Running Head: A MISSION TO INDONESIA
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A Mission to Indonesia: A Shaping Summer
Kristen Leah Metzger
University of Akron
College of Nursing
Honors Research Project
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A MISSION TO INDONESIA
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Abstract
PURPOSE: Everyone is a dreamer. Without dreams, there is nothing to push us forward. The
pursuit – whether of money or status or fame or something else – gives both meaning and
purpose to life. The following is a chapter of my dream: to change the world and how, in the
process, I was changed. METHODS: Certainly, one can be an instrument of change wherever
one is. But for me, during the summer of 2010, it meant that I had to enter the as yet unknown
world beyond my familiar hometown and city. I spent the summer of 2010 living in Indonesia. I
served with American medical missionaries as well as Indonesian healthcare professionals at
Bethesda General Hospital. While there, I kept a reflexive journal detailing the experience I
went through and how I was processing all that occurred.
RESULTS: The findings are the
blending of a culture with a person. They describe the perceptions, thoughts, and feelings of
finding professional and personal fulfillment in this context, as well as evaluate the personal
consideration of pursuing this area of nursing long term. They also explore the world of nursing
in a context of a developing area of the world.
A MISSION TO INDONESIA
For most persons living in America, having access to adequate healthcare is almost an
assumption. The cost of healthcare may be another issue, but Americans typically expect to have
access to the best medical treatment possible. Now, imagine having a debilitating disease and no
options for treatment, but also knowing that in another country, people are treated and even
cured of this disease as though it were nothing. Envision knowing of a cure and not having the
technology and supplies for treatment or the resources to obtain it. This depiction is very often a
reality in many places around the world. Indonesia is one of those places where people lack
access to healthcare. It is the fourth most populous country in the world and is a group of more
than 17,000 islands between the Pacific and Indian Oceans and between Australia and China.
This country is home to 240,271,522 people (CIA-World Factbook, 2009). And where there are
people, there are health problems and a need for healthcare.
This paper answers the following questions: What is the impact of current health
practices upon the children in Indonesia? What are the general diseases and health problems
affecting Indonesians? What are the social structures and health care system practices in
Indonesia? These questions are addressed from a professional perspective based on a review of
research studies. In an effort to balance the objective review of health-related research studies
about the Indonesian population is a personal narrative, written from first-hand experience while
on a mission trip to Indonesia during the summer of 2010. Personal narrative is a tool that
enables one to see the academic aspect of a study without losing sight of the human side of
research (Ellis & Bochner, 2000). The narrative addresses, in part, the following questions: How
is healthcare actually accomplished in a specific, rural Indonesian setting? How is it similar and
different from an American setting? What does the author, a nursing student, see as comparable
to the research provided beforehand? The paper ends with a personal reflexive analysis. This
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portion of the paper includes the author‟s critical thinking about her own reactions toward
nursing in a different culture, as well as the lasting personal and professional impact.
A Professional Perspective Based on a Review of Research Studies
The Health Problems in the Children of Indonesia
The World Health Organization (WHO Regional Office for South-East Asia, 2005) has
identified that malnutrition contributes to more than half of the deaths in children in south-east
Asia. Other major medical causes of deaths of children in this area include acute respiratory
infection, diarrhea, and vaccine preventable diseases, e.g., measles and tetanus. In selected
pockets, major medical causes of death include malaria and HIV/AIDS.
According to
Rudan, Boschi -Pinto, Biloglav, Mul holland, and Campbell (2008), more than 95%
of new episodes of childhood clinical pneumonia occur in developing countries (pg.
414). Indonesia is one of those developing cou ntries. The researchers investiga ted
disea se prevention and identified certain risk factors such as “cou ntry of birth,
malnutrition, low birth weight, non -exclu sive breastfeeding, lack of measles
immu nization, indoor air pollution, crowding, etc” (pg. 413).
As noted above, malnutrition accounts for more than half of children‟s death
in southwest Asia, making good nutrition another area of important concern for the
children in Indonesia. T he World Health Organization has created a new reference
called the WHO Child Growth Standard, which may better assess the nutritional
sta tus of childr en u nder two years of age (Madarina, 2009). When assessed with
this scale, 18.7% of Indonesian babies were classified as u nderweight. Stu nting
(low height for age) explained the weight of 66.9% of the babies, and wasting (low
A MISSION TO INDONESIA
weight for height) explained the weight of 39.7% of the babies (Madarina 2009).
This is important information because previou sly all babies classified as
underweight were treated with additional dietary su pplements. Now only babies
who are wasting will be helped by additional feedi ngs becau se researchers have
found that additional supplemental nutrition given to stunted babies actually only
increa ses their risk of obesity (Madarina, 2009).
Most children in south-east Asia do not receive adequate healthcare. In fact, less than
20% of sick children get medical care. This statistic supports the significant need for access to
good care, as well as the need for public education on the necessity of seeking good care.
(World Health Organization Regional Office for South -East Asia, 2005). Another
health pra ctice influ encing the health of children in Indonesia is family planning.
Schoemaker (2005) points out that the greatest factor in determining if women will
use contra ceptives is not primarily based u pon access to contraceptives , but on
attitu des a bou t family size and planning, leading t he researcher to determine that
efforts should focus on changing those attitu des.
Another indicator of health problems is infant mortality. The World Health
Orga nization (2010) reported limited nu mbers of health work ers in Indonesia, which
affects health service. In 2006, the ratio of general practitioners was 19.9 per
100,000 population while the ratio of midwife per 100,000 popu lation was 3 5.4.
