Sunday, January 05, 2003

43. TB

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Next evening I returned to the Dipo Hospital to find that the life support system for little Nur had been turned off and that Nur’s body had been transferred to the hospital morgue. Nur’s mum, who had been waiting for me in the hospital’s cavernous reception area, brought me up to date with events. She exhibited that disturbing cheerfulness that some Indonesians display at times of bereavement.

"The bill has to be paid before Nur can be taken home for burial," said Nur’s mum, with a polite smile.

"Please, you ask at the cash desk," I said morosely. "I don’t want to deal with these people." I was afraid I might lose my temper.

She made enquiries and returned with a bill for me to examine. The stay of several months in the third class ward was cheap. The main items of expenditure were for treatment in intensive care after the child had become brain-dead. They seemed to have added as many extras as they could think of. We were talking of many millions of rupiahs. "It looks much too expensive," I said. "Why should I pay for treatment after the boy was dead? Tell them I won’t pay for those final bits."

Nur’s mum negotiated with the pebbly-faced cashiers and then returned with a second bit of paper. "They won’t let us take Nur home until we’ve paid," she said. "But if we don’t need a receipt, we only have to pay half."

"If there’s no receipt, they’ll pocket the money," I said bitterly. "The third class ward needs a bit of money. Tell them I must have a receipt."

Having paid the full amount, and having got a receipt, I went in search of a doctor to ask why we had had to pay so much for treatment after the failed attempt at an operation. The only doctor I could find was a miserably thin young man with a scowl. He looked more like a poor Moslem than a rich Chinese. As we stood in a gloomy corridor near the third class children’s ward, I explained the problem.

"The operation was a major one. That’s why it cost a lot," said the doctor, who seemed impatient to get away from me.

"But I don’t think the boy had the operation. He had the anaesthetic only. And most of the expensive bits are dated after the child’s death."

"I don’t know anything about that," he said, glaring at me.

"Look at this hospital," I said, my voice rising. "Paint peeling from walls, old furniture dumped in corridors, water dripping through ceilings, children not getting any medicine, cashiers who suggest you don’t need a receipt."

"You have no right to criticise," said the doctor, almost spitting. "Remember this is the Third World."

"Singapore was a Third World country," I shouted. "But its hospitals are clean and well equipped. They don’t have oil wealth or mineral wealth like you. Malaysia has good hospitals."

As I made my exit I slammed the corridor door so hard I thought the walls might come tumbling down. The doctor reopened the door, came towards me in a menacing way, but then thought the better of it. He turned back towards the children’s ward.

I had to pay for an ambulance to take away Nur’s body. That seemed to be another rip-off. While we waited near the morgue for things to be organised I watched various bodies being brought into the hospital. One bulky man, face completely crimson in colour, had a knife stuck in his chest.


When I arrived at Min’s house, one bright Saturday morning in September, there was no sign of Min.

"He’s down the road at the old house," said Wati, wiping the snot from little Imah’s nose.

"Beside the swamp?" I said. "It’s not very healthy down there. Does he wash in the filthy water from the canal?"

"No," said Wati, frowning.

"Who’s he with?"

"His big brother. Wardi."

"Does Wardi still live down there in the old house?"

"Yes."

"I bought this house here because it has a toilet and a well," I said a little testily. "Min would be safer here."

"Mustapha didn’t turn up yesterday," said Wati, changing the subject to the one-eyed boy I was paying to take Min for walks.

"Has he turned up today?"

"I don’t know," said Wati. I wondered if Wati would have preferred the money I was paying Mustapha to have gone to her.

I took my vehicle as far down the street as the potholes would allow and then stepped carefully over wooden planks, gravestones and gangways until I reached the houses built on stilts. The sky was heavenly blue and the wooden shacks, some made colourful by bright paint and people’s washing, had a certain airy attractiveness which I had not previously appreciated. These homes had views of miles and miles of flat sunny marshland and there was no motor traffic.

Outside Wardi’s house I found Min, eyes gleaming with happiness. Min had a friend. His teenage minder, Mustapha, wearing a shy dutiful expression, had turned up to keep one eye on him.

It was agreed that we would go for a walk. Mustapha took Min’s hand, which pleased me, and together we strolled through the kampung to the house where Nur’s family lived.

The house was a one room hut built on top of wooden stilts which were embedded in the mud of the drainage canal. There was nobody at home so we moved on to the home of Sani and Indra.

