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Doktorarbeit / Dissertation, 2001
A note on methods of research
Chapter 1.The setting
Assumptions about health
Different models of health
The Eastern Indonesian context and traditional healers on Alor
Government health discourses
Chapter 2. International health in the context of development
Early health development initiatives
Primary Health Care: a new concept
Participation within health development
Knowledge systems or knowledge as situated practice?
Chapter 3. Examining Development Discourse and Rhetoric
The creation of concepts and the use of language in development
I wish to thank my supervisor, Dr Mark Hobart, for opening my eyes towards rhetoric and development in the first place. Without the thought-provoking conversations I had with him, my dissertation would not have been possible. Without the supervision of Dr Paul Rueckert, the enthusiastic assistance and suggestions of my co-workers and translators, Mr Marvel Ledo and Mr Yopi Laumaley, of Yohanna Sir and especially the many people we interviewed, members of the community as well as health workers and the village heads of Wolwal district who provided a glimpse into their lives, problems and expectations, the study underlying this dissertation could not have been carried out. Last but not least, I would like to thank my parents, my sister, Marina, Lulwa and Eilidh for their encouragement and support and Scott for his help in editing and providing well-needed advice.
I undertake that all material presented for examination is my own work and has not been written for me, in whole or in part, by any other person(s). I also undertake that any quotation or paraphrase from the published or unpublished work of another person has been duly acknowledged in the work which I present for examination.
This dissertation deals with different aspects of health and development in Eastern Indonesia. During an internship with a German development agency that had just initiated a health project in East Nusa Tenggara, Indonesia, several observations were made. Different stakeholders have different ways of speaking about health and development and attach different meanings to these concepts. These meanings are based on assumptions that have been developed throughout the last century through shifts in discourses. Further, the development agency uses a certain rhetoric when talking about the region, the problem and the people that forms a situation where external help is the only solution. The government has internalised this rhetoric and promulgates an ideology of health and development that might not fit into the people’s discourses but guarantees the regular inflow of foreign aid. Further, people react to official rhetoric in different ways either internalising it or resisting it subtly.
Key Words: Eastern Indonesia – health and development – local knowledge – biomedicine- official rhetoric – popular response
The villagers’ quotes and insights were gathered through questionnaires, focus group discussion, key informant interviews and especially observations that were made during my stay on Alor. It must be said, that at the time of the field work, I was gathering information for the GTZ and thus was bound to an institutional framework and an agenda that had been set out. Therefore, most of the relevant information gathered was more in an informal setting either after work or during breaks. It is fully recognised that in order to be able to give a more accurate account of the Alorese people’s needs and priorities, their opinions and response to development, health and their government, I would have had to stay much longer and work apart from an institutional framework within which my position had a certain meaning for the people I was working with. Therefore I would like to underline that I am using this experience and the material I gathered there only to underline certain points or give examples and not as a case study that I can base this whole dissertation on.
The motivation to write the dissertation on this topic stems mainly from an internship that I undertook in the summer of 2000 with a German development project in Kupang, West Timor, and from subsequent reflection provoked the course of my anthropology degree. The GTZ (German Agency for Technical Co-operation) had recently initiated a health project in that area with the aim of improving the health system and the access to health care in the Nusa Tenggara Timor district. The SISKES/GTZ project was implemented in January 2000 in the context of technical co-operation, with the aim of improving both the scope and quality of the district health system in Nusa Tenggara Timur (NTT), and further to encourage the local population to make increased use of the improved health services.
In order to achieve and implement the objectives, it was considered important to know about health needs as well as health care practices among the target population. My internship was thus aimed at providing a preliminary report on a rapid assessment of community health perceptions in the district Wolwal on Alor island, NTT. While working with the GTZ and in my research on Alor island, I soon realised that people had different ways of talking about health and development and that different meanings were attached to the two concepts.
During this experience, and following my course in anthropology, several questions arose that initiated my interest in further investigating health and development, discourse and rhetoric in Eastern Indonesia. How come health and development mean different things for different stakeholders in the project? What assumptions underlie these meanings? Where do different ways of talking and thinking about health and development stem from? How do they change and what implications do these differences in rhetoric and discourse have? The driving force behind this dissertation is the quest in finding answers to these deliberations.
In order to address these questions, this dissertation will use the case study as a background to then examine assumptions that underlie health and further place them within a broader context of international health in development. Within this context, the concept of Primary Health Care will be analysed in the light of the recent shift within development towards participation. Can real ‘participation’ take place if local knowledges are not fully acknowledged? Concerning this question, the notions, ‘indigenous’ and ‘scientific’ knowledges will be highlighted. These again will be placed in the broader context of development discourse and rhetoric. Finally the last part of this dissertation will deal with development rhetoric in practice and how this is reflected in popular response.
Several reasons, concerning the region’s socio-economic situation are stated in the GTZ reports and project proposals about why the health project was needed and finally initiated in the district of Nusa Tenggara Timur. Indonesia, on average, had made substantial progress in the development of its health systems until the economic crisis in mid 1997. (GTZ 1999a, Barlow 1991). However, there are great regional differences between the more prosperous provinces (e.g. Java and Bali) and the Eastern provinces such as the project region NTT. The region of NTT is located at the most Southern tip of the long chain of Indonesia’s islands (see Map 1.). The consequences of the economic crisis have had severe detrimental effects on the health sector especially concerning the availability of drugs and the nutritional status in that region (GTZ 1999a). According to international policy makers and the Indonesian government, the project region of NTT belongs to one of the most deprived provinces in Indonesia. (Corner 1991, GTZ 1999c) Especially concerning health and education, Corner states “the level of social development in the province, which is one of the poorest in Indonesia, is low.” (p.39) As indicated in Table 1. the rate of malnutrition among infants lies high above that of the rest of the country as do the maternal and infant mortality rates.
Table 1. Malnutrition, maternal mortality and infant mortality rates: National and NTT
Abbildung in dieser Leseprobe nicht enthalten
Source: GTZ 1999, p. 3
Malaria, acute respiratory infections and diarrhoeal diseases have been recorded as among the main causes of ill health in the region (GTZ 1999c). The principal reasons that are associated with the high morbidity and mortality rates in Indonesia are the remarkably low utilisation rates, especially among the rural poor (GTZ 1999c, World Bank 1991, see Table 3); the poor quality of the health services and, particularly in West Nusa Tenggara, their difficult accessibility. In addition, both the World Bank and the GTZ mention the population’s tendency to rely on self treatment and ‘traditional’ methods of treatment instead of making use of the ‘modern’ providers in the health centres. While the World Bank claims that the “sick poor use fewer modern curative health services and choose lower quality providers than the nonpoor”, the GTZ points out that among other elements, “geographic and traditional barriers lead to a low utilisation rate.” (GTZ 1999c, p.20).
Due to the above mentioned reasons and especially the economic crisis that caused a major setback in the Ministry of Health’s own striving to improve the country’s health status with government-financed community and preventive health programmes, the GTZ Report underlines the Indonesian government’s need for external aid to further strengthen their efforts in establishing an efficient and accessible health system.
In the project proposal of the GTZ, paragraph 3.2.2. states, among others, the following main activities of the project:
- To identify elements in need of change within the management of the district health system
- To provide financial means through the local governments as well as other financial resources (insurance subsidies, donations etc.) for the support and finance of the operation and maintenance of health institutions
- To choose and improve promising concepts and mechanisms for the participation of the population within health planning and the implementation of health measures
- To organise health education for the population and for community supported health institutions (GTZ 1999, p. 12-14)
Underlying the projects’ objectives and activities and in general behind the planning and implementation of health initiatives within development is a certain idea and of what health and illness mean or should mean for people. This concept of health is then reflected in policies and strategies. However, people attach different meanings to health and use different models when it comes to treatment. In the following paragraphs, Western assumptions about health will be highlighted and different medical models will be discussed.
