Resuscitating the Rainforest

Indonesian doctors show that stethoscopes might be the best defense against chainsaws
  • Gunung Palung National Park's rainforest canopy. | Photo by Tim Laman/National Geographic Creative
  • In Klinik ASRI, staffer Etty Rahmawati (left) gives a slideshow about Gunung Palung National Park while patients wait to be seen by doctors.
  • Yanti with Antonius on the day of her discharge.
  • Nurse Lidya Kristiana tends to a patient.
  • Sri Malianto, a former logger and current rice farmer and ASRI Forest Guardian.
  • Samido, a Javanese migrant, stands amid his chili pepper plants.
  • Wahono and an American doctor examine a patient in Penjalaan.
  • Irfai considers himself the leader of Penjalaan's farmers.

The patient, Yanti, is 19 but looks far younger. Her capri-clad legs dangle off the exam bed. Her slight arms are softened by baby fat, and her eyes, round and enormous, gaze out over nothing. At her side sits her husband of three months, Antonius, a gangly teenager with blades of gelled hair and a T-shirt that says DO WHAT YOU WANT. The pain in her head is more intense than any she has ever felt, and her eyes are suddenly failing--she can see only blurred colors.

Dr. William Wahono, 27, broad-headed, and known to patients as Dr. Willy, presses the sides of her neck, which causes her to wince. When he tries to coax her chin downward, she bends at the waist instead, leaning her whole stiff torso forward.

"Fairly significant nuchal rigidity," says Dr. Nur Chandra Bunawan, also 27, who is the clinic manager here at Klinik ASRI, a nonprofit medical center in the Indonesian province of West Kalimantan; its initials stand for alam sehat lestari, which roughly translates to "healthy nature everlasting." Two American doctors stand nearby, volunteering as consultants.

Yanti looks in the general direction of Wahono, who listens with a cocked head as she describes her symptoms: Four days ago, she started to lose her sight. Her head hurts right in the center. One doctor thinks it's meningitis; another, some kind of ophthalmological problem unrelated to the headache. They would test for meningitis, but in this rural clinic, located a five-hour boat ride south from the nearest hospital, they don't have the technology to perform a spinal tap. They consider referring her to an ophthalmology specialist at that hospital, in Pontianak.

Then Yanti's mother shows up with a manila envelope that reads RADIOLOGI.

The American doctors grumble--why did it take so long for the family to reveal that she'd already had a CT scan? "Sometimes they hope for a different diagnosis. They think her condition will be different if the doctor doesn't see the tests," Wahono says. He and Bunawan take the image to another room, where a light box hangs on the wall.

With one hand on his hip, Bunawan points at the white cloud seeping into one of the black spots in the center of Yanti's brain. "There is a tumor," he says, rolling the r. He leans back like a grain stalk in the wind, propped against a wall with his belly thrusting forward.

"It looks like it's in the optic chiasm," Wahono says.

Back in the exam room, doctors take turns shining a light into her eyes.

"There's the cup, but I can barely make out the disc," one says. They are talking about the appearance of her optic nerve. It's supposed to look like a bull's-eye, but the central circle is under so much pressure that it grows to the borders of the target. Yanti is Wahono's patient, and he discusses treatment options with the other doctors before calling her parents into a separate room. Yanti and her husband wait on the exam bed. "In Indonesia, we tell the family in a situation like this. They decide if the patient should know," Wahono says.

Yanti's parents tell Wahono that they know about the tumor and that the doctors in Pontianak told them it isn't in her brain but somewhere between her brain and her skull.

No, Wahono says. The tumor is in the center of her brain. It is inoperable. He pauses to give them time to absorb this, a technique he learned in medical school. "I tell them, and I wait," he will later say. This pause feels mechanical, as if he is silently counting down from 10. But true empathy comes from his eyes--the way they rest on Yanti's parents--and the way he leans toward them.

The town of Sukadana, where the clinic is located, butts against the edge of Gunung Palung National Park, a dank, vaporous orangutan haven. For many years, this forest has been ravaged by illegal logging, mostly done by individuals who need to compensate for low rice prices or who suddenly need money to pay medical bills.

