Indonesia Part II - Balancing Economic Development with Environmental Sustainability

Just like every party, every good trip deserves a theme.  For Indonesia, the theme we set out to explore was balancing economic development with environmental sustainability.  This is an especially appropriate question to consider when visiting Indonesia.  Again, let me do a little to set the stage on Indonesia.

While being the fourth most populous country in the world, Indonesia only has the world’s 17^th largest economy.  In my opinion, that’s not that bad.  Certainly no Japan but still safely within the G20.  GDP per capita is about $3,500 which is on par with what you would find in much of Central America or countries like Ukraine.  So… good but not great.  However, Indonesia has been blessed with being situated almost literally on a gold mine.  First, it straddles the equator and is drenched with copious amounts of sun and tons of rain and moisture.  Basically a natural greenhouse.  This is especially good for growing things like palm trees for palm oil (more on that later).  This rich biological gift existed in prior years as well and as a result Indonesia sits on top of large amounts of both oil and coal.  Until recently it was the only member of OPEC but has since become a net oil importer (hey, 240m people need oil).  Further, Indonesia has tremendous biological diversity as one might expect.  It has everything from komodo dragons to orangutans to just about anything else you might expect to find in SE Asia.  This biodiversity extends to the ocean as well.  Indonesia has approximately eight times the biodiversity of coral as the entire Caribbean.  Apologies as that stat might be slightly off the mark but I don't think it's off by much.

However, it’s already fully in the throes of cashing in on these resources.  Indonesia is the world’s fourth largest emitter of greenhouse gasses in the world.  Yeah, I know, finally punching its weight!  But in this case that’s really not great.  Especially since emissions will grow as Indonesia continues to develop.  Mostly this is due to the clearing of land for palm oil.  Small or large actors will clear virgin forest (that stores literally tons of carbon) and peat bogs with bulldozers and fire to make the way clear for the incredibly lucrative palm oil plantations that cover large swaths of Indonesia.  This releases massive amounts of carbon into the atmosphere while also wreaking havoc on Indonesia’s forests and biodiversity.  To boil it down to a Greenpeace campaign, glaciers and monkeys vs. palm oil and cash money.  Worse than this is the coal mining that goes on in the northern reaches of Indonesia.  Unlike coal reserves in the US, that lie far below the ground, Indonesia’s lie just under the surface and lend themselves to strip mines that literally uproot every tree in sight.  Not surprisingly, this is devastating to the local ecosystem.  These operations lead to massive runoffs, contamination of the water supply, and devastation of the region’s topsoil.  There is also significant oil production but it almost pales in comparison to the effects of palm oil and coal operations

Knowing all of this, you have to ask, what should Indonesia do?  It’s easy for us in the developed world to say that this type of reckless development is indefensible but it would ring pretty hollow considering the wanton use of the environment that we’ve shown in the past.  Plus, how do you really tell a poor Indonesian not to cut down some trees to provide for his family?  I know what decision I would make if it were between my children and the trees (or peat bogs) in my backyard.  Next, I’ll discuss this question from the perspective of government and corporate leaders in Jakarta.

Indonesia Part I - Setting the Stage

Stanford GSB, in its wisdom, insists that all students must complete at least one structured, global experience before completing the MBA.  At first I was a bit skeptical of the logic behind this requirement.  It seemed like insisting that all students, regardless of past experience were in need of a trip of this nature was wrongheaded and would lead to a misuse of some students time and resources.  However, as the pre-trip meetings gathered steam, I began to change my mind on the topic and upon reflection, I'm glad for the policy.  I'm certainly still digesting the lessons that I learned over my time in Indonesia (the subsequent blog posts will do something to address this) but I wanted to get started with laying the background before I jumped into my thoughts from the trip.

First, the trip.  Stanford offers 15 or so trip options for the first year students.  The trips must be to a country that you haven't spent serious time in before and are usually about 1.5 weeks in length.  The nice part is that second year students plan the entire trip covering country selection, travel logistics, and meetings.  All we need to do is rank the trips we find most appealing and cross our fingers that we get it.  Typically, you'll be matched with either your first or second preference and grouped with 17 of your soon-to-be-best-friends.  At that point, only a few meetings and some paperwork stand between you and a country you know nothing about.  In my case, Indonesia.

