HIV/AIDS is spreading rapidly because of the profound inequalities that afflict Papua
Carole Reckinger & Antoine Lemaire
Until now there has been no serious action from the government but only lip service. HIV/AIDS has become an emergency and it is too late to sit back and do nothing,’ declares David (not his real name), the head of a local NGO in the highlands of Papua. ‘If we want to save the indigenous population, and guarantee the survival of our people, then HIV prevention and treatment needs to become a priority in Tanah Papua (referring to the two provinces Papua and West Papua).’
David’s concern is well placed. Tanah Papua might only hold one per cent of Indonesia’s population, but its HIV/AIDS levels are reported to be 15 times higher than the national average. Of all the known HIV cases in Indonesia, 30 per cent occur here. Papua is facing a generalised HIV epidemic, the only place in Indonesia to be experiencing this situation. Initially, the response of the government had been slow but this changed with the implementation of the 2010-2014 National HIV and AIDS Strategy and Action Plan. The primary goal of Indonesia’s overall response to the HIV epidemic was to slow the number of new infections and the two Papuan provinces were named as priority areas of prevention. However, one major weakness of the awareness and prevention campaign was that it has often failed to take into account the cultural, developmental and socio-economic realities of Papua, especially in the highlands.
In our last photo essay, we looked at the general situation of HIV/AIDS in the highlands of Papua and how it is affecting individuals, families and society at large. This second photo essay explores the economic, cultural and socio-political realities on the ground in order to understand some of the causes of the epidemic and the efforts needed to abate it. The epidemic does not spread at random, but follows the social, economic and political faultlines that divide a society and puts the most disenfranchised segments of the population at risk.
A broken community
There are some 260 indigenous ethnic groups and they make up about half of Tanah Papua’s 3.6 million inhabitants. HIV prevalence is almost twice as high among indigenous Papuans than among migrants, and in some areas Papuans make up 80 per cent of HIV positive people.
This epidemic is spreading due to great social dislocation. Many Papuans believe that their traditions and cultures are slowly being eroded due to transmigration, rapid economic development, rampant resource extraction and repressive politics. The increased centrality of money coupled with a lack of paid employment in rural areas, has drawn many Papuans to the cities, severely eroding traditional social structures. Disorientation in the face of rapid change is visible in all urban centres where such social problems as alcohol abuse are prevalent.
Since the controversial inclusion of the western half of the island of New Guinea into Indonesia in the 1960s, Papua’s performance on a range of social indicators has ranked as Indonesia’s lowest. The heavy-handed approach of the security forces at any sign of discontent has generated a tradition of resistance by indigenous Papuans to Indonesian rule. Militarisation of the island, the role of security forces in resource extraction and the repression of Papuan social movements, have led the indigenous population to lose trust in the government and for them to experience a general loss of self-worth.
Indonesia’s 2001 special autonomy law was aimed at addressing the structural problems faced by Papuans. More than a decade on, however, most Papuans agree that it has failed to deliver. Today, only a small elite directly benefits from special autonomy. Despite a huge flow of funds into Papua, little sustainable educational and health infrastructure has been created and the majority of indigenous Papuans continue to be socially and economically sidelined. Cash and rice hand-out programs create dependency rather than helping Papuans stand on their own feet.
Urban life and migration
Urban centres are developing rapidly all over the island. The rising need for money in a traditionally moneyless society draws many, especially young people, to the towns. In Papua, HIV transmission takes places almost entirely through heterosexual sex. Increased mobility and urban life offer opportunities for a larger number of sexual partners, far from the prying eyes of family and community. Urbanisation and the encroachment of capitalist cultural and sexual norms are radically challenging traditional ideals about sex, courtship and pregnancy. There is a trend towards sex at a younger age, with a wider range of partners.
Indonesian newcomers control most of the commercial and economic activities. Indigenous Papuans are economically sidelined. Papua has a typical frontier economy, where very high returns can be made on small investments. The importation of consumer goods has had a significant impact on nutrition, with many Papuans turning away from traditional agricultural products to packaged noodles, oil and sugar. Poor nutrition compounds the immunosuppressive effects of HIV.
The seemingly uncontrolled creation of new districts through a process known as pemekaran (proliferation) benefits local political elites by giving them access to huge development funds and more political power and in no way serves the interests and well-being of the majority of Papuans. Pemekaran also plays into communitarian politics, dividing Papuans along clan and sub-clan lines. New districts, furthermore, mean more government jobs, drawing educated Papuans away from involvement in civil society and their home villages. New frontier towns are mushrooming everywhere, even in very remote, mountainous areas. These towns are hotspots in the spread of HIV.
In rural areas, healthcare services are few and far between. Most healthcare staff in the centres that do exist are migrants from other parts of Indonesia who do not speak local languages and have little affinity with indigenous cultural beliefs and practices. Most institutions, in particular the Ministry of Health, are run by migrants. Government healthcare services are affected with corruption, provide poor training for staff and often lack proper follow-up procedures. Many Papuans view them as part of the Indonesian colonial machinery.