In the West, health has become an obsession for most people. The gyms are overflowing with health conscious individuals of all ages. The healthy-body-image has dominated the media, and is present on every billboard featuring beautiful men and women advertising shampoo, shower gel, make-up and ironically cigarettes. People jog, cycle, swim, diet and pop vitamin pills in order to stay healthy and guarantee a long life. The fear of death and illness is no longer the peculiarity of hypochondriacs.. everybody wants to stay healthy and young. When it comes to health issues in development, western policy makers may assume that people’s main priority lies in their well-being and health status. Health is seen as a ‘universal’ interest, a basic need, a state to be striven for if ones future is to be secured. Primary health care officials assume that people consider health to be their main concern (Van der Geest et al 1990). Any behaviour that goes against the preservation of ones health is deemed irrational and ignorant, e.g. smoking, over-drinking, or using alternative medicines or healers that have not been proven to be ‘scientifically’ sound. The system of medicine in the West and the assumptions underlying health and illness are based predominantly on a biomedical ideology.
The biomedical model of health
Until the 1970s, Biomedicine was the main valid model or the ideal type through which other versions of medical forms were seen (Gaines and Hahn 1985). In modern biomedicine, the body and self are treated separately. The illness resides either in the body or the mind, not in both. The physician searches for the pathogen and goes about treating it as fast as possible, thus the examination of the patient is mainly physical (Hahn 1995, Sheper-Hughes and Lock 1987). The patient may be asked for the symptoms and the severity of pain or discomfort but relatively little time is paid on listening to the client’s thoughts on his/her illness. Social relations are seen as discontinuous with health or sickness and thus relatively unimportant in the context of examination (Gaines and Hahn 1985). The physician is often endowed with superior formal knowledge and patients might feel uncomfortable in asking too many questions, since the setting and the doctor’s air of professionality might seem intimidating (Stimson and Webb 1975). The Western-based biomedical mode of health is not the only choice people have in their quest for health services. Recently alternative models of health have become more and more popular in the West.
The ethnomedical model of health
In many ethnomedical systems, the mind body and self are not distinguished. The illness therefore cannot be situated in either mind or body alone, rather the individual is treated as a whole entity. (Sheper-Hughes and Lock 1987) Social relations are considered a key contributor to individual health and illness and thus quite important in the process of determining what is wrong. Especially in Far Eastern medicine, great importance is laid on personal acquaintance and harmonious interpersonal relationship between the patient and healer. A holistic approach is utilised when addressing the ill individual and diagnosis includes the observation, listening (not only to the sufferer but to relatives and friends that might have joined him/her), questioning and touching (Gallegher and Subedi 1995). Clients choose their healers and express doubt or dissatisfaction when they have the feeling that their opinion is left out in the negotiation of illness and curing. (Kleinman 1980).
In Indonesia there exist a variety of traditional ways of dealing with health and illness. Among the most well recorded is the Javanese system of indigenous health care. Explanations for health, illness and death are socially embedded in cosmological, spiritual and holistic notions of the body. This dissertation will not go into the details of the Javanese belief system but rather focus on what was observed concerning beliefs and treatment strategies on the island of Alor, NTT.
Traditional Healers on Alor
Apart from self medication with drugs from little kiosks and stalls on the market, the villagers of Wolwal often used traditional medicines and healers before seeking the help of a trained nurse in one of the health centres. Among others, the traditional healers that were mentioned several times were Orang pintar (wise man), Dukun bayi (traditional birth attendant or baby shaman), dukun (shamans) and Hamba Tuhan (Servant of God). The following paragraphs will concentrate mainly on dukun and Hamba Tuhan as they were mentioned most often when the villagers were asked which forms of treatment they used.
There are several different types of dukun. In general one can say that they all possess a certain skill or ‘power’ that distinguish them from the other villagers. As far as was known, the knowledge they have is passed on from generation to generation, or gained through the entering of spirits’ voices at certain holy places that inform and lead the dukun’s body and behaviour. The treatment methods of many dukuns include massages, herbal medicines and the use of other elements including darah ayam (chicken blood), beras tumbuk (stamped rice), air putih (clear water), batu - batu kecil hitam (small black stones) and baca - baca mantera (certain formulas). Careful attention is paid to the ill person’s complaints and felt symptoms as well as the family’s opinion and background information. The treatment may take up to several sessions and the length of each session can vary according to the severity of the ill individual’s pain and also his/her satisfaction with the healer’s performance. In contrast to popular Western belief, the villagers of Wolwal do not blindly follow blindly their ‘deeply rooted traditions’ but choose a dukun they believe are well-suited to their needs and capable in their abilities. People did not necessarily believe in the unquestionable authority of dukuns unless they thought that he/she was using black magic. The villagers refused to go to dukuns who they thought were charlatans or conmen. The following was exclaimed by a 45 year old woman in Wolwal Selatan. “No, I don’t use the Dukun (in that village), he is not very good... the last time I went, my back was hurting for the next three days.. my daughter does better massage.. I would rather use drugs from the kiosk.”
The other most frequent traditional healer that is used on Alor (and also among in other regions that are predominantly Christian in Indonesia) is the Hamba Tuhan. The Hamba Tuhan is often the first person that ill individuals (of Christian belief) seek after having tried self-medication since the services are free and include very close attention to the person as a whole. Healing does not take place in the usual sense of the word i.e. with any form of medication or physical examination. The Hamba Tuhan listens to the individual’s complaints, his/her relatives’ opinions and then prays to God in order to provide comfort and reassurance to the visitor and then gives advice on the next steps to be taken. He/she may refer the ill individual to the nearest health centre if the need is perceived.
The main differences in ‘modern’ and ‘traditional’ health services on Alor
It must be said that the main difference in the region of Wolwal between the ‘modern’ health services and the traditional healers is their way of treating their ‘patient’. It is for this reason that the ill person will seek either one or the other. As one villager in Wolwal Tenggah remarked: “The Hamba Tuhan is for the heart, the Pustus are for the head.” When people feel that their illness is a ‘normal’ illness, that needs curative care and ‘scientific’ methods to cure they would go to the nearest Polindes or Pustu. It seemed that when the illness has more of a chronic nature, such as back pain, or is considered a ‘serious’ illness, that cannot be explained through ‘scientific’ methods, one of the traditional methods were used. In respect of the treatment of the ill individual, the methods differed as well. While the modern health providers nearby often treat the patient as a passive recipient of information and drugs without much time for explanations, the traditional healers take much more time in listening to the ill persons complaints and thoughts about his/her own illness.
The ill person becomes an agent in his/her own treatment since he/she may or may not like the traditional healer’s treatment methods and can give comments or complain. Also, the relationship between the healer and the ‘patient’ is often a longstanding one. In the health centres, the situation is quite different. The patient often waits for a substantial time before being treated. The personnel are often unfamiliar to the villager and might even be intimidating within the busy and hectic hospital surroundings. The discourse in this context is a medical and bureaucratic. The patient’s knowledge about his/her own body is deemed irrelevant and of inferior quality in comparison to the formal education of the nurses and medical personnel. No attention is paid to the individual’s social environment or relationships, in fact the patient speaks relatively little. In this often brief encounter between the medical staff and the ill client, two different ideologies come together. The patient’s knowledge about his/her beliefs on health and illness are devalued due to a dominant discourse that places more value in the ‘scientific correctness’ of biomedical knowledge. Placed into the larger national context, manifold discourses are revealed.
In Eastern Indonesia current health discourses and official government discourse continue to be influenced by biomedical ideology and development rhetoric. Therefore, conflicts can arise between the state (or Western-led) and the village discourses (also see Hunter 2000 for further information on different microcosms of knowledge on the island of Lombok). State health personnel with biomedical knowledge gained from training in Western institutions view their formal education as much more ‘safe’ or ‘correct’ than the traditional healers who work with indigenous medicines that are handed down from one generation to the next. This is despite the fact that the Western-based system is relatively new with comparatively few practitioners than to the older, ‘traditional’ systems with quite a lot of practitioners.
Hunter (2000) speaks of ideological discourses of tradition and modernity between village and state which reveal the distances and differences of two social groups. The penetration of the modern health system and other state institutions into the village arena is a one-way superimposition, backed by local officials and bureaucratic structures promoted by the state, which advances and executes policies of development and ideologies based on western rationalities and modernities. In health issues, the state is interested in monitoring the nation’s health with the aim of improvement. “In contemporary times, the government has established public health as a monitoring mechanism of the population’s health status and welfare, maintaining its control through techniques of medical surveillance.” (Hunter 1996, p. 20)
Health, due to its status as one of the universal basic interests of each and every individual is used as a legitimate mode of surveillance. The efforts to monitor and control the nation’s health are underpinned by the United Nations and the WHO who promote ‘health for all by the year 2000’. Health is thus a powerful, socially embedded discourse (Hunter 2000, Pigg 1993). The question is how has this discourse developed and gained its power within development. The next paragraph will take a look at health within its broader context of development.
