© John Gribben at Kiosk

How to save the rainforest: build a health centre

Save the people, save the forest. In rural Indonesia, a pioneering clinic is showing how the health of people and forests could and should be intertwined. By Yao-Hua Law.

The roosters were still asleep when Sri Wayunisih woke her daughter, Puteri. They could not afford to sleep till dawn. Wayunisih had taken a day off from working on the oil palm estates and Puteri had skipped school for this trip. They had to reach their destination before everyone else. Wayunisih pushed her motorcycle onto the road and her daughter climbed on behind her. The Mickey Mouse keychains on Puteri’s school bag clinked crisply. The two of them were heading towards Sukadana, a coastal district in south-west Borneo and the capital city of North Kayong, home to the only clinic in the area, some 80 km away. Soon, the roosters were crowing, their calls joining the dawn prayers playing from the many suraus along the road, the buildings lit only by the waning moon.

An hour and a few wrong turns later, Wayunisih and Puteri reached the clinic. The one-storey rectangular complex shone like a beacon in the dark with its white-washed walls and zinc-plated roof. Wayunisih and Puteri removed their shoes and walked up the wide stairs to the rows of green plastic chairs on its verandah. It was just past 5am. In a few hours, patients would start to queue at the clinic, and Wayunisih and Puteri would be first in line.

By 8am, a small crowd of 15 adults and children were sat on the verandah. It was Friday, the least busy day of the week. Any other weekday would see all 40 chairs on the verandah filled. It was a September morning, the end of the dry season, and some T-shirts were already moist and sticky. Out in the yard, clucking chickens pecked for food among the grass and newly planted tree seedlings. A small brown snake slithered into a bed of dry bamboo leaves. High-pitched insect humming hung in the air. On the TV, a tiger stalked its prey. Colouring books lay open on a low table. Everyone in the room sat facing the eastern wall featuring a large white sculpture of a tree growing out of dense undergrowth, hornbills flying out of its canopy, the letters ASRI carved on its trunk.

ASRI stands for Alam Sehat Lestari, Indonesian for ‘healthy nature everlasting’ or ‘harmoniously balanced’. It’s the name of an Indonesian non-profit organisation based here in North Kayong on the western border of Gunung Palung National Park. Part of West Kalimantan province, North Kayong is more than five times the area of New York City and boasts mountains, rainforests and dozens of islands. It is home to about 107,000 people, almost half of whom make a living on farms, plantations and fisheries. The monthly income averages around 2.45 million rupiah (US$181), but one in ten residents make do with just 250,000 rupiah a month (<$20), much less than the World Bank’s $1/day threshold for poverty.

The obvious fact is: people need to earn a living to survive. In desperation, many fathers and sons log and burn the edge of the national park for timber and farmland. Conservationists speak of the park’s 108,000 hectares of swamp, lowlands and montane forest, which together house sun bears, hornbills, gibbons and about 2,500 orangutans. But to local people strapped for cash, the trees look like fixed deposits to be withdrawn in entirety.

© John Gribben at Kiosk

For many in North Kayong, healthcare is a dream and emergencies a nightmare. But if paying for a doctor is difficult, at least choosing one is easy: in 2016, there were only 168 nurses, 15 doctors and one dentist in the regency. Five of those doctors and that one dentist work in the clinic that Wayunisih and her daughter braved the dark road to reach, and it is here that ASRI has concentrated its efforts.

Since 2007, ASRI has been working with communities around the national park to improve the wellbeing of both humans and the environment. It started by setting up a clinic that provides villagers with not just the most extensive healthcare services in the area, but also incentives to stop them from logging in the park. The clinic offers up to 70 per cent discounts on medical fees to villages that stop logging, and ASRI aims for this to pile pressure on loggers to stop. Patients who cannot afford medical fees, and so might otherwise resort to illegal logging, can choose to pay with various non-cash options, including native seedlings or labour. ASRI also replants forests and trains ex-loggers to farm and run alternative businesses.

