The first AIDS case was detected in Indonesia in 1987 in Denpasar, Bali, and then at the following years the pattern following the same pattern like other sexual transmitted disease just like in most other countries. However, especially since 2001, injecting drug users are increasingly being reported with HIV infection, and then there was a high annual increase of HIV infection reported from injecting drug users in Indonesia: from 146 cases in 2003 to 1183 cases in 2004 (Ford, Wirawan, Sumantera, Sawitri, & Stahre, 2004). The latest report currently mentioned 50.1% of all reported cases of HIV/AIDS in Indonesia are injecting drug users. (Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006).

The following figure shows the increasing number of new cases of HIV infection found in Indonesia until 2006.

(Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006)
From that figure we can see that the trend of new cases for HIV infections in Indonesia is increasing (although there is a sudden decrease of new cases reported in 2003). Nevertheless, the epidemic of HIV infections in Indonesia can be considered low since it is estimated that there are about 170.000 people living with HIV/AIDS in Indonesia in 2005 out of more than 250 million people in Indonesia (Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006).

From the data in Indonesian Ministry of Health (2006), we can also see that 82% of people living with HIV/AIDS is men, that accounts for over 6000 cases. Also, we can see that in Indonesia, HIV infections are concentrated within specific groups with specific behaviour in the population. From the data in 2006, about 50.3% of HIV infection cases are from injecting drug users, 40.3% from unprotected heterosexual sex, while 4.2% from unprotected homosexual sex. Nonetheless, at the beginning, most HIV prevention in Indonesia was still targeted to prevent infections from unprotected heterosexual sex, with the acronym of ABC: abstinence, be faithful and condom.

While this condition is obviously different from developed countries such as Australia and United States, where the epidemic is found high in men who have sex with men (UNAIDS, 2007), there are several studies that shows the HIV infections epidemic men who have sex with men communities in developing Asian countries (Pisani et al., 2004; Toole et al., 2006; Wong, Zhang, Wu, Kong, & Ling, 2006).

In the study done by Pisani (2004) , they found that compare to other most at risk groups, the transgender waria is showing a concerning increase in HIV infection prevalence.  They found out of the 241 waria involved with the research, 53 were tested positive for HIV infections, a prevalence of 22.0%. This was significantly much higher than the other high risk group involved with the research, the male sex workers and the self identified men who have sex with men. The data from the government surveillance in Jakarta area in 2002 also shows 21.7% as the prevalence of HIV infections in waria community (Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006). In another research done by Joesoef, et al. (2003), although they did not look the rate of HIV infections, they showed a high rate of sexually transmitted disease, 43.6 percent for syphilis serologic reactivity of all warias involved with the research in Jakarta.In this reasearch also, they found that the rate for gonorrheae infection is 15.9 percent and for chlamydia infection is 6.2 percent.

Looking at this alarming rate of HIV infections and also other sexually transmitted infections within this group, we should consider the waria as an important aspect in HIV prevention in Indonesia. Especially, as we would describe it later, if we look that they have a vast range of sexual networks between them and their clients.

Waria
The term of men who have sex with men is an umbrella phrase to describe behaviour of gay men, bisexual men, transgender, and even self-identified heterosexual men who engage sex with other men (Young & Meyer, 2005). However, this phrase does not explain any specificity and any social and cultural identities, as in transgender waria, which is a specific term in Indonesia. (Boellstorff, 2004; Khan & Khan, 2006; Pathela, Blank, Sell, & Schillinger, 2006). Regarding HIV infections, there are many aspects of HIV infections which can be described differently within the umbrella term of ‘men who have sex with men”. There are bisexual and also self-identified heterosexual men who engage sex with other men which can be an effective way for HIV transmission. Nonetheless, this term of men who have sex with men are widely used in literature (Baral, Sifakis, Cleghorn, & Beyrer, 2007), although, it seems this term is started to lose the trend. Although men who have sex with men already recognised as a group with high risk behaviour which can transmit HIV infections, still, there are not many study focused in this group in many countries, including developing countries. However, in general, all the groups within the umbrella term of men who have sex with men, including waria, still face stigma and discrimination.

In Indonesia especially in Jakarta, transgender, often called waria, have the highest prevalence of HIV infection among other group within the umbrella term of men who have sex with men (Pisani et al., 2004). Not to mention also, that there are different risks between oral sex, anal sex, and even between insertive and receptive anal sex, which the waria is capable to perform that to their client.

As a most at risk groups of HIV infections, waria is also a marginalised community, mostly shunned by “normal” people because of their preference. In Indonesian legal term, however, currently we can say that it is not illegal to have a consensual same sex act between persons unless underage (International Lesbian and Gay Association, 2007). Nevertheless, each region in Indonesia can have different setting, and local rules have to be recognised. Cosmopolitan area such as Jakarta and Surabaya can tolerate some of this group within their community, but several region within Indonesia, especially with strict religion based regional law, due to the decentralisation system of Indonesia, like Aceh region with their Sharia law, made this subpopulation harder to reach, even though they exist. Overall, however, waria is the most prominent group which to some extent, have been recognised and accepted in Indonesia. Some prominent people in the entertainment industry are warias.

According to the Ministry of Health report, waria is a transvestite who usually also a sex workers, although not all of them, which are, more or less, culturally accepted. They are part of the commercial sex outlook in Indonesia. They usually provide oral and/or anal sexual service to other men. Interestingly, most male clients of waria consider themselves as heterosexual. Their cruising places are usually roadsides and public parks. It is estimated that there are between 7,800 and 14,700 of waria sex workers all over in Indonesia (Ministry of Health of the Republic of Indonesia, 2003). Because low level of condom use in an unprotected anal sex and they can have multiple sexual partner, making them vulnerable to HIV infections, even from Pisani et al. (2004) study it shows that among men who have sex with men in Jakarta, this group has the highest prevalence of HIV infection.

Until now, there still a few research done for HIV infections and waria in Indonesia. One of the recent research being done is from Pisani et al. (2004). This research was done in early 2002 where they identify many subpopulations of men who have sex with men in Jakarta, Indonesia. These subpopulations include transgender warias, male sex workers, their clients, and other men who have sex with men disregarding their sexual preferences.

Waria do not have sex with one another, and they sell sex to their clients who frequently are men who considered themselves as heterosexual, are married and have other female partners. It is estimated that there are about 173,000 to 340,000 clients of waria, according to Indonesian Ministry of Health report (2003).

While many warias are sex workers who seek for sex in public places, some of them keep a regular partner, which they consider as a husband. Unprotected sexual relationship between warias and their regular partner is high, making them vulnerable also to HIV infections. Estimation for this high risk subgroup is between 2,100 and 4,000 regular partners in Indonesia.

Looking at these two type of clients we can see that the impact of a waria in their sexual network through their client is high. A waria who has a  regular partner is still able to practice as a sex worker, where the client is a heterosexual men. This client then, can also be married, having a regular sex partner, or also still using services from female sex workers or even male sex workers. If one of the people within this sexual web get infected with HIV, it can be easily transmitted to others. Not surprising that we have a high prevalence of HIV infections in this group.