Most general practitioners and midwives are working in urban areas with limited
nu mbers in remote areas. Ronsmans, Scott, Qomariyah, Achadi, Braunholtz,
Marshall, Pambudi, Witten, and Graham (2009) studied infant mortality in two
districts in Indonesia (one was 72 kilometers from the nation‟s capital and the other
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was in a more rural location). The study found that for every 100,000 live births,
there were 435 deaths of babies. It also found that “only 33% of women gave birth
with assistance from a healthcare professional” (pg. 418). According to the CIA - The
World Factbook (2010), Indonesia has “18.84 births per 1,000 population,” which is
an average of “2.31 children born per woman.” This ranks Indonesia as having one of
the highest mortality rates. In response to this problem, the Indonesian government
put into practice a plan to try to put “a midwife in every village.” Hatt, Stanton,
Makowiecka, Adisasmita, Achadi, and Ronsmans (2007) fou nd that since 1986 this
program has reduced the number of infant deaths among both high and low
socioeconomic statu s Indonesians. They also fou nd that adequate help was still not
availa ble when persons needed emergency care.
General Diseases and Health Problems Affecting Indonesians
General diseases and health problems are fou ght both on a primary and
tertiary level. Ngm and colleagues (2006) describe the current state of the health of
Indonesia ns. Infectious diseases are the predominant sources of illness affecting
third world countries. But many third world cou ntries, including Indonesia, are
undergoing a shift toward noninfectious diseases. Currently both infectiou s and
non-infectiou s diseases are affecting the people of Indonesia, mak ing aggressive
healthcare prevention and disease management necessary. Many of the noncommunicable diseases can be prevented. Ng, Stenlund, Bonita, Hakimi, Wall, and
Weinehall, (2006) identified some of these risk factors as smoking, obesity, and
high blood pressure. The addition of non -communicable diseases to the already
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extensive list of diseases related to poverty creates a huge demand on the medical
system within Indonesia.
Disease management, or tertiary prevention , is also a necessary focu s. For
exa mple, Suriadi and colleagu es (2007) investigated risk factors for pressure u lcers
in an Indonesian hospital‟s intensive care unit. Their findings indicated that
patients with high interface pressure (the force between a patient‟s sk in and another
surfa ce), increased skin moisture, incr eased body temperature, and those who were
frequ ent smok ers were at higher risk of developing a pressure ulcer.
Researchers have also described the prevalence of other diseases are fou nd in
Indonesia . Malaria, typhoid, dengu e, chiku ngu nya, filariasis, J apanese encephalitis,
pla gue, measles, and polio also specifically affect the people of Indonesia (Center
for Disea se, 2010), and especially among the poor of Indonesia. Althou gh typhoid
wa s specifically studied by Ochiai et al. (2008), the researchers spe culate that the
prevalence of many infectiou s diseases could be decreased by improving water
quality and sanitation. However, the researchers also suggested that “vaccination in
high-risk areas [su ch as Indonesia] is a potential control strategy [for typhoid]
recommended by WHO for the short -to-intermediate term” (pg. 260). With proper
education, sanitation, and immunization, the nu mber of people affected by many of
these communicable diseases could be drastically lowered (Communicable Diseases
– Indonesia, 2010).
Panning, Grywna, van Esbroeck, Emmerich, and Drosten (2008) identified an
additional area of concern for the diseases affecting Indonesia. They found that
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travelers are at risk for contracting and carrying diseases uniqu e to Indonesia back
to their resident country. They explain that diseases su ch as chik ungu nya, malaria,
and dengu e fever do not have u nique specifically identifying symptoms, which
mea ns that it would be easy to overlook a diagnosis of these three diseases (pg.
420).
The Health Care System in Indonesia
The health care system of Indonesia consists of three levels: community health centers,
health sub-centers, and integrated service posts. Community health centers deal with outpatient
care, child and maternal care, immunizations, and other such programs. Health subcenters
primarily focus on child and maternal health care. Doctors occasionally visit, but these subcenters are primarily run by nurses. Integrated services posts do not have full-time workers.
These posts are occasionally visited by healthcare teams and often do not a have a building of
their own. Much care is done by volunteers (Bunge, n.d.). The World Health Organization cites
the governments increased efforts to add more of all three types of healthcare to the delivery
system, but there are still only approximately 0.6 beds per 1,000 Indonesians (World Health
Organization, 2007).
In addition to current medical providers, the people of Indonesia may also use “dukuns”
for their healthcare issues. Dukuns can be described as “traditional healers.” They give medical
attention to their patients as well as connect the spiritual and natural realm into their practices.
Many choose to see a dukun rather than a medical practitioner simply because of the high cost of
medical practitioners (“Saving mothers lives,” 2007).
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The Mission
Everyone has dreams. Dreams can push us forward. The pursuit of something in life
whether money or fame or anything else gives both meaning and purpose to life. The following
is about my pursuit of a dream to change to world. Certainly, one can be an instrument of
change wherever one is. But for me during the summer of 2010, it meant entering the yet as
unknown world beyond my familiar hometown city. During the summer of 2010, I lived in
Indonesia. I served with medical missionaries from the United States as well as Indonesian
healthcare professionals at Bethesda General Hospital, West Kalimantan, Borneo, Indonesia.
This ministry “is a religious, medical, and social outreach working among the under-served
peoples in the jungles of Indonesian, West Borneo. Initially established in the 1960's as a small
medical clinic to serve the Dyak tribal people of the Borneo rainforest, Bethesda Ministries has
continued to grow and expand in its areas of ministry” (Bethesda Medical, 2010). One of the
ministry‟s primary goals is to “be an instrument for the spreading of the Gospel of Salvation in
Jesus Christ to as many people as can possibly be reached through the avenu e of health care
which is competently and compassionately made available to any and all who come, especially
reaching out to those who are isolated and forgotten, poverty stricken, lacking in formal
education and who reside far from adequate sources of health care" (Bethesda Medical , 2010).