ASRI weaves healthcare, finances and conservation into one tapestry – a vision printed on the uniform of its conservation staff: “Masyarakat sejahtera, hutan sehat” (Prosperous society, healthy forests). This concept is now often referred to as ‘planetary health’, a term coined by the Rockefeller Foundation–Lancet Commission in 2015 to inspire research and action. But the beginnings of ASRI came more than a decade before that.

§

Back in 1993, when the then 21-year-old Kinari Webb first visited Gunung Palung National Park to study orangutans, the locals “had nothing” in terms of healthcare. “One of our field assistants, Pak Patin, was like a Wild Man of Borneo. He knew so much about the forests. I have never met anyone who’s more comfortable in the forest,” says Webb, a medical doctor from New Mexico, USA, and the founder of ASRI.

One day in the forest, Patin came to Webb, his eyes filled with the fear of death. “This is going to kill me,” he told her, his voice shaking. He held out his hand, bloody from a bad gash. Patin had accidentally cut his hand with his parang (machete). Webb looked at him in surprise. “OK, it is a bad cut, but it is just a cut,” she thought, “why are you so scared?”

Then Webb saw what had turned the Wild Man of Borneo into mush. If you have never had a tetanus shot, no antibiotics, and you are out in the middle of nowhere where your life depends completely on your hands, losing one means losing your livelihood – and your life.

“That was what it meant to have no healthcare,” Webb says, recalling one of her many epiphanies in that first year in the forest. While she tracked orangutans in the national park, she regularly heard the sound of chainsaws in the forest. The ground shook every time a giant tree fell. Webb wondered if there would be any forest left for the orangutans she was observing. She spoke to loggers and learned that they cut and sold trees to pay for medicine. “What would you do to get healthcare? What would you do if your child is sick? Just about anything.”

A year of these encounters ended with Webb ditching her PhD plans and enrolling at Yale School of Medicine upon her return to the USA. Her studies took her from Oregon to Connecticut to California, before Webb plotted a course back to Indonesia to set up a programme combining human and environmental health. She knew the two elements were entwined, but not how such a union would look.

Meanwhile, the people of Sukadana were losing their forests faster than ever. Since the mid-1990s, loggers had attacked Gunung Palung National Park with purpose. The sound of chainsaws and falling trees penetrated the thick forest. By 2003, the threat of illegal logging forced authorities to close the research station deep inside it. Logging and farms bit and chewed at the park’s borders, eventually eating up one-fifth its forests. When Webb returned after medical school, she was amazed and relieved to find much of the park’s core still intact.

In 2006, Webb formed a team and applied to open a clinic in Sukadana. The two-month application slowed to a six-month drag but finally, in July 2007, it opened.

Webb and her team went to all of the villages around the national park and conducted formal surveys – or “radical listening”, as she calls them. Leaders of farmers, fishermen and cooperatives, men and women alike, gathered to share their thoughts. ASRI asked the villagers: “You are guardians of this precious rainforest that is valuable to the whole world. What would you need as a token of gratitude from the world community?” The villagers requested two things: training in organic farming­ – meaning they wouldn’t have to buy expensive chemical fertilisers and pesticides – and quality healthcare that they could afford.

§

At 9am, Wayunisih was waiting by the room of Dr Alvita Ratnasari, a general physician. Wayunisih sat alert in her long-sleeved orange shirt and cross-stitched pink hat decorated with plastic flowers. She had dozed off waiting at the verandah and missed the first time her name was called. Beside her, Puteri wore a green surgical mask. A soft shout of “Semangat!” (Spirits up!) came from the room across the courtyard. The ASRI staff had just ended their daily meeting. Wayunisih watched as Ratnasari walked down the corridor towards her. She hoped the rumours about ASRI giving away free glasses were true, because she and her daughter hadn’t been seeing well lately.

ASRI started giving out eyeglasses in early 2007, hoping the handouts would engage the villages around Gunung Palung National Park. In those early years of the programme, there was not a day when you couldn’t hear chainsaws, says Webb. It reminded the team of the urgency of their work.