Nevertheless, several program already started to prevent the spread of HIV infections from this group. International donors and non governmental organisation, together with the government, especially the Ministry of Health are already targeting this group in their HIV prevention program. One of the examples is described below, the Aksi Stop AIDS program, which will end by the end of September 2008.

The Aksi Stop AIDS Program
One of the examples of HIV prevention program being done in Indonesia is the Aksi Stop AIDS program. This program is managed by Family Health International since October 2005. This program is funded from donors such as the USAID (United States Agency for International Development) and also The Indonesian Partnership Fund for HIV/AIDS. Currently the program is in its final year and will end in September 30th, 2008. According to their work plan (Family Health International, 2007) their goals are:

1. reduced incidence of STI/HIV/AIDS in most-at-risk groups (MARGs) thereby helping to prevent a generalize epidemic and
2. reduced incidence of STI/HIV/AIDS within the general population of Papua.

We can see from their goals that they are trying to prevent HIV infections epidemic by focusing on two groups, one based on geographic region: Papua, where the HIV infection prevalence is the second highest in Indonesia; and the other is targeted on most-at-risk groups, including waria.
About 60% of their program implementation is targeted toward these most-at-risk groups in seven provinces in Indonesia: Papua, North Sumatra, Riau islands, Jakarta, West Java, Central Java, and East Java. They recognise the importance of involvement of involvement of target populations, as mentioned in their work plan (Family Health International, 2007):

Realizing the crucial role each target population have in determining their own behaviors, FHI (Family Health International) will increase its emphasis on peer led interventions and peer education during Year Three. This will help ensure that activities address the specific needs and aspirations of each individual target group, as well as help empower and clarify responsibility for personal action and establish safer social norms within these often marginalize groups.

Of all the parts of the program, we will be discussing on the implementation of the program in the waria sub groups. In term of the waria sub-group, the program is focused on reducing the numbers of sex partners and also introducing and supporting several preventive behaviours, such as distributing and encouraging the use of condom and lubricant. The program also is encouraging people to use the Voluntary Counselling and Testing (VCT) services using behavioural change communication. Other messages include safer sex practice. These messages are broadcasted using SMS messages, internet, email and hotline service, publications, events and even outreaching in places where the warias used to gather, such as in the park. Several counsellors are also working with the waria communities in promoting positive prevention, partner notification and counselling in psychosexual matters (Family Health International, 2007).

In analysing this program, we can clearly see that this program is a start up point for improving the prevention of HIV infections in waria communities. In three years, the program managed to improve the network of waria reached with this program from 7,635 people in the first year up to 14,807 in the second year, and it is estimated that a total of 15,038 waria participants will be involved with this program by the end of the third year (Family Health International, 2007).

Nevertheless, we could see some improvement of this program in the future, especially when the actual program stops and thus depends on the initiatives of Indonesian to improve their prevention measurement to HIV infections. Sustainability of the program should be emphasised and we should see this in the capacity building program for the counsellors and also for the waria communities themselves. If this program will be successful, the core, empowered counsellors and waria can then also improve the condition in other regions in Indonesia, which the original program hasn’t covered up yet.

Other critique to this program is that this program has not mentioned specifically regarding the waria’s client. Although they did put overall client as the target of the project (Family Health International, 2007), yet they are much more focused on female sex worker’s client rather than waria’s client. The waria’s client is also important since as mentioned above, waria do not have sex with one another, and they sell sex to their clients who frequently are men who considered themselves as heterosexual, which are married and have other female partners.  Not to mention the regular partner of waria which they consider as a husband (Ministry of Health of the Republic of Indonesia, 2003). However, one important difference, waria sex workers have better negotiating skill compared to the female sex workers, since they have a male body (Boellstorff, May 2004). Therefore, an empowerment to waria, where they can negotiate a safer sex with their partner whether their regular partner or their client as a commercial sex worker, is an important thing in the prevention of the HIV infection in this group.

Suggestions
Strengthen HIV prevention in waria communities
From the above example we can see that there is an active of sexual partnership between waria and their clients, either as a commercial sex worker or from their life partner. Therefore, this will increase the likelihood of unprotected anal sex between the waria and their client. As most waria have low level of education, older age and survivor of social discrimination, most of them depend on commercial sex work (Riono & Praptoraharjo, 2008). Therefore it is important to recognise that both the waria and their sexual partner are important in the prevention of HIV infections. In term of the sexual networks, Riono and Praptoharjo (2008)mentioned that waria is not isolated with the other since they and their clients consider themselves as heterosexual, making them also open for other sexual networks, including other female or male sex workers, not excluding the injecting drug users. Therefore, it is important to improve HIV prevention measures in all aspect of this vast sexual network.

Involving waria and their client in the HIV infection prevention are also important to improve the waria community itself. As we know, the waria community is considered a low class community, where most of the time are shunned from the “normal” people (Boellstorff, 2004). Involving waria in the health program, not only as a participant, but also in deciding what is important for their community. To know what they think of themselves and decide for their own is a step for equal rights for waria within Indonesian people.

Strengthen HIV prevention in waria’s clients
Finally, we should also improve HIV prevention strategies for the waria client. Improving the negotiating skill of the waria will prevent unsafe sex. Also promoting behavioural change in sex, using condom and lubrication, directly to the client will develop a better protection for the community against HIV infection.

This group is rarely considered, nevertheless their number is important. They are considered as the key bridge between waria and the community. These men are considering themselves to be heterosexual. Therefore, we should also aim the prevention program for them.

Several preventive methods can be used here, particularly based on the program for the client of female sex workers (Family Health International, 2007).  For this type of group, we should encourage them to adopt a less risky behaviour. This comprised of trying to reduce the number of partner, and also consistent condom and lubrication use. This simple step should be taken to prevent further spread of the virus in the waria web of sexual network. Several groups are identified in this group, soldiers, construction workers, businessmen, civil servants, private workers, basically those who buy sex from female sex workers can also buy sex from waria, since these groups of men are considering themselves as heterosexual. For this, another outreach program just like those set up for the waria groups, should also be established. This outreach program can be established in workplace settings. However, there are some obstacles for recognising these groups since not everyone wants to be associated having a relationship with commercial sex workers, especially from waria. Therefore, I suggest that we should combine this campaign for targeting the client for both, either as a client of female sex workers or a client of waria sex workers. By combining both, where actually the same group of heterosexual men, in the same promoting campaign of behavioural change, we could prevent the spread of HIV infection in the heterosexual men, ether they as a client of waria, or as a client of female sex workers.

Improve Voluntary Counselling and Testing Clinic
Another improvement to the prevention HIV infection program for the waria community is the voluntary counselling and testing clinic. Waria have their own psychosexual problem, and we need to address this need. We should train the counsellor for HIV prevention for issues regarding waria. We should also promoting the voluntary counselling and testing clinic to the waria community. Setting up the voluntary counselling and testing clinic in places near where waria gather is one solution. In this clinic, waria can access HIV and other sexually transmitted diseases testing following a counselling. In the counselling sessions, a waria could discuss their sexual and also health issues. In this clinic, a waria could also have access for safe sex materials, such as condom and lubrication gel.

