coverapr02.jpg (8330 bytes)Latitutes 15 -- April 2002


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[Health And Body]
Quick Fix at the Puskesmas  by Injil Abu Bakar

“I’m scheduled to get my shot today, Mrs. Doctor,” said the old man, his shiny dark face peering through the door of the Puskesmas—short for Pusat Kesehatan Masyarakat or Community Health Center—where I worked in Tabanan, Bali. 

“What’s wrong with you, Sir?” I asked him as he took a seat.

“Nothing, really. The shots are so I feel fresher. You’re new here, right? I’m a regular at this clinic,” he informed me, appearing to grow impatient with my idiotic question. As I let loose a whole series of queries designed to gauge the state of his health, he got up from his chair and gazed out the window, seeming to search for someone less dim-witted than this bespectacled woman doctor.

“You’re a new doctor, right?” he finally concluded.

Five years have passed since that day. In those years, I’ve learned a lot, including the fact that most people in our community don’t like being asked—at least by doctors—about the ins and outs of their health. The longer such interrogations last, the more light they shed not on the patient’s condition but on the extent of the doctor’s stupidity. After all, traditional healers don’t feel the need to ask their patients about their family history, past medical history, allergies, diet or weekly exercise routine. What a waste of time! As one of my patients once reprimanded me, “Get to the point, Doctor!”

It would be misleading, of course, to claim that every Indonesian feels this way. A small number of people hold the opposite view, giving credit to doctors who quiz them at length. “Doctor, you’re so thorough!” they praise. And others who don’t like to engage with their doctors on issues of their health are nonetheless eager when invited to converse on other topics. Ask them about their business, their boyfriend or girlfriend, the price of rice, the rising cost of fuel, or the problem of traffic and they’ll be happy to chat. They’ll even recommend you to their friends, reporting that their doctor is a very friendly person.

I made my way to the senior doctor’s office to discuss the matter of an elderly man claiming it was his scheduled injection day. I had no idea what kind of injection to give him, what ailed him, or what he meant by “scheduled injection.” As I recounted the case, the head doctor alternated his gaze between a Mexican soap opera and his plate of fruit salad, and then he turned away to draw the curtains closed.

“Just give him vitamin B12. He’s a regular patient of this Puskesmas,” the doctor instructed two white-gowned nurses, who were engrossed in the struggles of a poor girl in Mexico City.

“But Doctor, what’s his condition?” I remained in the doorway despite the very clear instructions and the body language that was obviously telling me it was time to leave.

“Come on, why so serious?” the doctor chided me, leaning over to open a plastic bag of bright red coconut pancakes.

Idealism unvanquished, I returned to the treatment room to find the old man had already raised his sarong and readied his backside for my needle. His eyes were closed, and his hand clenched the edge of the chair.

“I’m ready, Doctor!” he announced.

“Sir, before I inject you, come on, let’s talk a bit first,” I insisted. “What exactly is ailing you?” This was the second time I had asked him that question.

“Come on, Mrs. Doctor. I’m a regular here. When did you get here? And you’re young. Just ask one of the other doctors. Everyone already knows about my medicine.”

Full stop. Deadlock.


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I went to the cupboard where the syringes and needles and vibrantly-colored vials of vitamin B12 were kept.  One eight-milliliter vial of vitamin B12, minus its lid, stood beside two used three-milliliter syringes. I stuck my head further inside the cupboard to look for a clean syringe. Then I turned to the next cupboard, just in case that grimy space was being used to store medical supplies. Unfortunately not. I ran to find the nurses, and found them actually sobbing as the story unfolded on the screen.  

“Excuse me, where do you keep the syringes?” I asked, standing in the doorway. Luckily the commercial break had begun. At least my presence wouldn’t be disturbing their mental enrichment program.

“There are some in the rack, aren’t there? In the same place as the vitamin B12. We put them together in kits,” explained the nurse, running her fingers through her newly-permed hair.

“Which rack would that be?” I asked.
The nurse, who clearly felt that this transformed coiffure had greatly improved her appearance, smiled sweetly, slithered out of her seat, took my hand and led me to the medicine cupboard. 

“What’s this?” she scolded, chuckling victoriously as she gestured toward the used syringes.“You’re too impatient, Doctor! How could you possibly not see a thing this big?”

“Yes, I did see this. But where are the fresh syringes? And this needle has been used,” I pointed out. 