Development planners base their health initiatives on the biomedical discourse mainly due to the perceived merits of its practice. This discourse has been developed over the past century and gained an allure of superiority especially with the medical successes, the WHO implemented small pox eradication campaign and the child immunisation programmes. There have been changes in the discourses of health development, leading to the concept of Primary Health Care with a focus on participation and rural-based health centres. It will be demonstrated how the concept of health within development has evolved and shifted.
From the 1940’s until the early 1950’s, development and health development was seen as a means of overcoming ‘problems’ with the introduction of Western knowledge and technology. It was assumed that those modes and operations that had met the needs of the ‘developed’ world were the appropriate templates for the developing world. (Stone 1992, Foster 1987, Justice 1987) The underlying assumption was that ‘the developed world possessed both the talent and the capital for helping ‘backward’ countries to develop, thus the international donor agencies, on the strength of their economic resources have dominated health policy and practices in the ‘Third World’ since World War II. Health programmes were seen as “exercises in the transfer of techniques, in the implantation of educational, preventive and curative services based on the biomedical model, in which the major problem is to persuade people to abandon their traditional beliefs and practices in favour of the new.” (Foster 1987, p.1041) ‘Rationality’ would win people over in accepting what was assumed ‘best for their own good’.
The failure of this approach and the increasing knowledge of the complexities of international development led to a different era of development thinking which was marked by a new rhetoric including catch phrases such as ‘basic needs’, ‘community participation’, ‘poor people’s priorities’ etc (Stone 1992) In the 1970s, the WHO and the UNICEF put a strong emphasis on Primary Health Care with its focus on preventative health care services in rural areas because of several reasons. Firstly, those development programmes that had focused too narrowly on agricultural production, family planning, income generation, or nutrition seemed to be ineffective because they failed to take into account the interconnections between these problems. Secondly, the results of top-down approaches that emphasised capital-intensive infusions of technology were disappointing resulting in the promotion of more locally oriented models of development (Pigg 1993).
Views on Culture within PHC
During this period, two different views of culture predominated among health planners and health project personnel. One view saw culture as a set of beliefs and customs that posed an obstacle to the implementation of a successful health project and was potentially even dangerous to the health status of the population. Here it was considered important to convince local people of their errors and accept the inherent truth and superiority of ‘modern’ medicine. The other view, that was mainly put forward by social scientists, considered culture within health as ‘indigenous knowledge’ and as a broader ideological and behavioural context within which different types of health care should be integrated (Stone 1992, Pigg 1993). Culture was seen much more as a potential resource for health development. This was expressed most openly in the attempts to integrate traditional healers and traditional medicine into PHC programmes. Primary Health Care became the newest fad in the health development approach and was supposed to be a flexible concept - in other words, a culturally sensitive approach that could be adapted as needed to fit local conditions in rural areas of the Third World. Thus, in recent years, international agencies have attempted to hire social scientists to advise them on the social and cultural appropriateness of their plans.
What went wrong?
Despite the efforts to include cultural knowledge in health initiative, most of the services failed to be fully accepted and used by the population (Justice 1987). Social scientists believe this to mainly be due to the assumptions that lie behind Primary Health Care. Core assumptions in the introduction of Primary Health Care are that the proximity and appropriate implementation of modern health services will lead to their use by the population, and that the indigenous form of health care is easily replaceable. Also, qualitative data collection concerning health topics often seems too time consuming and requires extensive field work when lives are to be saved. Health thus becomes integrated within the category of emergent ‘humanitarian’ aid. According to a development worker within health, “to be honest, there is not much time to ask about peoples’ opinions and feelings… people are dying out there and we can help.. how do you think I feel when I hear a woman whose baby has just died, say that she used the help of a dukun to blow smoke into its lungs so that the evil spirits will come out. The baby would still be alive if it had come to one of the centres”.
The involvement of social scientists is thus deemed secondary and is further complicated because anthropologists’ reports concerning health topics are often described as ‘jargonistic, too ‘esoteric’, ‘written for the university’ and thus more difficult to use in planning and evaluations (Justice 1999, Van der Geest 1990). However there are other reasons why Primary Health Care in it’s idealistic form cannot really be realised.
The international organisation
In the bureaucratic context of health administration, primary health care is readapted to fit institutional resources and needs. Plans are made miles away from local realities and do not really change despite the ‘cultural’ information that social scientists may provide. The advisors and consultants hired by the international organisations to assist have their own priorities and might not be interested in spending too much time in getting to know their socio-cultural environment. Although they are technically expert, not much is known about the socio-cultural situation, since real field work is time-consuming and perceived as uncomfortable and difficult. The experts in the international organisations earn a comfortable living from PHC. In order to succeed in their jobs, they have a certain agenda to follow that is prescribed to them by a far away institution that calls for diligence in writing reports and a good command of statistical methods in health (Justice 1987).
Personal success through the extension of a job, a career advancement or new publishing might be more important for the foreign advisor than the acquisition of different knowledges. The personal benefit depends more on successful programmes which are evaluated by how well they meet their statistical targets. Donor agencies state that the ultimate objective of financial and technical assistance is to improve the health status and thus they emphasise the collection of baseline quantifiable data from which to measure progress. This is done by showing a decrease in infant mortality and morbidity rates not by assessing the satisfaction or impact the programme has made on the society.
From the state’s point of view, national governments try to acquire more development funds via PHC (which also brings private gains to state officials) and therefore pay lip-service to the donor’s agenda. The donor’s influence is considerable through the formulation and application of their own criteria when providing support. Recipient governments respond by adapting their policies according to such criteria rather than formulating their own proposals as the basis of negotiation (Hunter 2000). In the exchanges between donor agencies and recipient countries, the donor’s priorities predominate and the real needs of rural villagers are too often lost beneath bureaucratic priorities. Health statistics, reports and educational successes do not necessarily mirror the needs in daily life.
Even if a programme was thought to be inappropriate to the people’s needs, an Indonesian health expert employed by the state might agree to the implementation of that programme in order to ensure his own job security. As Achmad points out, this may mean that health policy formulation is determined by elites without community participation (Achmad 1999). The very idea of asking ‘peasants’ for their opinions is seen by many Indonesian academics as unsuitable, as treating the villagers as though they were on the same level as the academics themselves (Dove 1990).
The villagers perceived needs of the villagers might be quite different from what the planners have carefully laid out for them. Preventive medical advice and health education might not be on the list of priorities. Curative medicine might be much more popular due to its immediate effect and rapid cure. Community participation schemes are time-consuming and energy-wasting. Instant financial aid might also be deemed much more important than health education and community participation. As Van der Geest et al point out, “they are faced with so many immediate problems that they cannot afford the long term view. For the same reasons they are relatively uninterested in improvements for the whole community but first want help for themselves and their close relatives.” (Van der Geest et al. 1990, p. 1030) .
In addition, why would people want to take part in ‘participation schemes’ if they are only ‘allowed’ to participate in a certain way that has been laid out by health planners? If an individual’s ideas, thoughts and skills are not genuinely being included into the initiatives as valuable information people will not feel like sharing their knowledge. When it comes down to it, health education, however grass-roots it might be, renders the recipient of the information inactive. The ‘scientific’ and ‘rational’ knowledge that has been internalised by health staff and favoured by development, constructs foreign ‘experts’ as agents, and local people as passive and ignorant. (Gardner and Lewis 1996, Hobart 1993) It is difficult for the typically highly educated and highly paid development planner to accept that a poorly educated and poorly paid villager knows far more about his own local health perceptions and illness categorisations than the expert knows or is likely to learn. Dove describes this fact as “threatening to those development experts who mistakenly interpret ‘expert’ as ‘all-knowing’, as opposed to the more modest but more realistic ‘all-resourceful’.” (Dove 1990, p. 7) Training or education that ignores the way people understand the world assumes that ‘scientific’ or rational knowledge is accessible and useful, and is therefore, unlikely to be successful (Gardner and Lewis 1996).