A better health service access for waria will improve their awareness for their own health. It is important for waria to recognise the importance of their role, therefore, by making sure their health, such as by regular testing with the clinic, we can make sure that HIV infection can be prevented within the community.

Improve waria rights in the society
Perhaps I consider this as a long term goal, but the main issue with HIV infections is the stigma facing the waria communities. With the stigma attached to the waria community, it is hard to improve their own health. Therefore, it is important for them to be recognised as a part of the society, where they can contribute and participate in the society. By eliminating the stigma of waria, we can make sure that the health status of all members of the society can be improved. To remove the stigma of waria, the involvement of waria in the community is important, making them not as a secluded groups, but part of the society.

Conclusions
There are many aspects of waria regarding their role in the prevention of HIV infections. Although they are under the term of men who have sex with men, they never consider themselves to be homosexual, but rather as heterosexual. The sexual network of a waria is vast, not only on their client as a commercial sex worker, which is a heterosexual man who could have access to other most at risk people, but also the regular partner of waria. This made waria prone to HIV infections, where this was proved with the recent research which shows a significantly high prevalence of HIV infections compared to other most at risk groups, except the injecting drug users.

While strategies to prevent HIV infections are being implemented toward female sex workers and also injecting drug users, we must also consider starting a preventive action for this groups, considering their vulnerabilities. Empowering the waria communities with program where they can encourage for safe sex, using condom and lubrication and negotiate with their client as a preventive strategy against HIV infections should be the main aim of a development program for them. They also should be given more role in the participation and especially in the decision making regarding their own community, making them have able to control themselves.

Other prevention strategies should also focused on providing a better health service access for waria, making them aware of their own health status. Finally, it is important to recognise the rights of waria, considering the stigma they got.

References

Baral, S., Sifakis, F., Cleghorn, F., & Beyrer, C. (2007). Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review. PLoS Medicine, 4(12), e339.

Boellstorff, T. (2004). Playing Back the Nation: Waria, Indonesian Transvestites. Cultural Anthropology, 19(2), 159.

Boellstorff, T. (May 2004). Playing Back the Nation: Waria, Indonesian Transvestites. Cultural Anthropology, 19(2), 159.

Family Health International. (2007). Aksi Stop AIDS Program, Year Three Workplan [Electronic Version]. Retrieved 1 September 2008 from http://www.popline.org/docs/1781/323687.html.

Ford, K., Wirawan, D. N., Sumantera, G. M., Sawitri, A. A. S., & Stahre, M. (2004). Voluntary HIV Testing, Disclosure, and Stigma Among Injection Drug Users in Bali, Indonesia. AIDS Education and Prevention, 16(6), 487.

International Lesbian and Gay Association. (2007). State-sponsored homophobia: A world survey of laws prohibiting same sex activity between consenting adults. [Electronic Version]. Retrieved 15 July 2008 from http://www.ilga.org/statehomophobia/State_sponsored_homophobia_ILGA_07.pdf.

Joesoef, M. R., Gultom, M., Irana, I. D., Lewis, J. S., & et al. (2003). High rates of sexually transmitted diseases among male transvestites in Jakarta, Indonesia. International Journal of STD & AIDS, 14(9), 609.

Khan, S. O. B. E., & Khan, O. A. M. D. M. H. S. (2006). The Trouble with MSM. American Journal of Public Health Family Health Across The Life Course, 96(5), 765-766.

Ministry of Health of the Republic of Indonesia. (2003). National Estimates of Adult HIV Infection, Indonesia 2002: Workshop Report. Jakarta: Ministry of Health of the Republic of Indonesia.

Pathela, P. D. M. P. H., Blank, S. M. D. M. P. H., Sell, R. L. S. M. S., & Schillinger, J. A. M. D. M. (2006). The Importance of Both Sexual Behavior and Identity. American Journal of Public Health Family Health Across The Life Course, 96(5), 765 <762>.

Pisani, E., Girault, P., Gultom, M., Sukartini, N., Kumalawati, J., Jazan, S., et al. (2004). HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia. Sex Transm Infect, 80(6), 536-540.

Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia. (2006). Situasi HIV-AIDS di Indonesia Tahun 1987 – 2006. Retrieved 15 July 2008, from http://depkes.go.id/downloads/publikasi/Situasi%20HIV-AIDS%202006.pdf.

Riono, P., & Praptoraharjo, I. (2008). SEXUAL BEHAVIOR AMONG WARIA IN 3 INDONESIAN CITIES. Paper presented at the XVII International AIDS Conference. Retrieved 5 September 2008, from http://www.aids2008.org/abstract.aspx?elementId=200713054.

Toole, M. J., Coghlan, B., Xeuatvongsa, A., Holmes, W. R., Pheualavong, S., & Chanlivong, N. (2006). Understanding male sexual behaviour in planning HIV prevention programmes: lessons from Laos, a low prevalence country. Sex Transm Infect, 82(2), 135-138.

UNAIDS. (2007). AIDS Epidemic Update December 2007 [Electronic Version]. Retrieved 15 July 2008 from http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf.

Wong, W. C. W., Zhang, J., Wu, S. C., Kong, T. S. K., & Ling, D. C. Y. (2006). The HIV related risks among men having sex with men in rural Yunnan, China: a qualitative study. Sex Transm Infect, 82(2), 127-130.

Young, R. M. P., & Meyer, I. H. P. (2005). The Trouble With “MSM” and “WSW”: Erasure of the Sexual-Minority Person in Public Health Discourse. American Journal of Public Health ETHICS AND RIGHTS, 95(7), 1144-1149.

Laporan Analisa Kadar Besi dan Mangan
Air produksi PDAM Kota Balikpapan untuk semua IPA memiliki kadar besi yang tinggi. IPA yang paling tinggi kadar besinya yaitu IPA IPA Gunung, IPA Batu Ampar, IPA Teritip dan IPA Gunung Tembak. Data di atas menunjukkan bahwa selama tahun 2009 – 2010, tingkat kadar besi maksimum terjadi pada Mei 2009 dengan nilai 13,68 dan terendah terjadi pada Mei 2010 dengan nilai 0,00.
Air yang diproduksi oleh PDAM Kota Balikpapan selain besi juga mengandung mangan. Hal ini terjadi pada semua IPA di PDAM Kota Balikpapan mengandung Mangan kecuali IPA Karang Joang. Data di atas menunjukkan bahwa selama Tahun 2009 – 2010, tingkat kadarMangan (Mn) maksimum terjadi pada Desember 2009 dengan nilai 0,507 dan terendah terjadi pada Maret 2010 dengan nilai 0,00.

Pemeriksaan pada 28 Oktober 2010 diketahui bahwa kandungan zat besi (Fe) pada IPA Km 8, Perum WIKA dan Karang Bugis melebihi standar, yaitu masing-masing 0,34 mg/L, 0,53 mg/L,dan 0,75mg/L sementara standarnya 0,3 mg/L. Kadar Mangan (Mn) yangtidak memenuhi syarat adalah sampel air di IPA Kampung Damai yaitu 0,19melebihi dari standar yang telah ditetapkan yaitu 0,1 Mg/L.

