Breaking With Tradition, Building Future Generations

Women in Aceh are tackling child health issues from the bottom up. Chriswan Sungkono reports.

Vaccinating the babies

The room is full to exploding. Packed with mothers with babies and toddlers on their laps, the infants’ piercing cries fill the small space, brewing the already stifling air.

Outside, more mothers line up, beads of sweat running down their temples, their hands gripping cards labeled “Kartu Menuju Sehat” (Card Toward Good Health). Near the back door, women ladle bean soup into plastic packets. In one corner, a woman operates a weighing scale as mothers place their babies on it while chattering to their friends.

The 16th day of every month is eagerly awaited in Layeun, a sleepy hamlet in the regency of Aceh Besar, particularly by young mothers. Today is “Posyandu Day”, the day health officials come from town to deliver basic health services for all, particularly for children under 5, under one roof. Besides consultations with mothers, about 70 of the village’s infants and toddlers are entitled to free compulsory vaccinations: for tuberculosis, polio and the like.

Picking their way through the crowd, lest they step on a child’s toes, mothers follow a five-step process whenever they bring their babies to this health post. Once registered and weighed, a health consultant checks the baby. If all is well and the baby is scheduled for a vaccination, they move on to the next table.

This is where the real action happens. An otherwise timid toddler may very well wig out at this point when they see the needle. Their screams are contagious, spreading to the other children in the place who wig out in a chain reaction. The deafening choir of cries, in turn, makes it harder for the adults to do their thing.

Nurbaiti Ahmad, though, manages to keep her composure. She rummages through the coolers looking for the right ampoule, draws the vaccine into the syringe, approaches the by-now-manic baby, and softly but firmly jabs him in his chubby arm, often while carrying on a conversation with the mother.

With years of experience under her belt, Nurbaiti knows perfectly well that it’s not the babies who pose the biggest hindrance to immunization.

“Babies are uncomplicated,” she says. “Put them in their mother’s lap, crying or not, and they’ll resign themselves to getting the jab. It’s often the parents who’re hesitant.”

Aceh was for many decades in a state of unrest fueled by the guerilla war waged by the separatist Free Aceh Movement (GAM) against the Indonesian Military. Integrated health posts (Posyandu), therefore, were a luxury, and immunization was a notion alien to many here.

Even as late as 2007, when foreign aid groups and NGOs were firmly ensconced among the tsunami victims in evacuation camps and reconstructed villages, very few parents understood the benefits of vaccination or were willing to have their children immunized, Nurbaiti says.

“We have to keep educating them, or children will keep dying,” says nutritionist Fitria Mayasari, a colleague of Nurbaiti’s. Their early approaches were met with opposition.

“Mothers tended to think their kids would get sick after being vaccinated,” Nurbaiti says, referring to the side-effects that often last several days. “But that’s a natural bodily response [to the vaccine].”

But while more mothers get used to the idea, the fathers are less willing to budge from their long-held misconceptions.

“Since the father is usually considered the head of the family, the mother needs his permission to take the baby to the Posyandu,” Fitria says. “Some moms do it secretly, but you can’t really hide the resulting fever.”

Things changed after the tsunami. Measures have been taken in Aceh by international NGOs (and to some extent by the government) to raise awareness about infant health. The Layeun health post, for instance, was established by the American Red Cross and PLAN. The village’s health programs are supported by World Vision.

Owing to the relentless campaigning by health officials like Nurbaiti and Fitria, the overall situation has improved.

“About 80 percent of families with children here now get their kids immunized,” says Juliana, a village midwife who has been stationed back in her hometown for almost two years now. The progress made during that short period is palpable.

Unlike her colleagues in larger towns who visit Layeun once or twice a month, Juliana is the resident health official in charge of this village of 800 people.

A midwife by training, Juliana must also tend to other ailments. The nearest hospital is 30 kilometers away, and transportation is seldom available to take patients there, so she has to make do with what little she has. Villagers normally bear children at home.

Almost all the children she has helped deliver were born healthy. Another two died minutes after birth due to untreatable congenital disorders.

Though working at the local level, the efforts by these health workers are instrumental in helping reach one of the primary goals of the UN’s Millennium Declaration. Millennium Development Goal No. 4, due in 2015, focuses specifically on reducing deaths among children under 5 by two-thirds.

The annual mortality rate for this group of infants worldwide is 8.8 million – roughly one every four seconds. Achieving that goal, then, is no simple task.

The most common causes of infant mortality are highly preventable: diarrhea, pneumonia, malaria and malnutrition. Providing the right type of food could, in theory, save nearly 4 million lives a year.

World Vision, among the world’s largest NGOs for children’s welfare, recently launched a global program to address the challenge of reducing infant mortality.

Its Global Child Health Campaign (GCHC) focuses not just on the child, but also on the mother’s health and HIV/AIDS.

Improvements in both aspects are critical to reducing infant mortality.

Indonesia is among seven nations on four continents – all signatories to the Millennium Declaration – chosen to pilot the GCHC’s initiatives. Notwithstanding the campaign’s global reach, its success (which eventually means the world’s success) clearly rests on the shoulders of individuals like Juliana, Nurbaiti and Fitria.