Local knowledge is based on assumptions that are different from that of ‘rational’ developmental knowledge (Pottier 1993, Hobart 1993) and thus needs to be included in order for health initiatives to be appropriate. In Indonesia the overwhelming majority of development experts in primary health care (national and international) still treat the rural villagers as their students as opposed to their teachers or fellow-teachers (Dove 1990). Despite the fact that participatory movements have made an effort in changing the view that culture and traditional beliefs are an obstacle to modernity, local knowledge is simplified and essentialised and still treated as in opposition to scientific knowledge. The following paragraph will show that it is impossible to create an artificial divide between different knowledge ‘systems’.
A note on the divide between ‘Indigenous’ and ‘Scientific’ knowledge
Throughout the past century an artificial divide has been made between scientific and indigenous knowledge due to the difference in status and basis of truth. One definition of indigenous knowledge describes it as the “common sense knowledge and ideas of local peoples about the everyday realities of living” (Dei in Agrawal 1995, p.418). Scientific knowledge, then has the allure of not necessarily being grounded in the realities of everyday life but on formal training that bases its claims to verity on statistical evidence and facts. It is impossible though to create an artificial and static divide between Western and indigenous knowledge for several reasons: 1) There is no homogeneity within any of the knowledge systems, there are several knowledges within the Western or indigenous category. 2) Elements separated by this artificial divide share similarities as Agrawal (1995) points out in, for example, “agroforestry, and the multiple tree cropping systems of small-holders in many parts of the world, agronomy, and the indigenous techniques for domestication of crops, taxonomy and the plant classifications of the Hanunoo or the classifications of the Peruvian farmers, or rituals surrounding football games in the United States, and, to use a much abused example, the Balinese cockfight.” (p. 421) And thirdly because the two knowledges have influenced and permeated each other throughout the last centuries and are continuously evolving.
Knowledge as situated practice
Hobart points out the importance of “treating knowledge as a practical, situated activity, constituted by a past, but changing, history of practices.” (Hobart 1993, p. 17) Thus rather than presenting local knowledge as homogeneous and systematic, it should be treated as diverse and fluid. The only way of mutual learning and participation is thus in the form of a dialogue taking account of the context, both individuals’ backgrounds, the language, and setting. I would argue that this is an impossible task for development initiatives since it is necessary for development planners to create some kind of homogeneity among people for the implementation of programmes. If one cannot categorise people into target-groups designating ‘the poor’, ‘the landless’, ‘women’, ‘malnutritioned’ how is one supposed to devise strategies to alleviate poverty, restructure land schemes, address gender-based inequality issues, and initiate health projects? Categories are shaped and key expressions invented in order to plan large scale development initiatives. These stylistic means give meaning and create assumptions about people and their need. The next paragraph places this observation in the broader context of development discourse and takes a look at how this is done.
Esteva gives the creation of the two concepts of ‘development’ and underdevelopment’ a specific date and time in history. January 20, 1949. On that day, President Truman, in his inaugerial speech called for the Americans to “embark on a bold new programme for making the benefits of [their] scientific advances and industrial progress available for the improvement and growth of underdeveloped areas.” (Truman in Esteva 1992, p. 6) With the pronunciation of the word ‘underdeveloped’, Truman had achieved the devaluation of two billion people. Since then, development has meant the struggle to escape from the shameful condition of ‘underdevelopment’.
Development had become a metaphor for the elimination of peoples’ (those defined as underdeveloped) own definition of their situations and social lives. (Esteva 1992, Escobar 1988) The West had thus established a global hegemony based on self-made ‘scientific’ laws that defined reality and created value systems that dominated how people think of themselves and their condition. Development has become the apparatus by which the production and circulation of discourses is used to ‘discipline’ the ‘Third World’.
The spread of development knowledge
Every development institution is based on a specific set of ideas and values that need to be disseminated in order to spread ideologies and reproduce power relations. Navarro alerts us towards the fact that the WHO, for example, while being a technical agency of the United Nations, is also a political agency which reproduces and distributes political positions through its technological discourse and practices. “Like any other international apparatus, WHO is the synthesis of power relations (each with its own ideology, discourse, and practice) in which one set of relations is dominant.” (Navarro 1984, p. 470) The ‘knowledge’ of development is used and spread by development institutions through applied programmes, conferences, expert meetings, consultancies and so forth. By the utilisation of certain forms of knowledge and the production of specific forms of intervention, these institutions constitute a network that makes the exercise of power possible (Escobar 1988). This power is then also executed by the production of labels, which the programmes form and reform together with the professional discourses that sustain them. The labels then shape the encounter of the agency and its ‘clients.
Language and its use in/for development
The importance of language in reflecting ideology is highlighted by Volosinov who points towards the fact that words are never neutral or meaningless..
“(...) we never say or hear words, we say and hear what is true or false, good or bad, important or unimportant, pleasant or unpleasant, and so on. Words are alsways filled with content and meaning drawn from behaviour or ideology. That is the way we understand words, and we can respond only to words that engage us behaviourally or ideologically.” (In Pigg 1995, p. 47)
How does the development establishment use language to help secure its power? Foucault, writes about discourse as a way of talking about and naming reality (In Escobar 1984). Reality can be portrayed in a way that reflects a state of ‘underdevelopment’ ‘backwardness’, in short in need of some form of help to ‘develop’ and move ‘forward’. Problems can be framed in a way that call for help and thus legitimise external involvement to organise and manage things. The language used by institutions reasserts the truth and inevitability of institutional practices and thus defines the grounds for specific forms of intervention, setting the terms of social relations (Pigg 1997). Ferguson, for example, shows how a development institution can use rhetoric to reassert the need for interventions by describing the World Bank’s portrayal of Lesotho’s socio-economic problems as those of a ‘Lesser Developed Country’ and thus in need of external guidance (Ferguson 1990). Wood (1985) speaks about the politics of development policy labelling, and points out the normatisation of discourses through language techniques.
Specific interests and values are represented as universally valid through the use of apparently rational categories and technical language. How these interests that are hegemonic in nature, become universalised is almost forgotten since they are constructed and articulated through unnoticed, common and familiar acts. Further, ‘labelling’ is the attribute of bureaucratic, professional, formal, and institutionalised public management of resources. A label is given to represent or rather misrepresent the situation of the labelled and this has been done especially under the donative policy discourse associated with development through the deployment of e.g. ‘target-group’ terminology (Wood 1985).
How does this ‘labelling’ appear in practice? The following chapter will look at how development rhetoric shapes realities, constructs concepts and defines ‘problems’ and people. In relation to this issue, I will mainly look at several development documents and government rhetoric. How is NTT as a deprived region spoken about? The project documents will be drawn on to show how a problem can be created through rhetoric. How does the Indonesian government internalise rhetoric in order to get funding? Which official rhetoric is adopted for which reason and by whom? How do the people of Wolwal respond to official rhetoric?
The following information was gathered from several sources. The GTZ (Gesellschaft fuer Technische Zusammenarbeit - German Agency for Technical Co-operation) project proposal and description for the NTT health initiative was used to show the agency’s rhetoric. Further, the BMZ (Bundes Ministerium fuer Wirtschaftliche Zusammenarbeit und Entwicklung- German Ministry of Economic Co-operation and Development) website provided the German government’s view. The speech of the Indonesian State Minister for Population (Dr. H. Suyano - Chairman BKKBN, Professor in Medical Sociology, Faculty of Medicine, Airlangga University) was found in the journal ‘Health Transition Review’ which features a special edition on the ‘International Conference on Population and Development, Cairo, 1994’ .
The rest was gathered from a book on the social and economic development of Nusa Tenggara Timur entitled: ‘Nusa Tenggara Timur: The Challenges of Development’. The contributions were gathered in the context of a seminar held in Kupang in 1989, concerning the identification and approach towards problems facing development in the NTT province. The seminar involved representatives from both central and provincial governments. Staff from line agencies, people from NGOs, and academics from Indonesian and Australian universities and institutions. The rhetoric of the following contributors was chosen to underline the argument:
Dr H. Fernandez - Governor of Nusa Tenggara Timur
Dr C. Barlow - Department of Economics, Research School of Pacific Studies, The Australian National University
Dr A.Bellis - Department of Economics, Research School of Pacific Studies, ANU
Dr L.Corner - National Centre for Development Studies, ANU, Canberra
Dr R.Gondowarsito - Centre for Migration and Regional Studies - Mercu Buana University, Jakarta
The identification of the problem and the portrayal of the area play a key role in development rhetoric. It will be argued here, that it is necessary for an agency to find elements in need of change in order to legitimise their presence in the region. Further, it is important for the national government to also give a certain image of the situation of an area in order to secure aid.