Untuk itu, wartawan Tribun Kaltim melakukan interview via email terkait hal ini dan hasilnya tercantum di Tribun Kaltim Edisi 17 Juli 2011.
Berikut ini kutipan email interview yang menurut saya lebih terstruktur dibanding artikel yang termuat.

Apakah kandungan besi dan mangan dibutuhkan manusia?
Zat besi dan mangan termasuk mineral yang dibutuhkan oleh manusia.

Kalau iya untuk apa?
Zat besi diperlukan dalam banyak fungsi tubuh, salah satunya diperlukan untuk pembentukan hemoglobin dalam sel darah merah
Mangan diperlukan dalam pembentukan beberapa enzim yang membantu proses metabolisme tubuh.

Berapa sebenarnya kandungan normal besi dan mangan yang dibutuhkan?
Kebutuhan tubuh akan zat besi bervariasi, bergantung usia, jenis kelamin, dan beberapa faktor tubuh lainnya, umumnya berkisar antara 10-50 mg/hari
Sedangkan untuk mangan, asupan kebutuhannya sebesar 0,06 mg per kilogram berat badan per hari, jadi bagi orang dengan berat badan 50 kg, membutuhkan 3 mg per hari

Bagaimana mengecek kandungan besi dan mangan dalam tubuh?
Untuk mengecek kandungan besi dan mangan dapat dilakukan pemeriksaan darah.

Apa yang terjadi kalau kekurangan dan kelebihan besi dan mangan? Penyakit apa saja yang bisa muncul?
Kekurangan besi mengakibatkan anemia alias kurang darah, merupakan penyakit yang masih cukup banyak ditemukan di Indonesia, dan ini berbahaya bagi wanita usia subur dan ibu hamil karena kedua kelompok ini mudah mengalami perdarahan.
Kekurangan mangan sangat jarang ditemukan.

Kelebihan besi juga jarang ditemukan karena mekanisme penyerapan besi di usus manusia sangat dibatasi oleh sistem tubuh manusia: kasus yang jarang ini kebanyakan karena penyakit keturunan.
Kelebihan mangan jarang ditemukan, umumnya terjadi pada pekerja industri yang menghirup debu mangan dalam jumlah besar (misalnya industri baja) dengan gejala berupa gangguan pada sistem syaraf, misalnya gangguan pada otot, mudah tersinggung, dan lain sebagainya.

Bagaimana pencegahan? Apa yang harus dilakukan untuk menormalkan?
Kekurangan besi diatasi dengan pemberian suplemen zat besi pada yang beresiko terkena anemia kekurangan zat besi (wanita usia subur dan ibu hamil).
Kelebihan besi dan mangan ditangani dengan pemberian golongan obat yang disebut chelation agent untuk mengikat logam yang berlebih dan mengeluarkannya dari dalam tubuh.

Apakah kalau besi dan mangan masuk lewat konsumsi air minum itu aman?
Zat besi dan mangan yang ada di air minum aman. Justru lebih banyak zat besi dan mangan yang dikonsumsi manusia melalui makanan dibanding melalui air minum.
Sebenarnya pengaruh kandungan kedua zat ini pada air minum terhadap kesehatan tubuh manusia tidak terlalu besar. Panduan kadar zat besi dan mangan yang ditentukan untuk air minum lebih ditujukan agar air minum lebih “tidak berasa” saat dikonsumsi, karena jika melebihi panduan kadar tersebut akan berpengaruh lebih pada rasa air minum (air akan memiliki rasa logam) dan jika digunakan untuk mencuci dapat menodai pakaian.

Berapa standar kandungan besi dan mangan yang normal dalam air yang kita minum?
Panduan untuk kualitas air minum dari World Health Organizaton (WHO) terbitan tahun 2006 menetapkan panduan kadar zat besi dalam air minum tidak lebih dari 0,3 mg/liter air dan panduan kadar mangan dalam air minum tidak lebih dari 0,4 mg/liter air. Seperti yang disebut di atas, kedua nilai ini lebih ditujukan agar air minum “tidak berasa” saat dikonsumsi.

Di Indonesia sendiri dinyatakan di Peraturan Pemerintah No.20 tahun 1990 tentang Pengendalian Pencemaran Air menetapkan untuk besi tidak lebih dari 0,3 mg/liter dan mangan tidak lebih dari 0,1 mg/liter air.

Apakah kandungan besi dan mangan akan berkurang atau bertambah ketika dimasak?
Tidak, karena mineral tidak mengalami perubahan saat dimasak. Mungkin saja ada tambahan dari logam bahan panci untuk memasak, namun umumnya tidak terlalu bermakna.

Bagaimana treatment terhadap air untuk menormalkan kandungan besi dan mangan?
Mungkin ahli teknik pengairan yang bisa menjawab hal ini lebih detil, namun umumnya dengan cara penyaringan, pengendapan dan aerasi air minum dapat menurunkan kadar zat besi dan mangan dalam air minum.

Proses akumulasi besi dan mangan dalam tubuh.
Berapa tahun kandungan besi dan mangan berlebih itu berdampak ke manusia?
Apakah ada periode akumulasi besi dan mangan. Misalnya per 5 tahun akumulasi, 10 tahun, 15 tahun?
Akumulasi zat besi dalam tubuh kemungkinannya kecil. Hal ini disebabkan proses penyerapan zat besi sendiri dalam tubuh sangat dibatasi oleh tubuh manusia. Akumulasi hanya terjadi pada beberapa jenis penyakit keturunan yang sangat jarang terjadi.
Akumulasi mangan juga jarang terjadi. Seperti yang disebut sebelumnya, keracunan mangan lebih sering terjadi pada orang yang menghirup debu mangan lewat saluran nafas.
Sedangkan penyerapannya zat mangan melalui saluran cerna oleh usus juga sangat dibatasi oleh sistem tubuh manusia. Selain itu tubuh manusia juga mampu mengeluarkan kelebihan mangan melalui liver.
Ada beberapa penelitian yang melaporkan keracunan mangan jangka panjang pada penduduk yang air minumnya melebihi berkali-kali lipat kadar yang dianjurkan WHO.
Namun belum ada penelitian yang melaporkan keracunan mangan pada penduduk yang air minumnya mengandung mangan mendekati kadar yang dianjurkan WHO.

Tentang hasil pemeriksaan kadar besi dan mangan di air PDAM Kota Balikpapan
Kalau melihat hasil  pemeriksaan tersebut, kesan saya adalah kadar besi dan mangan di PDAM Balikpapan berfluktuasi, dan kadang fluktuasinya menyebabkan kadar zat tersebut melampaui nilai ambang batas.
Jadi timbul pertanyaan apakah nilai yang melebihi ambang batas itu sering terjadi, atau hanya pada kondisi tertentu, kemarau misalnya?
Mungkin data yang diperlukan adalah nilai rata-rata (mean) dan nilai tengah (median) dari kadar kedua zat tersebut dari beberapa pengamatan yang ada untuk menilai apakah secara umum air PDAM Balikpapan sesuai dengan aturan ambang batas.
Oleh karena itu kesimpulan yang bisa saya berikan adalah dari sebagian sampel yang ada air PDAM Balikpapan tidak memenuhi syarat seperti yang ditetapkan WHO (2006) atau Permenkes (2010).

