So here is one of the clinical dilemmas we face all too often here:

So here is one of the clinical dilemmas we face all too often here:

We have a 50+ year old man with a mass in the R upper lobe of his lung that was found in August and presumed to be cancer (long-term smoker).  He returned last week and really was not looking as sick as we thought for 6 months further along.  So...does he really have TB or another process going on?  Unfortunately, he lives on an island some 4 hrs away.  Still, he was able to afford a chest x-ray in Ketapung, so he returned with that this week and the mass is much larger -- still suspicious for cancer, but he is just not very sick and has no nodes we can palpate.  About the only thing we could actually treat would be TB; however, there is no DOTS (direct observed therapy for TB) worker in his village.  Add that to the substantial risk that if we treat him for one month, he likely will be lost to follow-up and increase the risk of developing MDR Tb (multidrug resistant).  Also, in-order-for the government clinics to prescribe the TB drugs for free, they require more proof of tb than what we have for him.  What to do??  Nur will call the govn doctor in his village and try to convince him to give a trial of TB meds for a month and provide follow-up.  We simply cannot risk treating him incompletely for TB.

Always, the care we provide is balanced with the ability of patients or families to afford what we suggest (sometimes x-rays or surgery).  Many decisions are made to forego the treatment we suggest because it's not affordable.  We do an amazing amount of care with just good clinical judgement.

We have just four more clinic days before departure and will see what new or old problems will confront us.

Jim

Sent from my iPad

Look at that lovely "cast" for Rakus.

Look at that lovely "cast" for Rakus.  BUT by the time we got back from the clinic tonight she had wriggled out of it.  So, I guess we will let her be.  She is becoming quite adept at hopping.  

Pictures Goat Exchange

The house where we purchased the goats

Weighing the goats

Miftah and Hen, two ASRI staff along

Broken leg, Goats, and Beach

It is Wednesday AM and  I am sitting in the dental office waiting for some dental patients while Hotlin scrubs the dental chair with a disinfectant concoction with a toothbrush.  Obviously there are no patients at the moment but that could change as soon as someone picks off one of the "tickets" from the nail outside the front door.  No rain for the last few days, so the sun is shining which will make for a very hot day under the tin roof. Thankfully, there is a fan behind me.

There is much effort being expended to complete reports/applications/gather local supporters etc. all targeted at hopefully obtaining financial support from USAID for the building of the much hoped for hospital.  The process is slow but it sounds like there are three contractors who will bid and the design is also being adjusted so that part of the hospital could be built and then expanded if funding requires.  So we hear "America" frequently in the morning discussion, but really do not know what is happening.  There is an architect here who is the point person.

Patrick continues fixing things and will put in a sink in one of the patient rooms...this makes washing hands MUCH easier.  Most of the other patient exam rooms have sinks as does the dental office.  Talk about things to be thankful for!  We will work with him regarding the bikes and will hopefully be able to establish some kind of maintenance program.  BUT at least people are putting the bikes that still have some life under the shelter in front of the clinic. Slow progress...but progress

Now for the broken leg...it isn't one of ours or any of the staff's.  BUT we inherited a small, very pretty cat named Rakus who came along with the house.  Monday night she appeared holding up a paw and let Jim examine her, revealing a broken leg at the joint between the upper and lower leg. Now what do we do...soon there were four of us hovering over her attempting to fashion some way to stabilize the break.  We had to call one of the nurses for some supplies and used tongue blades.  Well, it didn't work and within an hour we took it off.  She was/is eating and was getting around with her three good legs.  BUT we have now devised another split which will stabilize better had have rigged up a way to keep it in place using the stocking net I had packed my (now moldy) shoes.  She has been unbelievably patient with all of this and has never tried to bite or kick after that first exam.  

Yesterday was a day filled with a great experience.  About midway through the morning Satiawati, the woman who is in charge of the Goats for Widows program came and with some translation help asked if I wanted to go with her to see the goats.  She rides a motorcycle and I REALLY like motorcycles at this point.  One is cool riding on a motorcycle!  Two of the staff who work with conservation and   the organic gardening program were along.  Realize that at this point I didn't know if any of the others spoke English.  Off we went to a house about 20 minutes away.  We were invited in, left our shoes at the door, sat on the wooden floor and waited until three goats arrived.  Their legs were tied, they were hung upside down and weighed on a make shift scale hung between two trees.  

Then we returned to the house, sat on the floor, and after some discussion, money changed hands (counted multiple times including by the man's wife!) .  We were buying the three goats for the program.  By this time Mifta had revealed that he could speak more English than I knew so I was getting some help.  Back on the motorcycle and off we went down more narrow roads, past homes, rice fields, a school here and there to another home which had some furniture and was obviously lived in by a family with more wealth.  After a bit of waiting, here comes the motor bike with the huge double baskets on the back and inside the baskets....all three goats being brought by the man who sold them!  Shortly three widows who were to be the recipients arrived and there was a small celebration on the "porch" of the house.  The man who lives there is a Forest Guardian - one who works for ASRI as a monitor against illegal logging in the village.  We were served coffee, crackers, and water and there was much laughter, many photos etc.  In short it was a real celebration and I was thrilled to see this great gift to the women.

Off we went, heading to lunch I thought, but first there was one more stop.  After another 10 minutes or so, we arrived at another area where people were gathered under a large tree.  The children  were running about and a few tried out their English which is always fun.  They know as much English as I do Indonesian, but we both try.  This event was a passing on of a goat, one of the requirements of the widows who receive goats through the program.  Soon up walked an elderly woman leading a goat and under tree there was another elderly woman who could have been her twin.  The rope was passed from one hand to the other, pictures were taken, there was lots of laughter.  How special for a very poor woman who now can keep any future baby goats as her own, to pass on the gift.  My heart was truly full.

So, we did make it back to lunch and the egg plus small white egg plant dish was quite good.  I rather wish they wouldn't fry their chips in the same oil as they fry the fish, however!  

We rode to the bank in the heat of the day because bankers hours are a real thing here and were able to withdraw the cash we will need for our weekend trip.  Talk about a wad of cash!  In all we withdrew 5,000,000 Rupia which will cover our plane tickets and the cost for the three days in the national park.  We had to put it in our backpack as it simply won't fit in our wallets.  