While in Indonesia, I lived in an apartment on the hospital grounds with missionaries and
Indonesian doctors. The mornings were spent in health care settings. The afternoons were spent
with an Indonesian language tutor, and the evenings were spent in Bible studies, basketball
games, or other activities. Some afternoons were also spent helping teach the nursing student‟s
English language class.
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Right from the outset, some adjustments needed to be made. There were no windows in
any buildings (just screens), torrential rain falls, and squatty potties. There were a few westernstyle porcelain toilets on the hospital grounds, but the vast majority of restrooms consisted of a
hole in the ground over which to squat. Because there were no glass window panes, I would
sleep to the sound of crickets and wake to the sound of birds, chickens, dogs, or rain. Often
these would wake me even before my alarm clock. Although I was in Indonesia during the dry
season, I did not escape some torrential rain falls. One moment would be sunny and the next, the
sky would break open with rain. And sometimes it did not even matter if you had an umbrella or
not. If it was raining hard, you just accepted that you would get soaked.
Everywhere I went, I
took my dictionary, my Bible, and my umbrella.
At the start of each week I went to a different setting in the hospital, e.g., emergency
room, maternity, general wards, charity ward, intensive care unit, and surgery, armed with my
stethoscope, Indonesian-English dictionary, a smile, and a prayer. The doctors spoke English
well, but the nurses had about the equivalent of the average American‟s high school Spanish
abilities. The language barrier made both the nurses and me nervous, but I could usually win
them over with my attempts at their language, several language blunders, and lots of laughter.
General Health Care
Bethesda General Hospital literally is in the middle of the jungle. It is located in a small
village that consists of a few store fronts and many homes. The closest city that would include
restaurants and shopping for things beyond “mini mart essentials” is about an hour drive. But
people come from all around because this particular hospital is known for excellent care and staff
who are genuinely concerned for their patients. The hospital rightfully has a good reputation.
A MISSION TO INDONESIA
They use what would be considered in America as ancient and out-dated equipment, but they do
amazing things with what they do have. The hospital is in the middle of an area of poverty
where healthcare is a privilege, not a right. Hospital staff sees and treats particularly terrible
cases, partly related to factors such as poor sanitation and malnutrition and infectious diseases.
This is due, in part, to that fact that the people delay treatment due to the cost of healthcare, an
additional burden to an already poor community. Poverty and remote access also affect the
hospital itself. One of the first things that mortified me at the hospital was that plastic gloves are
a luxury of America. They have reusable, sterile gloves for procedures, but for everyday use,
there are no gloves.
Indonesia also is plagued by secondary diseases, such as hypertension and diabetes, as
well as more serious diseases, like malaria and tuberculosis. As an older missionary nurse told
me, “Everyone in Indonesia either has tuberculosis, is coming down with tuberculosis, or
recovering from tuberculosis.” The first time I listened to a patient‟s lungs who had tuberculosis,
I just kept telling myself, “don‟t breathe and don‟t touch anything else.” I was struck with the
knowledge that if this person were in America, he would be in a private room with reverse air
ventilation, and I would be wearing a special suit to care for him. But again, that is a luxury of
America. The reality is this man was still sick and still needed care.
Maternity Ward
During my second week at the hospital, I started on the prenatal ward. I helped
administer medication and used a strange stethoscope to listen for the fetal heart beats. Then the
midwife motioned for me to help her in the delivery room. She only knew a few words of
English. The nurses helped me scrub in and get “sterile” – Indonesian style, which includes
wearing rain boots. None of the mothers get epidurals here. I was struck by how different and
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simple everything is here. There are no fetal heart monitors and no IV machines because the
electricity is not reliable. However, the nurses are excellent because they have to rely on
themselves and not machines. As soon as the baby girl was born, they handed her to me! Then
they motioned for me to use the suction machine and feed the small tube down her nose. I was
so nervous. I kept thinking, “Where is my clinical instructor to talk me through this?!” I gave
the mother pitocin to prevent postpartum hemorrhage, and I gave the baby her first shot, which
was an injection of vitamin K. We assessed, weighed and measured the baby. After that
experience, I started to spend some time in the afternoons in the library. I was reminded of how
much more I had to learn before I graduated.
General Ward
The hospital staff deals with many motor vehicle accidents because there are few laws to
govern driving on roads. While on my rotation through the general wards, I had the role of
wound care nurse, which meant that another nurse and I changed dressings each day. One
woman had been in a bad bus accident 10 days previously where the bus had rolled upside down.
The accident resulted in a huge wound on her left leg and an even worse wound on her right leg.
Ten days after the accident, the wound on right leg still extended across the majority of her thigh
and was still gapping, because only four stitches had been used to bring the edges closer
together. There was what may have been an open reduction internal fixator on that leg as well to
repair the fracture. In spite of hot temperatures, the nurses worked so slowly during the dressing
change. And then the patient asked us to turn the fan off. When we did, I got dizzy and had to
sit down. Then they needed my help, so I pushed through regardless of the sick feeling all over
myself. After two weeks on that ward, this particular patient and I became friends though we
could barely communicate. She would always smile when I came in and chatted happily though
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I only understood a small portion. The last day I was on the general ward, there were also
nursing students on the ward. Some of them were my English students as well, so they were not
afraid to try to talk to me. The wound nurse gave me the job of changing all the dressings on my
own! After a week here, apparently in her mind I had transformed into a real nurse. But I had an
audience of nursing students, which made me nervous. They just kept filing in to watch me.
