Why ASRI/Health in Harmony’s Borneo Project is Cool.

Why did we come all the way to Borneo?  Well…I was intrigued enough by ASRI/Health in Harmony’s integrated health and conservation project in Sukadana that I wanted to see it for myself.  The basic idea is that in this rural area in Western Kalimantan, Borneo, providing affordable healthcare allows people to stop cutting down the rainforest to pay to go see a doctor, preserving orangutan habitat and a globally-relevant carbon sink.

A bit of background: in med school we pretty much learned how to treat individual human patients, and as a young doc I thought that learning that made me a very smart and useful human. And then, in a humbling process that happens to most of us, at a certain point, having seen the same patients in the ER over and over—for non-healing infections, substance abuse, trauma, or other reasons–I realized that it didn’t matter what medicines I gave them if they didn’t have a dry bed to sleep in and enough money for food.  I learned to pay more attention to what we call the “social determinants of health,” things like income and income distribution, education, unemployment, job security, early childhood development, food insecurity, housing, social exclusion, gender, race and disabilities.

And then, after working with children with malnutrition and Indigenous populations in the Arctic, it became clear that actually–the social determinants are themselves underpinned by ecology.  Food security varies with temperature and rain patterns.  Housing is impacted by permafrost melt and extreme weather.  Drought can be associated with population displacement, and conflict, which leads to myriad, sometimes-catastrophic health consequences.  I started reading quite a lot about climate change just before spending 6 months working with Médecins Sans Frontières(MSF)/Doctors Without Borders.  The literature makes it clear that changing climactic conditions will have huge impacts on the ecological determinants of health–and therefore the social determinants (take a look at my TEDx Talk for a 16 min overview).  Reading later about soil, nutrient flows, and biodiversity–the picture broadened to include myriad issues that we need to deal with if we want to continue to have a stable ecological platform to support the social determinants of health.

An increasing number of health workers worldwide are following a similar thought pathway–and in 2015 the Lancet coined the term, “Planetary Health,” defining it as “the health of human civilisation and the state of the natural systems on which it depends.”  Personally–I love the comprehensiveness of this term–the way it entwines global health with ecological health and brings the bottom line of it all clearly into view: if we want to maintain the health of people around the world–we need to improve the care we’re providing to the planet–so it can keep taking care of us.  And given our current-day situation–we need to start doing this–as we say in the ER–“STAT!”

Which is where Health in Harmony and ASRI’s program comes in.  Kinari Webb came to Borneo to study orangutans, and then realized that much of their rainforest habitat was being destroyed by logging.  When she asked the villagers why they were logging, a frequent answer was that they needed cash to pay for healthcare.  She asked them–if affordable healthcare were available–would they be willing to stop logging?  The answer was yes.  So she applied for, and got into Yale medical school, heading into her studies with the hypothesis that saving the orangutans required preserving forest–and that the best way to do that was to come back when she was a fully-trained MD and to open a clinic to provide affordable healthcare.

Fast-forward some years.  Unlike many of us who abandon our pre-med ideals and dreams once absorbed into the medical vortex–the now-Dr Kinari Webb came back to Borneo and catalyzed a process in partnership with Indonesian colleagues to provide affordable healthcare in rural Borneo. Health-in-Harmony, an American NGO, is partnered with an Indonesian NGO named ASRI, which provides the on-the-ground services. They operate near Gunung Palung National park, a 90,000 hectare park that covers a vital watershed that supports more than 60,000 people.

More than 70% of the lowland forests within the park’s buffer zone were deforested between 1988-2002.  Starting in 2007, Kinari (who speaks Basia Indonesian) and her team conducted 400 hours of community meetings, and the villages unanimously agreed that they could stop logging if they had access to high-quality, affordable healthcare and training in alternative livelihoods.  Their 2007 baseline survey found that the communities bordering the park were very poor, with an average income of $13 per month.

They came up with a plan that has 5 parts: (quoting Health in Harmony materials):

1-monitoring logging activity through community meetings, satellite imagery, and surveys;

2-providing healthcare in ASRI’s hospital, which offers non-cash payment options and progressive discounts to villages as they reduce rates of logging;

3-making alternative livelihood opportunities available through training and assistance to people who want to stop logging;

4-conducting conservation education programs for all ages

5-planting native rain forest trees in the park to restore critical habitats for orangutans and other species.

I became aware of Health in Harmony and ASRI’s program a little over a year ago when Jonathan Jennings, the former deputy head of Médecins Sans Frontières(MSF)/Doctors Without Borders-Canada took the job as Executive Director of Health in Harmony.  Coming from the world of humanitarian medicine, he needed a briefing on climate-health and was introduced to me by mutual friends at MSF.  Through our conversation about his new job I became intrigued–was there really a hospital that was taking not only ecological feedback loops into account–but incorporating elements of a just transition away from a resource-based economy?  Could they possibly be going about this process in a way that seems to avoid most of the colonial mistakes of development work?

When Jonathan later asked me to join the Health in Harmony board I was interested enough in the possibility that maybe they actually were making good progress at this complex intersection of human health, social determinants and ecological determinants that I agreed to join.  And then, during a call this past January when it turned out that they had a gap in clinical coverage right at the same time that my husband and I had already booked time off but hadn’t yet made plans…we decided to jump into a visa-application flurry, buy airplane tickets and come see for ourselves!

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