ASRI first focused on healthcare and farm training in an attempt to sever the locals’ dependence on illegal logging. Then, in 2009, they started their first reforestation project along the southern border of the national park.

I visited Laman Satong reforestation site with Jackson Helms, then the conservation research director at ASRI. Not a single bird was tweeting in the afternoon heat. The air was still, filled only with the shrill calls of insects and the crunch of dry leaves under our feet. Large trucks thundered by on the road beside the forest. Hassan*, coordinator of the site, walked in front of us. With a tinge of embarrassment, he confessed that he was once a logger. As he felled trees, he began to wonder if any would be left for his grandchildren to see, and so in 2009 he joined ASRI as a labourer and worked his way up. “Now my son helps me water and plant the seedlings on weekends,” he said, smiling. As we walked by a patch of alang-alang grass, Hassan pulled a thin stalk and played with it between his lips.

We stood on a strip of soil and gravel, a few metres wide and barren but for grasses inching in from the edges – a fire break designed to halt the advance of forest fires. Helms looked at the grasses with concern. “Grasses have grown back since we weeded them. We need more maintenance,” he said. Hassan nodded.

We left the fire break and turned into the forest. Trees stood apart in the thin undergrowth, lit by ample sunlight that broke through the sparse canopy. In a mature and undisturbed South-east Asian rainforest, thick blankets of palms, gingers and saplings would fight for every spot in the canopy’s shadow. Giant trees would rise on buttress roots that stand like walls. But this was a young and recovering forest.

Hassan pointed to the right of the trail. I squinted and spotted a thin stem with thinner branches poking up almost a metre from the leaf litter. Nothing impressive, I thought – just another young plant trying to survive.

© John Gribben at Kiosk

That young plant turned out to be a seedling of Borneo ironwood planted by ASRI. The only species in its genus, ironwood is endemic to South-east Asia but found mostly in Borneo. It is an excellent construction material: its wood is so dense that it sinks in water, but is also extremely resistant to fire and rot. Transmission poles made of ironwood last at least 20 years in the tropics, conceding only bits of their surface to the relentless attack of fungi and termites. Locals have long been using ironwood, which they call ulin or belian, to build everything from roofs and boats to bridges and coffins. Its strength is much desired, but ironwood grows very slowly; trees can reach 50 metres high and their trunks over two metres wide, but getting to such size would take over 1,000 years. A century ago, huge ironwood trees stood in the forests, grown from seedlings that sprouted before the first stone was laid at Angkor Wat, seedlings that grew into mighty trees as humans replaced arrows with rockets and axes with chainsaws.

Few of those mighty trees remain. When chainsaws began whirring in Borneo, they bit into ironwood first. Without intervention, this symbol of Borneo timber will be gone in a few decades.

In 2009, the national park office assigned 20 hectares to ASRI’s maiden reforestation project. By 2013, ASRI had reforested almost 20 hectares in Laman Satong, only to suffer a ravenous fire that consumed all but half a hectare. Since then, the conservation team has replanted 16 hectares. By the end of 2017, they hope to be back to 20 hectares of reforested land. This feat has demanded much effort and about 121,000 seedlings, many of which were contributed by clinic patients. Since 2007, nearly 900 patients have paid their medical fees with native seedlings – mostly from fruit trees growing in their villages. In the first nine months of 2017, 53 patients paid with 4,371 seedlings.

Of course, a supply of seedlings isn’t enough to combat deforestation – issues like tenure of land and the economic conflict between growing trees and using the land for farming have a larger, more immediate influence. And it’s worth saying that ASRI’s belief in reforestation is not universal among conservationists. Andrew Marshall, a tropical ecologist at the University of Michigan, describes ASRI’s reforestation efforts as worthwhile, but thinks that protecting the remaining forests is a much cheaper and more effective approach than kick-starting regeneration. “It’s just really hard to grow back tropical forests,” says Marshall, who has spent 21 years in Gunung Palung National Park, adding that we won’t know if reforestation works until well after we’re both dead.