Okay, time to move away from logistics to start talking Indonesia.  The first thing to understand about the country is its scale.  As I learned in literally every meeting, Indonesia is made up of 17,000 individual islands stretching over 3,000 miles (greater than the width of the continental US.  Indonesia is home to 240m people making it the fourth most populous country in the world (just after the US).  Stretching the word scale a bit, Indonesia also houses incredible demographic diversity.  The archipelago supports over 300 ethnic groups speaking 700 languages / dialects.  Can you imagine trying to make generalizations to cover a country like this?  I hope so since I'll be making some later on...

Next, we should turn our attention to Indonesia's recent past.  Well, recent-ish.  In 1600, the Dutch laid their claim to Indonesia via the Dutch East India Company.  They didn't control much beyond the coastal regions until the 1900s but at that point the end was already bearing down on them.  In WWII, Japan invaded Indonesia and expelled the Dutch.  Then, when Japan surrendered, the founding father of Indonesia, Sukarno (not Suharto) declared Indonesia independent.  The Netherlands tried to get Indonesia back after but colonialism was so passé at that point.

Sukarno ruled Indonesia as an authoritarian until an attempted coup d'etat weakened him politically (despite a violent purge of Communists) and General Suharto assumed control in 1968.  Suharto made a number of reforms to Indonesia's economy but ruled with an iron fist and allowed tremendous corruption.  Finally, in 1998, he resigned amidst the instability of the Asian Financial Crisis.  Transparency International estimates that Suharto embezzled $15-25 BILLION over his 30 year reign.  

Sukarno

Suharto

Since the financial crisis, Indonesia has been steadily regaining lost ground.  Since 2007, its GDP has grown at over 6% a year.  Given the Global Financial Crisis, this is an incredible statistic.  Corruption still plagues the country but it is currently rated investment grade so... not too terrible at least.

Okay, that is a basic grounding in Indonesia that in no way does it justice but that should suffice for our purposes.  In my next posts, I'll dig into some of the reflections from my trip.

What Could be Stereotypes

I was doing some light reading on scaling up treatment for pneumonia, malaria, and diarrhea in a selection of countries when I came across what could be gross stereotypes of crests.  But they weren't.  So, I did a little more searching and found some other crests / emblems / shields that I particularly liked.  And here they are:

1.  Djibouti:  Pretty solid.  What defines us? Machetes, a spear, and a shield.  And we're not bad with MS Paint.

2. Zaire: Jaguar! Spears! Scimitar!  I'll be honest, I like this one.  Pretty hardcore.  Okay, technically Zaire isn't around anymore but still, good work.  This is also a step up from MS Paint to PowerPoint.  I could have made this.  I am a fan of the motto though.  Justice, peace, labor.

3. Mozambique:  Hmm, suspicious... same red star as with Djibouti.  But, I dig the gun and bayonet crossed with the hoe.  Very agrarian / communist of Mozambique.  I can't get over the weird water at the bottom though.  It looks like it's surging up on the right.

 
4. Democratic Republic of the Congo:  And last but not least, the current incarnation of Zaire, the DRC.  As if it didn't already have enough problems.  Basically it just took what it had as Zaire from above and took it down three notches.  Probably the rattiest big cat I've ever seen plus super low res spear and saber. Seriously.  Same motto but now it is sitting on top of a mud block.  I'm not impressed, DRC.  I'm throwing my hat in the ring for v2.

Mo' Money, Mo' Problems

As a baby photographer, I’ve been tasked with taking photos of each of our clinic sites, to document the processes and also possibly produce some promotional material worthy images. Our director, who this week is in Washington meeting with ‘the highest guys at USAID and PEPFAR,’ has repeatedly told me that the pictures are ‘very important politically.’



Today I visited Makambako, a small town on the Tanzam highway between Iringa and Njombe. The town was dry and dusty, but the clinic was actually a quite nice and new. As I walked around taking pictures, I noticed that there were two distinct groups of people: those who wanted their picture taken and those that turned away from the camera. I tried to focus on the kids who liked the camera, but soon I heard grumbling from the crowd around me. I saw two traditionally dressed older women scowling at me, and rubbing their fingers together. Yes? I asked, feigning innocence. Money first! they hissed at me with narrowed eyes. A small boy beside them positively yelled, ‘GIVE ME MY MONEY FIRST!’

