Conservation and Health: A Case Study in Borneo

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Forty years ago the island of Borneo was covered by the world’s oldest and perhaps most biologically diverse rainforest. Logging and land conversion has since led to deforestation of about half of this great island. Even most national parks in Borneo are now being illegally logged. It is an ecological disaster of the first order.

Forest People in Peril

Orangutan means “forest person” in Indonesian. Among mankind’s closest relatives, these highly intelligent great apes are important models for our understanding of anthropology, psychology, genetics, and medicine.

Orangutans once ranged across all of Southeast Asia. Today, due to hunting and destruction of the rainforest on which they depend, only about 15,000 to 20,000 survive in scattered areas of Borneo and Sumatra. Only major financial commitments by developed nations or private donors, along with well-planned conservation strategies, can allow hope of saving the orangutan and the forests of Borneo.

But there are other “forest people” who must be considered in this effort. Kalimantan (Indonesian Borneo) has a population of 9 million people, of whom 70 percent live in rural areas. Three million of these are Dayak, indigenous peoples whose traditional home is the forest. The Dayaks’ well-being has been historically neglected by governments and industries in favor of the interests of migrants from Java and other islands. Conservation efforts cannot afford to likewise neglect them.

Per capita incomes in rural Borneo are even less than the $680 yearly national average for Indonesia. Roads, electricity, water, and sanitation are lacking in some parts. According to the World Health Organization, as of the year 2000 only 65 percent of Indonesia’s rural population had access to safe water, and only 52 percent had access to adequate sanitation. Because the Indonesian government health system has less than $6 to spend each year on each person it serves, even basic health care in rural areas of Borneo is minimal. As a result, people often suffer and die from malnutrition and infectious diseases that could easily be prevented or treated.

Complex Relationships

Rainforests are tied to the well-being of local people in many ways. They provide critical ecological services by safeguarding water sources for drinking and fish; protecting farmland against erosion; preventing floods, drought, and extremes of tropical heat; reducing insect pests and disease; and absorbing dangerous toxins such as mercury. From an economic standpoint, rainforests and the diverse plants and animals within them represent precious “natural capital.” Besides wood, they produce foods, medicines, and products such as rubber and rattan for local use or sale. They can also provide ecotourism income and local recreation for current and future generations.

On a global level, rainforest plants help protect against global warming by storing enormous amounts of carbon. They are also a potential source of many undiscovered foods, medicines, and other products. Finally, more important than their dollar value for many people around the world, rainforests also have inestimable aesthetic and spiritual worth.

Yet local people in Borneo, faced with poverty and pressing basic needs, may not think of rainforests in global, long-term, or aesthetic ways. For many, rainforests are simply an exploitable resource that can produce logging income in the near term. Each day in Borneo more centuries-old trees fall to the chainsaws of men earning $2 a day, and float downriver to illegal timber mills. Income from logging may provide money for food, housing, school, health care, and material items such as motorcycles and satellite dishes. Logging companies may also bring roads and electricity to communities that have not had these amenities before.

Unfortunately, cash from logging in poor rural areas, going as it typically does to young uneducated men, also often weakens families and communities. Corruption, ethnic conflicts, exploitation of indigenous peoples, exodus from countryside to city, and income inequality typically increase. The frontier society a logging economy creates is often rife with alcohol, prostitutes, violence, and gambling.

Rainforest logging in Borneo is a “boom and bust” economy. If it continues, when the forests are gone in 10 or 20 years, will local people be any better off? Is Borneo going from poverty and “underdevelopment,” to “maldevelopment,” environmental destruction, and more human misery than before?

New Models for Conservation

Efforts to save Indonesia’s rainforests have had little success so far against the onslaught of legal and illegal logging. A 1999 review by the World Bank of integrated conservation and development projects (ICDPs) in Indonesia (none of which included a health component) reported that, despite spending well over U.S. $100 million in external financing over the preceding decade, “most of the attempts to enhance biodiversity conservation in Indonesia through ICDPs are unconvincing and unlikely to be successful under current conditions.” Further damage to the land has been done by government-sponsored transmigration, conversion of forests to plantations, mining operations, and the enormous forest fires of 1997-1998 and 2002. Challenges for protecting remaining rainforests include financial constraints, rapid encroachment of logging, local poverty, widespread corruption, and political instability.

In this context, sustainable conservation must address the needs of local communities and compensate them for foregone timbering income. In post-decentralization Indonesia, newly powerful local governments are now responsible both for planning the use of their forests and for meeting the needs of their constituencies. Because of this, conservation agencies are attempting “conservation contracts” with local governments and communities, offering a range of incentives in exchange for better cooperation with conservation goals.

