This is part 4 of former Fairfax Media Indonesia correspondent Michael Bachelard's series on Papua. The introduction to the series is here and here are part 1, part 2 and part 3.
'In June last year, seven doctors were sent to this town, but five didn't want to come. In September they tried to send another four and all four went back to Jakarta.'
Dr Poby Kamendra is the head doctor at the puskesmas (local health centre) in Bokondini, a town that once served as a Dutch colonial administrative centre in the highlands of Indonesia's Papua. He is from Sumatra, sent by the Indonesian health ministry for a two-year stint as part of a program to service the outer islands.
The Tabuni family of Wamena struggling with two members suffering from HIV/AIDS. (January 2013/Michael Bachelard.)
Poor education in Papua means there are few locally trained doctors. But not many from outside Papua want to stay in these hard postings with their thorny health problems.
One young physician arrived for his two-year stint in a taxi via the bumpy road from Wamena. He got out and looked around, then climbed back into the same taxi, returned to town and was never seen again.
Dr Poby, by contrast, finds the work satisfying. On the desk in the consulting room are testing kits for patients diagnosed that day with tuberculosis which, along with HIV/AIDS, is in epidemic proportions here. In the eleven months to November 2014, he diagnosed 26 new cases of HIV and three of AIDS.
Dr Poby has educated many people about how to take the HIV medication. It's provided free under an Indonesian Government program, but village people find it difficult to stick to the schedule for taking it. He's introduced an immunisation program, particularly for tetanus, which is common but for which patients previously had to find their way to Wamena. He has also trained health kaders, or village-level honourary providers. In mid-2015, Dr Poby's tour ends and he will go back home.
Bokondini's health centre is part of a network of 25 in the local region. But only two of these centres (the other is in the capital, Tolikara) are operational; the remote centres remain empty, their staff absent. Even in Bokondini, most of the local staff don't turn up, though they are punctilious about collecting their salaries. Dr Poby points to a roster behind him that contains more than 20 names, but he, an assistant and a nurse (who is also from outside Papua) are the only ones on duty when I call.
The money to run the centre, buy medications and do outreach in the hills is rorted long before it gets to the front line. 'The allocated budget for this centre is 100 million rupiah (about $A10,500) for three months operation. But we only get 65 million,' Dr Poby says. 'In 2013, from an allocated budget for outreach (visits to remote villages) we only got 15 million ($A1580). It was supposed to be 125 million ($A13,200). So what can you do?...I don't know where the money went; it went missing before it got to the puskesmas.'
Prior to Dr Poby's arrival, it is said, the head of the health clinic herself would wait for the fresh medicine to arrive, then board the truck, drive it back to Wamena and sell it to the pharmacy there.
There are also racial problems – the ethnic Papuan patients do not always trust the Malay-Indonesian doctors. 'People will say "those straight hairs are always trying to kill us, poison us, giving us the wrong medicine"', says veteran Wamena-based missionary Sue Trenear. 'If someone dies there has to be a reason. Someone has cursed them, given us the wrong medicine.'
Up at Lolat, an even more remote village, the head of the health centre, Elsona, a local man, actually lives in Wamena, and so the Indonesian-built health centre never opens. Honourary kaders, women from the village who learned their skills from the missionaries decades ago, have built their own consulting room with local materials.
Their leader, Lea Sobolim, learned what to do from the missionaries. On the day I visited, she treated ten people using medicine brought by a local NGO, Yasumat. The local government, recently formed after a split from a larger administrative area, has no distribution method. 'If patients come they'll get medicine if they are sick, but the other facilities are not there, like towels, heating water,' Sobolim tells me. 'In the missionaries' time those things were basics'.
Sobolim, limping up and down muddy paths, gives off an air of maternal competence. She can administer almost all medicines, she boasts: 'Injections, depending on the illness. If the patients have malaria, they have to go to Wamena. If they are wounded from being cut, I'll treat them.'
Stitches? 'I can do them.'
Broken bones? 'Yes.'
Service delivery to remote regions is a tricky affair even in a rich country such as Australia. But in Papua, with HIV/AIDS on the move, life expectancy at about 50 years, and no apparent plan to address the problem, the need for a better solution is acute.