Vini and Dewi: Midwives of the Forest

In my last post, Taking Planetary Health on the Road (and River), I promised I'd tell you more about two superheroes in the heart of Borneo. These heroes are midwives named Dewi Susandi, and Tri Roma Uli Vini Talenta Siringo Ringo—who, understandably, goes by Vini.

Vini stands in the exam room of her midwifery clinic, which is also her house.

Dewi and I take a selfie. I'm wearing a T-shirt she traded me, featuring Kurt Cobain of my own Seattle!

These two incredible women spent the summer training at the ASRI Medical Center near Gunung Palung National Park, on Borneo's western coast. In November, they moved to Nusa Poring and Beloyang villages, small communities comprising only a few hundred homes each. They're remote, with no cell signal, internet access, central electricity, or paved road to the nearest city. During the rainy season, the dirt road often floods, making the only form of transportation a many-hours ride in a motorized canoe down the sinuous river.

Dewi and Vini's first task was not medical care, but fixing up the buildings that would become their home and clinic.

Vini’s house was an empty government building, originally built to house a midwife but never staffed, now lent to ASRI. Dewi’s was an unoccupied home offered on loan by one of the village elders. Residents of the two communities helped patch leaks in the metal roofs and paint the walls—soft blue for Vini’s house, warm yellow for Dewi’s.

The mobile clinic team — Fitri, Vini, A'an, Kinari — and I stand on the porch of Vini's house-clinic in Nusa Poring.

Since they opened their house-clinics, Vini and Dewi have together treated over 400 patients. They live in their clinics, so these two women are on call 24 hours a day, seven days a week.

Dewi has delivered four babies safely in her Beloyang exam room. Vini gives out 25 doses of birth control to women in Nusa Poring every month. She has three or four patients interested in copper intrauterine devices, which have the potential to provide reliable contraception for 12 years at a time. ASRI is working to make intrauterine devices and implants available soon. Just imagine: if three women in each of the nine villages want intrauterine devices, and each device lasts ten years—that alone would provide 270 years of protection against unwanted pregnancies.

But Dewi and Vini do much, much more than provide birth control and assist with births. They treat all kinds of patients. Many families refuse to be referred to the government hospital because they can’t afford the medical bills. That leaves Vini and Dewi, as the only healthcare providers in the region, responsible for all sorts of medical emergencies. (Update: since I wrote this post, ASRI has hired a full-time nurse and doctor to join the Bukit Baka Bukit Raya team.) Dewi has even admitted ten in-patients to her house-clinic, cleaning and cooking for them on her own time.

Midwife Vini and nurse A'an sort medicines in the dark amid a rush of patients. Not having a connection to the electrical grid makes healthcare harder. There's no refrigeration, and lighting and phone charging are limited to the capacity of a few solar panels.

On my first night, I had the honor of staying with Vini at her house-clinic in Nusa Poring. I arrived with the rest of the mobile clinic team, late in the afternoon. I dropped my backpack in Vini's bedroom, where we shared a technicolor mattress. The exam room was across a narrow wood-floored hallway, and the kitchen was at the back. Behind that, a wooden porch sloped down toward the muddy bank of a wide, swift river.

Within a few hours, patients were lining up on Vini’s porch and waiting cross-legged on her hallway floor. I want to describe a few of these cases for you.

A mother brought in her four-year-old girl, suffering from three fevers a month, febrile seizures every time, and diarrhea several times a day. Dr. Fitri felt her spleen, checked her inner eyelids for anemia, and consulted Vini about recent cases of malaria in the area. (Malaria is carried by mosquitoes and isn't contagious person-to-person, but if someone in the area has malaria, it's more likely a mosquito will pass the disease on to others.) The mother had been crushing adult medicine for the fevers, but it was hard for her daughter to swallow the bitter powder. Dr. Fitri prescribed paracetamol syrup to bring the fever down and stop the seizures. She also prescribed worming medicine, a standard treatment every six months, and an antibiotic for the diarrhea, which might have been caused by amoebas in the drinking water.