“Yes, that’s it, the needle for injections.” It seemed she had little clue what I was talking about. I don’t need to continue this story. Clearly the matter of used syringes that had been sitting in a cupboard for who knows how long, and had been used on who knows how many backsides, was of no interest to her whatsoever. As a look of total surrender washed over my face, the permed nurse finally seemed to pity me.

“If you’d like to clean the syringe with alcohol, we have lots of alcohol here,” she said, directing me to two bottles standing on a shelf.

“So never share needles, especially among young people, and don’t be enticed into sinful behavior like using drugs, free sex and drinking alcohol. Those are the ways of Westerners and we needn’t follow their example. Moreover, now that AIDS and Hepatitis B are rife, you must never share needles!” So went the lecture of the Puskesmas doctor. It was 11 a.m. and the Puskesmas had organized an educational talk for local residents. The audience nodded their heads. The old man who had come first thing in the morning for his injection was also present. He was grinning broadly, showing his firm grasp of what was being said.

This was my first official day as a resident in the public health clinic. All the theory that I had learnt in eight semesters of medical school seemed to fade in the face of practical reality. Over and over again, I asked myself whether I had done something wrong. Why did the doctors and the nurses regard me as some strange creature? Why were they laughing at my idealism? Why were they making me feel as if my knowledge was worthless and inferior, having nothing to do with being a real doctor? Later that night, I broke down in tears.

My parents knocked at the door of my room. My mother appeared with hot tea and fried bananas. My father stroked my head.  

“Only a few more months!” he consoled, adding a hearty “Hang in there!” 

Strangely, after feeling so depressed, the next day I woke with a new spirit. I enthusiastically headed off to the clinic, thirty kilometers from my house. My mother had changed the oil in my motorbike the night before. My father had polished the black Honda Astrea’s body. It made me sad to see them express their hopes in this indirect way—their hopes that my public health residency would not be undone. I was touched to see them polishing the spokes of my motorbike until they gleamed. They chose not to discuss my discontent of the previous day, but by caring for the vehicle that would take me once again to the clinic, they showed me how high their hopes were for my eventual graduation.

“There will be an inspection today!” said the nurse as soon as I arrived.

"An inspection from where?” I asked.

“We have to get ready!” she said, ignoring my question. Extraordinarily, that morning the television was off. All the clinic staff were sitting at the table with long rulers and colored marking pens and sheets of paper, their eyes cast upwards in thought. My presence seemed to be of little consequence. I stood there for half an hour, marveling at how changed the clinic seemed from the day before. Everyone was silent, fiddling with their rulers and markers and charts until…abracadabra! They handed their papers to the head doctor. He deftly pinned the fifteen sheets up on the clinic bulletin board. The papers bore the following information:


1.Numbers of women who die in childbirth

2.Scope of immunization program for under-five year olds

3.Family planning acceptors


I remember being especially impressed by the figure for immunization of under-five year olds. “Wow, 98%, nearly 100%!” I exclaimed. 

“Hush, don’t exaggerate too much,” the woman who ran the immunization program scolded. “If I write 100% it’ll be too obvious. I’ll just put 98%.”

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The next round of preparation for the inspection involved women running off to the corner food stall to buy a whole load of freshly made snacks. Several others went off to the kitchen to boil some water for tea—super sweet, tealeaves adrift. The inspector came. The remainder of the program involved eating. Drinking tea. Chatting about this and that. Exchanging forced smiles. Being hospitable.  We were reassured that the report of the inspection would be very positive, excellent even. In other words, I should learn and follow their example. After the inspector left, the situation returned to normal. The television came back on and Maria Mercedes resumed her sobbing. With everyone else so happy that the inspection had been deemed successful, I took the opportunity to talk with one of the nurses about the injection episode—the episode that had made my life hell the previous day.

The Puskesmas, she explained, was allotted five clean syringes per day. Three of them, however, were stolen by corrupt staff, leaving only two—one of which I must use to carry out our elderly client’s daily “scheduled injection.” Usually the nurses and doctors who work at the Pusekesmas in the morning see patients privately in the afternoon. The doctors seemed, for the most part, to be far more enthusiastic about their more profitable afternoon practices—and many of the patients did too. One morning I met a man at a food stall near the Puskesmas who appeared very ill. He reassured me he that was going to go to the doctor later on that day.

“Why not be seen now? The doctor is in at the Puseksmas,” I said with attempted conviction.

