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Malaria: A 25% Solution.

May 5, 2012

 I visited three new sites and one longstanding project. All faced enormous gaps in medicines, diagnostics and malaria control activities. In some areas the last bed net distribution was 3 years ago, and no indoor residual spraying had been done in over a year. Although a few areas were overstocked with rapid diagnostic tests, many had none; most had no artemisinin combination therapy (ACTs, the first line treatment) or pediatric ACT formulations. Oral and parenteral quinine was generally available, but not parenteral artemisinins, and there were few transfusion materials to treat people with severe malaria-related anemia. These disparities sometimes existed within the same administrative zone.

This article certainly feels accurate based on experience in Indonesia & Timor-Leste. Here, funding covers little more than 1/4 of standard interventions. As a result, transmission continues only minorly abated, with all that entails. Instead of moving towards control, we’re simply dealing with temporary reductions in a continued epidemic.

Is malaria a preventable disease? Yes. We can stop the great majority of cases and deaths. Eradicable? I’d like to find out. But with the weak and impartial application of even the existing tools answering this question is entirely impossible.

http://blogs.plos.org/speakingofmedicine/2012/04/25/responding-to-malaria-a-view-from-the-ground/

New chapter.

February 11, 2012

So, I’ve been accepted to a position in Timor-Leste, as a malaria control education officer. This is quite a step for me, and the exposition of a lot of collected knowledge. I’ll certainly be keeping you updated, and blogging more regularly.

Partners in Health release new “how to” guide

September 27, 2011

Partners in Health (PIH) have over the years proven themselves on the forefront of medical aid, working with communities to improve health, and expanding greatly the set of healthcare needs which are considered ‘acceptable’ and deserving targets of assistance. For this reason, I’m excited that PIH have released a new guide, summing their experiences over the last several decades, with a particular focus on building the systems needed to provide healthcare in challenging and low resource environments.

Partners In Health Program Management Guide.

I haven’t read it yet, but I’ll be sure to post further once I’ve got through it.

Kirsch, notes on Hyndman

June 7, 2011

There are few writing about Papua on either side of the border that explain the social dynamics of bodies as well as Stuart Kirsch. One particular text, untouched in my thesis (it was one thing I inexplicably failed to stumble over) is reproduced at length below. While the process of transformation of facts and rumors frequently occurs when these are taken from specific Papuan contexts and placed in alien locations or contexts, cogeneration frequently occurs.

[223] “I argue that political and critical discourse often marginalize and dehumanize the refugees in the process of enhancing their own rhetorical power.”

[228] “In 1987, an article by David Hyndman in the Cultural Survival Quarterly was partially reprinted in a national … Jaya with the tapeworm Taenia solium, a parasite that can cause cysticercosis in humans, leading to convulsions and death. Hyndman, an anthropologist, argued that the tapeworms had been deliberately introduced into Irian Jaya as a form of biological warfare against indigenous Melanesian populations. He made these assertions despite the research of a parasitologist sponsored by the World Health Organization (Desowitz 1987) who concluded that the parasites had been inadvertently introduced into Irian Jaya when a number of pigs were brought as gifts from Bali, where the parasite is endemic. Hyndman further suggested that the domestic pigs raised by the refugees were hosts to the parasite, even though there is no medical evidence to support this position (Fritzsche, 1988; George Nurse p.c.). The original article, cleverly titled: “How the West (Papua) Was Won,” made quite a splash. Had its speculative claims been true, endangering the refugees as well as their neighbors in Papua New Guinea, the situation would certainly have provoked international intervention.

In other examples of critical discourse about the refugees from Irian jaya, the attempt to present the strongest possible case against Indonesia sometimes leads to false or exaggerated claims. Such assertions may have the unintended consequence of striking fear into the hearts of the very proponents of the argument claim to support. sensationalist reports about helicopter gunships and armed river trucks patrolling the [230] Fly River (Nietschmann and Elev. 1987) or phantom OPM operations blockading the shipment of copper and gold from the Ok Tedi Mine along the Fly River (Matthews, 1992) do little to calm the refugees.