"How are the twins?" I asked their mum, who was seated at her front door, sorting out her washing. My driver had told me that the doctor at the hospital had declared them to be cured.

"Fine," said mum, in a slightly vacant manner. The twins, who were standing some way behind their mum, still looked malnourished, like small teddy bears minus the stuffing.

"What did the doctor say?" I asked.

"He said they were better," said mum.

"Everybody well?"

"Yes."

I could see a pitifully emaciated little girl seated on the steps of a house a few paces distant. "Who’s the little girl?" I asked.

"That’s Aisa. Sitting next to her mother," said Mustapha.

I walked over to Aisa’s mum. "Is the little girl well?"

"She’s got a cough," said the plump young woman.

"How long has she had it?"

"Long time."

"Does she eat a lot?"

"No. Doesn’t want to eat much."

"Fever at night?"

"A little."

"Tired? Doesn’t want to play?"

"Yes."

"Want to come to the hospital for an x-ray?"

"Yes."

I was surprised at her willingness. Min, Mustapha, Aisa, and her mum got into the back of my van and we drove, with windows wide open, to the nearby Teluk Gong Hospital.

After various tests had been carried out, the bespectacled lady doctor invited us into her room. We had a long conversation in English.

"Looks like Tuberculosis," said the doctor.

"If it is TB, how long will the treatment take?" I asked.

"At least six months, and it could be a year, or longer," said the doctor. "Children usually get better fairly easily, with good nutrition, which is not guaranteed in this area."

"Some adults don’t seem to get better." I was thinking of Asep in Bogor, and a host of others.

"If the adult’s been ill for years and years, getting no medicine, the lungs and other organs may become permanently damaged. Then, even if the patient gets treatment and is cured, he or she is likely to get frequent bouts of pneumonia and other such infections. People like that may not live long. It’s vital they get diagnosed early."

"I’ll get my driver to make sure Aisa comes to the hospital," I said. "It’s amazing how many people have TB."

"It’s the number one contagious disease in this country, in terms of deaths," said the earnest doctor. "Indonesia’s probably in the top three in the world, in numbers of cases."

"How can a person avoid TB?" I was thinking partly about my own welfare.

"Sunshine," said the doctor beaming. "It kills the bacteria. Sunshine, fresh air and good nutrition. Also, stay away from the sputum of any infected person who’s not getting treatment. Watch out if your taxi driver coughs. If the patient’s been having their TB medicine for at least two weeks, they shouldn’t be a danger."

"Why’s TB so bad here?"

"It’s a poor person’s disease. They’ll build expensive facilities for rich people with cancer or heart disease, but not for people with TB. Not enough top people die of TB, but that’s changing."

"Why changing?"

"Maybe a top official meets a girl in a disco and they kiss. He gets TB. Maybe the rich businessman has food in a restaurant where the chef has TB. The other thing is the fast spread in HIV. TB’s a big problem and getting worse very quickly. In some areas perhaps twenty per cent of the population may have it in the active form."

"Is the government doing anything?"

"The medicine’s too expensive for most of those who’re sick. You need a cocktail of three different medicines. The patient may buy the medicine for a fortnight or a month, feel a little better, and then stop buying it. The bacteria becomes drug-resistant. The patient then passes on the drug-resistant germ to ten or fifteen new people. Once there are a few cabinet ministers infected, then they may waken up."

"What about the cheap government clinics, the Puskesmas?" I asked.

"Have you been to one?" asked the doctor, with a twinkle in her eyes.

"Yes, it had a health worker, but no doctor. The place was filthy. Everyone seemed to get the same injection from the same needle. And nobody seemed to be getting free treatment."

"A huge number of these places are not equipped to deal with TB or any other such disease. No X-rays, no skin tests, no sputum tests, no blood tests. There are lots of Puskesmas clinics but not enough decent people to make them work, and not enough money. Ideally the doctor or nurse must actually see the patient take the TB medicine. And the medicine must be free. We need a big American drug company to invent a cheap new antibiotic."

"How would Aisa have got TB?" I asked.

"She’s probably surrounded by people who’ve got it," said the doctor.

"My driver brings a few people along here each week. He’d better bring some of Aisa’s family too."

"They may be all right. People can have the bacteria in their body but not have the active infection. The skin test may be positive, but not the sputum test or x-ray." The doctor turned to Aisa’s mum, speaking in Indonesian. "How many children do you have?"