Rumours are rife that HIV was intentionally introduced to decimate the indigenous population. The fact that these conspiracy theories can flourish is a good indicator of the Papuans' feelings towards the Indonesian authorities. Trust towards government-run hospitals is low and many will only go there as a last resort.
The absence of high quality health services and education throughout the region not only facilitate the spread of HIV, they also severely impede any efficient response to the epidemic. Indeed, although provincial governments have made HIV testing and treatment free, many Papuans do not have access to healthcare testing or treatment and are not reached by awareness raising campaigns.
Access to medicine
Access to medicine - Carole Reckinger & Antoine Lemaire
Testing facilities are available only in urban areas. Most people who undergo testing of their HIV status do so because they are showing serious signs of recurring opportunistic diseases such as tuberculosis, dysentery or pneumonia, meaning that they are already at an advanced stage of the illness.
If they are diagnosed, many people have to walk for days to the closest urban centre to get their monthly supply of anti-retroviral (ARV) medicine. Stigma is also still widespread and many people are reluctant to pick up their medicines for fear that friends or family will find out about their status. Although ARV medicine is free, other essential medicines such as Cotrimoxazole, used as a treatment of infections before antiretroviral drugs can be administered, are not.
Education faces the same problems as health care, and functioning state schools are very rare. There is a serious problem of teacher absenteeism and, upon leaving school, many Papuans cannot read, write or perform basic mathematics. A culture of apathy within the government bureaucracy and large parts of the population is partly the result of an education system reminiscent of Indonesia's Suharto era. Schools fail to teach students to be critical and proactive and this makes it difficult for local activists to involve local communities in HIV prevention programmes. Education is an essential part of HIV prevention. It has been shown that higher levels of education delay sexual activity and increase prevention and protection.
Most AIDS awareness raising campaigns are developed in offices in Jakarta, Europe or Australia, far from the cultural and socio-economic reality of Papua. They often replicate initiatives in place in the rest of Indonesia, where HIV is localised and concentrated among intravenous drug users, sex workers and men who have sex with men. It would be more useful to look at Papua New Guinean programs, which have proved successful because they are adapted to the local cultural context. Kalvari, a church based and locally run clinic in Wamena, is one of the rare places which uses cultural references, drawn from pig farming and crops protection, to explain the virus.
In Timika, a mixed-churches youth organisation leads a participatory workshop with street children. The aim is to raise awareness about sexually transmitted diseases (STDs) and HIV as well as to build their confidence in everyday life. They are also encouraged to raise awareness about sexually transmitted diseases in their community. Street children are becoming more and more numerous all over Papua and HIV infections among them are high and increasing. In most places very few organisations work with these children, if at all.
Indonesian peddlers set up their pop-up shops along the main shopping street in the highland town of Wamena. Most of the products they sell are meant to increase men’s sexual stamina, size and prowess. Even so, talking openly about condoms and sex is still a problem in most churches and among cultural leaders. This presents a major obstacle to the design and implementation of HIV prevention campaigns.
The growth of urban centres and natural resource industries has always given rise to prostitution, and Papua is no different. In Timika, with a population of 130,000, and growing by 10 per cent every year, 600 sex workers are officially registered with the local government. Most HIV outreach programs focus on commercial sex workers in line with the guidelines of Indonesia’s national HIV program. Although attention on them and their clients is essential, this focus misses a large part of the problem. The registered sex-workers in semi-official brothels and massage parlours, almost all of whom are migrants from other Indonesian islands, tend to have relatively good HIV awareness and access to condoms. However, the mainly indigenous Papuan street prostitutes lack both.
The HIV/AIDS epidemic in Papua is being shaped by the deep inequalities that affect Papuan society, and is further deepening those inequalities. For Papua's indigenous population to survive the HIV epidemic, a unified, culturally appropriate awareness-raising campaign must be implemented from the bottom up, with the support of the Indonesian government. But an HIV campaign will only slightly slow the spread of the virus if significant changes are not made to improve health and social conditions. Those changes, in turn, won’t happen unless the government recognises that Papuan norms, values and cultures are as valid as other Indonesian norms, and are not remnants of a backward culture that is threatening the unity of the country. This is a huge challenge, but if not properly addressed, a major health disaster is imminent.
Carole Reckinger (email@example.com) has been interested in Indonesian and Papuan social and political issues since first visiting the archipelago over a decade ago while studying Indonesian and Southeast Asian studies at the School of Oriental and African Studies (SOAS). She has lived and worked in different parts of Indonesia, including Wamena and Jayapura.
Antoine Lemaire (firstname.lastname@example.org) studied Social Anthropology at SOAS. He has lived and worked in different parts of Indonesia and Papua. He is particularly interested in the impact of capitalism on material culture in indigenous societies.
Inside Indonesia 118: Oct-Dec 2014