I could feel the mood change in the crowd as everyone turned to stare at me, and I felt an involuntary sense of disappointment and disgust. I lowered my camera and stood silent for a moment, debating how I could explain in my elementary Swahili that I was not a professional photographer who would profit from these photos. That actually, I was a taxpayer that was indirectly paying for the free service their sons would receive today, and that these photos were to help ensure the continued supply of that service.

Of course I couldn’t explain this, so I waved and left the crowd. I felt annoyed, but I knew I had little right to be angry. Most of the people in the crowd were poor enough to make a good living off what I spend on coffee in a year, and furthermore, how could I convince a group of subsistence farmers that I had this fancy camera not for work, but simply because I enjoyed it as an inconceivably expensive hobby? Perhaps these Tanzanians have met photographers or heard about photographers that profit from their photos, and in that sense they do have a right to demand some payment. Morally, it doesn’t add up for a photographer to take a photo of a child in destitute poverty and then sell it for hundreds or thousands of dollars as art.

Africa is a culture shock, but from my highly affluent lifestyle back home to the dirt roads of Makambako, I can’t escape the pervasively corrupting influence of money. I feel sad to see the little boy shouting at me for money, but of course this fixation on money is only a byproduct of having so little of it. But do I have any moral ground? Maybe Americans don’t scowl and shout at strangers for money, but we are certainly willing to bomb civilians and impose economic sanctions in order to protect our wealthy way of life. I guess this is also impolite, just on a grander, and more acceptable scale.



But speaking of photography, I want to plug my friend spencer’s photos, which are infinitely more compelling than mine. He is in the Zambia, probably saving children, but I’m not sure. You can click through the photo to get to his flickr stream.

Vignettes from Honduras

I suppose I can't let Linda dominate the blogging too much since my boy B has dropped the ball so badly.  But, since I'm writing this on a plane and can't research my next post, military drafts, you'll get just my musings.  But let's call them vignettes and not musings.  So, over the next ten minutes you'll get to read about, gov't inefficiency, gov't efficiency, community activities, non-profit bumblings, and for profit excellence.

Plates in Process (Government Inefficiency)

I bought my motorcycle in mid December with no license plate and left Honduras in early April still with no plates.  I never got a Honduran motorcycle license either but that’s another issue entirely.  Apparently there is about a one year delay on getting plates of any kind in Honduras.  A friend from work told me that it was due to a lack of materials and some slow bureaucracy.  Last I checked, metal was in decent supply so I’m chalking up about 11.5 of the12 months up to bureaucracy / inefficiency. 

Don’t worry though, I had a permit to drive without plates.  I had to renew this once every three months.  This consisted of standing next to long desk and waving my expired permit and a 50 lempira note a lá late night bar style until a functionary grabbed it.  After about a two minute wait, my permit returned with a smudged blue stamp giving me another three month’s grace.

On the flight back, a chubby American that was living in Honduras told me that if your plates get damaged (in a fender bender let’s say) it is advisable to have a counterfeit plate made.  This pokes another hole in the lack of materials theory.

Overhead (Government Efficiency)

Much of my work required interacting with members of the government’s Promotion of Agriculture office.  This group is part of the larger Secretary of Agriculture (equivalent of our USDA) and is a legit organization of it’s own.  I’m on a first name basis with it’s Director (shoulder brush off).  Anyways.  What an interesting set up.  When you walk in, no reception.   Nothing.  Just stairs.  I told a passerby what I was there for and they led me up to flights of stairs and down a hallway to a door with a rainbow colored word art sign.  This was the office of PRONAGRO.

After my meetings, we would exchange emails so that I can follow up with more questions as I had them.  Everyone uses yahoo, hotmail, or gmail addresses.  No official .SAG or .PRONAGRO or even .gob (that’s spanish for .gov for you gringos). 

That’s how you cut overhead America. 