Apakah aman untuk dikonsumsi? Secara umum tidak ada masalah terhadap kesehatan tubuh manusia jika memang ingin mengkonsumsi air saat kondisi paling buruk dengan kadar besi 13,68 mg/l atau kadar mangan 0,507mg/l.
Dengan asumsi seseorang mengkonsumsi air 2 liter air perhari (berdasarkan panduan kebutuhan tubuh manusia), maka kemungkinan saat kondisi air paling buruk seseorang akan mengkonsumsi 27,36 mg besi dan 1,014 mg mangan per hari. Jumlah sebesar ini masih bisa ditolerir tubuh karena secara umum tubuh membutuhkan sekitar 10-50 mg besi per hari dan 3 mg mangan per hari.
(Sebagai perbandingan tablet tambah darah yang digunakan untuk mencegah anemia pada ibu hamil paling tidak mengandung 60 mg zat besi dan 1 ons kacang paling tidak mengandung 1,8 mg mangan.)
Kesimpulannya kadar zat besi dan mangan setinggi itu dalam air minum tidak memberikan pengaruh buruk terhadap kesehatan.

Namun patut dicatat air dengan kadar besi dan mangan setinggi itu akan membuat air berasa logam sehingga tidak layak untuk digunakan sebagai air minum (dan tidak memenuhi syarat yang ditetapkan WHO dan Permenkes).

Jadi singkatnya kadang kala airnya tidak layak namun tidak ada pengaruh buruk terhadap kesehatan. Untuk menyikapi hal ini, kita tidak perlu khawatir mengenai dampak air yang telah kita gunakan kepada kesehatan kita, namun kita tentu saja harus tetap berusaha agar kita mendapatkan air yang berkualitas (sesuai dengan panduan yang berlaku), baik dari pihak PDAM maupun konsumen, misalnya dengan menjaga kebersihan dan kesehatan lingkungan agar sumber air tidak tercemar.

Ada perbedaan standar antara kadar mangan dari PP No. 20/1990 yang menyatakan 0,1 mg/l dengan Permenkes No 492/Menkes/ PER/IV/2010 yang menyatakan 0,4 mg/l (yang sesuai panduan WHO). Sebaiknya kita ambil saja aturan terbaru.

Setelah penambahan kandungan besi dan mangan dari air dan makanan, apakah mungkin dalam sehari asupan besi dan mangan dalam tubuh melewati ambang batas kbutuhan? Kalau iya, berasal dari makanan apa umumnya? Apa dampaknya terhadap kesehatan? Pendek dan Panjang?
Bagaimana mencegah kondisi itu?
Tentu saja, seperti yang sudah disebutkan sebelumnya, setinggi apapun kadar zat besi dan mangan di air, konsumsi zat besi dan mangan oleh manusia tetap lebih besar melalui makanan.
Meskipun ada konsumsi zat besi melalui makanan, secara umum masih aman karena:
1. Kalaupun ditambah melalui makanan, masih cukup besar jarak mencapai nilai atas jumlah zat yang dianjurkan dikonsumsi (50 mg untuk besi, 3 mg untuk mangan bagi orang dengan berat badan 50 kg). Ini hanya nilai anjuran konsumsi, nilai untuk timbul gejala keracunan berbeda lagi.
Jika menelan zat besi dan mangan berlebihan, gejala yang timbul umumnya adalah diare atau konstipasi, dan ini umumnya terjadi pada orang yang berlebihan meminum suplemen zat besi dan mangan (seperti tablet tambah darah yang mengandung 60 mg zat besi). Dapat dilihat di sini nilainya masih jauh dari nilai zat besi dan mangan yang terkandung pada 2 liter air (dan tentu saja orang tidak akan meminum air tersebut semuanya dari PDAM apalagi jika rasa air PDAMnya sendiri sudah tidak enak)

2. Meskipun jika seseorang menelan zat besi dan mangan berlebih, tubuh sendiri punya mekanisme yang ketat dalam menyerap zat besi dan mangan dari usus. Meskipun mengkonsumsi zat besi dan mangan sebanyak itu, hanya sebagian kecil yang diserap usus, dan sisanya dibuang melalui kotoran.

3. Khusus untuk mangan, seandainya pun dalam darah mengandung banyak mangan (yang jarang terjadi jika melalui penyerapan usus, lihat nomer 2), maka liver/hati akan segera mengeluarkan kelebihan mangan melalui empedu.

Efek jangka pendek dan panjang bisa dikatakan minim (lagipula tidak selamanya air PDAM memiliki melebihi anjuran kadar zat besi dan mangan di atas peraturan). Sehingga tidak diperlukan upaya mencegah hal ini selain tentu saja memperbaiki kualitas air sesuai peraturan.

Obesity in children is a condition in children (and adolescent) characterised by a weight measurement above the mean for their height and age and also a body mass index above the norm.

Body mass index is calculated using the formula

body mass index = weight (kg) / [height (m)]^2

(American Obesity Association, 2005)

According to American Obesity Association,  a children with body mass index above 85^th percentile from the population is considered overweight whereas 95^th percentile or above is considered obese. About 15% of American child are either obese or overweight (American Obesity Association, 2005).

Causes

Actually, there are many factors related to child obesity and they have complex interaction between each other. Firstly, parents who are obese or overweight usually have obese or overweight children too.  This condition could be the result of genetic predisposition towards being, or can also be caused by sharing the same unhealthy eating behaviour (Wikipedia contributors, 2007).

Secondly, children who do not have enough physical activity are much more prone from obesity. Recent technological advances eg. computer, video consoles and cellular phones make children unable burn off calories they acquire from food. Hence the body will store this excess of energy as fat in adipose tissue (Wikipedia contributors, 2007).

Thirdly, unhealthy eating behaviour, as mentioned before, becomes increasingly spreading with the popularity of fast food restaurants and junk food. It is more common for parents to take their children out to eat instead of home-made cooking; some blame this on growing advertising campaign on television, internet websites, and other mass media. Even if it is not a fast food restaurant, eating out too often will result in weight gain (Wikipedia contributors, 2007). School condition is also a factor, where unhealthy food selection on the school cafetaria or limited physical activity opportunity in school can make children gain weight (Van Staveren & Dale, 2004, pp. 44-5). Other factor involved is psychological factor, where children eating behaviour is caused by stress or negative emotions such as boredom, anger, sadness, anxiety, or depression (Wikipedia contributors, 2007).

Finally, pathological factors such as hypothyroidism, Cushing’s syndrome, certain neurological problem, or the use of drugs such as steroids and antidepressants can lead to obesity in a child (Wikipedia contributors, 2007).

Effects

Several studies have pointed out that obese children are more likely to have obesity in adult life, altough a study conducted by Viner and Cole shown otherwise (Viner & Cole, 2005, p. 3).

Childhood obesity can lead to life-threatening conditions including diabetes, hypertension, heart disease, sleep problem, cancer, and others (Wikipedia contributors, 2007).

