 million bikes and over 800,000 more cars on the roads by the end of this year compared with the start. Remove the several thousand that will be reduce to scrap by crashes, and its still a huge net addition.
For an idea of how far Indonesia has to go in making its roads safe, check out this presentation by Eric Howard. There’s lots he doesn’t mention — the political incentives to finance the building of sub-standard roads, the fact that Indonesians think road safety campaigns are just another way for policemen to extract bribes — but there are some priceless photos that show just why for most Indonesians, it’s probably far more dangerous to make your way to work or to school than it is to have sex.
A statue outside a health centre in Enarotali, in Indonesian Papua
Reading the newspapers in cities across Papua, I cannot help but notice the full-colour ads for penis extensions. In only half an hour, with no invasive anything, men can see their organs grow, thicken, harden, for ever. The ads are explicit about the results, down to the last half centimetre; clients can choose both the length and girth of their organ, up to 20 cm by 6 cm (the more modest promise diameters of just 5.5). All of this with just some magic oil and a few prayers, guaranteed free of side effects. The “Specialists in Vital Organs” promise services for women, too, tightening up our fannies “until you are like a maiden again”. And for both sexes, they will pray away our sexually transmitted infections.
Why the obsession with sex organs, and why especially in Papua? Are people encouraged by the blatantly erotic sculptures that are common in these parts? Do migrants from other parts of Indonesia feel inadequate on arrival in Papua, or do they feel the magic will be especially potent in the nether regions of the nation? And isn’t it mildly ironic that all of the people offering their dick-swelling charms claim to be from Banten in western Java, where mystics sometimes break their fasts by eating light-bulbs? They offer other mystical services too: tying down your spouse, implanting a protective aura, ensuring you get promoted or elected. But most of their force is expended on delivering: “What other people only promise, we prove with results that are Large and Long”.
It turns out that the penis obsession is not, in fact, confined to the tens of thousands of immigrants from the rest of Indonesia who have been sucked east by Papua’s booming economy. I learned this when I asked a Papuan nurse in one of the province’s largest hospitals what brought men to outpatient services. Three things, he said: injuries resulting from violent fights, injuries resulting from traffic accidents, and prison. Prison? Do people get sick in prison? “No, that’s the penis stuff.” Prisoners, Papuans and others, are operating on one another’s members — inserting ball bearings and biro parts, threading hair through the urethra. A doctor friend who ran an STI clinic in Papua for many years says he saw a lot of penises embellished with horse hair, but the nurse said since that’s in short supply in prison people weave ornaments from their own locks. Not surprisingly, many of these go septic, hence the hospital visits.
My doctor friend blames the porn industry for the penis-plumping craze. “People watch these porn films where everyone has a giant dick, and they begin to think that that’s the norm.” Certainly porn films are enough of a norm in Papua to have their own nickname: “film o-ya”. The name derives from the script, which in many films does not go much beyond the repetitive groaning of “Oh yah!, Oh yaaaaaah! Oh yaaaaaaaaah!
A more serious aside: data newly released by the Indonesian Ministry of Health show that one in four of the Papuan women who are selling sex to their men-folk on the streets of the Papuan highland town of Wamena are infected with HIV, while well over half have another STI. Perhaps because condoms don’t fit snugly over the horsehair, three in four of these infected highland women are not using protection with their partners.
West Papua will lead the fight against corruption, drugs, and HIV/AIDS
After another giant geographic leap (roughly the equivalent of London to Tehran) I find myself in Manokwari, West Papua. Tanah Papua, Indonesia’s eastern extremity, has the country’s highest rates of HIV, and also its highest levels of stigma. Which makes me wonder who came up with this commitment, made on an ageing poster that has pride of place outside the provincial Governor’s office. It declares:
The West Papua government will lead the fight against:
KKN (Corruption, Collusion and Nepotism)
Narcotics and illegal drugs
Though hopeful donors have been pushing voluntary testing and counselling clinics on Papua for years, all the clinics I’ve visited in the last week report that the truly voluntary “I’ll just go along and see whether I’m infected” walk-in client is rare. Most are referred to the clinics by health staff who see signs and symptoms of AIDS — often, in other words, after people have been walking around with HIV for a decade or so. Why don’t more people want to get tested? Perhaps in part because we still tell people AIDS can’t be cured. But also because we are equating HIV with distinctly undesirable things like corruption and illegal drugs. It brings us back to the eternal prevention dilemma. We want people to think HIV is undesirable, because we want them to protect themselves from infection. But we also want to stop treating it like some horrid plague which deserves to be feared (and financed) more than any other inconvenient, chronic, treatable disease.
If you’ve been reading this blog much, you’ll have gathered that the parallel with corruption is not actually so far off for Indonesia, in that corruption is also an undesirable, inconvenient and chronic disease. At least HIV is treatable.
AIDS prevention poster in Southeastern Maluku, 2011
I have a collection of daft AIDS posters going back years, but I’m glad to say they are getting harder to find. This one, in Saumlaki, the main town in the remote Tanimbar islands, was thus a great find. The headline reads: AIDS: there’s not yet any cure! On the right is this helpful information:
You can’t avoid it by:
Choosing your sex partners on the basis of their appearance
Drinking/injecting antibiotics, alcohol, or herbal medicine before and after having sex
Washing your sex organs after having sex
Some, including the South African president Thabo Mbeki Jacob Zuma* and uber-philanthropist Bill Gates would take issue with the last point. I, of course, would take partial issue with the second — you can avoid AIDS by taking medicine, you just can’t avoid HIV that way. But the most egregious part of this ad is the illustration.The population of Tanimbar is largely Melanesian. Overwhelmingly the highest HIV risk for them is the sex they might have on their frequent money-spinning travels to neighbouring Papua. Indonesian Papau, rich in minerals, forests and much else, is swimming in cash. It is also swimming in HIV; it’s epidemic looks more like East Africa 15 years ago than it does like any other part of Indonesia today. And it is populated not by pointy-nosed tourists with straight blonde hair but with flat-nosed Papuans with crinkly black hair.
Most AIDS posters are pretty useless, in my opinion. But this poster associates HIV with Western tourists slow-dancing under the palm trees — an “other” that most people here will never come across, while saying nothing about commercial sex in high risk areas (Papua, but also with the local transgender (or waria) population). Those are very real risks that many certainly do face, at least if Astuti, one of the latter, is to be believed. She excused herself early from a grilled fish dinner because her phone rang. Not her Blackberry, that’s for friends and family, but her “HP selinkungan” (cheating phone). In Tanimbar from neighbouring Kei for around a year, she hasn’t had a day without clients. And though she has helped distribute condoms and promote testing in other cities around Indonesia (in some of which one transgender sex worker in three is infected with HIV), she’s seen no sign of an HIV prevention programme in Tanimbar. By maintaining the fiction that something is being done about HIV prevention in Tanimbar, this poster is a lot worse than useless. It is actively dangerous.
*(Thanks to Thakhani for correcting my presidential confusion.)