Dodging the invisible tsunami

In the languid countryside of Lamno, along Aceh Jaya’s majestic coastline, 4-year-old Zaini lies limp on the floor of his house. He barely moves as his mother watches over him and his younger brother plays around him. His hands are taut, his gangly feet almost lifeless.

The sixth of seven children, Zaini was born in a makeshift hospital in Banda Aceh six months after the tsunami wiped his parents’ village, 80 kilometers from the provincial capital, off the map. Zaini’s birth wasn’t smooth. Lacking an instrument sharp enough to cut his umbilical cord, the hospital staff failed to do it in a single try. It took them three attempts, and many minutes, to finally do it. Yet he was as perfect as babies could be.

On the third day, worried that he was exhibiting some irregular responses, his parents took Zaini to a shaman. They spent a year in vain going from one shaman to another, even as far as Sabang, the westernmost tip of Aceh. But not to doctors. None of them could cure Zaini. Finally his parents decided to go to a pediatrician, who diagnosed Zaini as having a certain neurological disorder, and prescribed some medication.

But instead of improving, the medication induced in Zaini a seizure so protracted and severe most people in the camp where his family lived thought death was nigh.

Only his mother persevered. For her, hearing his cries soften was a miracle in itself. They never went back to the doctor, and stopped seeking any kind of solution altogether.

Today, Zaini is too weak to stand, crawl or even sit. Nor is he able to talk, although he grins when his mother tickles him, brandishing a set of healthy teeth, and laughs unabashedly, his eyes rolling around animatedly. That’s all he can do now besides cry and try to turn his head when somebody calls his name.

Like many other children born in the tsunami’s aftermath, Zaini never received proper treatment as soon as he was born. It is likely his muscular atrophy was caused by tetanus, which he contracted from that blunt, non-sterile instrument they used to cut his umbilical cord.

Neonatal tetanus, the form that attacked Zaini, affects 1 million births worldwide and kills around 300,000 children annually, almost entirely in developing nations.

The 2004 tsunami, by comparison, claimed 290,000 lives, and it struck but once.

A vaccine for tetanus exists that can prevent millions of unnecessary deaths. But like most children in Aceh, Zaini never got his jab.

His mother shows no sign of wanting to have him treated, even when every month health officials provide simple treatments for free, just a few kilometers away.

“When my friends’ kids get sick, the doctors give them expensive medicines,” she says, adding it’s the prospect of paying through the nose that prevents her seeking proper treatment for Zaini.

Encouragement to do so, however, flows in from fellow mothers, especially those working as healthcare volunteers.

Rawati and Ipah Zuhra are among two such volunteers in the village. For five years they have worked together to raise public awareness about health issues, back when they were still living in an evacuation camp. In those days, aid groups found it hard to get people willing to volunteer for health causes. The two signed up, although their reasons were quite unusual.

For Rawati, the gig meant she could finally learn to write, while for Ipah, it was the opposite: she could write already but, oddly enough, she couldn’t read. So they joined forces. In the field, Ipah would read whatever instructions had been given to them, and Rawati would write down anything that needed to be recorded. The two taught each other.

Having already mastered both skills, they keep volunteering because they understand the importance of educating the villagers, and of breaking the age-old beliefs that pose serious health threats if allowed to persist.

Take breast-feeding. While it’s almost universally acknowledged that babies, in normal conditions, must be breast-fed exclusively for at least the first six months, mothers in Aceh often give their newborns a softened paste of rice and bananas as early as the first day.

“They do it when their babies cry,” says Ayu, a World Vision manager for Aceh Jaya. Born and raised in Aceh, Ayu received that very treatment herself as a baby.

“Parents think babies are hungry when they cry. And they think breast milk just won’t do,” she continues. “So they feed them something more, you know, solid. More filling. Things that babies aren’t ready for.”

Rawati, a mother of four, used to do that too, “before I knew it was wrong”. Now she only breast-feeds her baby. This wasn’t easy at first.

“My mother-in-law, who’s a renowned shaman, told me to give the baby bananas,” she says. “I couldn’t outright refuse, nor could my husband, who agrees with me. So I bought bananas and got the other kids to eat them while she wasn’t around. It worked!”

Persuading mothers to do as health officials advise is not without its challenges.

“It takes a whole lot of coaxing and incentives, like free food, to get them to even come to the health post with their kids once a month, so imagine what it’d take to get them to change their feeding habits,” Ipah says. “Eventually, though, we start earning their trust.”

She says this is most apparent in the habit among many mothers now to bathe their babies as soon as they’re awake.

“It’s a small thing, but it builds up from there,” Rawati says.

Ipah lauds the efforts by the many NGOs focusing on health issues in her village, adding she is determined to keep championing the cause, “even if there’s no more help from outside”.

But there will be.

“World Vision and our partners will continue to empower the people, though not always financially,” Ayu says. “But we can’t do this alone.”

With 6 million children to save by 2015, aid must go hand in hand with growing public awareness. Only then can the world stop future generations from suffering and dying from preventable diseases.

Let Zaini be the constant reminder that there is still much work to do.

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