Children with obesity can also suffer teasing from their peers, or even harassed or discriminated by their own family. This condition makes obese children have low self-esteem and prone to depression (Wikipedia contributors, 2007).

Treatments

The best way to to treat obesity is to prevent it. Several study shows that once a child becomes overweight, intervention of merely physical activity is not significant (Reilly, et al., 2006, p. 3).

Conclusion

Child obesity is a condition in children and adolescent characterised by a weight measurement above the mean for their height and age and also a body  mass index above the norm. This condition is caused by overweight parents, lack of physical activity, unhealthy eating behaviour, psychological, and secondary due to disease.

Children with obesity are more likely to have obesity as an adult, thus lead to several conditions such as diabetes, hypertension, heart disease, sleep problem, cancer, and others. Low self-esteem and depression are psychological problems related to obesity in children.

Bibliography

American Obesity Association. (2005, May 2). Childhood Obesity. Retrieved March 20, 2007, from American Obesity Association: http://www.obesity.org/subs/childhood/

Reilly, J. J., Kelly, L., Montgomery, C., Williamson, A., Fisher, A., McColl, J. H., et al. (2006, October 6). Physical activity to prevent obesity in young children: cluster randomised controlled trial. Retrieved February 27, 2007, from bmj.com: http://bmj.com/cgi/content/full/333/7577/1041

Van Staveren, T., & Dale, D. (2004). Childhood obesity: problems and solutions. Journal of Physical Education, Recreation & Dance , 75 (7), 44-54.

Viner, R. M., & Cole, T. J. (2005, May 17). Adult socioeconomic, educational, social, and psychological outcomes of childhood obesity: a national birth cohort study. Retrieved February 27, 2007, from bmj.com: doi:10.1136/bmj.38453.422049.E0

Wikipedia contributors. (2007, February 27). Childhood obesity. Retrieved March 20, 2007, from Wikipedia, The Free Encyclopedia.: http://en.wikipedia.org/w/index.php?title=Childhood_obesity&oldid=111439127

Indonesia has among the fastest growing prevalence of people infected with HIV in Asian regions. Nonetheless, the prevalence in Indonesia itself is still low: according to the Data and Information Centre from Indonesian Ministry of Health, around 0.2 percent from the total population. However, since Indonesia is the world fourth most populous nation, this number means that currently there are a total of about 200.000 people living with HIV in Indonesia (UNAIDS, 2007).

The first AIDS case was detected in Indonesia in 1987 in Denpasar, Bali, and then at the following years the pattern followed the same pattern like other sexual transmitted disease just like in most other countries. However, especially since 2001, injecting drug users are increasingly being reported with HIV infection, and then there was a high annual increase of HIV infection reported from injecting drug users in Indonesia: from 146 cases in 2003 to 1183 cases in 2004 (Ford, Wirawan, Sumantera, Sawitri, & Stahre, 2004).

From the data in Indonesian Ministry of Health (2006), we can also see that 82% of known people living with HIV/AIDS is men and are concentrated within specific groups with specific behaviour in the population: about 50.3% of HIV infection cases are from injecting drug users, 40.3% from unprotected heterosexual sex, while 4.2% from unprotected homosexual sex. There are also several studies that show the HIV infections epidemic men who have sex with men communities in developing Asian countries, including Indonesia (Pisani et al., 2004; Toole et al., 2006; Wong, Zhang, Wu, Kong, & Ling, 2006).

2.     Political will to curb HIV epidemic

To answer with the HIV infections pandemic, the government, with the presidential decree number 36/1994, established the National AIDS Commission. This commission were created to prevent and to take integrated and coordinated, inter-sectoral actions against AIDS in Indonesia. This commission is headed by the Ministry of Welfare and also with the coordination of other Ministries, such as Ministry of Health and Ministry of Internal Affairs (Presiden Republik Indonesia, 1994).

It is aimed to prevent and to take actions against AIDS according to the current regulations, in accordance with the global strategy set by the United Nations, and also to increase community awareness for AIDS and improving the intersectoral, integrated and coordinated prevention and actions against AIDS

In 2003, another presidential decree was set up to improve this commission. It stated that the commission actions are coordinating measures in actions against AIDS, including prevention, education, health service, surveillance, and control of AIDS, epidemiological observation on vulnerable populations at risk of infecting HIV, health education, health campaign and regional and international cooperation in preventing against AIDS (Presiden Republik Indonesia, 2006).

3.     Is it improving the condition?

The program set up by the central government, regional government, non governmental organisation, and the support received from foreign donors in the form of HIV awareness and prevention programs throughout Indonesia have been improving some of the situation of HIV infection in Indonesia. A survey on condom use in sex industry in Indonesia in 2004-2005 reported that 61% of sex workers in brothels said that they had use a condom in the last time they sold sex. A prevalence of 57% was found in sex workers who didn’t work in a brothel. (UNAIDS/WHO, 2008).

For injecting drug users, the program is focused on reducing the use of non-sterile injecting equipment. In Jakarta and Medan, where programs such as these are reaching the injecting drug users, the survey found out that more than 80% of injecting drug users said that they always used clean needles (UNAIDS/WHO, 2008). The harm reduction method, which has been set up as a model for Indonesian government to tackle the growing HIV infections from injecting drug users group in Indonesia, was established by the Sentani Commitment (see Appendix), as an agreement between the National AIDS Commission and regional governments (National AIDS Commission, 2004).

While programs to prevent HIV infections in female sex workers and injecting drug users have been showing some degree of success, another vulnerable populations is still have lower priority in AIDS prevention program. A report in 2004 mentioned HIV infection levels of 2.5% in men who have sex with men, 3.6% among male sex workers, and 22% on waria (Indonesian term for transgender) sex workers in Jakarta, the capital of Indonesia. Almost of them are practicing risky sexual behaviours. It is stated that 65% of the male sex workers and 53% of men who have sex with men in Indonesia reported having unsafe anal sex with male partners and also 54% of the male sex workers reported that they had sex with women in the prior year (Pisani et al., 2004).

However, when we look at the trends in the following figure, we can clearly see the increasing number of new cases of HIV infection found in Indonesia until 2006.

(Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006)

Also we have another graph showing the model to predict the number of HIV infections in Jakarta, just from the data taken from one population: the injecting drug users.

(UNAIDS/WHO, 2008)

From the above graph, we can see that the situation in Indonesia is still far from improving.  In addition, although the overall HIV infection prevalence in Indonesia is still low, if we look into the regions of Indonesia, we have a number as high as 2.4% as the adult prevalence rate of HIV infection in the Papua province (Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006). The Ministry of Health vision of Healthy Indonesia by the year 2010, which set a goal of 0.9 percent of maximum prevalence in 2010(Menteri Kesehatan RI, 2003) in all regions of Indonesia, seems farfetched. In the following section, we will discuss problems in the implementation of the policy for HIV prevention in Indonesia.