Later, the nursing students told me that all the students in my English class like me. YAY!!! At
that point, my self confidence sky rocketed. After the kind words of the wound nurse, I finally
felt competent as a nurse in the hospital. And when the nursing students told me that they liked
me, I was overwhelmed with reassurance. Such moments of encouragement helped push and
drive me forward.
One particular patient in the general ward had uncontrolled diabetes. He had developed a
foot ulcer, which now encompassed most of his foot. Several of his toes had been amputated.
To look at it, it was like something had eaten away half of his foot. The strange thing is that his
daughter had to convince him to have the surgery. He kept refusing because he was a farmer,
and so if it came to losing his foot or his life, he was not going to choose to lose the foot.
Without a foot, he would no longer be able to work in his fields. This would mean that instead of
providing for his family, he would become a burden to his family. I just can‟t even image that
thinking.
This patient was scheduled for an amputation to begin while I was in my language class.
So after language class, I ran back to the operating room. When I got there, I was surprised at
how high they were amputating. After 15 minutes of watching, I realized that this was not the
man who was getting an amputation but a lady who had a fractured femur. The bone was broken
and was not pretty – or clean for that matter. And her lower leg was bent the direction that the
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knee joint does not normally bend. It is by far the worst thing I had seen. The surgeon (Dr.
Indra) was putting all of his body weight into getting the bones into the correct position again. A
pre-med student from the States also at the hospital for the summer commented how amazing it
was that some surgeries were so intricate and detailed and delicate and that others were just
brutal – almost primitive or cave-man like. It was amazing when I saw my anatomy books come
to life as I watched surgeries.
Then I realized that the patient was awake, and I was in complete shock. She was
watching our faces from behind a sheet and trying to read our facial expressions. My heart
longed to walk over, hold her hand and comfort her, but I didn‟t know if that was culturally
appropriate. Then another doctor walked in and held her hand for a few minutes before leaving,
so I knew it would be accepted. The doctor said that they did not give the woman general
anesthetic because it was too expensive. I cannot imagine anything worse than being awake
during a surgery like that and hearing everything. After a while, I walked over and put my hand
into hers and started stroking her hair. She spoke a little English and I used a little Indonesian.
She was twenty seven years old and had two little kids, a boy and a girl. She was scared but
trying to be brave. I can handle watching gross surgeries, but it was so different when you held a
patient‟s hand and looked into their eyes and watched them grimace. Oh, how my heart was
breaking as I prayed for her. The vital sign monitor seemed to stop working, and she said she
was getting sleepy. No one seemed to notice, and all my insides were freaking out. “Was she
going into shock?!” But she looked into my eyes, squeezed my hand, and said, “I sleep. You
stay.” I told her I would hold her hand till it was all over. After a bit she became really agitated,
and someone gave her an IV push of something, which must have been a sedative. The nurse
said to me “tidur” (which means sleep), pointed to the patient, and he put tape over her eyes. He
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motioned that I could let go of her hand, but I felt like I should not because I had told her I would
not. At this point I realized that I had already missed so much of the surgery. I remembered Dr.
Scotto back at the University of Akron stressing in lectures that just because someone is
immobilized, it does not necessarily mean they cannot feel and remember. So I kept holding her
hand, and I was glad I did because I would periodically squeeze her hand to perhaps let her know
that I was still there. In a few minutes, she squeezed back with a death grip, and it seemed that
every few minutes, she would squeeze really hard, perhaps just to reassure herself I was still
there. Those moments were hard for me, but they became some of my favorites thus far because
in those moments, I knew that it would be cool to be a doctor or a surgeon. But I also knew that
I wanted to be a nurse. I wanted to look into my patient‟s eyes, stroke her head, and squeeze her
hand when she is scared. In that moment, that was more important and meaningful to me than
anything else, and so that is what I did. I held her hand to the bitter end. They bandaged her foot
and I saw that the tendon in her last two toes had been severed and were limp.
After dinner, it was back to the operating room to observe the amputation. It was a fairly
“clean” surgery. When they finished sawing the bone, they put the foot and partial tibia/fibula
that had been amputated (wrapped up) on the table. The premed student from the States and I
agreed we would never be able to watch horror films again because we had just seen one. In
general, the surgery went well, and they sewed off all the arteries and veins, filed the bone edges,
filled them with wax and stitched up the wound. A few days after the operation, I was again
dressing his wound on the general ward. His family was with him, and he was happy and
smiling. I enjoyed seeing it but could not help wonder what would happen after he was
discharged and went back home. I had no idea. Would the attitude he currently had carry him
through or would going home turn out to be very trying for him. I did not know. And I still do
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not. I can only hope that he would learn as I was that sometimes experiences that seem difficult
at times grow us stronger.
Surgery
I mainly observed during the surgery rotation. One day, a little ten year old girl with six
fingers on her left hand came in for surgery. It was almost like there were two bones coming off
the thumb. Dr. Leo cut them both long-ways down the middle (including cutting the bone that
way). Then they joined the two pieces but cut off one of the 2 fingernails. It didn‟t look all that
great when they were done, but at least it was better than before.
Later that day, a woman needing an emergency caesarean section came to the hospital.
Dr. Indra and Dr. Tantan scrubbed in around six or seven o‟clock in the evening. I had seen very
few births during my labor and delivery rotation in the States and had seen far more in Indonesia.