Reforestation is a relatively new addition to ASRI’s endeavours. On my visits, it seemed to me that the locals viewed ASRI more as a clinic than as a conservation outfit. Marshall says the organisation has made a real healthcare contribution to the local communities and saved many lives ­­– he recommends the clinic to his assistants. “ASRI’s contribution to conservation is less clear. [But that’s] not just ASRI’s issue – it’s generally difficult to assess the effectiveness of conservation.”

Forests are gifts that people give their great-grandchildren. Forest regrowth, even when aided by tens of people planting hundreds of thousands of seedlings, cannot be rushed. When seedlings survive and grow into trees, the shade from their canopies prohibits weeds growing, protects other seedlings and facilitates the forest’s natural regrowth. “We plant only a fragment of the native species that would occur here,” Helms told me, “but in a few hundred years…” His voice trailed off as his hand swept out in an arc before him. “We just get it started, and then the rest of the process takes over. We hope.”

§

Back at the clinic, an Indonesian couple watered seedlings and removed weeds along the parameter. When the husband – a scrawny farmer in his 40s – and his wife travelled five hours by boat and motorcycle to the clinic, they did not expect to be gardening for ASRI. The husband’s teeth had decayed below the gum line, and chewing was agony. A neighbour recommended he and his wife visit the ASRI clinic to see the only dentist in the regency, Deo Develas.

Develas, a 26-year-old wiry man with short hair and narrow rectangular glasses, joined the clinic in 2016 against his parents’ advice. Eager to help the needy and to test his skills in a rural setting, the new graduate had left the malls and cars of Jakarta for the hills and bikes of Sukadana. He sees six to ten patients every day, many of whom don’t have a toothbrush. Once, Develas had to install a full set of dentures for a 30-year-old man.

As the husband explained his problem to Develas, the dentist strained to follow. The man’s front teeth had been extracted by a dukun (traditional healer), and the gap hampered his pronunciation. Develas suggested dentures to replace 20 of the man’s teeth, which would improve his speech, chewing and confidence. But the procedure would cost 2 million rupiah, a daunting sum, as the farmer couple had lost most of their crops to storms. As the husband and wife turned to leave, Develas told them about the non-cash payment options. The couple were “excited to start”. They had no seedlings, but they could work to pay for the dentures. For the next two weeks, the couple slept in an empty room at the clinic while they nurtured the clinic’s seedlings and organic farm.

“I am so happy to help them with the non-cash payment, and it wouldn’t make them expect free treatment,” said Develas. Several of his patients had paid with seedlings, he said, beaming. “One of the trees in the forest will come from my patient!”

While many of the ASRI staff are locals, the five doctors and dentist came from much larger cities. After work and on weekends, they hike trails or watch sunsets on a long beach just 10 minutes from the clinic.

At the end of that beach is a café selling iced sugarcane juice, a favourite in the dry season. In front hangs a banner with the words “STIHL HOT” (sic) flanked by images of people singing into microphones.

The owner of the café is Wan*, a local who speaks softly and walks with a slight limp. Wan turned 40 this year, and for the first time in 21 years, he is without a chainsaw. When he was 19 he was desperate for work, but he had neither skills nor capital. When a timber boss offered him a 2.5 million rupiah loan to buy a chainsaw, Wan took it, agreeing to sell all the trees he cut to his boss at one-third the market price. Thus Wan began to log.

For two decades, Wan took his chainsaw into the forests of West Kalimantan, picked any tree that was “straight enough” and cut it into 4-metre-long planks on the spot. Working alone, he then lugged the planks out of the forest on his shoulder. Armed with a chainsaw, Wan needed just two days to reduce a tree 12 metres tall and a metre wide into planks. It occurred to me that Wan must have cut down ironwood trees.

“Logging destroyed my body,” he said when we met, grimacing. “Even now, it hurts here, here and here,” he added, pointing to his hands, elbows, shoulders and legs. “And this” – Wan placed his left foot on the table and pointed to a scarred dent near his toes – “was where a tree squashed my foot.”

