Jan 21, 2018 Last Updated 3:31 AM, Jan 6, 2018

A mysterious illness

A mysterious illness
Published: Jul 06, 2013

Brooke Nolan

Akbar and Eka live in a small village on an island in Southeast Sulawesi. The island, Wawonii, has a population of approximately 30,000 people. Like most of the people of Wawonii, Akbar and Eka are farmers. Rice, cacao, cashews, coconuts, beans and corn are their main crops. In the evenings, Akbar catches fish in his small wooden boat for the family’s dinner.

By 8am on a Monday, Akbar has usually been working in his fields picking cashews, clearing overgrowth or planting seeds for at least an hour. Today, however, he is still lying on his bed, having barely slept the night before. He has a fever. He is wearing the same thin jacket and sarong that he has been wearing since he started getting hot and cold shivers a few days ago.  Akbar is suffering from panas dalam – literally, ‘heat inside’.

Akbar hasn’t washed for three days. He limps. He hasn’t eaten much more than a few boiled bananas since he became ill. He has an open wound on his calf. A pus-like substance leaks out of it. On the sole of one of his feet are many clusters of small red-brown dots. ‘The heat wants to escape’ Akbar says, pointing to his calf and the sole of his foot. ‘Akbar has panas dalam’ says his wife, Eka. ‘Doctors call panas dalam sarampa (measles). Here we call it me’apu.’

Akbar says that panas dalam is not infectious. Going to the clinic or taking medicine will not cure panas dalam; the body must cure itself. ‘Panas dalam is from malaria. Only once the heat has exited the body is the person cured,’ he explains. ‘If the heat doesn’t leave the body, or if it leaves and returns, the person suffering from panas dalam can die very quickly.’

A question of balance

As in many parts of Indonesia, local people on Wawonii often talk about the affliction of panas dalam. But what is it? How is it caused? How is it cured? The answers to these questions are as diverse as they are indeterminate. But instability in temperature, direction and balance are three features consistently mentioned in discussions about panas dalam.

As in many parts of Indonesia, and indeed across Asia, health is viewed in terms of a balance (or lack of balance) between social, spiritual and physical elements. A few days earlier, Akbar’s elderly mother had become so ill that she had to be taken to the hospital in the provincial capital, Kendari. This happened at around the same time as the pus began oozing out of Akbar’s calf muscle and the dark red dots appeared on his foot.  Akbar was getting sicker because he was thinking about his mother. His wife called their son, Iskandar, to find out how her mother-in-law was faring. ‘Thank God, his mother is improving now. Once he knows this, Akbar will improve too,’ she says.

Balance in one’s physical surroundings is also considered to be important. Local people say panas dalam usually occurs during the shift between dry and rainy seasons when the weather is unpredictable. These conditions disturb the body’s internal equilibrium. As well as changes in temperature, wind exacerbates the onset of panas dalam. The ‘eastern wind season’ lasts from May to August, while the winds blow from the west from December to March. People say windy nights bring on the types of hot and cold shivers that Akbar is suffering from. Almost all the villages in Wawonii are within walking distance of the coast and are unprotected from strong winds coming in from the sea.

Among the other causes of panas dalam is an over-consumption of hot foods. These foods may be hot in temperature, such as fried snacks, or those considered to have hot characteristics, such as turtle, durian, jackfruit, garlic or mango. Some say panas dalam begins with gastric secretions that spread from the digestive organs upwards to the oesophagus. It is therefore recommended that sufferers sleep with extra pillows in order to keep the head high. It is also important to regulate the temperature of their surroundings. Eka usually fries food in the kitchen inside the house. Today, however, she is frying food over an outside fire. ‘If someone has panas dalam, we have to fry food outside. If not, the increased heat inside the house causes the illness to worsen,’ she says.

And so, just as the excess heat in the body of someone afflicted by panas dalam must be expunged, so too the excess heat in a house whose occupants have panas dalam must be expelled. There are two elements at work here: action and metaphor. The close association between houses and bodies, where the house is often conceived as a metaphor for the body, is common in many Eastern Indonesian societies. In Sumba, for example, the death of a relative is expressed in ritual speech as the destruction of the clan house. In Sulawesi, tongkonan houses are also closely linked to Torajan identities and the bodies and spirits of their ancestors. Among the Ngaju Dayak of Central Kalimantan, houses are associated with femaleness and are believed to possess souls.