4.     Problem in program of HIV prevention

Although the government already set up a commission accountable directly to the president, we can see that the problem with HIV infections in Indonesia is still growing. In the following, I would like to discuss several points why the policy against HIV in Indonesia is still unable to achieve its goal (such as in the Healthy Indonesia by 2010). There are 4 main problems that I would discuss, two related to the target of the program, in dealing with the sexual transmission of HIV infection, and also transmission in injecting drug users.  The others two related to the decentralisation process in Indonesia and on funding.

4.1.          Extensive sex network and geographical difference

Sex industry in Indonesia itself is extensive even though their legality is questioned. A survey on 1994-1995 found that there were 71,281 sex workers in Indonesia (Endang, Ivan, Walter, Noni, & et al., 2002), even though the actual number should be higher. Prostitution is not allowed in Indonesia, and sex workers who were caught soliciting in the streets can be sent to a rehabilitation camp. Nonetheless, brothels are somewhat accepted especially in the big cities: they are not illegal, there are no rules regarding this, the illegality of prostitution only concern on those who sell sex on the street. Therefore the local governments have regulated sex works in these brothels, providing health facilities and put certain limitations. Nonetheless, this unclear status for brothels can pose a problem for maintaining sustainable health program in preventing HIV infections.

The vast regions in Indonesia also made an obstacle in the program to prevent HIV infections. In most Indonesian provinces, such as in Java, Bali, Sumatra, and others, the common transmission of HIV infections is through injecting drug users. However, in Papua province, we have a different transmission pattern.

Papua is rivalling Jakarta in terms of HIV infections prevalence: a prevalence of 2.4% for overall adult HIV prevalence, and this could reach to as high as 3.2% in remote highlands of the Papua province (UNAIDS/WHO, 2008). In this region, unprotected sex is the main mode of transmission. Based on data from the UNAIDS/WHO, there’s a high proportion of men engaged in high-risk sex, with 25% reported that they had sex with non regular partner (over half of it were paid sex) and 20% had more than one sexual partner. From this report we can also see that the use of condom is uncommon. It is reported that only 14% who said that they use condoms for paid sex, and even only 3% said that they had use condom every time in previous month. Another problem with the Papua province is sexual violence. It was mentioned that 12% of women has experience sexual violence, even from their domestic partner. Therefore, to prevent increasing HIV infection in Papua, the main concern is to provide better sex education and also to promote and to distribute condom throughout Papua region. (UNAIDS, 2007)

4.2.          Harm reduction policy for injecting drug user

Even though the term of harm reduction itself is still controversial, whether it is a broad term of measures encompassing strategies of limiting supply and minimising harm, just like in Australia, or just strictly only a part of the strategy to tackle drug abuse specifically to minimise the harm of using drug (Ball, 2007).

According to Beyrer, Kumarasamy and Pizer (2005), the problems with the implementation of harm reduction policy in Asia, including Indonesia, can be categorised into three categories. The first one is this policy is considered as a way to say that it is all right to have people who abuse drugs and that this behaviour is only an expression from several people that tend to take risks. The focus of the harm reduction (at least in the narrow definition) then is to minimise the harm from using drugs regardless whether the status of using drug is right or wrong or wherever the drug comes from, since it is the health sector itself would bear the brunt if HIV infections (and also Hepatitis B and Hepatitis C infections) spreads from injecting drug users. Whether drug addiction itself pose a serious health problem to the community, where increasing drug user would also means increasing number of neurologic disability and psychosocial problem, would be tackled by the limitation of supply of drugs, not by the harm reduction system. I think that if Asian countries, especially Indonesia, want to fully implement harm reduction policy, both minimising the supply and managing the harm of drug abuse should put into practice. Therefore, the harm from bad practice of injecting drug users (for example needle sharing) can be minimised while effects of drugs to individual and society itself can also be minimised through controlling/ reducing supply of drugs in the black market.

Nevertheless, it is interesting to see in Iran, another Asian countries with high Muslim population, just like Indonesia, that the head of Iranian Judiciary declare, regarding on this dilemma between public health and drug control, after considering the Islamic principle of “doing no harm to oneself or others” and “the worst harm is eliminated by a lesser harm”, that the public health is more important in controlling the spread of HIV infections (as the worst harm) rather than control on drug abuse (which considered as a lesser harm)(Ball, 2007).

The second obstacle of harm reduction policy, as in many Asian countries, is the legal system (Beyrer et al., 2005). The current legal system in Indonesia still considers that the abuse of drugs is illegal and can be punished. The problem arise with this is that the harm reduction policy is usually set up several places for injecting drug user to access clean needles and also places to dispose them properly. Injecting drug users also need place for them to get some treatment, education, and referral. If setting up these places can pose a threat in the security of the community and also risking the injecting drug users being caught by the police, there should be some compromise between the rights of injecting drug users and also the rights of community for security. Therefore if we want to set up a safe haven for injecting drug users so that they can safely gain access of clean needles, treatment, education and referral, the provider of such place must be able to provide legal protection for their client from being arrested in that places. Obviously we should just put safe domain for injecting drug users everywhere, but we must understand first where injecting drug users needed mostly.

Another aspect of the legal system is related to the status of possessing injection equipment: eg syringe. Although in Indonesia it is not illegal to carry needle syringe, however, it is regulated under prescription only. In several countries, there are laws that prohibit people to possess injecting equipment, but eventually experience from developed countries shows that if this regulation is abolished, it really removes the practice of needle sharing between injecting drug users while does not really have much effect on the prevalence of new user (Deany, 2000).

In addition to that, if the legal system can work to accommodate the harm reduction system, the police can also act an important part in HIV prevention among injecting drug users. Police then should refers drug users for treatment rather than incarcerate them.

Finally, the last obstacle is on financial support and coverage of harm reduction program. Other than providing a safe place for injecting drug users, a program on harm reduction of drug abuse must provide a continued supply of clean needles. They also need human resources to run the program such as medicals and paramedics, counsellors, and others. Perhaps it is hard to put some money from the budget just to “satisfy” the need (or rights?) of injecting drug users, however, this is needed to prevent further problem in public health. And this problem in funding will be discussed in the next section.

From this we can see that the problem is much clear: whether the society accepts such behaviour and deals with the harm caused by it and whether the government is willing to conduct such program.

4.3.          Problem in regional implementation

In 2007, 23 provincial governments reduced their HIV budget by a total of 5.72 billion rupiahs, to be put toward the expenditure of regional election, even though President Susilo Bambang Yudhoyono called for an increase in the state’s budget for HIV/AIDS during a cabinet meeting in July. In Papua, for example, the provincial government allocated Rp 10 billions for its regional AIDS commission in 2007, but only 1 percent of the budget was realised. The government did not consider HIV/AIDS a priority because the number of infected people remained small compared to patients of other diseases. In December 2007 the Ministry of Health recorded 6,066 people with HIV and 11,141 with AIDS. The National AIDS Commission said it needs more than Rp 1.5 trillion in 2008 to deal with the virus, which most of the budget would be spent on prevention programs, but the central government has promised to provide Rp 1 trillion only. The commission estimated the number of people with HIV/AIDS would reach 400,000 in 2010 and one million in 2015 across the country. (The Jakarta Post, 2008).