Evening was spent at the beach covertly drinking a can of beer with three of the other volunteers.  Two of them had plastic mugs to more easily camouflage their beverage.  The sunset wasn't spectacular, but the breeze was welcome and the company good.

Time here is beginning to feel short.  There is so much more to share, but it will have to wait.  I want to rewrite my ASRI kids report, who by the way, went hiking in the local national forest yesterday.  They are the ones who will work to protect the rain forest in the future.

Monday miscelaneous

The clinic day is over but the internet is still working so a few thoughts.

It is going to take a while before we automatically don't think "monkeys" when we hear noises on the roof or in the trees outside our house.  After a  week or so of absence a group were in full force this morning.  The branches were waving  and I managed to get a photo of at least one of them.  We are looking forward to our trip to Tanjung Puting National Park. The new resident who arrived yesterday will go with us for the three day trip.  We will be staying/sleeping on a boat called a klotok and are counting on seeing orangutans, many kinds of monkeys, birds and flowers.  I have heard no reports of trouble with leeches which was my original fear about visiting the rain forest.

We will also miss the nightly sounds of our resident Tokay gecko and have fun keeping track of how many times he makes his characteristic call.  Supposedly it is always between 3 and 5.  It is unique and I really don't mind even during the night.

Let's talk meals:  Jim has become the king of soft poached eggs on toast every other morning and we use the frying pan to make toast.  That also works for toasted peanut butter sandwiches.  Yami makes and leaves us a meal everyday including Saturday.  They always include rice, some vegetable mix which is often the better part of the meal, tempe or fried tofu and the some kind of main dish which is put over the rice.  Sometimes it is small pieces of chicken with some sauce.  I think they often use cloves, and occassionally it is too spicy to eat.  We avoid the fish which is served at  lunch at the new  yellow house which is the entire small fish and not that good.  We occasionally eat at the cafe next door and have soto  which is a kind of soup:  broth, pieces of  rice cake, peanut sauce, hard boiled egg, noodles, a few piecesof shredded chicken all for 50 cents.  We doctor it with some hot sauce, sweet soy sauce and line.  And we really like it.  The other choice is chicken sate which is quite similar minus the broth and with pieces of chicken on skewers.  That costs $1.00.  

Life in the dental clinic continues.  Last week we had the major rain that Jim mentioned right in the middle of a difficult root canal.  What with the electricity going out at least twice, waiting for the generator to kick in, then the roof leaking between Monica and myself as I held instruments and passed various items, it was quite exciting.  She just keeps on working.  I should also mention that we are both barefoot and today I practiced  turning the suction machine off and on with my big toe.  That is what happens when it is on the floor and we both have gloves on which we are keeping as sterile as possible.  Still hurts my heart to see the children come in for tooth extractions.

WE are seeing watching lots of old movies and reading lots of books  It is DARK here beginning about 6:30 and there is really nothing else to do.  It is VERY important to have the computer battery charged basically all the time in case the electricity fails.  It is very irritating to reach the last 15 minutes of a movie and have the battery start pinging!  

That is all for now....56 patients today for the MD's.  Monday is the busiest day.

Love to all, Lauri

Fwd: 2 pictures for you

Check out the fingernails in the photo taken by Diane, a previous MD volunteer here.  I'm still looking for the man....  Rather wonder how long it took to grow these!

---------- Forwarded message ----------
From: Diane Dakin <diane.e.dakin@gmail.com>
Date: Wed, Feb 20, 2013 at 11:05 PM
Subject: 2 pictures for you
To: Lauri Young <lyoung@cfu.net>


 So have you done karioke night at the  hotel yet??!!  And seeing your
email about the  finger nails- how about thisone fromthe hardware
store in town!!
 I sure wish you were stopping in Seattle on your way home. I am so
enjoying living vicariously and I am sharing the notes with a friend
who is going in June with his son who is starting med school in the
fall.
 Ciao or rather slamat malam! Diane

You have been sent 2 pictures.


IMG_1476.JPG
IMG_1448.JPG

These pictures were sent with Picasa, from Google.
Try it out here: http://picasa.google.com/

It's Monday morning

It's Monday morning and I am sitting here waiting for clinic to get started.  We have one doc who is screening for the cataract clinic today and another home sick with an insect bite, so the remaining two will be busy.  Ilana, a third year Stanford resident arrived yesterday and will be a great addition.  

Last week, US AID made a site visit here.  This team consisted of the head person for Indonesia, based in Jakarta along with a couple of his folks, and the overseeing organization (makes sure that our tax dollars are being spent as planned) that is based in Manilla.  ASRI is hoping to get a major contribution from AID for building the hospital, but their funds are for conservation (which is clearly the purpose of this clinic and hospital). So, it will be a hard sell, but still a good possibility. Fortunately, AID really loves ASRI and has been supportive of the conservation efforts and the excellent record-keeping and care being delivered.  So...we had some good conversations with these really personable folks and are hoping for the best.

This whole concept of regulation and policing of expenditures is in direct contrast to what we have seen locally.  Truckloads of illegally logged lumber will drive down the street and they do not get arrested.  Suddenly, the chainsaws in the national park go silent when the park officials show up.  Enforcement is, at best, spotty.  All of which makes us even more grateful that we have laws and responsible agencies to protect our national treasures.  

A word about smoking here:  So many people smoke (mostly men) and we have learned that cigarettes are a government monopoly, thus, very little effort is made to curb the habit.  And, they are really cheap. In fact, the television ads for cigarettes have a tiny safety statement that lasts all of a couple of seconds and has print that needs bifocals to be read -- wonder why???  We are now seeing COPD (emphysema), lots of stroke and hypertension -- all the ravages of smoking.

Our weekend was hot, damn hot.  Saturday, we took a 1.5hr walk, then did some biking around town trying out different bikes, and finally a 10 mile ride (one-way) to see large fruit bats as they emerged at twilight (only, the bats were mostly no-shows -- didn't get the message that we were there to observe).  The ride home in the dark was ok but not as pretty as the ride out.  For some reason (we blame the heat), we were really wiped by the time we got home --about 7:30.  So, I spent the whole of Sunday, except for an hour at the beach, reading my fourth book (The Help).  I cannot remember when I last spent an entire day reading for pleasure.  Thankfully, I still have two books on the IPAD.