Soccer in La Esperanza (Community Activities)

I went up to the town of La Esperanza for some interviews and stayed with a co-worker.  On our way back from an evening meeting, we stopped in the central square where there was a soccer match underway.  Every night there are two games in this square between many team’s in various leagues.  The teams were composed of all ages.  Teenagers and 60-year-olds ran around the field with equal abandon if not equal speed. 

There was one especially short player that I noticed.  My colleague told me he was one of the Lencas, an indigenous group that lives in the area.  Apparently he runs into town to play.  10km each way.  Not bad.

Debt Forgiveness (Non-profit Bumblings)

I stumbled across this little gym in an NGO report on Honduras.  I’m sure this was a huge revelation to them.

(ii) the debt forgiveness mandated by the government of Honduras has distorted the lending market and encouraged a culture of nonpayment, which is a challenge to overcome;

Who would have ever guessed?

Data Visualización (For Profit Excellence)

My preferred Honduran periodical, La Prensa, published a little gem of data visualization every day towards the back of the paper.

Impressive and sobering.  It shows the reported crime in San Pedro Sula over the last three days.  The key icons are the sprawled bodies (homicides) and the guns (armed robberies).  The red icons with cars are car robberies and the blue icons with busses are bus robberies.  I worked just under the “s” in Noroeste in the top left and lived on the left side of the map just under BLV Los Proceres.  Relatively safe areas.

Letter from Njombe Town

Last weekend, the campaign team and I made the two-day journey (on Tanzanian time, which is really a one day journey in normal time) from Dar es Salaam to Njombe, in the far southwest of Tanzania. I had loaded up my podcasts and my sleeping hat for the ten highway hours, but I ended up with my eyes glued out the windows for most of the trip. I saw Hillary Clinton (or at least the diplomatic motorcade of), as well as elephants, giraffes, zebras and gazelles, although I think the Hillary is not actually native to this area.

I also saw the most astounding poverty I’ve encountered in my life. On one of my free days in Dar, I visited a ‘cultural museum park,’ which exhibited various mud huts used by different tribes in the country. I toured each of the musty low-grass-ceilinged structures with a flashlight, and tried to imagine what it could possible mean when a sign pointed to two square feet of dirt floor and said ‘The Living Room.” But after all, it was a museum, and I like modern art, so mostly I was able to relegate it to an abstract ideas area of my mind and move on.

But all along the Tanzam highway, I saw villagers living in mud structures and collecting firewood. These mud homes weren’t even as nice as the ones in the museum, but were shabbily thrown together and covered with sloping straw mats. I watched small children chasing each other around the houses and women carrying bundles of rice or wood on their heads. Here was the abstract in reality.

Being in Njombe for the past week, I’ve also noticed the distinct and sometimes surprising markers of poverty in town life. The per capita GDP in Tanzania is $500. To drive myself crazy, I like to think about how my annual medical school tuition is $50,000, or 100 times more than what the average person here makes in a year. For the golden price tag of 50 grand, I am provided with the online password to a cache of lecture videos, about four school sponsored keggers, and the legitimacy to travel here as a summer intern. It’s a funny idea to imagine, on the one hand, a laptop with lecture videos that amount to my medical education, and on the other hand, 100 Tanzanians. Or, if you like, my Macbook, and two Tanzanians. Or my iPhone, and one Tanzanian. These comparisons make life seem so unbearably arbitrary.

So what is life like in a town with a per capita GDP of an iPhone? I think on of the first things I noticed going up and down the one road in town is the lack of any bookstores, or music shops, or art establishments. For $500 dollars a year, you don’t get any of these niceties. What you do get though, is a choice between 15 different churches in which to worship. The churches are invariably the nicest and largest standing structures in town, and their soaring spires make an odd picture beside small stands selling used socks and potatoes. Not surprisingly, everyone is religious.

Poverty also does not lend well to culinary creativity, and ‘Tanzanian cuisine’ consists of rice, beans, steamed maize called ugali, fried chicken, friend potatoes, fried eggs, and fried potatoes with eggs. Ordering at a restaurant means getting a plate of one of the three things they have, which rarely changes day to day. Amazingly, local people don’t seem to notice the monotony of it, and ask me sincerely if I’m ‘enjoying Tanzanian food.’