“I can’t be bothered. They have different medicine there. You only get the real medication if you go to the private clinic!” he told me, asking for assurance that I would not tell the clinic staff what he had said.  It was true that the Puskesmas followed different standards for prescribing medication than those I had learned in medical school. Antibiotics were almost always prescribed for three days only. When I protested, the chemist pleaded with me to be realistic. The amount of antibiotics received by the Puskesmas every month was far less than what was needed. But silently I always wondered why every patient who complained of a sore throat and every child who came in carried on her mother’s hip was loaded down with antibiotic powders and prescriptions.  I learned even more about medications the day a half-kilo bag of white pills turned up on my desk. There was nothing on the bag to identify what its contents might be. I went down to the chemist and asked him, “Sir, what are these pills? And who are they for? How is the patient supposed to know what kind of medication they’re taking if it doesn’t come with any identification?”

“You’re new here, Doctor. I’ve been here for a long time and I know all the names of the medications by heart. You need more experience! It’s not that hard to know what’s what. After all, we only have twenty different kinds of medication.”  But wasn’t the medication for the patients? Didn’t they need to know what kinds of drugs we were prescribing them? The very friendly chemist assured me that the majority of his customers didn’t want to be blinded with science. They came to the Pusksemas because they wanted to be cured, not because they wanted to learn the names of medications—especially not the long and convoluted names drugs seem to go by nowadays! That would only put their heads in a spin!

Indeed I found it true that, in general, patients felt that the more medication they had to take, the quicker they would be cured and the better they would feel—especially if that medication came in the form of colorful pills, and most especially if it came in the form of modern-looking capsules. Nearly every patient, no matter what their illness, went home with at least three different kinds of medication. Patients who complained of a headache, for example, were sent home with three packages: one containing antalgin (headache tablets), the other vitamin B and a third vitamin C. Most likely, they would also have been given an injection of vitamin B12. These medications seemed to make the patients feel better—even if they didn’t cure them of their problems—and they seemed to make the doctors and nurses feel that they had served their patients well.

The Puskesmas doctors were also reluctant to break up their patients’ love affairs with injections. A friend of mine once even suggested that this “love affair” was a key to healing. If the patients really believe in the magical power of injections, why don’t we just give them what they want? Not only does it encourage them to come to the Puskesmas where their health can be checked, there’s no harm in injecting somebody with vitamin B12. In fact, the converse is true—it can be good for the body. But what of AIDS, Hepatitis B, and other diseases that can be spread through contaminated needles? It seemed I still had a lot to learn.


Injil Abu Bakar is a physician who lives in Denpasar, Bali.

On paper, the Puskesmas program is an extraordinarily progressive one. In order to staff the thousands of clinics needed to cover Indonesia’s huge population, the government requires that every medical school graduate agree to serve three years in a public health clinic before being granted a license to practice. This means that the inhabitants of Irian Jaya or Sumba should receive the same standard of medical care as those of Jakarta or Bali.

In practice, however, things don’t always work out that way. Although there are some doctors who appreciate the challenges and the chance to help the underprivileged that the Puskesmas provides, many doctors view their mandatory service with little enthusiasm. Doctors complain about the low wages and the simple facilities. They speak of a lack of intellectual challenge and the horrors of being “dumped” in some isolated area.

When the Puskesmas program first started, doctors were allowed more leeway in choosing the areas in which they wanted to work. But the vast majority signed up for relatively pleasurable posts like Bali, and few were willing to work in areas like Ambon, Kalimantan or Eastern Indonesia. The government then came up with categories for each Puskesmas: normal, isolated and very isolated, and set wage levels higher for the latter than for the former. But even this new policy was not enough to encourage doctors to serve in isolated locations. For while a Puskesmas doctor’s wage in Bali or Jakarta may be only Rp500,000 (US$50) a month, there are plenty of opportunities for extra income. Most doctors in Bali who work in clinics in the morning see private paying patients at their own practices in the afternoon—something there’s little chance for in a place like Irian Jaya.

During the Suharto era, when most matters, including medicine, were infected with corruption, doctors with good family connections could get preferential postings. Not only could they receive the coveted Bali spots, they might even find themselves working in Sanur, Ubud or Kuta where a dollar-paying tourist might walk into one’s afternoon practice. Meanwhile, those doctors who came from politically problematic backgrounds could expect to be assigned to the most remote villages. After repeated protests, the system is now more fair. Doctors may choose what province they are willing to work in, but the details of what city or village or clinic are up to the Department of Health. Provincial assignments are filled on a first-come first-served basis. One can wait up to three years for a place in Bali, but if one is willing to work in Ambon, for example, the assignment will likely come through quickly, allowing one to finish up and gain an official license to practice all the sooner.

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