Portrayal of the area and the ‘problem’
“NTT, with its dry climate, weak communications and badly developed infrastructure, is one of the poorest parts of Indonesia. It certainly deserves attention to its problems from official quarters, which must predominantly involve the NTT provincial government with support from Jakarta.” (Barlow and Bellis, p.3)
The portrayal and description of the area or region that is to be ‘worked on’ is an important factor when it comes to creating a ‘problem’ that needs to be solved. In the case of the NTT region, rhetoric abounds with descriptions of its poor infrastructure, low health and educational status, and poverty. The province is described and characterised by ‘considerable handicaps, general poverty and backwardness’ (Corner 1991, p. 49). The word ‘handicap’ describes a helpless state that is seriously lacking something and cannot move forward. Similarly, to describe a region as ‘backward’ fixes it in a static condition of lying behind. The connotations connected to the word are even more clear if we take a look at the synonyms which include the adjectives sluggish, unwilling, retarded, slow or stupid (Thesaurus 1996, p. 45). After having asserted the general ‘backwardness’ of the region, the next step for development rhetoric is to underline the need for external help.
The need for external help
This is then achieved by highlighting the importance of improving the situation through advanced technologies or ‘modern’ innovations. “An assumption of almost all participants at the two meetings was that the peoples of NTT need help in the form of better technologies, advice, and improved physical and social infrastructures to realise potentials for improvement and growth.” (Bellis and Barlow 1991, p.4) Since NTT is very poor, much remains to be done in a situation where public resources are limited. And here the “assistance of foreign donors in improving NTT through integrated development projects”, is inevitable (Bellis and Barlow 1991, p.5). The people of NTT are not capable of helping themselves nor should they rely on their previous forms of technologies or skills since these are not only outdated but not good enough and thus invalid. In a concluding remark, Barlow reinforces this idea.
“There seems no doubt (...) that external interventions by government and other parties are needed to help realise the potential of NTT for growth and improvement. The world of traditional activities at village level crucially requires assistance from outside in the form of better technologies, skills and credit to use these technologies, and improved physical and social infrastructures.” (Barlow 1991, p. 235)
Not only does this quote ‘leave no doubt’ as to the need for external aid, but it also creates an artificial concept of a ‘village world’ in which the poor villagers struggle away with their unskilled labour and inappropriate technologies. Further, he mentions ‘traditional activities’ which are not specified, leaving the reader to imagine a world in which time stands still and people go about their life untouched by exterior influences and erring in their ways.
The government officials have internalised this view, referring to the situation as in serious need of external ‘control’ and disciplining. Concerning the high unemployment rates in NTT, the Governor remarks:
“If this situation is allowed to continue without serious efforts to control it, I am concerned that it will create social symptoms with a negative impact, which will be marked by an increase in crime statistics, in the form of hold-ups, robberies, etc. These in turn will hinder the paths of the wheels of government and development.” (Fernandez 1991, p.8)
The government and development agency have joined hands in their quest to save the region and the people from downfall. The ‘wheels of government and development’ convey an image of perpetually forward moving wheels that are constantly trying to overcome the barriers laid by the local people’s ‘misbehaviour’. In the adoption of development rhetoric, this government representative has internalised the depiction of the people as ignorant and needy as is demonstrated by the following quotation: “Speaking of equal distribution, another face of NTT flashes through our imagination: a face that represents a group in society with low income, level of education, and standard of health; a group that has not yet been fortunate enough to enjoy the greater fruits of development.” (Fernandez, p.8) Despite the fact that he himself is from the region, a divide is created between himself, who has benefited from the ‘fruits of development’ undoubtedly through formal education and foreign aid, and the villagers whom he considers as ‘the other’. He further underlines his adherence to the development agenda by underling the apparently mutual aim of the development agency and the government. “In raising the income level of the people of NTT, we can raise their standard of living and foster self respect and a sense of dignity.” (Fernandez 1991, p.10) The ‘we’ reinforces the idea of the government’s role as agent in the active participation during the planning and processing of development initiatives and reasserts the view of the passiveness and lack of agency of ‘the people of NTT’.
It is clear, that the main aim of the complete adherence to development rhetoric is to attract aid, and this is not only for the benefit of the so-called villagers but for the benefit of the government officials who can pocket substantial amounts of money. As Achmad describes, income generated from health services is one of the most important sources of revenue for the local government (Achmad 1999). Thus when Fernandez comes to the actual point of his speech with his rather direct exclamation that he hopes that “for foreign aid donors, the outcome of this seminar will provide material for consideration that is decisive, especially for expanding current aid as well as providing new aid as we approach the period of take-off” (Fernandez 1991, p. 11), the doubt remains whether this aid will actually ever reach those it should benefit.
The local people and their traditional world
When it comes to the rhetoric surrounding ‘the people’ who are supposed to benefit from the ‘fruits of development’, the predominant view is that their condition is also their own fault. It is due to their sluggishness and resistance to ‘move forward’ that the situation cannot change. Embedded in their conservative and ‘traditional world’ they seem cut off from modernisation which is negative and calls for a change.
Communication to the ‘outside world’ is difficult due to the remoteness of NTT from Java and the poor infrastructure. “This feature is (...) reflected in the restricted flow of ‘information’ from outside, where local people generally tend to be conservative and slow to appreciate the merits of possible new ventures.” (Barlow and Gondowarsito 1991, p.22) The aim of this portrayal is again to convey an image of helplessness and incapability, of people limited and bound to their traditional methods. Traditional methods of health care are considered inherently risky and of lesser quality than biomedically oriented services. The high maternal mortality and morbidity rates of NTT are attributed also to the use of traditional midwives that are not formally trained and therefore who are thought to lack the skills and hygienic standards of trained medical staff. The GTZ suggest that people in certain regions of NTT are bound to deeply rooted traditions and therefore prefer the use of e.g. traditional midwives (dukun bayi) during pregnancy despite the high risks involved in a birth at home.
Traditional cultures and lifestyles are regarded as clear signs of underdevelopment and as severe obstacles to necessary socio-economic advancement. If development rhetoric were to give a positive light to the ‘traditional activities’ of local people, their skills and innovations, and provide an insight into what the people really think, development initiatives may seem half as attractive, since their need would be severely put into question.
Concerning health issues, a strategy within development rhetoric is to link the topic of poverty and health, since poverty is a dominant feature on the agenda of international organisations and always attracts attention and aid. By attaching health to the issue of poverty, the initiative belongs among the priorities of development politics of the German government (BMZ 1999). Thus the local people become ‘the poor’ that need to be targeted and the programme is portrayed as contributing to not only the satisfaction of their basic need, ‘health’ but also to the decrease of poverty by raising the people’s awareness of their situation and making them conscious of the health services around them. The GTZ for example, describes the ‘target group’ as “predominantly consisting of poor people. The amount of poor people in the region concerned is high and the initiative will improve their living conditions and will further boost their productive potential by limiting the periods of time where they cannot work due to illness (GTZ 1999c, p.5).