"Thirteen," said mum, grinning.

"How come all the families I meet have huge numbers of children?" I said, addressing the doctor. "I thought family planning was supposed to be working here."

"Some people say the figures are manipulated to impress people like the World Bank," explained the doctor, speaking again in English.

"Manipulated?"

"The population growth rate figure may be higher than that published by the government. There have been successes, but mainly due to non-government agencies. You’ll find a lot of the better educated people use family planning."

"How good is the KB, the government family planning organisation?"

"They’ve won international praise," said the doctor, not bothering to keep her face straight. "I know one of the officials. He finds time to run a business and is very rich."

"I met someone like that. He’s a civil servant but he runs a hotel."

We took Aisa and her mum back to their home; and then Min, Mustapha and I continued our walk.

Mustapha led us along a sunny path with colourful shanty houses on one side and a wide flat plain of grass and marsh on the other. We stopped at an open-sided wooden shelter, a bit like a bus stop, to have a seat. A smiling schoolboy on an old bike cycled up to us and began chatting to Mustapha. The schoolboy had a small pocket transistor radio which he switched on to provide some dangdut music. Min stood up and began to dance. I thought to myself: in spite of the lack of clean tap water, this is a beautiful and friendly place.


During the October holiday I enjoyed a candlelit dinner with Anne, Bob and Pauline at their house in Menteng. Bob was attired in a business suit, Anne was wearing a white Rita Hayworth-style dress, and Pauline had on a silky blue top and short denim skirt. I felt slightly underdressed in old trousers and open-neck shirt; but, as always, I was made to feel relaxed and welcome.

Our first course was Betawi Beef Soup, which Anne informed me contained shallots, coconut milk, candle nuts, lemon grass, limes, cinnamon, celery, ginger, coriander, cumin, garlic and beef.

"How’s business?" I asked Bob, as we supped the racy soup. Bob was looking slightly wan and tired.

"Not good."

"Problems?"

"The number one problem is the way staff get employed," said Bob. He always spoke in a gentle manner, with a hint of a smile at his mouth. "They’re not taken on because they’re good at the job. They’re hired because they’ve got the right religion, the right family connections, the right ethnic background. A Christian woman from Medan, for example, is only likely to hire people from her own tribe, no matter how incompetent they are."

"Can they be trained?" I asked.

"You show them a better way to do things. You explain that it will make their lives easier. It will lead to higher pay. They listen. They smile. Then they obstinately ignore the advice from the foreigner. Productivity stays low. You feel paranoid. You feel they’re ganging up on you. You wonder if they’ve put some strange powder in your tea."

A skinny little maid brought in the second course, which was a spicy chicken stew containing kampung chicken, shrimps, tumeric, tomatoes and lime juice; and hopefully no strange powder.

"So business can be stressful at times," I said to Bob, as he poured me some White Burgundy.

"I was stressed last week," said Bob, trying to supress a yawn. "We were in court. We had a perfect case. We acted against this well connected businessman because he was owing us a fortune. He had no real defence, but he won."

"How come?" I asked.

"The story is that his lawyer contacted the judge and offered a hundred million rupiahs. The offer was accepted and the lawyer handed over a suitcase full of money."

"You were unlucky with your judge," I said.

"Someone told me it’s the norm," said Anne.

"Makes it difficult to do business," said Bob.

"Well, I suppose it’s more subtle in Europe and America," said Anne. "You know how much a judge earns here, officially? About the same as my driver. You know how much a lawyer can screw out of people in America?"

Anne proceeded to give us the benefit of her knowledge of Indonesian history. She explained that, under Dutch rule, civil servants were paid such low wages that they were forced to supplement their incomes by taking bribes and siphoning off government funds.

Pudding was sweet rice balls flavoured with coconut sugar and pandan leaves. They were so good that we made little conversation while devouring them.

We moved to the living room to enjoy our Java coffee.

"Is it more corrupt here than in Europe or America?" asked Pauline, as she unpeeled a mint. She was sitting on the settee with her knees up to her chin.

"Well, it’s corrupt in a different way. Here it’s more blatant," said Bob. "Government ministries quite openly give contracts to firms owned by their relatives. Rumour has it that up to 80% of the budgeted funds can end up in the pockets of government officials."

I then proceeded to tell them about my experiences at the Dipo Hospital.




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