I love watching births; it is completely a miracle. I always get tight-chested and think, “Cry, cry,
cry, baby” just when the baby is born. Everything went fine during the caesarean section, and
Dr. Indra stitched up the muscle layer. Normally, the patient‟s general practitioner would take
over at this point, but Dr. Tantan told me to get sterile and finish so I stitched up the fat layer.
She coached me all along the way. She did the first half of the top stitches to show me, and I did
the last half. It was amazing and something I can say I will probably never get the chance to do
again. Then I had three stitches to go when Dr. Tantan was called back to the ER. She left me
alone in the hands of an OR nurse who could not speak English. Both the nurse and I looked at
each other worried, but the nurse looked relieved when I looked at him and said “Saya tau sedikit
bahasa Indonesia,” which mean “I know a little Indonesian.” Studying the language paid off.
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One day a young married woman came into the clinic at the hospital. Her symptoms
started out as a toothache. She had taken out the tooth herself with a sharp stick. and it became
infected. Then she had developed Ludwig‟s angina. Her throat was swollen, and she could
barely open her mouth. Then pericarditis developed. I was able to watch the doctors drain the
pericardial liquid with a huge needle. Then they placed two chest tubes in the area, but she still
was not going to survive. As my mind constantly tried to process all that I saw, I wondered if
she would have been dying in the States? I don‟t know. Maybe not. Is it fair? Is it fair that I
was born in America and she there? Is it fair that I have health insurance, and she was sitting in
a room she shares with many people – the charity ward? Are we very different? And maybe I
have not been around death enough. Maybe one day it will seem less raw – but maybe not. Are
we not supposed to be able to fix everyone and anywhere? I guess there are limits, and I guess
living in the middle of nowhere, you face death more frequently, but I don‟t like it. So much else
in life does not seem to matter when you look death in the face. It shocks one into reality and
into considering what in life is really important.
Intensive Care Unit
While “on call” with Dr. Tati one night in the emergency room, I inserted a foley catheter
and then watched a caesarean section. We spent most of the time in the intensive care unit (ICU)
where we alternated time spent suctioning and helping a little baby breathe. We had to use the
infant ambu bag and then an oxygen mask because they only have one ventilator in the ICU, and
another baby was on it. The baby we were taking care of was born prematurely and was even
then only eight days old. The mom had been only seven months along at birth. I cannot even
imagine what the parents were going through; they looked to be around my age.
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The next day was my last day of working in the hospital before going home to America,
and I worked in the ICU. When I arrived, I found they had one less patient. The little baby we
brought to the ICU with Dr. Tati the previous night had died early in the morning. The little
baby whose feet I had held so tightly to warm them up so that we could get an accurate pulse
oxygen reading that night now was represented by an empty bed. I hated death, and I thought
about those parents who looked my age. I cannot imagine having a baby at my age, let alone
losing a baby – 8 days old.
As I started working in the ICU that day, I watched the little baby on the ventilator breath
with retractions due to pneumonia. Little did I know that he would die that day while I gave him
chest compressions. His pulse was 180, and his pulse oxygen was hovering in the low 60s. We
thought the baby may have had a seizure before self extubating. The nurse had me start bagging
while she got ready to re-intubate, but her attempts were not working. The heart rate was in the
20s, and he was not going to make it. He defecated while we were suctioning. Then liquid was
coming out of his mouth. By this time I had been given back the job of chest compressions. I felt
all of his tiny ribs and watched his heart rate disintegrate. The mom, who had been crying, left
the room. Grandpa held the baby‟s legs and hands the whole time. Dr. Tati and I looked into the
baby‟s eyes. He had died. Mom returned, crying. Dad remained emotionless but hugged his
wife. We took out the IV and other equipment and washed the baby up. Then I watched Grandpa
wrap him up carefully in a blanket. All the while I was thinking that little babies are not
supposed to die! They are supposed to bring such happiness! What should I do? Do I just move
on? Does my day just continue? It does not seem like it should. It does not seem right. I
watched the face of a young mother when her life fell apart, and now it is time for me to go to
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language school. It just does not seem right. It only seems right that the world should stop at
least for a while.
Public Health
The hospital serves about 50 villages in remote areas of the jungle. Each village is
visited monthly by a healthcare team from the public health division of the hospital (PKMD).
The villages are reached by foot, car, boat, small plane, or a combination of several. The team
sets up a clinic to see patients, as well as give children‟s vaccines, do children‟s well checks,
distribute female contraception, and do prenatal checkups. I went on several trips to remote
villages, each lasting about three days. I was able to go with a team on a small plane run by New
Tribes Mission to the village of Pare. Another trip was a seven hour car ride deeper into the
jungle.
We would go to a village and set up a clinic. Some villages had a specified building,
although others used the village leader‟s house. In additional to check ups, the healthcare team
also provided mosquito nets and food, such as beans, rice, and nuts to the community at a
reduced price. On one trip, while doing checkups, I saw a little boy with lumps all along his
neck. I asked the doctor who had come on the trip about it, and she said that the little boy had
tuberculosis that had infected his lymph nodes. During one village trip, I saw a little girl with
blond hair. I talked about it with a missionary later and learned that Asians never have yellow
hair. Most likely, the little girl had worms. The patients seen on these outreach trips live at a far
lower state of health because of little access to care, high medical costs, and lack of
implementable interventions. On these village trips, one is more likely to see the effects of living
in an impoverished and remote location. It is also in these areas that malnutrition and diarrhea,
especially among children impact health most significantly. We taught patients that a simple
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20
way to stop the effects of diarrhea was to give the child clean water with salt and sugar in it.