We have also been thinking alot about infrastructure or the lack thereof.  There is no central water system or sewer system and, as we have noted, no system of garbage control.  Our water (at the house) comes from a well in-front-of the house and is pumped to a large tank up the hill from the house, thus gravity feed to fill our barrels in the bathroom and to operate the shower.  So much is dependent on the people who must provide their own services.  As we were riding to the bat place, I watched a man bathing in the ditch water -- a frequent and likely usual place for those who have no water in the house (the majority, I would say).  We have so much for which to be grateful.

We have heard about the snow in Iowa.  Hope you are all well.

Jim

Re: 3 pictures for you

Friday morning -- a few thoughts and observations:

Last night, no power from probably 3PM until after midnight -- ate by headlamp again.  Really heavy rain with wind during the afternoon and our house has all kinds of dust from the thatched rood.  No ants last night -- another bonus-- and I avoided my usual cappuccino during the afternoon, so slept much better -- this instant stuff must be loaded with caffeine.

Cappuccino -- 30 cents;  soto (soup) -- 50 cents:  a pineapple -- 50 cents.  Fried noodles -- one dollar,

Lauri is busy preparing for her English class this afternoon.  After that, we will bike to the juice place and buy some more fruit and coffee.  This weekend, we are planning to bike, at sunset, to a place that has huge bats, we are told -- need to find some better bikes for that ride of 30 minutes or so.

Patrick and I will do a little bike work this weekend, I think.  At least, perhaps, we can keep the newer bikes operating well.

Jim

Sent from my iPad

Fwd: 3 pictures for you

Leaving the restaurant at night. I'm the one in white in the back with a headlamp.

frying something with little fish...Jim likes the doughnuts also available.  I prefer chocolate

Preparing to make paper

An Unbelievable Rain

It's Thursday afternoon and we are having an unbelievable rain storm at present -- literally can't hear each other talk.  Just saw a man who's eye was burned with the sap from a tree he was cutting -- a couple of days ago -- has a cloudy cornea and nice, big corneal burn after staining.  Hopefully, the measures we are taking will save his cornea and, thus, his vision.

Just helped Patrick analyze the spin cycle of the washing machine -- had quit spinning -- and we found the problem.  Now, since we will never do the needed fix, we are looking at a work-around that might just work.

Can't believe with this rain that we still  have internet, but rest of the power if from the generator.

Jim

Major challenge!

This morning at the 8 AM meeting as the staff gathered to share information gathered over the past day(s) we received a call from Kinari (one of the founders of this entire effort) reporting that there has been either an initiation or an increase in illegal logging in a village  (Tanjung Gunung)  near the national park we are near.  The village is near the coast and through the village runs a road which leads to a research station in the park as well as the sought after trees.  It is one of the most pristine, not logged areas in the park and the challenge to the ASRI staff is to come up with a plan.  So, I look around the group and think what in the world can this really small group of people do?

When this information was given there was an audible moan/gasp from the group and this continued as more information was heard.  What was translated for me is that the national park staff is insufficient to adequately patrol the park and there is also a "mole" in the village who alerts the loggers when the park patrol will come to their area.  The villagers have said via a meeting with the ASRI staff previously that they wouldn't log if they were given cows because then they could farm more efficiently.  But there is another problem and that is flooding from the sea which would take an expensive dam to build to control.  And the area the dam would need to be built in is in the national park and thus prohibited.  Talk about a Catch 22.  So, as we start the clinic day, Hotlin (the second founder) and the man responsible for the reforestation/organic farming program (I think) are huddled in a back room around a cell phone talking and planning.  I am reminded that the effort being expended to protect the forest is being done for all of us...for the climate...for the wildlife diversity  and for the knowledge that is gained from the research i.e. new medications??  An update will come later...

NEWS FLASH!!  Two nights sleeping with out ant bed visitors.  On Monday after the clinic but before the shops close between 4 and 7 PM we high tailed by bike to the local "department store"  With the help of the dictionary we found a spray which we used in spite of the warning of the newest volunteer to arrive, Patrick, that we should be careful with such sprays in developing countries as they may contain substances banned in the US.  We sprayed, closed the doors to the room, and sat outside enjoying a cool drink waiting for the fumes to dissipate.  This isn't a problem as there is no direct contact between the walls and the roof except for some supporting frame .  It seems to have worked in the room we are in, but there is still evidence in the other bedroom.  But we are celebrating at the moment!

Life with ants is interesting...we basically keep everything free of food/crumbs sweet drink rings etc.  When Yani, the helper for our house, leaves us our evening meal, all the dishes are sitting on plates filled with water.  This creates a barrier as evidently ants can't swim.

Patrick arrived two days ago and is a grand addition to the crew.  He is a repeat volunteer i.e. 3-4 times, and comes with a wealth of skills in the construction/electrical/plumbing area.  The last time he was here, he built 4 wells operated with a treadle.  This time he arrived with the PVC pipe, Dewalt tools, plus whatever else he needs for various projects and says that he hopes to build 10 wells in the various villages..  This meant he paid for 400 lbs. of overweight luggage!  He brought a suction machine for dental use which was damaged in travel so he is on the search for replacement parts.  Our hope is that we will also be able to set up a bike maintenance program.  He brought the parts we requested.  Patrick has a big personality, has worked all over the world, and the standing joke is that he still doesn't speak much, if at all, Indonesian.  Oh yes, he also likes rubber chicken jokes!

Jason and Nadi left last Thursday and we will be receiving another Johnson and Johnson scholar (internal med. resident) from Stanford this weekend who will go to another national park where there are feeding stations for orangutans.  We also hope to see probiscus monkeys plus many others.  .  Jim and I gathered at the boat dock and saw then safely loaded into the narrow speed boat.  We also "met" what looked like a horse shoe crab but is called the turtle of the sea.  Huge, and very interesting.  It had been caught right by the dock.  I hope to send a picture.

