How to save the rainforest: Build a health center

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. 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 kilometers away.

An hour and a few wrong turns later, Wayunisih and Puteri reached the clinic. It was just past 5 a.m. By 8 a.m, a small crowd of 15 adults and children were sat on the clinic verandah.

It was Friday, the least busy day of the week. Any other weekday would see all 40 chairs on the verandah filled.

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.

North Kayong is more than five times the area of New York City. 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.

A beach house-type hut in Gunung Palung National Park, Borneo, Indonesia.

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 But to local people strapped for cash, the trees look like fixed deposits to be withdrawn in entirety.

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.

Selling trees to pay for medicine

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. 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.

Workers at an illegal logging operation in Gunung Palung National Park.

“What would you do to get healthcare? What would you do if your child is sick? Just about anything,” says Webb, a medical doctor from New Mexico, USA, and the founder of ASRI.

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.

The villagers requested two things: training in organic farming¬ – meaning they wouldn’t have to buy expensive chemical fertilizers and pesticides – and quality healthcare that they could afford.

Engaging the village

At 9 a.m., Wayunisih was waiting by the room of Dr Alvita Ratnasari, a general physician. Wayunisih hoped the rumors 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 program, 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, the national park office assigned 20 hectares to ASRI’s maiden reforestation project. By 2013, ASRI had reforested almost 20 hectares, only to suffer a ravenous fire that consumed all but half a hectare.

Since then, the conservation team has replanted 16 hectares. 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.

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 it works until well after we’re both dead.

Giving up the chainsaw

On a long beach just 10 minutes from the clinic is a café selling iced sugarcane juice, a favorite in the dry season. The owner of the café is Wan, whose name has been changed, 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.

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 recognized 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 his café. 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 program. Ex-loggers have left their chainsaws with ASRI in exchange for farms, fish ponds and cafés. But the program 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, said, “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.

Getting diagnosed

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.

“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.”

Wayunisih 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 programs rely on donations and international 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 and expand the clinic into a fully-fledged hospital.

Executive director Monica Nirmala is banking on the new hospital and the recently-developed Indonesian national health insurance scheme for more income. It’s an amazing plan, but one that’s already looking precarious.

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    The hospital isn’t yet qualified under the insurance scheme, and it’s unclear if it will qualify. “Honestly, I just don’t know what’s going to happen,” said Kinari Webb. ASRI isn’t perfect, but it’s trying.

    Later that afternoon, I found Dr Ratnasari reading a book from the clinic library. Ratnasari, who is always smiling when she speaks, had 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 like Wayunisih. 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.”

    This is an edited extract from an article first published by Wellcome on Mosaic. It is republished here under a Creative Commons license.