The clinic is the centerpiece of ASRI's larger system, which is designed to simultaneously prevent the degradation of Gunung Palung and offer high-quality, low-cost healthcare to those who live near the park. The amount patients pay is based on the success of conservation efforts surrounding their home villages, and all Indonesian women are entitled to free birth control. A person from a village with a sawmill and a lumber storage facility will pay the most; a patient from a village where no logging has occurred in the past four months will pay the least. All patients have the option to barter with crafts (which are later sold at fundraising events run by ASRI's partner organization in the United States, Health in Harmony), organic cow dung, labor, organic fertilizer, or seedlings that fit the needs of ASRI's reforestation projects. Some patients even make the five-hour boat journey from Pontianak because they have heard that ASRI provides better healthcare than the hospital there.

Yanti and her husband have come on motorbike from Kepayang, a village to the southeast where logging still occurs. It doesn't directly border the national park, meaning they will pay a higher price for care. The doctors admit her as an inpatient. They want to at least relieve the swelling in her brain so she can go home pain-free and with her vision restored.

Sri Malianto, a rice farmer who lives about 10 miles from the clinic, looks out his window and, for a flashing moment, while trying to stay serious and humble, lets a smirk break onto his face.

His village recently shut down its sawmill, which caused the health center to give its residents a better rate. "It's very rewarding," he says. "The people here are very positive about the tiered system."

The rainforest begins as a green wall across the road from his house. Most of the forest is protected as part of the national park, but an institutional boundary doesn't keep people from felling trees. While logging has decreased since ASRI was founded in 2007, it still goes on.

Malianto was a logger from 1995 to 2007. Now, he volunteers as an ASRI Forest Guardian, or SaHut (short for sahamat hutan, or "best friend of the forest"). Sensing a need for stronger community involvement in its rainforest protection efforts, ASRI founded the SaHut program in 2011. Each of the 30 SaHut volunteers lives in a different village near the rainforest, and half a dozen are ex-loggers. Malianto gives talks in his village about the importance of a healthy rainforest, his main point being that water, which comes down to them from the rainforest hills, flows cleaner and more steadily when filtered by tree roots. He also teaches people about organic farming, which ASRI hopes will be adopted by former loggers in need of income.

Malianto's wife brings in plastic wineglasses full of watery orange syrup--a popular drink in West Kalimantan. As we sip, he talks about his days as a logger.

"You cut the tree down, then cut it into logs, then drag everything out," he says. "It takes several days in the forest. It's painful work." He does not miss logging, but its economic appeal remains obvious. Back when he logged, a tree about five feet in diameter was worth $4,000 and took about three days to cut. Today, that same tree would be worth $20,000. He made $5,000 off rice farming in 2012.

Malianto says he will never go back to logging because the forest is too important. He even convinced his parents to abandon logging for rice farming. The most pressing task now, he says, is to help others understand their dependence on the trees. If he hears chainsaws near his village, he will find the loggers and try to explain this to them. "I usually know them, and they listen to me," he says.

Malianto's comments conjured memories of a trip into the jungle I'd taken two days earlier with his brother-in-law, Muslianto. He wanted very badly to show me orangutans, but we saw none. The whole trip he was shrugging his shoulders and saying, "Orangutan nest. No orangutan." We spent one night in a sort of wooden fort in the rainforest. He kept slipping away and reappearing out of the dark to show me animals with his flashlight--bats in a banana tree, a turtle in a net, a rat that looked like a small pig. At one point, we hiked up to a vista where the valley rolled out below us. We could hear birds and the resounding growl of chainsaws.