Another new experience...yesterday I went to school with Etty. She conducts classes for the children in the 23 villages surrounding the national park  This program is called ASRI Kids and is the program I am writing a report for to go to the donors.  Interestingly, this program was in response to daughters of a previous volunteer who asked why the children who lived near the park didn't get to see it and the wildlife in it.  In fact, when Etty did some pre-testing using a blowup globe and asked the kids to put stickers where orangutans lived.  The US, Australia plus many more countries received stickers.  Once they learned that ONLY Borneo and Sumatra have orangutans plus other wildlife and people come from all over the world to see their treasures, the kids were proud and in post testing have shown a much greater understanding of why and how the forest needs to be protected.  Etty's course which is continually evolving is a once a week course for 2 month followed by 1 and 2 month monitoring.  Each class is two hours and takes place at the school in the afternoon targeting 4 and 5th graders.  School is out for them at noon, so they have to return and they absolutely love it.  They learn about dental hygiene, the forest and the animals that live there, the importance of protecting this special place, trash and how to compost organic trash, the importance of and how to plant and care for trees (actually receive 4 seedlings to take home) and much more.  Yesterday we were making paper out of "trash" - used paper.  Picture a large wash tub filled with "blenderized" soggy paper and being mixed by lots of eager hands (only a little flicking of sticky paper at each other).  Then screens attached to a wood frame were lowered into the mix, lifted flat with the water draining ou and the pulp on topt, decorated with flowers and leaves and then put against a drying board and a "presser" used to press out the water while the frame is held in position.  Once the frame is removed the pulp sticks to the drying board and at the next visit, paper is removed.  Talk about eager kids!  They are also learning English too so we had fun with a few phrases.  One little girl dressed in pink told me that her name was Linda...that one I could remember.

Making paper is a way to teach children that what is trash can have other uses.  They will be the next forest guardians!

Now on to fashion....There are lovely ways to wear the head covering but I have yet to discover how it stays in place.  BUT I can not imagine how hot it is.  As for the men...long fingernails at least one per hand are considered a fashion statement.  I had thought there was a utilitarian purpose such as starting the pealing of various kinds of fruit.  WRONG

A man for whom we did some dental work yesterday had one little fingernail that was an inch long and two others including a thumb which approached that length.  I bet he doesn't do dishes!

As for the electricity forecast of yesterday.  It didn't go out until suppertime which was about 6:30 by which time it is totally dark.  So we ate some kind of soup and fresh bread and pineapple followed by rice pudding made with left over rice for Jim and a piece of chocolate for me.  The electricty appeared fairly soon afterward. It is interesting to note that all the blubs, house, shops, clinic etc are CFL's.  The only problem is that they are suspended too high which makes lighting after sunset challenging.  For a while last night I was reading by head light while Jim enjoyed his IPAD.  I'm saving a few books on my Kindle as down loading here would be a real trick.

New challenge.  Disposal of left over dental filling material which contains mercury.  At this point there isn't a procedure..we will need to persue. Also another young woman who prefers a tooth extraction to a root canal followed by dentures.  So hard for Monica and me to understand their lack of desire to preserve their teeth.

All for now!  another dental patient and the report to finish.  And in an hour we will see what is for lunch at the yellow house (which may actually become yellow thanks to Patrick's efforts) which we may enjoy  or else there is Amadi's next door.  More about the food later.

Love to all!

So, to finish my earlier note

So, to finish my earlier note.  My first case of leprosy this afternoon -- recurrence from previous treatment for one year.  It looks to be involving the nasal septum now, so we are trying to find the needed meds for this retreatment program.  The nasal smear was positive for bacilli as well as the erythema nodosum lesion on her leg.  I am told that she had multiple nodules on both arms that are now gone.  If you are interested, for recurrent leprosy, the treatment is rifampin, minocycline and ofloxacin all given only once a month for two years.

On we go -- just returned from the purchase of some ant stuff -- hope it's not too toxic for us.  

And, just  met Patrick who arrived for his third trip here of several months each time.  He will be digging wells, fixing things, doing wiring and likely a million other things.  He lives in Seattle and has built several  houses for himself.  Sounds like a renaissance man of sorts.  He will enliven the environment for our last couple of weeks.

Jim

Sent from my iPad

Ants!!!

It's Tuesday and we have finished the morning clinic and are about to start on the afternoon.  This morning, we said goodbye to Jason and Nadi and they are headed back to the US after a couple of nights in Kuching.  Jason's fellow resident, Ilana will arrive Sunday and also go with us to Tanging Putting the following weekend to see up-close the orangutans and other primates and birdlife.

Just when we thought we had the ant thing under control with switching beds, the ants, once again, out-foxed us.  Last night, I was having trouble getting to sleep -- thought I was feeling something, but then decided it was just paranoid thinking after all.  But, after getting up to the bathroom for about the third time around midnight, I had a look with my headlamp and ants were all over my pillow and sheet and mosquito net.  So...we spent the next 30 minutes killing as many as possible and checking-over each piece of bedding (several were summarily thrown out), then reversed our heads and managed to sleep the rest of the night fairly well.  Today, we are on the hunt for some potent insecticide.

Likely, the most helpful info I have imparted to this group of docs has been my experience with eye problems.  Fortunately, I received some good basic teaching early in my career and I have a fair level of confidence with several common eye disorders.  It seems that daily we see several folks with some eye problem and they really need to be able to manage many of these.  So far, we have seen glaucoma, iritis, episcleritis, punctate keratitis, conjunctival papilloma (we removed it), chalazion, corneal foreign body (for a month), acute hordeolum, allergic conjunctivitis, and likely others.

More later

Jim

Ants aren't the only thing that bites!!

Greetings everyone!  It is true that ants bite..but today at lunch sitting outside our former home, "the yellow house", on the bench I was reminded that there are multiple sources of bites here...this time it was the bench which is split and the parts separate and are more than eager to pinch your seat.  So far, no snakes, but ants, mosquitoes and benches are in this category.  We have learned that the malaria bearing mosquitoes bite in the early morning and evening and basically patients who are seen with malaria in the clinic aren't from here, but are from some of the off shore islands.  As for dengue fever...those are the ones that bite during the day and we have seen local cases of that fever.

Friday was my first introduction as an English teacher and it really was fun!  There were about 12-15 students from the clinic...nurses, people from the pharmacy, the IT guy who is a real entertainer, etc.  Always beware when traveling.  People understand more English than you know!  They were eager learners and before long we were working on phrases such as "I am"  I have" I gave" in all the tenses and lots of nouns.  There was lots of laughter and unbelievable, they want to return next Friday and talk about time.  I learned that in the Indonesian language there is only one word for arm...and that includes everything from fingers to the shoulder!

Friday after work we joined a group sitting at the beach which was followed by a time at one of the food stands there selling fresh coconut milk/coconut direct from the nut.  Of course I forgot the camera....but the mental picture of the young man surrounded by a pile of coconuts hacking away with his machete will remain.  I'd recommend sugar and a straw.  Jim paid for part of the group which resulted in everyone singing happy birthday to him because on ones birthday here, you do the treating.