Tree after tree, Wan cleared his loan in five years. The chainsaw was rightfully his, and he continued to log. It was all he knew. Yet after two decades of logging and a crushed foot, he had little to show for it. The riches of the timber trade land far from the men nearest the trees. “Most months I had no savings. I feared for the future of my family, but what else could I do?”

Wan was sceptical when he heard of ASRI’s Chainsaw Buyback Entrepreneurship Program. According to the programme, ASRI would buy Wan’s chainsaw for 4 million rupiah (below market value) and invest additional capital to fund a joint business with him. Once Wan repays ASRI’s investment with profits from the new business, he will own the business outright. Wan had always wanted to run a café, but he worried about failing. Without a chainsaw, how could he feed his family? His wife, who had been supplementing the family income with odd jobs, persuaded him to give up logging. She recognised the heavy toll it was taking on her husband’s body and the paucity of income it offered in return. Finally, in February 2017, Wan sold his chainsaw to ASRI and started Stihl Hot Café.

“‘Still Hot’ is a good name,” I said as Wan walked me out of his café. “Shows that your coffee stays hot.”

“Oh, but ‘Stihl’ is the brand of my chainsaw,” he said, confused. He laughed at my misunderstanding – I’d thought it was a spelling mistake. “I named the café after my chainsaw because it has fed my family for 20 years. I want to remember that.”

Wan designed and built the café himself – the tables and benches, even a karaoke room installed behind the coffee bar. Thanks to a healthy sale of juices, coffee and karaoke, he has been earning a 500,000 rupiah net profit every month since May. He has already started to repay ASRI.

His example has motivated others to join ASRI’s buyback programme. Ex-loggers have left their chainsaws with ASRI in exchange for farms, fish ponds and cafés. But the programme at present cannot fund more than 10 ex-loggers, and it will take several years to prove its success. And while encouraging loggers to give up their chainsaws might seem like a great idea for the forests, it could also backfire. Bronson Griscom, director of forest carbon science at the Nature Conservancy, told me that, “Counterintuitively, chainsaws can be a powerful conservation tool. It is not the tool that is the problem, but how it is used.” Griscom worries that when loggers are barred from jobs and income from natural forests, and pushed to make their livelihood from other lands, it could drive a long-term shift to convert forests into land for other uses.

Griscom focuses instead on the conservation benefits of low-impact logging, in forests where full protection is not viable. His team helps logging companies in East Kalimantan obtain Forest Stewardship Council certification – an international and industry-recognised standard of responsible and sustainable forestry practices. To get certified, the logging companies must minimise damage to the forests, respect the rights of local communities and share revenues with them. Ultimately he hopes these outcomes will be achieved across Indonesia through national regulations. “We find that certification is turning loggers into conservationists and can support a long-term sustainable economy that depends on keeping forests as forests. In contrast, if we push locals out of forestry, the long-term interest of local communities can shift to deforestation.” 

These concerns remind me of Helms’s words when we ended our visit to the Laman Satong reforestation site. Before Helms became a conservationist, he was translating Arabic with the US Marine Corps in Iraq. “War is a monster, a huge social movement that nobody can control or understand. In a way, conservation is like that too,” he said with a snicker. “You do things that you think help people, but in the end it may not.”

§

Wayunisih sat in Dr Ratnasari’s room at the clinic. It has a desk, a wall-mounted fan, an examination bed and a window that opens onto trees. Wayunisih told the rosy-cheeked doctor of her “smoky” vision and abdominal pain. Puteri sat by her mother, fiddling with her mask. After examination, Ratnasari told Wayunisih that her eyes were deteriorating with age and have mild cataracts. Puteri has developed nearsightedness.

© John Gribben at Kiosk

“Can you give Puteri glasses to help her see better?” asked Wayunisih. “No, the glasses we give for free are for seniors and do not work for Puteri,” said Ratnasari. She sketched an eye on paper to help Wayunisih understand Puteri’s nearsightedness. “As for your cataract, it’s too early for a surgery, but you will need glasses with UV protection.” Wayunisih quickly typed the instructions into her flip phone.