The need to (re)educate the people
Therefore, the only way forward in development and official discourse is the (re)education of the Eastern Indonesian people, who are believed to be mentally stubborn and backward, in order for them to leave their old views behind and finally accept the benefits of modernity and the impacts of Western development. A re-education concerning health issues also refers to the view that a consciousness about health (in the biomedical sense) must be raised among the population if any improvements are to take place. Thus, two of the main components in the GTZ’s aim to improve the quality of the health services and reduce the barriers against their utilisation are educational means for the health personnel and the ‘health-consciousness-raising’ among the population. (GTZ 1999c, p.4) Because the people of NTT have not yet realised the full merits of curative biomedical medicine, they are in need of specific measures of ‘enlightenment’. This view is clearly expressed in the following statement. “Through relevant ‘enlightenment measures’ and the improvement of preventive services, the population should be encouraged to use the curative services promptly and therefore avoid illnesses.”(GTZ 1999c, p.19)
This is considered especially important in the area of NTT, where the level of education and particularly health education is considered way below that of the national level and thus may cause a bit of an embarrassment to the central government and the rest of Indonesia. This is possibly one of the other reasons, apart from paying lip-service to the international organisations, why the need to educate the people in the NTT province is not only present in the rhetoric of development planners but has also been embraced by the government. As Fernandez underlines, “human resources are a determining factor in the success of development, and in this respect the quality of our people’s education and health needs to be improved, in order to bring it closer to the national level.” (Fernandez 1991, p.9) The education of the people implies a much larger change, namely the abandoning of previously held values, attitudes and behaviour. The ‘ignorant’ population needs new knowledge, despite the fact that this new knowledge might not be what they want, nor reflects what they believe. Education is not only about giving people the possibility to use new information when they deem appropriate, it is also about imposing a different type of belief system. This is especially important when it comes to family planning initiatives for example. “Attitudunal and behavioural change is the basis of any family planning programme. Almost all family planning programmes begin by trying to get the idea of the small family accepted by the population. The success or failure of a family planning programme is reflected in the extent to which it has achieved attitudinal and behavioural change.” (Suyano 1994, p.122)
Participation as the new ‘fad’ in development
As previously mentioned, development initiatives have made a shift in the recent years, turning towards the ‘participation of the people’ as an important factor if initiatives are to succeed. The German government uses the word participation and other key words such as ‘empowerment’ and ‘ownership’ in order to show that their policies accept the importance of including and listening to local people’s views, interests and opinions. As the BMZ affirms, “participation is an important prerequisite for successful and sustainable development work. Participation contributes to the fact that the contributors feel responsible for the programmes and projects (‘ownership’) and can include their cultural values and interests. In this way participative development work supports the self induced improvement of living conditions in the partner countries. It broadens the possibilities and capabilities of the target groups to engage themselves in the improvement of the setting (‘empowerment’).
In the project proposal for the NTT health systems improvement initiative, the GTZ also points towards the relevance of target group involvement in the reform of the Indonesian health system (GTZ 1999c). However, the concept of ‘participation’, especially in health seems to be more of a new development fad than a real effort to include local peoples’ ideas and concepts (Stone 1992, Pigg 1993). The literal sense of the word is to ‘share’ or to ‘take part’ in something. (Thesaurus 1996, p. 406) When it comes down to it though, not much sharing is done.
Health staff are not really encouraged to listen to traditional healers (Pigg 1995b, Pillsbury 1982) nor are agency staff genuinely interested in taking part in ‘alternative medicine work shops’. The biomedical health system is given much more credit and professionality as than any other systems would seriously be taken account of in a health project. There is no real dialogue between the people and the agency staff; this would mean extensive field work which is time consuming and not very popular among international ‘experts’(Van der Geest et al 1990, Foster 1987). Participation sounds good especially since growing critique of top-down strategies has made planners revise their language when talking about initiatives at primary health care level. The word also implies equality in knowledge, authority and power, in practice this is not the case. Despite the rhetoric, limitations to participation are also laid out in the German government’s policy documents as is demonstrated in the following quote. “In concrete cases (e.g. concerning predominantly technical questions) less intensive participation in the form of ‘involvement’ or ‘information’ can be useful and appropriate.” (BMZ 1999, p.3) Thus it is quite clear that participation of the local people is somewhat restricted particularly when it comes to technical aspects, which need external ‘professional’ and ‘expert’ knowledge.
The Indonesian government’s role in development work
This is also the case when it comes to the government’s involvement. The government can suggest the initiative and therefore expose the country to external involvement (and thus attract funding) but when it comes to the actual implementation, control is taken out of the government’s hands. “It may well be desirable, indeed, for the government with its limited resources to act (outside the areas of its special responsibility in providing services and infrastructures) in the role of co-ordinator and monitor. This stance would leave commercial businesses, NGOs, and foreign agencies in their respective spheres to undertake most actual development work.” (Barlow and Gondowarsito 1991, p.30) The actual development work is then taken over by the international agency who will secure their place (and their jobs) in the respective region. This is also reflected in the German government’s policy towards partner country involvement. Albeit the fact that the GTZ prides itself with the fact that it is a bilateral organisation and acts only together with the ‘partner country’s’ government’s co-operation, certain limitations are set by the German Ministry for Economic Co-operation. It is clearly stated, that “the participative aspect of the co-operation implies that the partners should be prepared and capable for dialogue and communication on all levels. Apart from that, they should be willing to yield power.” (BMZ 1999, p.7) The word ‘Partner’ or ‘Partnerland’ (partner country) is often utilised to define the recipient country. This definition is again part of development rhetoric, since the sense of ‘partnership’ implies full equality between the recipient and the donor concerning decision-making and planning which is all too often not the case.
In order to properly analyse the popular response to official rhetoric in NTT, the fieldwork that was done during the internship is not enough. The gathering of information was carried out within an institutional framework, namely that of the GTZ, at the initial stages of the project implementation. Therefore, only several observations that were made during the course of the work on Alor will be highlighted.
It is extremely difficult to give an accurate picture of how people respond to rhetoric through questioning, since one cannot assume that people are likely or willing to completely open up and reveal their real thoughts and opinions on certain topics. People always seemed influenced by some other force and it seemed that they quite often accepted the rhetoric of the party that was perceived to have more authority.
An observation was made for example when a government official came to Wolwal Barat. He addressed only the village leader (kepala desa), who seemed to be very conscious of his authority and eager to please and appease him. In addition, while questioning the villagers of Wolwal district, the village leaders were often present and interrupted the conversations, openly encouraging villagers that were hesitant to voice ‘their opinion’ and participate. Thus, when the village leader was present, it soon became clear that people were more or less voicing ‘his’ opinions rather than their own.
Furthermore, during the interviews and focus group discussions with women, men always seemed to be around and had considerable impact on what their spouses, female relatives and daughters said by interrupting them, verbally reinforcing some points and laughing at others. Also elderly women had an influence on younger women in that they usually dominated in the conversations or directed the discussion towards points they were particularly interested in. Additionally, my status as a ‘development worker’ also had an impact on what the villagers and village leaders of Wolwal were telling me since they were intent on getting several points over to me and leaving others out. And of course women responded differently to me than they did to my male colleagues, and men seemed happier talking to my colleagues than to me.
Taking full account of these deliberations, the following assumptions concerning popular response to official rhetoric were made. Andersen in Graham remarks about Western concepts of politics being absorbed and transformed within Indonesian Javanese mental structures, “in any such cross-cultural transfer, the inevitable thrust is to appropriate the foreign concept and try to anchor it provisionally to traditional ways of thinking and modes of behaviour. Depending on the conceptions of the elite and its determination, either the imported ideas and modalities or the traditional ones assume general ascendancy.” (Graham 1994, p. 136) This was also observed among different villagers however for different reasons. The village leaders had appropriated official discourse concerning health, possibly because it improved their relations with powers outside the village and reasserted their own power within the village. A health project strengthens ties to the common villagers and thus increases status and power. Also, there is competition between the villages and the various village leaders for the implementation of projects, since development projects are seen to be a step towards modernity and thus important for the image of the village.
The villagers of Wolwal seemed to have adapted the official rhetoric in a sense that they did not openly resist the official discourse concerning health. Here, the Western concept of health seemed to have been internalised in that modern health services and medicines were accepted and used when it came to certain illness types, such as malaria and diarrhoeal diseases. This adherence expressed itself in several ways. In Wolwal, the people were prepared to pay more if they received quality curative services. As one elderly man exclaimed: “The cost does not matter if I get good services.” Moreover, villagers were quite open in their criticism of the health centres and pointed out that they would use them more if only they were properly serviced. The main points of complaint concerned the difficult accessibility of health centres, the long waiting times, the unfamiliarity of staff, the lack of appropriate drugs, but especially the absence of health personnel from their assigned posts (See Pos Kupang article in Appendix). Thus it can be said, that the ideology promulgated by the state concerning health had made its way into Wolwal villagers discourses.
Nevertheless, the people had found a way to place the governmental concept of health into their behaviour and actions without giving up their previous methods of curing. In a sense both systems still co-exist without one having gained more authority than the other. The people of Wolwal visit their familiar healers when they have the feeling that the illness could not be treated by health staff at one of the centres and vice versa.