Sanitation is also a huge issue, especially during childbirth in these remote areas. Many people
think that just because something is wet, then it is clean. The public health workers also taught
patients that when mothers in villages are giving birth, whoever is assisting the birth must
maintain sterility. It is vitally necessary that whatever is used to cut the umbilical cord must be
cleaned properly beforehand.
The Indonesian population, especially in the less developed areas, is very animistic –
believing in spirits and the supernatural. Many times there was a witch doctor serving the
community also. Often families would give their children names, such as bowel gas or bird
poop, so that spirits will not disturb their children. Once the children were older and more likely
to survive, they would rename their children.
Reflections and Impact
There are many seasons of life, and each brings encounters with unique challenges and
joys, shaping us as we embark upon the next season.
So the question is not „Does my story reflect my past accurately?‟ as if I were holding a
mirror to my past. Rather I must ask „What are the consequences that my story
produces? What kind of person does it shape me into? What new possibilities does it
introduce for living my life?‟ The crucial issues are what narratives do, what
consequences they have, and to what uses they can be put. These consequences often
precede rather than follow the story because they are enmeshed in the act of telling (Ellis,
& Bochner, 2000, p. 746).
In an effort to change the world, I discovered that all the while, I was changing as well. I
knew I was changing into a different person the first time I navigated my way through an airport
alone. I knew it the first time I responded to a question in a foreign language. I knew it the first
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time I called my apartment in another country “home.” And I knew it when leaving that country
turned out to be so painful. I was different. When I left Ohio, a friend wrote me a note that said,
“Whatever you feel is normal. It is not a sign that you should have stayed home, or you are not
cut out for missions.” It went on to outline the different phases of culture shock. In an effort to
grasp at a sense of stability, I would try to gauge myself as to where I was along that continuum
during the time I was there. Some days were hard, and some days were easy - but each of them
important. How was I to then live? The question began to haunt me before I even left Indonesia.
I had been faced with life directing questions before and probably would again in the future.
What would be different? Who am I to become?
I have heard that life is all about expectations. But the problem was that in setting out, I
was expecting the unexpected. When I started the journey, I felt like a blank slate because I had
no idea what I was in for, but my eyes were wide open to take in everything. Looking back, I am
actually glad for that because it made everything that came my way a uniquely good experience
and kept me from being disappointed. I knew I would see a healthcare system very different
than that found in America. I knew I would see first-hand the diseases and the health care
experiences of Indonesians. I knew I would be caught off guard and grossed out. But I also had
hopes to become a nurse who could see the world through more than just the lens with which I
had grown up. I hoped to move beyond my current worldview and to open the windows of a
much larger and diverse awareness of the world. In doing so, I hoped to become a nurse better
equipped to serve and change the world.
Nursing theorist Madeleine Leininger studied and developed the area of transcultural
nursing and formulated the Culture Care Theory of Diversity and Universality. However, I had
studied this theory before the mission, the theory became particularly relevant when I thought
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about my work on this mission. Leininger considered the various segments of a culture from a
holistic perspective and describes their effects onto health practices and beliefs. This allows for
the further analysis of how best to care for patients (Alligood, & Tomey, 2010).
Leininger developed this theory into a framework known as the sunrise model. This
model gives a holistic picture of how the influences in one‟s life affect the delivery of nursing
care. These influences include one‟s cultural worldview. The model depicts other influences,
such as technological factors, religious and philosophical factors, cultural values and beliefs and
lifeways, political and legal factors, economic factors, and educational factors (Alligood, &
Tomey, 2010). To blindly assume that all cultures are the same or that all stereotypes of cultures
are accurate hinder effective practice. To simply assume that one is free of cultural bias and
therefore able to transculturally care for a patient also hinders effective practice. Culture is
always involved, whether it is the care giver‟s culture, the patient‟s culture, or a combination of
both. In order to effectively implement transcultural care, one needs to be acutely aware of how
one‟s own culture affects current care practices. Also necessary is an examination of the culture
being investigated. This is often done through qualitative research, although it may also be
achieved through quantitative means. But in order to specifically understand persons‟ cultural
influences to direct effective care, one must understand their way of life and its influences on
perception of health and well being. (Alligood, & Tomey, 2010). Amidst the knowledge that I
was personally changing, I was trying to get an accurate view of myself as compared to the
culture of which I suddenly became a part. I would constantly define the two, separate them,
analyze them, and eventually work with and through both of them to give the best care to the
patients.
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I can honestly say that I never really knew what loneliness was until the summer of 2010.
Being away from everyone I was close with and having to make all new friends, most of them
whose first language is not English posed quite a personal challenge for me. At the same time, I
grew in spiritual depth as never before. I came face to face with the religion I claimed to believe.
When things were difficult, I had two options. I could either run to or run away from all I
claimed to believe. I would say that there is nothing more important in life to me than the
Gospel – the message of Jesus Christ coming as a perfect substitute for the punishment of men‟s
sins in order to make us right with God. That was what Indonesia was about for me. It was a
meshing of two things that I was so passionate about – nursing and the Gospel. Someone once
told me that the worth of something is seen in what you are willing to sacrifice or give up for it.
No one was forcing me to go to another country. My heart ached to take those two things I loved
to places that did not have access to either, but living that reality was not without sacrifices. For
me, I actually wanted to forego normal food, clothes, language, and all things familiar because of
the greater value of something else. After about five weeks, the excitement of living without all
those things definitely began to wear off. But that‟s what I wanted. I wanted to see how I would
handle it after that point. I wanted to see if I could make it.