Health services for local people living in or near rainforests are often lacking, and health issues rank high among local perceived needs. Health-related services may therefore be something that conservation groups can offer to increase cooperation as well as to directly benefit local communities.

Good Health for Conservation

Poor health, poverty, and environmental degradation are interlocking problems calling for integrated solutions. For conservation to be a more attractive development path than logging for local communities, some conservation funding must go toward measures that offer people direct economic and social benefits, including job opportunities, improved transportation, communication and housing, and better health and educational services. Simultaneously addressing rainforest conservation and the health needs of the poor creates a powerful synergy to foster international investment in both. Over time, a conservation-oriented health program can also lead to:

• More sustainable use of natural resources through education about health-environment linkages (protecting water sources, avoiding slash-and-burn, developing indigenous medicines)

• Improved well-being of indigenous rainforest communities, important allies for conservation

• Decreased demands on forests to provide for people through better family planning and slower population growth.

Kelay River Punan Health Project

The Nature Conservancy, the world’s largest private conservation foundation, is presently working to save one of the last large undisturbed tracts of lowland rainforest in Kalimantan, the Kelay forest of the Berau district. The estimated 1,500-2,000 orangutans recently documented there represent about 10 percent of the remaining world population. Human population density is low in this area, and destructive logging is not yet a major problem. The Nature Conservancy’s strategy is to create cooperative agreements with the key stakeholders whose decisions and actions will determine the fate of this forest (local residents, logging companies, and the district government), addressing their needs and concerns while still protecting the forest.

For local residents, mostly Punan Dayaks in villages along the Kelay River, incentives for conservation include providing alternative employment, assistance with farming, and development of markets for non-timber forest products. The Punan are the traditional semi-nomadic hunter–gatherers of the Borneo rainforest. They are a shy, gentle people who have often been marginalized and exploited by other groups. The Punan on the Kelay were moved to their present homes 20 years ago by government and church settlement schemes. They are among the poorest and least-served of any people in Borneo. In recent years even the government’s child vaccination program has not come this far upriver. In a February 2003 community health assessment, The Nature Conservancy, teaming up with the Orangutan Rainforest Health Initiative and Indonesian non-governmental organization Community Outreach Initiatives, confirmed previous estimates that one in three Punan children dies before reaching adulthood.

In response to these findings, the team has developed a model conservation health program—a health program that links the satisfaction of community health needs to conservation objectives. This program works with the local health system in Kelay villages adjoining critical orangutan rainforest habitat. It trains villagers in community health care, with local nurses as leaders, emphasizing community participation, education, maternal-child health and family planning, and environment-health linkages such as the importance safe water sources. The program aims to cost-effectively and sustainably improve both conservation outcomes and human well-being in the target villages. Partners include the district health department and other government agencies, local health providers, and local communities and their leaders. The project has also involved students from the provincial medical school, Mulawarman University, in order to give them a chance to gain field experience in community and environmental health.

Building a Health System

Beginning in 2002, two years before the implementation of the Kelay River Punan Health Project, the project team held meetings with leaders at the appropriate ministries and at the community level to gauge interest, obtain clearances, and gain support. The team then took pains to understand the framework of local health care, and used local and district health profiles and other available health data—including results from its February 2003 community health needs assessment—to identify health status, needs, and service gaps. In August 2003 we conducted a thorough baseline survey of the target villages, which included tests for malaria and measures of children’s heights and weights. The community assessment, besides yielding valuable information, was also an intervention: it engaged the village communities and laid the foundation for the health program to come. Training courses were held for nurses and for villagers in the fall of 2003, and the program began in the villages a few months later. Monitoring and evaluation activities continue to be held quarterly and a full review is done annually.

The Ministry of Health of the Republic of Indonesia has for more than two decades implemented a rural health system for villages throughout Indonesia. This system is based on a hierarchical structure in which posyandus (village health posts) represent the first level of health care delivery. Posyandus provide basic elements of maternal and child health care in small villages including family planning, immunizations, nutrition, and diarrheal disease control. Village volunteers (kaders, or village health workers) who have received three to six days of initial training from puskesmas (community health center) nurse-midwives staff the posyandus. They are supervised by puskesmas nurses who visit monthly. Pre-natal and well-child clinics are also held during these visits.