More than simply inciting terror however, such discourse also encourages the refugees to seek a military solution to their predicament, a strategy that must be regarded as millenarian. Yonggom members of the OPM sometimes boast of magical techniques that enable them to transform themselves into crocodiles at river crossings to evade capture, or rites that permit them to withstand a volley of Indonesian gunfire without harm. Encouraged by outsides, the OPM train in the rain forest along the border with their bows and arrows, machetes and vintage weaponry.

Not only is the hope for a military solution to the problems in Irian Jaya unrealistic, but this perspective also discourages the refugees and OPM from pursuing alternative political strategies. Political moderates among the refugees even risk denunciation as traitors. Thus the conspiracy theories and millenarian solutions of critical discourse are promoted at the expense of any possible rapprochement between the refugees and the Indonesian government. Proponents of critical discourse often overlook refugee interpretations of events and ignore the impact of their discourse on the refugees themselves.

[229]”given that Hyndman’s argument has not been substantiated however, … Thus Hyndman’s claims about biological warfare were directly transformed”

None of these should be simply discounted; there is valuable truth value in each of these rumors, which give us considerable information about how people understand themselves and their relationships with others. Self-aggrandisement is a common strategy in the face of existential threats, and the idea of genocidal power being exercised is itself instructive. Hyndman’s claims would not float if there was not a receptive environment in which they could exist. The disease cysticercosis, ruptured the social world in which the Yonggom and refugees live(d), and was a deadly, previously unexplained source of death. Otherwise healthy people would lose their sanity, fall into fires, and have seizures and fits. Like HIV/AIDS in the two decades subsequent, it recontextualizes relations through its inexplicability.

What is less explicable, and less worthy of sympathetic analysis, is the relationship that these refugees claims had with those outside Papua. In turning their suffering into a political instrument, without direct regard for their immediate (rather than future) wellbeing in the face of military repression, foreigners took advantage of rhetorical positions that held no cost and which positioned them as the saviours of those in need.

Every death is political.

June 6, 2011

Every life is political, in that it has weight and meanings that can be used for a variety of positions (often a much larger set of meanings than are actually used). But deaths are especially so.

Papuan sickness and death have acquired great meaning in the last two decades, and writing about Papua has often corralled them onto the sides of independence pamphlets and websites about injustice. While there are very obviously political implications to the death of Papuans, particularly when these occur from preventable diseases or are the direct result of agents of the Indonesian state, they deserve a far stronger countenance, one which illuminates the disease and its functions directly. People don’t just die, even when their deaths are deliberate. Rees and Silove (2008) do this to an extent, Leslie Butt (along with Morin, Munro and others) more so.

Deaths without context float around, adrift, depositing meanings on whoever touches them. What is needed is more context (complexity), not less.

[Draft, to be reconfigured with reference to Fassin’s conception of the biopolitical death.]

Notes on cysticercosis.

May 19, 2011

A much older Papuan health problem illustrates the trajectory of a rumour, and how parallel medical discourses can bypass the political context in which these rumours exist. Cysticercosis is a disease affecting the brain which is transmitted through parasitic tapeworms. It first emerged in Papua among the Ekari in the Paniai Lakes district in 1971, following the introduction of tapeworm carrying pigs from Bali. The subsequent gradual spread of the disease to other parts of Papua, including highlands Jayawijaya District, has meant that the disease has become a serious health issue throughout Papua.

The pigs were given to Papuans by the military, at the suggestion of Suharto as softeners to a population who were at best ambivalent about the Indonesian presence in their territory. The introduction of infected pigs from locations where the parasite is endemic to where the disease was not known was soon a significant cause of ill health and death among the indigenous Ekari. Questions about the possibility of intent to infect were raised as a result of the obvious connection between the disease and the military. Other connections were drawn from its spread among Christians rather than Muslims. This was due both to transmission through pigs and dogs and the eating of pork, and the reduced susceptibility of immigrants due to their different hygiene practices. This claim was intensified by the presence of transmigrants from elsewhere who sought to settle in the Paniai Lakes, providing a visible motive for the claim.