The main reasons that were given for the frequent use of traditional healers (and especially dukun bayi - traditional midwives) was the fact that they were familiar to the community members, and signifiantly could be scrutinised, questioned and doubted. Between the ill villager and the healer, a direct dialogue is possible. In this setting, the hierarchical order found among client and physician or nurse is not present and therefore illness and treatment negotiations lie in both the hands of the healer and in those of the individual. As Rieks and Islander (1990) reaffirm, complete acceptance of a ‘modern’, ‘Western-based’ health care system means giving up (at least in part) a health system villagers can control and understand for a system independent of and often incomprehensible to them. “It means giving up a health system in which they set the priorities for a system whose priorities are set by village leaders and health centre staff.” (p. 82)
Further, subtle forms of resistance could be felt when for example the villagers politely sat at gatherings and discussions without uttering a word or only agreeing but not adding any input and possibly not really listening to what was being said. As long as people can find niches by which they can resist government promoted ideologies or even if people assimilate official rhetoric according to their needs without giving up their own rhetoric, there is still hope that dominant discourses that are embedded in power relations will not fully infiltrate peoples thoughts and beliefs. The question is for how long this will last?
During the course of this dissertation several observations have been made. It has been discussed why and how the biomedical model has become so strong in development planning while ethnomedical models are devalued. Moreover, answers have been found to how biomedical discourses are created and shaped within health development and how they can reach a remote village in Eastern Indonesia through ‘agency-rhetoric’ that is adapted by the national government and spread through state officials. It has been shown how all agency is potentially removed from people when development initiatives ignore local knowledges on health and insist on imposing views that have been developed in the West throughout the past century. These views are then often internalised by those in positions of authority and shed a depreciative light on everything that is termed ‘traditional’.
However it has also been briefly outlined that people are not passively accepting health discourses but taking bits and pieces and adapting those aspects that are relevant to their needs or resisting them by continuing their use of healers and traditional medicines.
Unfortunately processes of adoption and assimilation are ‘uni-directional’, local discourses are not approved or accepted when it comes to health initiatives. Even when qualitative data is collected it is not sufficiently used.
Health is a difficult issue to address when it comes to the social sciences. Medical anthropologists, for example, are placed in an ambiguous position when working within development. Despite realising the negative impact that certain practices have on an individual’s well-being, they are aware of the implications that would follow if they voiced their (Western-biomedically-shaped) opinion. However, their main task is to demonstrate that discourses are shaped and values are formed for reasons that lie in power relations that have developed throughout the century and are continuing today.
Months after my internship, a team of physicians and medical staff had been sent to the island Alor as part of a co-operation between the WHO and the GTZ project in Kupang with the aim of eradicating an illness that was described to me by the villagers as the ‘getting larger of genitals’ and later turned out to be Filariasis. The team moved in, treated all those suffering from it and moved out again. I do not know how the villagers reacted or how they feel now. A ‘medical success’ had happened before their eyes… it is possible that this has strengthened their view that “Western medicine is stronger” and development is a good thing, it is also possible that this event passed by and life has set in once again without too many changes in peoples’ views and daily deliberations. My colleague and friend Marvel has left the project. He told me that there did not seem to be enough communication between the officials at the Ministry of Health based in Kupang, the foreign staff at the GTZ project and the people of Wolwal. “Everybody has their own agenda.. nothing is done hand-in-hand. I cannot change anything.”
The Indonesian Health System
A new national health system, aimed at attaining “health for all”, was constituted under the Indonesian Ministry of Health with an annual budget of 3.8% of GNP for the Fifth Five-Year Plan (1989-93) in accordance with the New Order Government’s National Development Policy and Strategy (Hunter 1996). The national health system was thus part of the New Order development strategy for economic prosperity and modernisation and is incorporated into Indonesia’s Five-Year Plans (Repelita). During the second half of the First Five-Year Development (1969-74) the idea of primary health care as government policy first received support (Hunter 1996). This policy gave the Puskesmas (health centres) the central role in bringing health care to the Indonesian population. Community and preventive health services in Indonesia are organised in a three tier system (see Table 1.). The upper tier consists of the health centre (Puskesmas) which is designed to provide both curative and preventive health services. Here usually a doctor if present or if not a nurse proves curative care. The middle tier is made up of the health subcentre (Puskesmas Pembantu) a term which is now applied to all the units below the level of the health centre. The subcentre combines curative care and maternal and child health functions. The head of a health subcentre is usually a nurse or midwive, and the total staff generally numbers less than three. At the periphery of the system there has been a dramatic expansion of integrated service posts (Posyandu) at village level. These are not permanently staffed facilities, but take the form of a monthly clinic held in borrowed premises, at which the visiting team from the health centre reinforce resident village health volunteers (kaders). Virtually all health centres are administered and said to be owned by the second level regional governments.(World Bank 1991)
Table 1. Primary Health Care Model
Abbildung in dieser Leseprobe nicht enthalten
Source: Adapted from Hunter 1996, p. 28
The public health system provides biomedical services through a referral system composed of different levels which stress different policy aspects. At the local and district levels, services are mainly directed towards preventive and promotional community health activities, but at the higher national levels the main focus is on curative and rehabilitative (hospital) activities (Hunter 1996).
Excerpt of conversation with Ola Kanis , 93 years old, Wolwal Barat, Date 26/8/2000
T. (translated by Marvel): “How did you become a dukun?”
Dukun (completely ignores me and the question): “The hospital in Kalabahi (the capital of Alor) has my name. If they cannot detect reasons for the illness, they will send the patient to me. If there is black magic there is no scientific reason, they call me. There was a woman who came to the hospital, she was vomiting blood and bleeding from the nose. I came to the hospital and touched the belly button and the blood stopped. The people who have black magic in them run away from me because they are scared.”
T. (again translated): “..Ah, yes, .. would you like to share with us further how you treat the people that come to you.”
Dukun (starts glaring at me): “No!”
T. : “Errr.. we would be very interested in learning from you how you became a dukun and how you treat the people that come to you.”
Dukun: “It is secret!”
T. (By this time I feel a little disconcerted and try reformulating the question): “Errm... I understand, .. maybe you could tell us a little about your background.”
Dukun (long silence... he is obviously starting to think he is wasting his time and energy on my ignorance and looks bored): “It is secret. Evil spirits. So many people have been cured by me.”
T. (I try changing the topic): “So... what do you think of the Polindes and the Pustu?”
Dukun: “Those midwives are just giving injections. Those injections are just useless. There are other reasons why people are ill - spiritual reasons. I have cured many people.”
(The dialogue continues in a similar fashion and soon after the Dukun leaves rather impatiently)
Abbildung in dieser Leseprobe nicht enthalten
BMZ (1999) Die Entwicklungen im Einzelnen. Available online at [wysiwyg://6/http//www.bmz.de/median/evaluierung/EvalBericht18/EvalBericht_2.html
GTZ (2000) Report on Sectoral Workshops of Health Projects in Nusa Tanggara Timur, Kanwil Kesehatan, Propinsi NTT
GTZ (1999a) Improvement of the District Health System in NTT, Project Introduction Sheet
GTZ (1999b) Indonesian - German Technical Co-operation, Minutes of Meeting with Ministry of Health of the Government of Indonesia, Kupang
GTZ (1999c) Projektbeschreibung, Eschborn, Germany
GTZ (1999d) Project NTB/NTT The involvement of Seameo-GTZ Nutrition Project
Books and articles
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Cooper and Packard (eds) (1997) International development and the social sciences: essays on the history and politics of knowledge, University of California Press, Berkeley
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Escobar, A. (1988) Power and Visibility: Development and the Intervention and Management of the Third World. In Cultural Anthropology 3(4), pp. 428-443
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 See Maps 1 and 2 in Appendix.
 Life expectancy rates: 1976: 52.2 years; 1996: 63.9 years
Infant mortality rates: 1976: 109/1000; 1996:54/1000 (GTZ 1999)
 Translated from German: “Die geringe Qualitaet der angebotenen oeffentlichen Gesundheitsdienste, die hohen Kosten insbesondere fuer Krankenhausbehandlung sowie traditionalle und geographische Barrieren fuehren zu einer geringen Nutzung.” (GTZ 1999, p.20)
 Translated from German. See Appendix for full project proposal
 The treatment strategy most often followed in the West is based on the Cartesian duality between mind and body.
 This is not to say that everything ‘natural’ or ‘traditional’ is necessarily better, healthier or wiser than Western medical concepts and treatments.