This government system is under-funded, understaffed by under-trained health workers, and in many villages practically nonexistent. The Kelay River Punan Health Project’s goal is to work closely with the existing government health system to provide educational and material support and allow it to function as it was intended. Since the annual government per capita health expenditure is $6, and the majority of this goes to urban areas, we expect to be able to make a significant impact on local health at a surprisingly low cost.

The Setting: Kelay Subdistrict

The Kelay Subdistrict is largely undeveloped and forested. Roads are few and most access is by river. Prior to establishing the project, our team surveyed seven villages on the Kelay River. At Long Gie, the largest of these villages, the main road from the district capital at Tanjung Redeb meets the Kelay River. Long Gie is divided in two by the river. People living on the northern bank (Long Gie Sebarang) are almost all Muslim and largely from other islands (such as Java) or other parts of Kalimantan, while residents on the southern bank are almost all Protestant and largely either from the indigenous Punan or Kenyah. The other villages we surveyed are smaller and located upriver of Long Gie on the Kelay. The inhabitants of these villages are almost entirely Punan.

Among the villages we surveyed, the smaller, upriver Punan villages generally had lower economic, health, and educational standards than Long Gie, especially Long Gie Sebarang, as measured by numerous indicators. At Long Suluy, the last and largest of the upriver villages and an important way station for local gold and gaharu collecting, there are a few Muslim outsiders permanently stationed as well as a relatively large number of nonresident gold and gaharu collectors passing through.

Implementing the Program

The health intervention in Kelay is underway. It aims to improve village health in the study area by strengthening the local government health system at the puskesmas and posyandu levels, training village health workers and villagers in a range of disease prevention and primary care measures. Community Outreach Initiatives has extensive experience in community health assessment, village health worker training, and project monitoring. Nurses were recruited from the community and trained in our approach and in how to be effective community health mobilizers. For the training, we adapted Indonesian national Integrated Management of Childhood Illness guidelines and utilized Community Outreach Initiatives’ training materials as made available by the World Health Organization-Indonesia. These materials are tool kits for training courses at the health center level and the village midwife level. They focus on clinical skills as well as record-keeping, monitoring, and methods for facilitating village health worker workshops. They include modular training materials, aids (such as wall charts and photos), and training videos.

Community participation is important for the success of the project. The project includes elements of all five areas of posyandu activity, but each area’s relative proportion is site-specific, depending on local needs and preferences. The project’s general approach considers that learning is a mutual process: health learning and information are exchanged between program staff, community health nurses, village health workers, and villagers. For example, some of the village health workers are traditional healers (dukun) whose health care-delivery skills our team seeks to improve while we gain from them a better understanding of the local traditions of health practice. Village volunteers have also been recruited to assist in data collection, to be done in conjunction with the interventions. The project will monitor a range of health, environmental, and economic indicators on a coordinated schedule.

Bringing Conservation and Health Together

Conservation of orangutans and forest resources, coupled with sustainable development for local people within the Kelay watershed, requires a dynamic integrated approach involving many stakeholders and agencies, each with a particular area of expertise. The overarching goal of the Kelay River Punan Health Project is to make the district an appropriate model of sustainable natural resource management suitable for replication at the East Kalimantan provincial level and at other locations across Indonesia. We anticipate that demonstrating the positive impacts and cost-effectiveness of the Kelay conservation health program will allow us to reach our eventual goal: to bring similar programs locally adapted to other orangutan rainforest areas in Borneo and Sumatra.

Presently most health resources and training in Indonesia are in urban areas. There is little focus on rural community health in medical school training, despite 70 percent of Kalimantan’s population being rural. We believe that our program will demonstrate that promotion of preventive medicine and health care for rural communities is a cost-effective and equitable use of scarce resources.

Mulawarman University began to admit medical students in 2001. It is only the second medical school in Kalimantan, and its curriculum and graduates will have an important influence on health in Kalimantan. By involving faculty at the Mulawarman medical school in our project we hope to increase attention to village health care in medical education and health policy at the local, provincial, and national level. We also expect that this collaboration will help bring attention to the links between health and conservation.

Saving the orangutan from extinction in the wild will require a massive international effort. We see ourselves as part of a team of communities, people, conservation groups, businesses, governments, and aid agencies dedicated to saving orangutan rainforests and improving the well-being of the local people.

Robbie Ali (robbieali@yahoo.com) started the Orangutan Rainforest Health Initiative (ORHI), the first and only organization dedicated to bringing quality health care to communities in and near orangutan rainforest habitat. ORHI’s mission is to improve health for local people in Borneo and thereby support efforts to conserve the orangutan rainforest.

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