Saturday AM we were up early for a ride as it was cool.  We were loving it, and almost all the Indonesians had on sweat shirts or jackets.  No wonder they can take the heat better than we do!  The first round of the town was extremely frustrating as my bike was basically not ride-able.  A few carefully chosen words and some good tinkering has it better.  One of the impacts we may have is that the worthless bikes which were taking up space beneath the shelter at the clinic are gone and we have encouraged the staff to try to make sure their bikes are parked out of the rain.  A shelter is also being built near our house which will house the bikes for two clinic houses.  We still plan to put together a procedure for caring for the bikes along with an period of teaching for Eka who will be the one in charge when he isn't repairing our roof.

I can't remember whether I'd mentioned the hole in the thatch created by monkeys cavorting or not...but it it now patched as is a second one created in the same way.  Perhaps some morning we will awake to a monkey in the house.  That could be very interesting!

Saturday night we were introduced to a truly special road and place.  There is a new dock not too far from our house which is sued to dock boats during the dry season (which is NOT now), as the water is too low at the dock where we arrived.  The road/path to this dock takes us through a part of the rain forest which i VERY nice.  Lots of butterflies, a troupe of monkeys playing in the sun, huge trees, a real jungle.  The cement pier is very long and about 6" wide.  A challenge on our bikes but there was space at the end for a small picnic for one of the volunteers who was leaving the next day.  We tried two new kinds of tropical fruit, but our pineapple addition was the hit.  We had to head back home as by 6:15 it is dark and we needed the headlights we didn't bring.  Our night was capped by dinner next door at Hotlin's by headlamp and small kerosene lamp.  The electricity was off and stayed that way until after we were asleep.   

Sunday's event was waking to lots of ants in our bed....and they do bite.  Evidently the rain has brought them out, but they were all over..the bed, the netting, our clothes etc.  Thankfully there is a second bedroom in the house so we moved there, packed up all clothes we aren't wearing here i..e. sleeveless tops and picked the ants of the others that we do wear and hung them in a different spot.  BUT the new positive discoveries are that one of the banks uptown will accept our VISA card so we don't have to worry about getting cash AND we discovered that the shower head in our bathroom actually does work.  It is much easier to get the soap off when the water is coming down and not being rinsed off by throwing buckets of water at yourself.

We are continuing to love the people here...both the staff who are highly competent and the patients.  I am enjoying helping Monica and we have started on a root canal, done lots of extractions including one by me (!), some fillings and I'm really great at holding my little flashlight as her spot light.  Today we took pictures of some kind of connective tissue growth in a child which developed after a tooth extraction 8 months ago.  These pictures will be sent to a consulting dentist.   

Each morning starts with the morning meeting at 8 AM which is attended by the entire staff.  Everyone has the opportunity to contribute and there is good participation.  This is the opportunity, when translated, to learn about all work of ASRI.  It is a continual reminder that the purpose of ASRI is to protect the rain forest and that the clinic a  means to that end.  Once again, villages who do not log, have stopped, or are doing less receive graduated discounts at the clinic.  So there is lots of community pressure and support to not destroy the forest.  Patients are able to pay with hand craft, primarily weaving s and carvings, but this really isn't happening.  The prices at the clinic are too low for this to be as necessary as it once was.  There has been some talk about increasing some of the prices as the clinic needs to increase its ability to self support.

As a reminder.....check out the web site   healthinharmony.org which will give you some of the evaluation detail of their programs, annual report, news etc.  It is really quite impressive!  I believe I've mentioned that there are plans to build a hospital beginning this summer if funding is received.  This includes receiving a grant from USAID which Hotlin and Kinari both say is a stretch as they have to convince the grantors to see the connection between a grant which targets health care and preservation efforts for the forest.  Hotlin is training for a marathon the purpose of which is to raise money for a new dental suite in the anticipated hospital.  This means that she is running by herself at 2 AM sometimes,  4 AM others and I marvel at her determination.  There are efforts underway to obtain some support from a local credit union for more fuel efficient stoves.  They would still burn wood, but use much less which would help with asthma, and, of course the cutting down of trees.

We found the post office and mailed a note to  Nora, our 8 yr. old granddaughter whose class is collecting mail from around the world.  Can't find a postcard here...no tourists here...Was an interesting experience.  We waited for a handwritten receipt for the stamp!

Love to all... We going out for dinner tonight and the hotel to say goodbye to Jason and Nadia.  They will be missed.

More Pictures for you

Newest and latest

It is Friday morning and thus the clinic is closed although some immunizations are being given.  Jim and Joseph are searching for a replacement wheel for the bike he was riding back from the juice place last night when he and a motorcycle had a minor collision.  There is a problem with this "wrong/right" side of the road business.  He says that he turned in front of the motorcycle, but the guy could have stopped but didn't.  The result is a sore hip for him, no cuts etc. thank goodness, and a ruined front wheel on one of the better bikes.  OOPS.  But it looks like there is a replacement available although there has been some discussion re size and Jim was right!

I have interviewed the woman who does the environmental education in the schools surrounding the national forest and will write up a report for the donors supporting the ASRI kids program.  It was great fun to hear how this program developed and to learn that the children originally did not know that orangutans only live in Borneo and Sumatra.  They thought they lived in the US as well as lots of other countries.  Once they realize how special this place is, they are proud and want to take care of it.  More later on this if there is time and the internet holds.

Which is a problem.  We need more band width (perhaps) and a switch can't be flipped, any change requires a trip somewhere so we work hard  with the computers in the AM and always cross our fingers.

My latest fun adventure was traveling yesterday to Ketapang about 2 hours on a very bumpy road, but very intresting drive.  The two travelers in the back refer to their trip as being "popcorn" due to all the "popping" up they do as the driver manages the bottom scraping pot holes.  There were two goals of the trip.  First a trip to the park office to present a letter asking for support from whomever for a grant application to USAID.  There was lots of conversation and much laughter with people in the park office and perhaps a request in the form of a letter was passed but I didn't see it.  In the car as we left, Hotlin said that the person the letter was addressed to was in the building, but she couldn't just walk in and give him the paper work,  She needed to present a letter of request, he needs to think it over, and then at some future time there will be a meeting or something..  Sound vague???  Nothing is easy here by our standards.