FROM THE FRONT SEAT OF A PICKUP TRUCK, Wahono says, "They told me that when people in Penjalaan get sick, they don't go to the doctor. They wait and die."
Wahono is making a house call in ASRI's mobile clinic, a pickup full of basic medical supplies that visits a different remote village each week. In Penjalaan, the houses are nothing more than weathered sheds on stilts, their wood drying out in the equatorial sun. Women and children sit along the grassy banks of a roadside ditch, brown water gurgling between their toes. It feels isolated, like a separate world from the rest of the province.
The patient lives in one of the wooden sheds sandwiched between the muddy ditch and the rainforest. There is barely anything inside the house—a few cans of motor oil, a plastic mat to sit on, a sack of chemical fertilizer. Light pours in through a single window and shines up through the floorboards. Kids huddle in a corner, and the patient sits cross-legged in the middle of the room. He is wearing basketball shorts and a huge T-shirt, and he looks malnourished, his skull prominent, his eye sockets deeply cratered, his legs rubbery and bone-thin at the thigh. The tumor on his kidney is so large that it bulges like a melon on his abdomen.
Wahono and the man speak in Indonesian for about 15 minutes before another man comes in and takes over the conversation. He produces two manila envelopes, like the one carried by Yanti's mother. Wahono slips out a scan of a thorax and holds it up to the window. One side looks normal. The other side is covered by a white blob.
"You can see how the diaphragm is being forced up," he says.
The man wanted to have surgery and waited at the hospital for 20 days, but no doctor would schedule him for an operation because he had failed to provide blood. Wahono explains that when the risk of significant blood loss is high, patients must bring blood to the hospital in case a transfusion is needed. In the end, Wahono suggests they put out a notice to friends and family. Ten bags would be a good goal.
Above the forest outside, clouds brew high and thick, a typical sight in the Borneo sky. At the other end of the village, people line up at a well that ASRI just installed. The well produces clean water that seems limitless. But as we drive away, we see more people bathing in the ditch by the road. Perhaps they don't know about the well yet. Or they think that the line is too long. Or they just don't want to change.
A hundred yards down the road lives Irfai, one of several organic farmers in Penjalaan who received training from ASRI. He has invited me to see the farm he shares with six other men.
When I enter his house, I find all of them waiting on the floor amid little teacups and huge tubs of cassava chips. They are transmigrants—their home state, Java, is so crowded that the Indonesian government offered them free land in exchange for moving. Five years later, they are still melancholy over their prolonged separation from home.
"We miss the culture of Java and our families," one says. "We miss the Javanese tradition."
"We didn't know each other before, but we moved here at the same time and became like a family," says another.
The farmers tell me that ASRI has taught them the best ways to implement organic farming techniques. They've also received goats and plants and taken seminars on how to market their produce. Much of their manure and fertilizer comes from patients of the clinic, who used it as currency. But as they speak, they shift into complaints. They want certain expensive tools. They want cameras to photograph their farm. They want the cows they were promised. While the tools and cameras are not in the farmers' future, the cows supposedly are.
Irfai takes me outside. He points to some acreage overgrown with weeds. This is the pasture that they are required to provide before ASRI will give them cows, which will produce more fertilizer than the goats they use now. The pasture has been there for several months, he says, and there still aren't cows in it. They must wait until the nine other organic farms in the area get their pastures ready because ASRI wants to distribute all the cows at once.
"They are not ready. But we are," Irfai says, frowning amid rows of chili pepper plants. "We are excited to have more fertilizer. We are also excited to take care of the cows."
Irfai walks me through the farm—mostly chili peppers, with some rambutans and palms to round out the harvest. Then he shows me a spindly gray tree set off to the side. It's a gaharu tree, a high-risk, high-reward crop that he hopes will eventually rot into a dark, fragrant substance called agarwood, to be sold as an ingredient for incense and perfumes. There are stories of people disappearing into the national park for two weeks at a time and returning with $100,000 worth of it. One of the farmers knows of a university in Java where he can buy a fungus that encourages rotting. In three years, they will inject the fungus into the tree and wait as the leaves fall off and the wood blackens.
ASRI's organic farming program is headed by a short, smiling man named Miftah, who is strolling among the chili rows with his hands clasped behind him. I ask him why ASRI doesn't encourage the farmers to plant more gaharu trees.
"It is not reliable," he says. "The soil here is too soft for the roots to take hold. I don't think it will succeed."
He says the program's primary purpose is to help farmers generate income so they aren't driven to log the rainforest. The organic part is secondary, and is harder to push than farming in general. "Most of these farmers want instant results," he says. "Many people here really trust the chemical fertilizer, which makes the farming easier. It's very hard to get them to switch."
After four days in the clinic, Yanti sits with her husband, kicking her legs over the edge of the hospital bed. Her mood has changed. Still blind, still in the same capris, she has been relieved of her headache by a course of prednisone—a steroid that decreases her intracranial pressure. She will take it for the rest of her life. She is ready to go home.
"We tried everything we can, and we know it's inoperable, so we hope a miracle will happen," Antonius says, his hand cradling Yanti's as if it were a newborn animal he hoped to keep alive with his gentleness.
"I feel blessed that I can still see a little bit of light," Yanti says, smiling wide but struggling with where to aim her eyes.
That evening, I watch as Antonius helps Yanti onto his motorcycle in the front yard of the clinic. It is humid and cooling off. They pull away, and the young doctors return to their house, which isn't so different from a house where American college students might live (although space is so scarce that Bunawan and Wahono must share a bed). Bunawan lays his gangly body across the couch. Tomorrow, all across the region, the organic farmers will tend their plants, the Forest Guardians will give their talks, and at Klinik ASRI, the doctors will receive a new round of patients. For now, though, they just turn on their iPads, play video games, and fall asleep.

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