Amoebiasis is a nasty form of diarrhea caused by water-borne amoebas (technically, amoebazoans), most commonly the one pictured here: Entamoeba histolytica. This individual is a trophozoite, a growing stage in which it's actively absorbing nutrients from its human host. Amoebazoans are not plants, animals, fungi, or bacteria -- they are single-celled eukaryotic protists.
Image credit: Stefan Walkowski, Creative Commons Attribution-Share Alike 3.0

Here are three Entamoeba histolytica bacteria (the light blue blobs) that have eaten human red blood cells (dark circles). These amoebas cause disease by penetrating the wall of the large intestine and causing bleeding and diarrhea while they munch our blood cells.
Image credit: CDC, public domain.

Once the daughter was helped, the mother explained that she too was dealing with an illness. From the symptoms, Dr. Fitri thought it might be a bleeding stomach ulcer brought on by too much ibuprofen, which the patient had been buying from a store, or maybe the bacterium Heliobacter pylori. That, and anxiety for her daughter. Dr. Fitri prescribed omeprazole to decrease stomach acid, and iron to counter the blood loss. Most importantly, she asked the patient to stop taking ibuprofen.

Scanning electron micrograph of Helicobacter bacteria. This bacterium's spiral shape, for which it is named, allows it to penetrate the mucous of the stomach lining and evade the body's defense of stomach acid.
Image credit: CDC/Dr. Patricia Fields, Dr. Collette Fitzgerald (PHIL #5715), 2004, public domain.

A man came in with an allergy to Round Up. When he sprays his crops, he wears rubber boots and tall socks that rise over the top, but they get soaked with the pesticide. His feet end up swimming in a pool of Round Up for hours a day—a chemical that was recently found by a US court to cause cancer. His feet are cracked and painful, the skin thickened and fissured. He’s at risk for secondary infections. If he stopped using Round Up, he says, he’d have to cut the sharp grass that’s invading his fields with a machete, turning a day’s work into a week’s. He’s also chewing tobacco and having stomach pain. Vini handed him a salve for his cracked skin, but told him two things he didn’t want to hear: to heal his ailments, he would need to stop using Round Up and stop chewing tobacco.

Dr. Fitri describes a treatment plan to a patient's mother, while Vini checks the pharmacy shelf for the prescribed medication.

As we were getting ready for bed, two worried men showed up on the porch. Their older sister had given birth three nights before, and she was still bleeding. Midwife Vini, Dr. Fitri, and Nurse A’an immediately started putting on their jackets and arranging to borrow a motorcycle from the neighbor. As I lay down to sleep, they took off on the muddy road into the dark, starry night.

“They might be saving a woman’s life tonight,” said Dr. Kinari as they rode away.

Vini on the back of a community member's motorcycle for a middle-of-the-night house call.

If the mother had a retained placenta, the health team would give her medicine to induce contractions. If she had an open tear, they would suture it. And if she had a uterine infection, they would treat it with antibiotics.

Their precarious journey took 30 minutes by motorcycle, followed by a 25-minute walk when the mud got too deep. When they found the mother, they were relieved to see she wasn’t actively bleeding, just draining old blood from childbirth.

As they tended to this mother, another patient appeared. He was having a Chronic Obstructive Pulmonary Disease (COPD) exacerbation—a complication from smoking cigarettes, wood smoke from cooking, and smoke from slash-and-burn fields. The patient’s lungs were inflamed, making it hard for him to breathe and putting him at risk for a virus to get in. Dr. Fitri knew he needed a medicine to temporarily damp down his immune system, but she didn’t have it with her. Luckily, the man who drove the ASRI team back to Vini’s house on his motorcycle was able to pick up the medication and bring it back to the patient with COPD.

This all happened while I was sleeping. The next morning, before I woke up, the team was already treating a woman with a severe, recurrent urinary tract infection. Dr. Fitri recommended she drink lots of water, but boiled water, and the patient said no—it doesn’t taste as good. The phrase for boiled water here is air mati, "dead water." She, like most of the community members, prefers to drink air hidup, "live water," which poses a serious problem for the control of waterborne typhoid fever.

After that patient had come and gone, I woke up to the cries of a four-year-old boy with a persistent cough, a sign of tuberculosis. You can read more about typhoid and tuberculosis in my nest post, coming soon!

