Forest People

My father and I woke at 4:30 each morning to the sound of a loudspeaker on our neighbor’s roof announcing the call to prayer. We would both read by the light of our headlamps before rising with the sun for our morning exercise routine. I would run through the rice patties on my regular circuit past one of Sukadana, Indonesia’s many bird’s nest soup factories, five-story silos where swiftlets (birds) meticulously crafted their saliva-based nests, only for them to be harvested weekly to sate the ever growing demand for the delicacy in China. We both ate a breakfast of fresh fruit before walking down the street to the ASRI clinic, Indonesian headquarters for Health in Harmony, a conservation-medicine NGO based out of Portland, Oregon.

Morning rounds were always held in English for the sake of the visiting medical students and volunteers like my Dad—a family physician—and I—(a premedical student at the time). However, patients almost exclusively conversed with our Indonesian counterparts in the local language: Bahasa Indonesia. After morning rounds I joined the conservation team and daily broke a common rule of most global health programs by mounting my friend Yayat’s motorcycle to venture out to the border of Gunung Palung National Park where we were attempting to build a wildlife corridor between two pieces of protected land. Our goal was to use this corridor to promote animal movement and thus gene flow between different sections of the park. Yayat spoke not a word of English and I only knew numbers in Bahasa but that was usually enough. We worked in the rainforest until noon, ate a lunch of rice and fish so salty it made your ankles swell, and lounged a bit by the river before returning to the clinic where I would join the medical team for afternoon rounds and group lecture.

The medicine in Sukadana varied from the exotic including malaria and dengue fever to the more familiar like diabetes and chronic obstructive pulmonary disease (COPD). The COPD was chiefly due to the town’s habit of burning its trash; Sukadana is nearly three hours by boat along the coast from the provincial capital of Pontianak and no infrastructure exists for trash disposal. Despite the variety of diseases, all the patients that presented to the Alam Sehat Lestari (ASRI) clinic tended to be very sick. Our patients turned to western medicine only as a last resort, preferring the more familiar practices of their local shamans. There seemed to be a shaman for everything—bone shaman, skin shaman, heart shaman, you name it—and they almost always seemed to do a remarkable job. Only when all the shamans were thwarted by a disease did a patient turn to us. Though frustrating, this pattern was somewhat unavoidable since western medicine remains so new in this part of the world.

Other cultural idiosyncrasies were less easy to stomach. One such encounter involved a 12 year old girl who had been brought in by her parents for recurrent headaches. When I first met her she was happy and smiling and teasing her younger brother in the waiting room of the clinic. With some prying, her parents revealed that she had already been diagnosed with a glioblastoma with midline shift—a terminal diagnosis. They had not told their daughter. They wanted to marry her off before anyone else in the community found out. Indonesia has such a rich and colorful heritage. I was often struck by the remarkable grace of the people and the beauty of the culture. However, I saw no beauty in what these parents were doing to their daughter. I still don’t know the best way to process such encounters and yet, it is the nature of our work that we will each face uncomfortable situations, regardless of where we practice.

On one of our weekends, my father and I traveled to Tanjung Puting National Park in Central Kalimantan on the island of Bonero. After a puddle jumper flight from Pontianak, we boarded a small houseboat that was to be our home while in the park and traveled up through the winding waterways that extend like arteries into the heart of Borneo. There, in the depths of one of the least explored, most wild rainforests left on earth, we met Orangutans. There is nothing in this world quite like staring into the eyes of one of the great apes. For starters, they stare back, but more than that, the more time you spend with them and the longer you look into their eyes, the more you see of yourself in them. No other experience has left me more committed to the efforts of the conservation movement.

In Indonesian, Orang-Utan translates directly to “forest people.” In a very broad, sweeping sense, this nomenclature highlights one of the principal differences between western culture, which places a premium on individuality, and eastern culture which looks toward the commonalities between people and groups. Rather than focus on the differences between humans and apes, the Indonesian language reinforces their similarities by referring to Orangutans as people who live in the forest. I think there is a lesson here that relates to how we should interact with cultures whose values may not always intersect with our own. The similarities between us almost always outweigh the differences, and that is an important lesson to keep in mind, particularly when you are working in the context of global health and you encounter situations that you may find deeply distressing. In the end, to sit in judgment of those things that we may see as wrong serves only to perpetuate wrongdoing.

Yet, I still find encounters like the one with the 12 year old girl to be one of the most personally challenging aspects of the practice of medicine. Anne Fadiman, author of The Spirit Catches You and You Fall Down: A Hmong, Child, Her American Doctors, and the Collision of Two Cultures spent a good chunk of her life grappling with this type of challenge. In her book, Fadiman writes, “‘Cultural humility’ acknowledges that doctors bring the baggage of their own cultures—their own ethnic backgrounds along with the culture of medicine—to the patient’s bedside, and that these may not necessarily be superior.” She cautions against holding too rigidly to our own cultural underpinnings when faced with a world full of such rich diversity.