Tom Hyndman described the disease as a method of counterinsurgency in research described in 1983 by Tapol, and repeated the claim in a number of papers. By the late 1980s his research had been given further publicity by Cultural Survival in their journal Cultural Survival Quarterly, and Hyndman was explicit in his claim that the disease was a component of biological warfare.

The reproduction of these claims in West Papua: the Obliteration of a People has meant that they have had much greater currency and wider distribution than they would otherwise have had. The book’s status as one of the few human rights related documents to emerge on the subject of Papua during the 1970s and 1980s has meant that when historical claims are examined, the claims contained within it have been treated as possible evidence. Such a use is found in Brundidge et al., Indonesian Human Rights Abuses in West Papua: Application of the Law of Genocide to the History of Indonesian Control, a document produced by students of the Allard K. Lowenstein International Human Rights Clinic, Yale Law School. This document was prepared by students, but has since found much wider circulation as a compilation of evidence of possible genocide. The Brundidge et al. document makes no comment on the status of the claims, except to replicate them as they are found in Obliteration of a People. It is also found on the website of Yale University’s genocide program, where together with Obliteration of a People, an article by Survival International, and a small number of generalised webpages and books, it is presented as reason for Papua’s inclusion in this program.

Through its republication by Hyndman in academic papers, and repeated mention in West Papua advocacy materials, this rumour has been delocalised and stripped of the context in which it arose. It now forms part of a global circulation of claims about genocide in Papua. There has been an absence of research which would connect or disconnect claims about Indonesia’s use of military power to medical issues such as cysticercosis and HIV/AIDS, in large part caused by Indonesia’s reluctance to allow such research within its territory. As a consequence, these claims will continue to circulate as fact, unchallenged, unverified, and unexplored.

Neglect

May 5, 2011

Foucault suggests that all forms of power are ultimately manifested in their effects on the body.

Working from this proposition, the effects of military and political power in Papua, might be viewed not only in terms of violence and political control, but also in poverty and disease. Public healthcare has been neglected in Papua for several decades. The neglect has become particularly apparent as much of the rest of Indonesia has developed.

Public-health indicators, although incomplete, suggest
that the general health of Papuans is poor.5,6 Malaria,
upper respiratory tract infections, and dysentery are
major causes of childhood morbidity, with infant
mortality ranging from 70 to 200 per 1000.5 More than
50% of children younger than 5 years are undernourished,
and immunisation rates are low.5,6 Maternal mortality is
three times the rate of women in other parts of Indonesia.5
HIV/AIDS rates are 40 times the national average,7
and the epidemic is being fuelled by a burgeoning sex
trade, low levels of literacy, and inadequate services for
prevention and treatment of this disease.1

However, rather than positing Papuan miasma as exceptional2 – a radical deviation from a developmentalist norm – it makes more sense to see it as the far end of a continuum of healthcare neglect in late 20th century and early 21st century Indonesia. At a far end, private hospitals enjoyed by elites in Jakarta and Denpasar, and at the other, Puskesmas of rural villages in Papua and Nusa Tenggara Timur.

While foreign and Papuan activists have sought to link Papuan deaths to the Indonesian state, they have not always done so in ways that emphasise neglect over other forms of culpability. For this reason and others, the subject of health in Papua, and particularly the HIV/AIDS ‘epidemic’ has been politically sensitive. A number of diseases have been directly politicized, including cysticercosis (taenia solium) and cholera, while others again remain outside the purview of politics except as they relate to neglect in general senses.

S. Rees and D. Silove, “Speaking out about human rights and health in West Papua,” The Lancet 370, no. 9588 (2007): 637-639.
A subject I will return to.