At 9 am, we took a wooden boat up-river to the town of Mengkilau. The banks shifted quickly from houses on stilts, children bathing, and banana plantations to dense forest.

Dr. Fitri and the ASRI team step out of the motorized canoe for a mobile clinic visit to Mengkilau.

A girl followed the ASRI team expertly on wooden stilts.

Before Dr. Fitri, Vini and Aan could unpack their bags, patients were waiting. An elderly woman complained of abdominal pain. A younger woman had an open, cherry-red, grapefruit-sized scrape on her calf from her motorcycle falling on her.

Then, a man ran up to the porch, catching his breath and carrying a folded paper note. Dr. Kinari read the hand-written Indonesian and looked up. “Dewi has a patient in critical condition. We have to go.”

The team leapt up, apologizing to the other patients. They would have wait or find us later. Within ten minutes, we were back on the river, motoring to Midwife Dewi in Beloyang. The canopy closed above us. Chains of epiphytic staghorn ferns dripped from overhanging branches. The roar from the motor slowly deafened my ears until I could hear only a muted rumble.

Midwife Vini prepares to help her fellow midwife with whatever emergency may be at hand.

When we arrived, Midwife Dewi led the team to her patient, a middle-aged man who had drunk six bottles of arak, a homemade rice liquor, the night before. He’d been unconscious all day in a hypoglycemic coma. He began to wake when Dewi spooned him sugar water—only to punch Dewi in the face and yank out his IV line! Dewi remained calm and finally relaxed the patient. For the next hours, he moaned and rolled on the exam table, already experiencing symptoms of withdrawal. A family member explained that his whole family suffers from severe alcoholism, and his teenage son died from drinking two years ago. The case made us all deeply sad, as alcoholism is one condition even the most talented doctors struggle to heal.

Dr. Fitri offers a young patient a dose of liquid medicine.

Midwife Vini records the vital signs and medical history of a man waiting for treatment in Dewi's house-clinic.

Then a second patient arrived, his middle finger bandaged in a bulging wad of cotton. Dewi led him to the sink, where she exposed his finger tip: a blood-red tip, severed almost down to the first knuckle. The patient had placed his hand on a tree trunk, where a cow was tied with a rope. The cow spooked and ran, cinching the rope down and slicing off the man’s finger. Dewi assured him the skin will heal over as long as he keeps it clean and free from infection. The appointment was interrupted by an angry banging on the door. It was the man’s wife, furious because she had heard he’d been drinking and lost his whole hand! (She later returned to apologize—she’d heard an exaggerated story, and she had been angry at her husband, she explained, not at Dewi.)

This is what healthcare looks like here: creative, collaborative, and deeply needed.

Many of Dewi and Vini’s patients practice illegal logging in the national park. They need money, Vini explained to me, so they cut trees. Many people do this type of work, she emphasizes, the majority of her patients. But her healthcare is a step toward changing that. Vini and Dewi’s patients can pay with tekin, or handicrafts—beautiful baskets woven of rattan fiber and dyed with charcoal and tree pigments. They can also work on clinic maintenance to pay their bills.

Vini stands with a hand-woven and dyed basket a patient used to pay for healthcare.

The hardest part of her job, Vini says, is the remoteness: no cell signal, no electricity, and terrible roads. Vini told me a story to illustrate the challenges of her job. One night, a family member of a sick person came to her house and knocked on her door. The family member drove her on the back of his motorcycle 45 minutes to his house, where she was able to see the patient. The ride through deep red mud in the pitch dark was harrowing. Vini recalls feeling like she could be thrown from the motorcycle at any moment, but she made it to the patient and back home in one piece.

“At first I felt it was difficult to work here,” Vini told me through a translator. “The road, no electricity. But now I start to enjoy my work here.”

The best part of her job? Vini told me through a translator, “I feel grateful when I can help people heal.”

Vini and Dewi are helping heal more than individual patients. By accepting non-cash payments for high-quality medical care and linking their work with conservation, the ASRI clinic is helping heal the human-inclusive ecosystem, from rainforests to rivers to human bodies.

Read about ASRI's creative approach to collaborative survival with two particularly difficult bugs, tuberculosis and typhoid, in my next post—coming soon!