After that visit we attended the grand opening of a newly built orangutan rescue and rehabilitation center.  And this was impressive and a very big event.  Multiple "tents" were put together on this open field facing a blue and white building which turned out to be the office for this center.  Under the primary tent there were about 200 plastic blue chairs with the first two rows of chairs covered in white with big blue bows.  As we checked in we were each given a box of "snacks" and a rolled up poster.  We were then shown to seats on the second row right behind a group of dignitaries representing different levels of government as well as the vet who started the entire project - a woman from Spain who is behind the entire center.  Speeches, speeches and more while I watched a winged creature of some kind crawl in and out of the hole by my feet and then we had a tour.  We did not see any orangutans but there were about 25 already at the center.  They are very susceptible to human diseases and any treatment is done with as little human contact as possible.  This really was an impressive, multiple building, site.  The hospital, complete with operating room, lab, Xray, medication cabinet etc. was the cleanest area I have seen arriving in Borneo.  Spotless.  There were multiple small buildings with small cages with climbing ropes for orphaned, hurt, or ill baby orangutans, and a very large enclosed forest area for the juveniles which does allow them to climb out the top, but they come back at this point.  Eventually they will house adults, but are not ready.  Adult orangutans are  8 - 10 times stronger than humans, and they aren't yet ready to house them.  25 or so are currently at this site and more will be moved from a transitional site shortly.

This event was also interesting in that we met a group of volunteers who are here participating in the constructiion....basically a Habitat international group although they are with the International Animal Rescue org.  They are here for a month, from Norway, Australia, Great Britian +.  They pay their way and for their housing and food and a certain amount greater than their expenses to support the project.  They are digging drainage ditches (this entire area is basically a swamp), footings for buildings, building a wood walk way etc. etc.  

I also had a very interesting talk with one of the managers of the construction who has lived in Borneo for 8 years and has along history with the Intentional Animal Rescue group.  He was one of the westerners running around with a big camera and recording all of the events.

Following the tour, everyone in attendance was fed and I am guessing that number between 200 and 300.  This is a BIG deal.  Again we had rice with beef - a sign of the importance of the event as beef is very expensive (and nothing like we are used to), rice, spices, water, langsat (a kind of fruit which is very good but lots of work to get out. Real plates were used and washed behind the office.  There is no HyVee to call for catering, so I can only imagine the effort it took to put this event together.  Oh yes, there are four vets and they rotate call.  I was told that about 3 years ago a baby orangutan was brought to the ASRI clinic with a bullet wound but did not survive.

It was very good to see this facility and to realize all the efforts that are underway to help the orangutan survive.  Some of the problems are that they get into farmers crops (because the farmers have encroached on the forest) and are captured to be kept as pets or actually harmed.  

We also have a second hole in the thatched roof which led me to a slip this morning returning from my "shower".  So, Jim ad I are fine but both nursing a somewhat sore hip.

All for now...lunch is calling...although we may visit Amadi's cafe next door instead.  And I have been preparing for my first English class.  This WILL be interesting!

Love to all,

Lauri

Group picture at the school.

Successful treatment of Hotlins blood collection under her toe nail
from running.  Jim taught the procedure

Kids bringing bamboo stakes to trade for toothbrushes in a village at
side of National Park.  They receive health/dental hygine education as
well as teaching concerning saving the forest.

Group picture at the school.

3 pictures for you

Three pictures
1.  our resident Tokay Gecko
2.  Harvesting rice - on our bike ride to clinic
3.  Our new house

1.  our resident Tokay Gecko

2.  Harvesting rice - on our bike ride to clinic

3.  Our new house

It's Friday Am

It's Friday Am and it was, again, raining earlier.  The hole in the roof was patched yesterday and now we have a new hole -- resulted in a slippery bit of concrete floor and a slip for Lauri this morning.

Last night, while returning from the "juice bar" with Jason and Ronald, I made a stupid biking mistake and pulled into the traffic (on the left side here, so still forget that from time to time).  Anyway, I saw this motorbike to my right, going very slowly, and I expected him to stop, but not to be.  Very slowly, he rode right into my front wheel and I had a slow-motion fall -- no injury at all.  I have no idea why he chose not to stop, but he totally pretzeled my front wheel, so I am off to the "shop" to buy a new wheel shortly.

Lauri will fill everyone in on the day trip to the orangutan hospital opening -- sounds like an interesting experience, once again.

Today is immunization day at the clinic, so lots of little kids here already.

I hope to spend some time on some news source today -- need to get a news fix.

Jim

So...I will attempt to write as beautifully as Lauri

It's Thursday AM and I am at the clinic while Lauri has gone to Ketapang with several others for the opening of an orangutan hospital.  So...I will attempt to write as beautifully as Lauri and describe the last couple of days.

Last evening, while sipping our before dinner cocktail (well, that's a bit of a stretch-- I can tell you that the straight lime squeezed on the gin does nothing to improve Bombay Saphire -- so got to find something else).  Anyway, the monkeys were once again jumping on the roof -- normal sounds, it seemed-- however, when I reentered the kitchen there was roof debris all over the stove and counter.  It seems as though one of the little buggers had punched a hole in our roof!!  So...I dutifully called Hotlin (dentist and founder and next door) -- her response "someone will fix it in the morning --it's only water".  And...needless to say, it rained hard much of the night so the bucket I placed on the counter had about six inches of water and the floor was very wet -- but the floors are designed to let the water through, so no sweat.

This morning, I made poached eggs on toast -- a total treat.  With the bread our helper is making, my calorie intake has increased nicely.  The bread toasts quite nicely on a frying pan -- new approach for me.

Yesterday's patients were interesting at times.  We discharged a young woman with Dengue and another with resolving bacterial enteritis (came in quite dehydrated and likely acidotic).  We drained a nasty scrotal abcess (and looked for TB).  An older man with advanced glaucoma in both eyes (pressures of 40 in one and 60 in the other).  A child with possible measles (more likely a viral examthem).

We now think we have more than one Tokay in the house -- at least Lauri thinks one is smaller than the other.  I have yet to take a tape measure to the little beast (am told they bite), so I will wait on my analysis.  At least we have had no rummaging in our plastic bags the last few nights.