Back to the fields

At home, Akbar is still lying on the bed in his sarong.  Eka tells him about her conversation with their son, Iskandar, emphasising the improvement in Akbar’s mother’s health. A faint smile appears on Akbar’s face. That evening, he drinks tea and eats sinonggi, a Kolaka speciality made from sago and fish. Then he returns to bed.

The following morning, Akbar says he is beginning to feel better. On the sole of his foot, the red-brown dots are fading. The pus on his leg has dried up. ‘The panas dalam is leaving my body,’ says Akbar. ‘Tomorrow I’ll return to my fields to pick cashews.’  

Although to outsiders panas dalam seems to describe a rather obscure combination of symptoms and situations, to Indonesians in places like Wawonii panas dalam is a frightening and potentially fatal illness. In seeking to understand how Indonesians see the relationships between their bodies, their health and their environments, we gain a glimpse into the way Indonesians perceive themselves in the world and the world within themselves.

Brooke Nolan (borneobrooke@gmail.com) is a PhD student at the University of Western Australia. She is currently undertaking PhD research in Wawonii, focusing on maternal mortality, women's agency and local concepts of health and illness.

Inside Indonesia 112: Apr-Jun 2013

Comments  

#10 +2 Kate 2013-09-04 03:03
This was a really insightful article, which I've just shared with some friends to assist in explaining some of the concepts of health over here. Thanks Brooke!
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#9 +1 theresia 2013-08-08 01:46
could this condition come from parasitic invasion? As pharmacist I have experienced that some skin diseases are caused by worms. Unfortunately the worms cannot be expelled by using common anthelmintics but need a special treatment with herbal decoctions or liver cleansing
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#8 +2 menusurfer 2013-07-14 22:26
Having worked in health in Indonesia since the 90's, I strongly agree with Ben, Hasan and Ronen, that this perception of illness in Indonesia reflects poor education on several levels of society, but also the very poor level of access to good quality health services in most remote or rural areas of Indonesia. Health equity is low in Indonesia. That the concept of 'panas dalam' and 'mask angin' is so strong, even in educated classes, is a travesty of health promotion and education efforts there. As for 'spirit', it still requires a huge amount of human spirit just to cope with these inequities in daily life.
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#7 +2 Lan 2013-07-10 18:23
With regard, specifically, to 'hot foods' or 'heaty food' as we say in Chinese - it is a 'traditional' (if I may) way of referring to what in the Western world is often referred to as acidic food. Likewise, 'cooling food' refers to alkaline foods. i.e. For some things there are logical/medical basis to what may sound like obscure fluffy wuffy superstitious yin and yang stuff to outsiders.
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#6 0 Sylvia Sidharta 2013-07-10 06:58
It would be useful to determine what the disease really is. Is it a skin condition, such as eczema or something else. Is it exacerbated by stress or physical conditions? It seems to me that all kinds of people are afflicted by "panas dalam", even people living in first world countries. It's all very well making people aware of these things but it would be more useful to obtain a medical expert's opinion on this. A dermatologist may be able to diagnose from the photograph
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#5 +2 Christine Perkins 2013-07-09 01:33
Even in western medicine there is not enough time given to 'the spirit'. Many names are applied such as 'the power of positive thinking'. I agree with other comments, there is clearly a need for more doctors, further public education on health and sanitation but let's not loose sight of the complexities and the spirit.
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#4 -5 Ben Miler 2013-07-08 12:44
As dumb as "masuk angin." Too many Indonesians still live in the dark ages, unaware of the etiology of disease - a huge failure of the educational system.
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#3 +1 Hasan 2013-07-08 08:55
There are many cases like this in many remote areas in Indonesia. Can be many causal or diagnosis. Need time for doctor or nurses to ask questions for differential diagnoses because diagnostic tools poorly available. Its can be malaria or viral diseases or parasites or just need to improve hygiene and sanitation. Treatment can be antibiotic or just symptomatic and keep the patients eat and drink to avoid worse condition. But if this case is in big city can be still the same because they have not enough money to pay diagnostic test needed or doctors in big city do not know or forget this kind of diseases. That's why they say this is " neglected diseases"
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#2 +3 Ronen Skaletzky 2013-07-08 05:14
This kind of illnesses will probably be diagnosed correctly by many 1st class medical hospitals in the world. Indonesia have two many 'mysterious' illnesses, - just because there are not enough medical doctors with adequate medical education...
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#1 +1 tempo dulu 2013-07-08 04:31
Ultimately, it doesn't matter what the cause of panas dalam is - provided that the sufferer has a strong enough immune system to recover.
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