 For more information on Javanese health care and rural practitioners see Rienks and Iskander 1990 and Slamet-Velsink 1996
 This information was gathered during research throughout the internship. Methods used were questionnaires (see Appendix), key informant interviews and focus group discussions. Apart from that personal interest sparked off long discussions with my colleagues. Due to the fact that my bahasa Indonesia was virtually inexistent, the material gathered through the above-mentioned methods relies on translations and also on observations.
 Alor is predominantly Christian. The Hamba Tuhan is not necessarily a priest in the usual sense but acts as a ‘priest of healing’. He or she usually has a further source of income since the ‘healing process’ is free.
 There are certain areas that are considered holy and avoided by people especially in the evening. It is said that spirits from the forest and air can enter ones body and change or influence your person and well-being. Slamet-Velsink explains this through the belief in the permeability of micro- and macro worlds. “(...) The human body and person is thought of as a microcosm that is constantly influenced by its engulfing human environment as well as by the macrocosm.” ( 1996, p. 70)
 Similar observations were made by Rieks and Iskandar who state: “It may be more difficult to become a good dukun than it is to become a good physician. In order to become a good physician one needs only the intellectual and economic resources to attend a university; but to be regarded as a healer entails the development and management of one’s own character and behaviour under public scrutiny.” (Rieks and Iskandar 1990, p. 81)
 My colleaugue passed this information on to me one evening after he had been discussing it with several friends of his.
 One woman of Wolwal Barat claimed she had gone to the nearest Pustu is the morning and went back in the evening, not having seen a nurse or received treatment at all.
 Following is an excerpt of observations made at a visit to the nearest Puskesmas. “The nurses are wearing military-like uniforms and seem rather hesitant to stop and talk. When I ask one of them where the ‘pregnant mothers’ unit is (a focus group discussion was to be held in one of the rooms), she shakes her head and whisks by (possibly because I was speaking in English).”
 This was one of the main complaints among the villagers of Wolwal. Women especially had the feeling they were not being given enough time to describe their perceptions of their suffering. Nor did they feel satisfied with the information that was given to them in return.
 See Appendix for a description of the Indonesian National Health System
 However, it seems that the ‘integration’ of traditional healers is but again a catch phrase that is not really put into practice. The process is not a two-way dialogue in which information is exchanged between the health personnel and the healers. Where possible, traditional healers (if they do not resist) are trained and then used as health promoters carrying development messages into the hidden heart of traditional societies. For further information on traditional health practitioners in national health care systems see Pigg 1995 and Pillsbury 1982
 This piece of information was not gathered as part of an interview but during a conversation
 Anthropological research may also cast a negative light on health development programmes and might therefore be considered threatening to the agency’s status
 Justice (1999) provides a good example of why health programmes are continued despite their ineffectiveness by providing an example of an assistant nurse midwive programme in Nepal. “This programme is part of the WHO/UNICEF support package in response to the government’s request for assistance. Accepting it has a variety of benefits for the government.” (p. 336)
 For example concerning injections. In Wolwal, several villagers mentioned that they were quite disappointed if they went to the health centre and did not receive any injections but only advice. “With injections, the force goes directly into the blood and brings immediate strength.”
 In more recent years, for example, Chinese medicine (especially acupuncture) has become more and more popular in the West and is used in medical jargon
 Full quote: “Despite the considerable handicaps, general poverty and backwardness shared by all the kabupaten (regency or district) in the province (...) some have succeeded in achieving relatively high levels of human resources development.” (Corner 1991, p. 49)
 Fernandez repeats this metaphor when he states that “ the wheel of development turns continuously, and in front of us stretches the future of NTT, which still requires much attention.” (Fernandez 1991, p.8)
 I had experienced a similar situation in Wolwal Barat when we were offered a cigarette each. My colleague after having declined quickly whispered in my ear: “Don’t accept them, you have to stand apart... otherwise these people think they can do anything with you. They are villagers, you have to show them that you are not.”
 The full quote: “The focus of Repelita V is on how to increase the income levels of people who have not yet enjoyed the results of development. Raising incomes does not only mean increasing the amount of money in people’s pockets, but more than that, enabling them to provide an adequate education to their children, to afford proper health care, and to build a brighter future. In raising the income level of the people of NTT, we can raise their standard of living and foster self respect and a sense of dignity.” (Fernandez 1991, p.10)
 Translated from German: “Gruende fuer die hohe Morbiditaet und Mortalitaet sind die schlechte Qualitaet und die eingeschraenkte Zugaenglichkeit der Gesundheitsdienste, die in einer geringeren Nutzung resultieren. Hinzu kommen in manchen Regionen tief verwurzelte Traditionen, die z.B. auch bei Schwangerschaften mit hohem Risiko der Geburt in haeuslicher Umgebung der Hilfe traditioneller Hebammen den Vorzug geben.” (GTZ 1999c, p.3)
 Translated from German: “Die Zielgruppe besteht hauptsaechlich aus Armen, der Anteil der Armen an der Bevoelkerungen der betreffenden Region ist hoch, das Vorhaben verbessert die Lebensbedingungen der Armen und foerdert ueber eine Verringerung krankheitsbedingter Arbeitsunfaehigkeitsperioden ihre produktiven Potentiale.” (GTZ 1999c, p.5)
 Translated from German: “ Die hier vorgeschlagene TZ-Komponente soll daher durch Ausbildungsmassnahmen fuer das Gesundheitspersonal sowie durch Anhebung des Gesundheits bewusstseins bei der Bevoelkerung die Qualitaet der Dienste verbessern und Nutzungs barrieren abbauen helfen.” (GTZ 1999c, p.4)
 Translated from German: “Durch entsprechende Aufklaerungsmassnahmen und die Verbesserung praeventiver Dienste soll die Bevoelkerung zur Krankheitsvorbeugung bzw. zur rechtzeitigen Nutzung kurativer Dienste angeregt werden.” (GTZ 1999c, p. 19)
 Translated form German: “Partizipation ist eine wichtige Vorraussetzung fuer erfolgreiche und nachhaltige Entwicklungszusammenarbeit. Partizipation traegt dazu bei, dass sich die Beteiligten fuer die Programme und Projekte selbst verantwortlich fuehlen (‘ownership’) und ihre jeweiligen kulturellen Wertvorstellungen und Interessen einbringen koennen. Damit unterstuetzt partizipative EZ die selbstbestimmende Verbesserung der Lebensverhaeltnisse in den Partnerlaendern. Sie erweitert die Moeglichkeiten und Faehigkeiten der Zielgruppen. Sich fuer verbesserte Rahmenbedingungen einzusetzen (‘empowerment’).” (BMZ 1999. p.1)
 The full quote: “Die Reformen des Gesundheitssystems auf Dorf-, Distrikt- und Provinzebene sowie neue Formen einer staerkeren Zielgruppenbeteiligung werden fuer die Umgestaltung des Gesundheitswesens in Indonesian richtungsweisend sein.” (GTZ 1999c, p. 10)
 “Im konkreten Fall (z.B. bei vorwiegend technischen Fragen) kann jedoch durchaus auch eine geringere Beteiligungsintensitaet in Form von ‘Mitwirkung’ oder ‘Information’ sinnvoll und angemessen sein.” (BMZ 1999c, p.3)
 “Die partizipative Gestaltung der Zusammenarbeit setzt voraus, dass die Partner auf allen Ebenen zum Dialog und zur Kommunikation bereit und in der Lage sind. Sie muessen ausserdem Willens sein, auch Macht abzugeben.” (BMZ 1999, p. 7)
 An interesting experience was made while interviewing a dukun, who was the first (but not the last) to ignore the prepared questionnaire. Please see the Appendix for an excerpt of the conversation with Ola Kanis
 This was especially the case in focus group discussions. In one such situation, a younger woman did not open her mouth apart from agreeing to what the others had to say, until the eldest one of the women left. Then she started loosening up and told us quite a lot about herself and her children.
 One such observation was made during a gathering in which we had to present the project and the objectives in the village hall. Not only did everybody seem bored but I could see two people had fallen asleep by the time we finished the session.
 Several male villagers had voiced this complaint and it was mentioned in the preliminary report.
 The New Order or Orde Baru Government refers to the Indonesian government during Suharto from 1965 until 1997
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