The government does not provide a garbage collection service. I didn’t realize this until one day when we were unpacking boxes and boxes of surgical instruments, and were left with a pile of plastic bags as waste. We asked some kids on the street to help us clear the mess, and a while later I stepped outside to discover them burning the plastic bags in a big pile in front of the house. I was overwhelmed by the intense smell of carcinogens filling my body, and I turned to a co-worker to ask what the hell they were doing. ‘What else do you want them to do with the garbage?’ she asked, bewildered. And then I realized, every household across town, and in the villages does this. This was the smell that I had noticed for days but couldn’t place. Njombe is developed enough to have Coke bottles and plastic wrappers, but not developed enough to have a central garbage service.

Hans Rosling has a great and simple idea about differentiating between the means of development and the ends of development. Healthcare, economic growth, stable government: these are only the means, and not the ends of development. They aren’t the things that make life worth living. But to have books, music, plays, cake, and lets not forget cookies, doughnuts, strudel, muffins, pancakes, turnover, and dessert sampler plates, etc, these are the things that really make people happy (or if you don’t like my hyper-western/sweets-centric value system, we can just say ‘culture’).

I think something that does amaze me about the local people I meet is that everyone seems pretty happy. Locals regard me with a confused look, but a simple hand wave and a ‘Mambo’ usually gets a big and ready smile. But still, I can’t imagine my childhood with no bookstore, no library, no music hall, no sports teams.

This post amounts to an ineloquent but realtime effort on my part to come to terms with the unfathomable differences between life here and my life waiting for me back home come August. But until I come to some kind of satisfying unified theory on this, here are some pictures of animals and such.



Elephants


Masaai girl herding cattle by the highway


Overturned truck with spilled cargo along the highway

Male circumcision, WTF? (what are the fundamentals?)

After heaps of requests from international fans, I’m finally ready to reveal the project that has brought me to Tanzania for the summer. This way at least, my friends can stop ending chat conversations and emails with ‘K go save some children!’, to which I can only reply ‘lol k thx bye!’ as they sign off, caught between feeling inadequate and not wanting to debunk their image of American medical students immediately eradicating poverty and disease by their mere presence on the continent. But anyways.

I’m in Tanzania this summer with a Johns Hopkins affiliated NGO that works on bringing innovations to practice in developing countries. Specifically, I’m here to help on an 8 week male circumcision campaign in the rural Iringa region of southwest Tanzania.

Before I go on, here’s a primer for the general audience. Over the past several years, three definitive randomized controlled trials (the most badass, legit kind you can do, for you non-medical folks) in sub-Saharan Africa have shown that circumcising adult males reduces their risk of HIV acquisition by 60%. SIXTY PERCENT. In fact, in all three studies, the differences in acquisition rates between the control group and circumcision group were so extreme that the trials were stopped early, since it would be unethical to allow the control groups to go on not receiving the procedure.

(If you’re curious about the science, the risk reduction has something to do with the high number of Langerhans cells on the underside of the foreskin, through which the virus particularly enjoys attacking and entering the body.)

When you factor in that circumcision is relatively low risk and inexpensive, you might conclude that circumcising as many men as possible in high HIV areas is a very effective strategy for preventing HIV transmission, which is what the WHO concluded in 2007. But now that the science is proven, the question becomes one of implementation.


(A branded truck advertising MC services. We'll be driving this around the countryside.)

The challenge is how to get the service to tens of thousands of men as soon as possible, which brings us to right now, when I’m about to embark on a 9 hour car trip from Dar es Salaam to Njombe, in southern Iringa, to kick off the 2011 male circumcision (MC) campaign. Although the Iringa Regional Health service offers circumcision services three days a week year round, they have contracted Jhpiego to help run an 8 week high volume campaign the will offer clinic six days a week to reach a high volume in a short period. This is the second year of the campaign: last year, the goal number of clients was 6,000, and the campaign ended up circumcising 10,000. This year, the goal is 20,000.

To reach out to and care for so many clients in a short time, especially in a rural area, the Jhpiego team uses several creative strategies. To generate demand in the community, the team created several radio ads, and employed a social marketing team to head to the field in advance of the clinic kick off.