Not much else to report today -- we are now over the half-way point and headed downhill.  Don't know what the weekend has in store, but Erika leaves on Sunday, so there may be a picnic on the new dock on Saturday (wherever that is).  We did buy a pineapple yesterday, but it appears to need some ripening.  Our supply of mangosteens is depleted, but need to so some more shopping.  Since Lauri is in Ketapang today, they likely will stop by a larger store -- will see what she returns with.

Jim

Jellyfish

This late morning, the first jellyfish sting that I have seen.  Important rule:  Do not wash with fresh water because it will force the toxin from the minute sacs into the skin --rather use acid wash e.g. acetic acid (vinegar will do) and leave on as compress for 15 to 20 min.  Next treat the pain and watch for cardiac dysrhymias.

Jim

Noises on the roof AND in the house

It is Tuesday morning and Monica (dentist) and I have just finished working with a young man and his big cavity along with an abcess along the gum line.  I am learning a bit of dentistry and am happily retracting cheeks, getting supplies, holding my little flashlight for extra light etc.  AND I have seen some of the worst teeth of my life.  This is due to a number of problems.  Many of the people simply do not brush, live a long distance away and thus have no regular access to dental care, and Monica says that they collect the rain water as drinking water and that the water is acidic.  She couldn't tell me the cause for that, but feels strongly that it contributes.  (All the more reason to be glad for our bottled drinking water.)

However....the Western world and its packaged goods is extremely evident here.  Apparently within the last five years there has been an exponential growth in beverages in plastic bottles, packaged foods of all kinds (even when we go out for fried noodles they start with Ramen noddles or similar), individual cups of water with straw etc.  The problem....no recycling program and basically people do not understand that these plastic objects are not biodegradable.  Apparently even some of the clinic staff at the beginning did not understand that.  There also is no organized garbage collection. The result?  Way too much litter everywhere and the prime disposal method is burning.  We watched a man ride up to an intersection with a plastic grocery bag drop it in the pile there already and ride away.  The next time we pass that intersection, the pile is burning.  I do not now how they can recycle here due to lack of the infrastructure to do it and it is a huge health problem as well.  We think it is even worse than where we were in Ecuador.  But people are receiving instruction in composting.

A few snapshots:

Yesterday as we were eating lunch at the little cafe near the hospital we were treated to campaigning in Borneon style.  Driving past was at least 100 motorcycles interspersed with a few cars and men waving madly as they passed. I am sure that was only a 10th of the number of motor bikes in this town, but it was still impressive. Evidently there is a regional election on March 24 and in a novel turn of events the man who has been the head of this area actually has some competition.  He is known as the "king" of Sukadana.  More on him later.

On our way to the clinic - by bike- from our new house we passed residents trashing rice in the field.  A blue tarp is spread on the ground and the people cut the rice stalks, gather a few together, and then basically beat them on the tarp to  release the grain.  The grain is then dried, again on blue tarps, in their yards or where ever.

House companions---- and we are not even going to mention the ants which I believe are viewing with cockroaches in other parts of the world to rule.  We have negated the "rule" that we would not touch cats or dogs due to concern about rabies.  First that does not seem to be present here and secondly, we have a house cat  that we have inherited   Her name is Rakus, and she is a lover.  Her favorite place is on our lap and her little heater is often too much to take.  She is outside at night and when we are gone, but her radar is perfect, and she is present when we even approach the door.

Now the monkeys!!  Since this house is set back farther from the road and this entire area of this village is basically a jungle like swamp except where it has been cleared for housing etc, we back lots of growing things, hence the monkeys.  They love to be on the roof and since half the house has a thatched roof and the other a tin roof, it sounds like they are about to come right through.  When we rush to the windows we can see then swinging through the trees.  How fun this is!

Now the Toket,  I need to look this up, but it is a large lizard creature, beige in color with red polka dots - really!  Monica told me that they are quite expensive...around 1-2 million Rupiahs.  They make an incredible loud noise and I finally found it last night hiding behind a wall hanging.  I did get a picture, but when we tried to show him to Jason, one of the docs who stopped by, he was long gone.  We later heard him in our bedroom, I think, but no second sighting yet

We also inherited Kinari's "helper" , Jani or yani or...who even though we still haven't met is wonderful.  She cleaned the floor, washed a few clothes, ironed my blouse, but most importantly baked us bread!  It is really quite good and we made toast in the frying pan.  We finally managed to open the tin of butter and have jam.  Talk about "fat city".  I have "asked" her via the dictionary and a few written words, to buy some eggs for us.  We're looking forward to eggs on toast for breakfast tomorrow.

Oh yes, the water problem is solved.  evidently this happens periodically, but the respective barrels are full right now and this is great!

This afternoon I will be tagging along with a Etty and Monica, and Julia (long term volunteer who is working with reforestation) to a school in a village away from here.  The plan is to exchange toothbrushes for bamboo stakes which will be used in the reforestation project Julia works with, Monica will give tooth brushing instruction, and Etty will teach about conservation.  It will be interesting just to be there.

Thursday a few of us will return to Ketapang for the opening of a new orangutan rehabilitation site.  Evidently they sometimes stray into farmers fields and are injured by the farmer plus other issues.  So a new facility has been constructed.  It will be interesting to see.  Hotlin says to be prepared for lots of speeches and then we will eat.  I am also hoping that there are some orangutans.  Do not know how this will be staffed and it will be interesting to learn.

Remember where the delete button is everyone!

It's Sunday evening and we are settled in our new lodging

It's Sunday evening and we are settled in our new lodging -- a nice improvement from the first place.  Yesterday, we took a three-hour walk -- long loop through town and other areas, stopping to talk with the hotel manager and look over their menu for our return in the evening..  Everywhere we go, we have children following along or greeting us with "Hi Mister" (sometimes Missus) and trying out a few words of English.  They are delightful.  There are no sidewalks, so we walk down the road with the traffic (were scolded early on for walking toward the traffic, as we are taught at home).

After our walk, we packed-up, had lunch (soto -- a kind-of soup) at the shop next door) and moved our things to Kinari's house.  We had time to chat with her before her departure today and learned more of her thoughts about health care and the conservation work here.  The conservation is really the reason for the clinic -- all to reduce logging and preserve what's left of the rain forest and orangutan habitat.  This afternoon, we saw monkeys in the trees outside and are told they like to play on the roof as well.  And, we have a resident cat that keeps the critters in control (although, something was in our plastic bags during the night and my sleep was far from good -- the 6PM cappucino may also have played a role).  But...we also have internet here even on the weekend and at night --  major bonus.