Because life in the jungle was such a drastically different world than the one I was
used to, at first I had to keep reminding myself that I was not in a cabin in the woods at an old
summer camp in my past. As our minds try to make sense of what is happening, it seeks to grasp
at the past to relate and make sense of everything. But there was nothing in my past that I could
relate to what I was experiencing. Some days I was acutely aware that I was out of my element.
I was still a nursing student, so there were a lot of things I could not do. At the same time, there
were also a lot of things I was not able to do simply because of the communication barrier.
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Many times I would have to simply take the role of an observer even though I so much wanted to
be a participant. The one skill I perfected beyond any other while there was taking manual blood
pressure readings. This was the simplest task for me to do because I was able to count in
Indonesian and because very little communication was necessary. At times I felt empowered by
even my limited ability to help. Other times I felt completely useless, but I would remind myself
that this was a small stepping stone to a greater end. This was a taste of what could be.
So on the days that I felt lonely or inadequate or tired, I would tell myself that Jesus
Christ, my Savior and Lord, was in Himself the source of everything I needed. In America, it is
easy not to experience those “needs.” As a Christian back home, I would say that I relied on the
Lord, but there are so many other things to rely on also – my bank account, my family members,
my country‟s sanitation laws, etc. Alone in the middle of the jungle, I learned a reliance on the
Lord that I never experienced anywhere else. When I ate food I did not know the source of, I
would pray for the Lord‟s protection over my health. When I was caring for a patient and felt
absolutely helpless and bounded by my inadequate access to modern healthcare means, I would
pray for the Lord to work when I could not. When I was tired and lonely, I would pray for
renewed strength and a satisfying sweetness of His presence with me. And in all things, my faith
grew as I saw the Lord work.
Occasionally, the answer to those prayers seemed bitter, but through that, I continued to
grow. I saw that though God is out for His own glory and my good, sometimes, that “good” is
not always an easy road. Sometimes, it is only through trying times that growth is most
abundant. The seemingly easiest path is not always the best. Because life is about the journey
and not a rush to the finish, every bump in the road is an important one, a shaping one. I knew
before I left that what I would experience would shape the way I viewed and pursued my future
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career. I knew that after seeing the poor, I would never again be content with just caring for
those able to afford the highest quality healthcare. When I came face to face with poverty, it is
hard for my heart not to be moved. Whether it was a nursing mindset or an American mindset or
a human mindset, my mind jumped to the question, “What can I do? How can we get these
people more of what they need?” But when those thoughts are followed logically to their
conclusions, the flaws are seen.
There is certainly a great need for healthcare improvements in developing countries, but
with such a large scale problem, how does one even begin to think about addressing it?
Certainly it cannot simply be a matter of sending money, for unless properly educated healthcare
providers and recipients are in place, the finances will have no lasting impact. It also cannot
simply be a matter of sending personnel as one would simply float a nurse to a different floor of
a hospital. Knowledge about different diseases, current indigenous or traditional healthcare
providers, as well as mindset of a culture of poverty, will affect workers headed to different
countries. Necessary steps must occur before impact can be maximized. It is important to assess
a country‟s current accessibility, affordability, availability of care, as well as the acceptance of
the traditional “western” mindset of medicine. Sometimes, the American healthcare model will
work well and sometimes, another model is needed. One has to consider whether or not it is best
to make a community dependent upon an outside source that may or may not be sustainable long
term. I would venture to say that the people‟s great need is not for nicer living conditions to be
given to them, though that would be good and helpful. More so, their need is for empowerment
in community development. Their need is to be equipped to be able to care for themselves and
achieve the ends that they deem of value, and not explicitly what outsiders deem valuable. Their
need is perhaps the cultivation of self-sustaining empowerment. The impact of foreign doctors
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and nurses on a society will be of value within certain bounds. Those bounds are a community‟s
ability to see the importance of such an act, as well as their acceptance of it. Unless the
community is a willing participant both on the front end through prevention and the back end of
disease management, the lasting effects in a community will be minimal.
My time serving with the public health division (PKMD) of the hospital helped shape me
in this regard. It also spurred a passion for public health which I am sure will come through in
my future pursuits of nursing. PKMD have such a focus on education, e.g., what to do if your
child has diarrhea, how to get proper nutrition, how to make sure instruments are clean before
performing any medical procedure. Often, it is assumed that if something is wet, then it is clean,
but the staff of PKMD must educate past this common belief.
So how do I now live in light of all I have seen and experienced? I have now developed
the habit of reading the international news. I want to know what is happening and get excited
when Indonesia is in the news, and I know the area. I get excited about different languages and
cultures. And in processing through all those things as well as looking into my own future, I see
the need not to just donate financially – though this is a worthwhile endeavor. I also began to
realize a desire growing within myself to be a part of that empowering change. I have to be a
part of this in the future. I think about it. I dream about it. I am drawn to it. How soon and
what it will look like in still unknown to me, but I am currently running toward that end. The
decisions I am making that affect my future are being made with that end in mind. So who am I
becoming? I dearly wish I knew the answer. But I am watching myself change and am excited
for the future. Indonesia will not be the last international stop in my journey. It only fanned the
flame for the future. Before graduating, I will be spending some time in Bolivia providing
medical/dental assistance on an outreach trip which I trust will be a further shaping experience. I
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have lived my life in a cultural reality that was similar but very different from the one
I engaged in during the summer of 2010. But through the exploration of the two
cultural realities, my personal and professional norms became better defined, were
challenged and enriched, and were further shaped allowing me to engage
transculturally in nursing care.
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28
References
A l l i g o o d , M . , & T o m e y, A . ( 2 0 1 0 ) . N u r s i n g t h e o r i s t s a n d t h e i r w o r k .
