Health promotion in remote Tello islands
‘Our friend is crazy, he was possessed by Satan.’The first time I heard these sentiments was in the village of Teluk Limo on the island of Tanah Masa. We were walking back to the jetty with three young boys to collect the team’s malaria education posters. We had unwittingly left the posters on our boat that morning.
Intrigued by the young boys’ comments, I asked them what the symptoms of this bizarre ‘satanic’condition were. As they trudged barefoot through the sandy village, they explained, ‘it often starts with a headache and is then followed by chills and fevers.’ On occasions this affliction may pass with little lasting effect, yet sometimes the victims will be left crazy or even pass away.
The Tello Islands are located one hundred kilometres south of Nias, off West Sumatra. The island group is made up of more than 50 islands and atolls, but only 18 of the islands are inhabited. There is a striking contrast between the postcard beauty of the islands, with their white sand beaches and towering coconut trees, and the poverty and disease which consume the villagers who live there.
This conversation took place in June this year, when I was working with SurfAid International. We were in the process of implementing SurfAid’s Emergency Disease Prevention Program. In essence, the program is a mobile clinic which operates in remote villages. A health team travels by boat to islands throughout West Sumatra. The team then gains access to villages by smaller speedboat. The team works alongside local government healthcare staff and village heads, holding clinics in village halls, schools, churches, mosques or even a villager’s house.
The main components of the program include the provision of measles immunisations, vitamin supplements, anti-worm medicine, malaria testing, education and treatment, as well as the distribution of mosquito nets impregnated with the insect repellent permethrin.
When the SurfAid boat arrived in the predominantly Christian islands, the team did not suspect that they were going to have to deal with accusations of satanism. After just four days in the area, rumours began to filter back to us that we were the ‘anti-Christ’.
The buzz was not for want of following bureaucratic procedure. Letters, warm greetings and an education program had preceded the implementation of the clinics. The team was purely medical in its orientation and had no religious affiliation whatsoever, let alone a satanic one!
The SurfAid stamp, it turned out, was the first catalyst for speculation. A normal ink-based stamp that washes off with water, we use the stamp to indicate when a child has already been immunised. This ensures that they do not come through the clinic for a second shot. The stamp with its medical cross and surfboard logo was interpreted as an inverted religious cross. With the accuracy of Chinese-whispers, the logo was soon said to represent the satanic digits, 666.
The drop of blood taken from the fingertip of one in five children passing through the clinic for a simple malaria test was then misconstrued as part of a ‘satanic ritual’. Furthermore, the permethrin-impregnated mosquito nets that were distributed to every family in each of the villages visited were questionable in the eyes of some villagers. ‘I used my net last night and it put me into a trance…I didn’t wake throughout the night and I slept through my morning chores’. Was this the first time that the villagers had enjoyed a full night’s sleep without the constant whine and itch of the Anopheles mosquitoes that plague the archipelago?
Five years ago, physician and surfer Dr Dave Jenkins chartered a yacht in the Mentawai Islands to search for the perfect wave. The surf proved to exceed his expectations. However, what he also discovered was a community of islanders who were suffering and dying from a number of preventable diseases, including malaria.
Concerned by the inequality of lifestyles, Dr Jenkins went on to establish SurfAid International, a non-profit organisation dedicated to the alleviation of preventable disease through community-based health programs.
The setbacks in the Tellos were new challenges for SurfAid. The organisation has always stressed to its workers the importance of explaining in full every aspect of our activities to the communities within which the organisation works. A special ‘socialisation’ team was established to go from village to village explaining SurfAid’s activities. The more we shared information and plans with the villagers, the greater their understanding increased of us and ours of them.
Once a bond of trust was established, the community and the team would start working in tandem to persuade the remaining doubters that modern medicine would be able to help them and that any fears of black magic were unfounded.
Never before had the team experienced such difficulties with the implementation of this exact same program. Everything had run so smoothly on Simeleu Island and mainland Nias. Never before, however, had the team reached such remote areas where modern medicine was so foreign to the local communities. Slowly, as we moved further and further out into the Indian Ocean to some of the most remote islands in the archipelago, the team began to streamline the program in an effort to adapt to the challenges that it was facing.
The SurfAid stamp was replaced by a piece of masking tape stuck to the upper arms of the immunised children. The malaria tests with their precious drops of blood were disposed of in front of the villagers after each clinic. One of the community facilitators trained in malaria education would tie himself up in a mosquito net during the education program to prove to the villagers that permethrin was not going to render them unconscious.
With perseverance and the support of the local healthcare staff, the rumours slowly began to dwindle. In fact, the earlier hesitant acceptance of the mosquito nets and the suspicions surrounding the malaria tests were not only eliminated, but villagers began showing great enthusiasm for these aspects of the program.
Small fishing craft would edge close to our boat in the late afternoon with fishermen’s reports that their village head had forgotten to include a family on the list of households. Certain villagers had subsequently missed out on the distribution of mosquito nets. They would often turn up with a note of authorisation from their village head and explain their concerns about the forgotten family’s risks of getting malaria if they had no net. They would then go on to tell us with such amazement of how since they have been using their nets, ‘no mosquitoes have even been brave enough to come into our homes’.
Similarly, villagers began to complain that only one in five children had been tested for malaria, arguing that everyone needed to be tested. Some villages wrote letters to request that we come back to their village because some of the children had been away at the time of the tests.
However, perhaps the most memorable example of evidence that the local communities were slowly accepting our efforts was in one of the last villages we visited. We overheard one child chant ‘It’s the anti-Christs!’, before his friend tapped him on the shoulder to explain with a wide grin on his face, ‘they’re not anti-Christs, they’re anti-malaria!’.
Little access to healthcare
Throughout my two months in the archipelago, I became accustomed to hearing numerous exotic explanations for disease. There is not a lot of modern medical care available to the villagers who live in the Tello islands. The only puskesmas(community healthcare centre) is located on the main island, Pulau Tello, which is up to five hours by boat from the furthest islands.
This community healthcare centre only has one doctor, and he has only visited three of the inhabited islands in the chain of islands. With no public transport between the islands, the villagers, who make a meagre living from fishing or the sale of copra, find it almost impossible to charter boats to reach the main island and its limited medical facilities.
Unfortunately, with the exception of clinical diagnosis, the centre has no way of diagnosing malaria; it has no microscopes or rapid diagnostic tests. Similarly, the only drug it has available for treating malaria is chloroquine, and according to a number of sources the malaria throughout the archipelago is primarily chloroquine resistant.
During the two months in the chain of islands, SurfAid carried out a total of 683 rapid diagnostic malaria tests and found a 25 per cent malaria prevalence rate throughout the area. In addition to this, the team immunised, de-wormed and provided vitamin A supplements to more than 1000 children aged six months to 15 years.
The organisation also distributed more than 7400 mosquito nets along with soap and nutritional supplements. Another 490 people received medical attention and treatment. Although SurfAid’s other missions may have benefited greater numbers of people, none has reached individuals so isolated or so far removed from assistance.
Back on dry land after two months on the boat in the Tello islands, the team reminisced over a bowl of chicken noodle soup. Suddenly, we heard the strains of the Sex Pistols in the background, belting out ‘I am an anti-Christ’. We looked at each other. For us, the lyrics of this irreverent song had taken on a whole new meaning.
Kristen Stokes (firstname.lastname@example.org) is a field worker for SurfAid International.