Last night, we took Neahga our for dinner before his departure today -- nice evening watching the sunset at the hotel, but Lauri and I made dinner choices we regretted.  I am finding it hard to make choices I like, perhaps since I am recovering from my first episode of tourista on Friday.  Hopefully, that will also be the last.  Don't know why, but Lauri always seems to avoid this better than I, even though we both eat and drink the same thing.

Right now, I am thinking that Arizona next winter sounds fantastic!!  The young docs are a pleasure to work with and they will keep me afloat for the next four weeks, but may need an infusion of calories when I get home (and some good beer!!).  I did buy a bottle of Guiness today in Ketapang, but really doubt it will be as good as what I have at home in the keg -- homebrew, that is.  We will have a new cook now with this house, so there is hope the food will improve.  As Lauri said tonight, this diet is so far from what we eat normally.  And...if any of you look kindly on us upon our return, please avoid the chicken -- I suspect I am growing tailfeathers

Just returned from an unexpected invite to a Chinese New Year celebration, complete with new foods.  Wish my stomach were better so I could enjoy it more, but still was interesting and, as usual, very gracious hosts.  Time for a quick shower and bed and, hopefully, no wee beasts to wake  me tonight.

Jim

Continuation Sunday Feb.10

We are now back from the New Year dinner celebration with a local family and it is peacefully raining....again.  This is the rainy season or getting near the tail end of it but perhaps it will help our water issue....

This afternoon's introduction to the family Chinese New Year celebration was when we were at the ticket agent's home to pay for our flights.  I am sure that the process is not Western in that much time was spent before we paid and then after.  We are working on patience and realize that we certainly are not in control!  We sat in this very basic room on wooden chair/benches (rarely upholstery here due to humidity), cement floor, a few pictures hung almost along the ceiling and a collection of traditional cookies - all small and beautifully shaped on a coffee table before us.  We tried all 7 or 8 of them, this didn't take much encouragement and they were very good.  One was almost a Scottish shortbread; and we had our first coke in weeks.  Alex speaks good English so we were able to talk a little bit and let her mother know how much we enjoyed the cookies.  It is still difficult to get my mind around the fact that we counted out 5,640,000 Rupiah.  Those zeros keep getting in the way.

Earlier I did attend church with Hotlin while Jim and Okto, the driver, sought out the ATM and attempted to buy coffee.  No luck on the later due to everything being closed.  This was a church in the Presbyterian style (according to Hotlin) and could they sing!  Half the service was in song and some of the time I sang along.  I could read the words, even though I had no idea what they said.  The choir of 5 women wore matching dresses and ALL of the people were welcoming.

Tonight's dinner, which came after we had left overs in our house and we were filled :>)  was in a Chinese family's store on the main street.  Hotlin knocked on a metal door...I would have sworn the place was completely closed up.  But the door came open and we walked through the little shop and then through a long corridor with side rooms absolutely full of supplies for his store.  We later learned that he supplied other stores as well as through his own shop.  The family was sitting in what is their living room around a center coffee table, concrete floor, plastic chairs, cases of beverages stacked 2/3rds up one wall, with a TV playing a  broadcast by Joel Osteem on one end.  Eight of us were affiliated with ASRI with another family also as guests.  This time there was an entire meal  followed by the same cookie options along with the Chinese traditional orange and a tropical fruit mangosteen.  It was an enjoyable time and came just as we were feeling a  little cranky about being sweaty once again with no good water supply.  The people continue to amaze us with their willingness to include us and are always welcoming.

That is it for now.  I will send more pictures tomorrow...at least that is the plan.  I have another report to write and possibly the clinic will be busy.  Over the weekend a young MD from the community died and doctors in a neighboring area are on vacation.  The young Indonesian Docs. told Jim that they were going to be gone and that he and Jason, the resident from Stanford, were going to be really busy.  Then they smiled.

All for now.  

New Address

Greetings everyone!  It is Sunday night and we are in our new location.  It is just down the road, past one of the entrances to the beach and around a couple of corners.  It will take us an extra 5 minutes to travel by bike to the clinic tomorrow morning and it may require a poncho if the heavens open up again.  But right now we are sitting in comfortable chairs with the fan on, music from the IPAD and actually connected to the internet.  All of this a coup.  The only downside is that we basically have no water.  Which will have to be rectified tomorrow.

As Jim as let you know, we have moved to Kinari's house as she left this AM for Bali and will be gone until after we leave.  This is a great gift to us as this house is much nicer.  The only challenge appears to be the source of water for washing etc.  (We do have bottled drinking water but that is actually low too.  Tomorrow will be a big day!)  Because this house is on a  hill the water has to be pumped up into a holding tank higher up and then it flows by gravity into the collection spot for our bath as well as for flushing.  Well, the pump appears not to be working right now.  Ecka, the young man who is the newly hired repair person was here but no magic yet.

We left this AM at 6 AM to take Neaga, the conservation guy who is leaving  and Kinari to the airport in Ketapang about 55 miles away but really a two hour drive if all goes well.  It was an interesting ride...bone jarring sometimes, but interesting.  Lots of houses along the roads in various states.  The poverty is ever present and apparent.  Many times they are gray wooden houses on stilts surrounded basically by marsh with a narrow wood walk way from the road.  The houses/shops line the road and are very close together.  Kinari said there is no separation between public and private life here.

We had plenty of time at the airport and this visit gave us an opportunity to learn the ropes for our flight to the National Forest later this month as well as when we leave for Bali.  Security was a snap although I am sure that we will pay for extra weight, but we were told to ask if they could help us out...we might get alittle taken off!

We then visited a fairly big grocery store and loaded up on comfort food as well as some OJ of a questionable color and Blue pepsi.  Ever heard of it????  Us neither!  Then there was lunch and a wait until we were able to pay the ticket agent who had arranged two flights for us...one was from Singapore to Pontianak months ago.  Turns out she is Chinese and today is the Chinese New Year so most of the shops in the town were both closed and decorated with red paper lanterns.  Her "office" was in her home and our visit there turned out to be an opportunity to be a part of her family's celebration.  More on this later!  Hotlin just arrived to check on our water....and now we are headed off for the town's New Year's celebration.

Back soon. 

mailing: A few pictures