M a r y l a n d H e i g h t s, M O : M o sb y E l se v i e r.
B et h esd a me d i ca l a n d so ci a l mi n i st r i es . ( 2 0 1 0 , Au g u st 2 7 ) .
R e t r i e v e d f r o m h t t p : / / w w w. b o r n e o h o s p i t a l . c o m /
Bunge, F. (n.d.). Country studies Indonesia: health. Library of Congress: Federal research
division. Retrieved on 2010, March 31, from http://memory.loc.gov/cgibin/query/r?frd/cstdy:@field(DOCID+id0078)
Center for Disease Control . (2010, February 18). Traveler's Health: Indonesia
Retrieved on 2010 March 31, from
http://wwwnc.cdc.gov/travel/destinations/indonesia.aspx#diseases
CIA - The World Factbook Indonesia . (2010, February 17). Retrieved from
https://www.cia.gov/library/publications/the -world-factbook/geos/id.html
Is the WHO the author? Is Communicable diseases: Indonesia. The name of the publication?
(2010). World health organization. Retrieved (2010, March 31) from
http://www.who.or.id/eng/ourworks.asp?id=ow1#3
Ellis, C., & Bochner, A. (2000). Autoethnography, personal narrative, reflexivity. In N. D.
Denzin & Y. L. Lincoln (Eds.), Handbook of qualitative research (pp.733-762).
Thou sand Oaks, CA: Sage Publications.
A MISSION TO INDONESIA
Hatt,L., Stanton, C., Mak owiecka, K., Adisasmita, A., & Achadi, E., Ronamans, C.
(2007). Did the strategy of skilled attendance at birth reach the poor in
Indonesia? Bulletin of the World Health Organization , 85(10), Retrieved
from
http://search.ebscohost.com/login.aspx?direct=tru e&db=rzh&AN= 200970338
4&site= ehost -live
Madarina, A. (2009). Adoption of the WHO Child Growth Standards to classify Indonesian
children under 2 years of age according to nutrition status: stronger indication for
nutritional intervention. Food & Nutrition Bulletin, 30(3), 254-259. Retrieved from
CINAHL Plus with Full Text database.
Ng, N., Stenlu nd, H., Bonita, R., Hakimi, M., Wall, S., & Weinehall, L. (2006).
Preventable risk factors for noncommu nicable diseases in rural indonesia:
prevalence study using who steps approach. Bulletin o f the World He alth
Organization, 84(4), Retrieved from
http://search.ebscohost.com/login.aspx?direct=tru e&db=rzh&AN= 200917603
9&site= ehost -live
Ng, N., Van Minh, H., Tesfaye, F., Bonita, R., Byass, P., Stenlund, H., et al. (2006). Combining
risk factors and demographic surveillance: potentials of WHO STEPS and INDEPTH
methodologies for assessing epidemiological transition. Scandinavian Journal of Public
Health, 34(2), 199-208. Retrieved from CINAHL Plus with Full Text database.
Ochiai, R., Acosta, C., Danovaro-Holliday, M., Bhattacharya, S., Agtini, M., Bhutta, Z., et al.
(2008). A study of typhoid fever in five Asian countries: disease burden and implications
29
A MISSION TO INDONESIA
for controls. Bulletin of the World Health Organization, 86(4), 260-268. Retrieved from
CINAHL Plus with Full Text database.
Panning, M., Grywna, K., van Esbroeck, M., Emmerich, P., & Drosten, C. (2008). Chikungunya
fever in travelers returning to Europe from the Indian Ocean region, 2006. Emerging
Infectious Diseases, 14(3), 416-422. Retrieved from CINAHL Plus with Full Text
database.
Ronsmans, C., Scott, S., Qomariyah, S., Achadi, E., Braunholtz, D., Marshall, T., et al. (2009).
Professional assistance during birth and maternal mortality in two Indonesian districts.
Bulletin of the World Health Organization, 87(6), 416-423. Retrieved from CINAHL
Plus with Full Text database.
Rudan, I., Boschi -Pinto, C., Biloglav, Z., Mulholland, K., & Campbell, H. (2008).
Epidemiology and etiology of childhood pneumonia. Bulletin of th e World
Health Organization, 86(5), Retrieved from
http://search.ebscohost.com/login.aspx?direct=tru e&db=rzh&AN= 200993374
7&site= ehost -live
Suriadi, Sanada, H., Sugama, J., Kitagawa, A., Thigpen, B., Kinosita, S., & Murayama, S.
(2007). Risk factors in the development of pressure ulcers in an intensive care unit in
Pontianak, Indonesia. International Wound Journal, 4(3), 208-215. Retrieved from
CINAHL Plus with Full Text database.
Saving mothers lives in rural indonesia. (2007). Bulletin of the world health organization,
85(10), Retrieved from http://www.who.int/bulletin/volumes/85/10/07031007/en/index.html
30
A MISSION TO INDONESIA
Schoemaker, J. (2005). Contraceptive use among the poor in Indonesia. International Family
Planning Perspectives, 31(3), 106-114. Retrieved from CINAHL Plus with Full Text
database.
World Health Organization Regional Office for South-East Asia. (2005, August 30). Child
Health and Development Retrieved from
http://www.searo.who.int/EN/Section13/Section37/Section376.htm
World Health Organization (2010, March 22). Indonesia: Health profile. Retrieved from
http://www.ino.searo.who.int/EN/Section3_24.htm
World Health Organization (2007, August 6). South-east Asia: Health resources. Retrieved from
http://www.searo.who.int/EN/Section313/Section1520_6826.htm
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