“Can I drip honey on Puteri’s eyes? People told me that helps.”

“No, please don’t do that!” said a concerned Ratnasari, who has had patients with ulcers on their eyes from washing them with “leaf juice”. “Honey goes into our mouths, not our eyes.”

For another 15 minutes, Ratnasari explained to Wayunisih how irregular meals were giving her stomach aches and gastric acid reflux. The doctor reminded Wayunisih to stick to regular meals and avoid sour and oily foods, then made her repeat the instructions. Wayunisih thanked Ratnasari but was clearly disappointed that Puteri did not get free glasses. “But the service is good and I know what to do now,” said Wayunisih before she hurriedly left for Ketapang, the nearest city with an optometrist, two hours away.

Every day, over 40 patients visit the clinic, paying 100,000 rupiah each on average. Patient fees pay for 40 per cent of ASRI’s healthcare operations, while all of ASRI’s conservation programmes rely on donations and international grants. Helped by its sister organisation in the USA, Health in Harmony, ASRI has been securing donations and winning grants from prestigious bodies like the Whitley Fund for Nature and the US Fish and Wildlife Service.

But if donations and grants run dry, ASRI will be shackled with a budget deficit of 85 per cent or even more as they gear up to reforest 100 hectares a year. Sinking into the red is a scenario that executive director Monica Nirmala and her team plan to avoid. ASRI is manoeuvring to diversify and raise income. A potential collaboration with a search engine company that uses advertisement revenue to plant trees could pay for ASRI’s seedlings. Meanwhile, the clinic is expanding into a fully-fledged hospital that provides both out-patient and in-patient care, including surgeries. ASRI has paid to train specialists in radiology, gynaecology and internal medicine who will serve for at least five years. The clinic also recently became a service provider for the Mandatory Health Insurance Scheme, a nationwide universal healthcare programme launched in 2014. By 2018, all Indonesians must enrol in the scheme under registered healthcare facilities.

Nirmala is banking on the national health insurance scheme and the new hospital for more income. The aim is to get the hospital self-sufficient in 10 years, otherwise it would not be a “healthy health business,” she says. So far, ASRI has registered only 600 people on the insurance scheme, a number which they must improve on.

It’s an amazing plan, but one that’s already looking precarious. The ASRI hospital is designed under a new category recommended by the Ministry of Health for rural areas, yet this new category isn’t accounted for in the health insurance scheme. I pressed Kinari Webb on this, and she said: “Honestly, I just don’t know what’s going to happen. We have like a year to figure and maybe there will be new laws passed or maybe there won’t. We may try to get an exception, I don’t know.”

ASRI isn’t perfect, but it’s trying. I’m reminded of something Bronson Griscom told me: “The difficult, chronic question we face is how local economies in these landscapes have a vested interest in keeping forests as forests.”

Later that afternoon, I found Dr Ratnasari reading a book from the clinic library. It was about ultrasound techniques, something the 27-year-old GP did not learn in school. But at the ASRI clinic, where doctors see patients with conditions more severe and variable than in the city, she has found that she must learn a lot more than her urban peers.

Ratnasari, who is always smiling when she speaks, has just renewed her contract at ASRI for another two years. Her parents and city friends have never understood why she chose to come to rural Sukadana and delay her specialist training. Was it, as she said, the skills she could learn in Sukadana, or maybe the satisfaction of helping patients who could only pay with sweat and seedlings?

“I love my window,” she told me, staring out the window in the room where she had treated hundreds of patients, the same room where she had told Wayunisih not to drip honey in her daughter’s eyes. Outside, trees and seedlings of shades of green, yellow and brown swayed in the breeze, trees and seedlings that a husband and wife may have watered to pay for his dentures. Chickens scratched the ground, turning over leaves to look for insects, while an occasional bird zipped by. We heard crickets, birds and leaves, but no chainsaws.

“I have never seen so many tall trees outside my window. This is a painting. A live painting.”

*Some names have been changed.