4.4.          Problem on funding and sustainibility

In relation to the previous discussion on regional implementation of the policy, we can see that it was expected for the regional government to increase their spending on promotions against HIV infections. This is because Indonesia is still depending on foreign donors to tackle the issue of HIV infections. Foreign donors provide up to 70 percent of funds to prevent HIV infections in Indonesia (Pathoni, 2008). However, donors such as the United States and Australia are expected to decrease AIDS-related assistance partly because they now consider Indonesia a middle-income country. This means that programs on HIV prevention in Indonesia should emphasize on sustainability.  We shall look at one example: the Aksi Stop AIDS program.

The Aksi Stop AIDS program is a program of HIV prevention where USAID, in cooperation with the Family Health International and working together with the government of Indonesia through the National Commission of AIDS (Family Health International, 2007). This program is aimed to reduced incidence of STI/HIV/AIDS in most-at-risk groups (MARGs) thereby helping to prevent a generalize epidemic and reduced incidence of STI/HIV/AIDS within the general population of Papua (Family Health International, 2007, p. 5).

The program itself were recently came to an end in September 2008, where it was expected that we have (Family Health International, 2007, p. 5) :

•        Increased coverage of most-at-risk groups with tailored interventions and improved uses of risk reduction behaviours, practices, and access to and use of services; and

•        Increased ability of implementing agencies to regularly monitor, evaluate and improve program performance, thus achieving expanded coverage.

We can see that from this example that sustainability of the program is very important. After the program ended, and we have the output of improved implementing agencies in HIV prevention, therefore we can expect the outcome is the continuity of the HIV prevention program.

5.     Conclusion

In conclusion, we can see that although Indonesian policy on HIV prevention is already set, they have to deal some of the issues which are different from other countries: the extensive sexual network, the geographical difference in HIV infection prevalence and main method of transmission, problems in implementing the harm reduction policy for injecting drug user, problems arose with decentralisation, where regional governments don’t prioritise HIV preventions, and also the problem with funding and sustainability. In dealing with the increasing number if HIV infections in Indonesia, therefore we need to develop a better strategy which addressing these issues.

References

Ball, A. L. (2007). HIV, injecting drug use and harm reduction: a public health response. Addiction, 102(5), 684-690.

Beyrer, C., Kumarasamy, N., & Pizer, H. F. (2005). Asia: Health Meet Human Rights. In K. H. Mayer & H. F. Pizer (Eds.), The AIDS pandemic: impact on science and society. Amsterdam: Elsevier Academic Press.

Deany, P. (2000). HIV and Injecting Drug Use: A New Challenge to Sustainable Human Development. UNDP HIV and Development Programme Retrieved 27 May 2008, 2008, from http://www.undp.org/hiv/publications/deany.htm

Endang, B., Ivan, W., Walter, D., Noni, E., & et al. (2002). Reasons for not using condoms among female sex workers in Indonesia. AIDS Education and Prevention, 14(2), 102.

Family Health International. (2007). Aksi Stop AIDS Program, Year Three Workplan [Electronic Version]. Retrieved 1 September 2008, from http://www.popline.org/docs/1781/323687.html

Ford, K., Wirawan, D. N., Sumantera, G. M., Sawitri, A. A. S., & Stahre, M. (2004). Voluntary HIV Testing, Disclosure, and Stigma Among Injection Drug Users in Bali, Indonesia. AIDS Education and Prevention, 16(6), 487.

Menteri Kesehatan RI. (2003). Indikator Indonesia Sehat 2010 dan Pedoman Penetapan Indikator Provinsi Sehat dan Kabupaten/ Kota Sehat. Retrieved 15 November 2008. from http://bankdata.depkes.go.id/data%20intranet/Dokumen/Indikator%20IS-2010.pdf.

National AIDS Commission. (2004). Sentani Commitment to Combat HIV/AIDS in Indonesia. Sentani: Office of the Coordinating Minister for People’s Welfare.

Pathoni, A. (2008). Foreign donors back away from Indonesia AIDS fight. Reuters 12 March 2008. Retrieved 1 November 2008, from http://in.reuters.com/article/health/idINJAK26649520080312?sp=true

Pisani, E., Girault, P., Gultom, M., Sukartini, N., Kumalawati, J., Jazan, S., et al. (2004). HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia. Sex Transm Infect, 80(6), 536-540.

Presiden Republik Indonesia. (1994). Peraturan Presiden Republik Indonesia Nomor 36 Tahun 1994 Tentang Komisi Penanggulangan AIDS Nasional. Retrieved 10 Novermber 2008. from http://spiritia.or.id/art/bacaart.php?artno=1053.

Presiden Republik Indonesia. (2006). Peraturan Presiden Republik Indonesia Nomor 75 Tahun 2006 Tentang Komisi Penanggulangan AIDS Nasional. Retrieved 10 Novermber 2008. from www.presidensby.info/DokumenUU.php/243.pdf.

Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia. (2006). Situasi HIV-AIDS di Indonesia Tahun 1987 – 2006. Retrieved 15 July 2008, from http://depkes.go.id/downloads/publikasi/Situasi%20HIV-AIDS%202006.pdf

The Jakarta Post. (2008). Local govts cut HIV budget for elections The Jakarta Post 13 March 2008. Retrieved 1 November, 2008, from http://old.thejakartapost.com/detailweekly.asp?fileid=20080313.@02

Toole, M. J., Coghlan, B., Xeuatvongsa, A., Holmes, W. R., Pheualavong, S., & Chanlivong, N. (2006). Understanding male sexual behaviour in planning HIV prevention programmes: lessons from Laos, a low prevalence country. Sex Transm Infect, 82(2), 135-138.

UNAIDS. (2007). AIDS Epidemic Update December 2007 [Electronic Version]. Retrieved 15 July 2008, from http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf

UNAIDS/WHO. (2008). Asia AIDS Epidemic Update Regional Summary [Electronic Version]. Retrieved 10 November 2008, from http://data.unaids.org/pub/Report/2008/jc1527_epibriefs_asia_en.pdf

Wong, W. C. W., Zhang, J., Wu, S. C., Kong, T. S. K., & Ling, D. C. Y. (2006). The HIV related risks among men having sex with men in rural Yunnan, China: a qualitative study. Sex Transm Infect, 82(2), 127-130.

Richard Smith in his article, How Not To Give A Presentation, published in the British Medical Journal writes many ways to do a bad presentation. There are times when you need to do a bad presentation. When you do, try forgetting that you have to do a presentation, or you can just arrive late, but not too late. The next step is preparing for a bad presentation. The author said” One way to prepare for a bad presentation is not to prepare at all” (Smith, 2000, 1571) but there is a risk of spontaneity. Therefore, it is best if we have careful preparation, such as a presentation for the wrong audience, or do it in the wrong length, “too long is much the best”. Another method is to ignore the topic and also put a long and dull curriculum vitae.

For a very bad presentation, presentation aids will come handy. These come in bad videos, inaudible tapes, wrong music, fragile props and Powerpoint presentations “… that use every feature the software offers” (Smith, 2000, 1571). Bad slides can be with too much information with small fonts. Put them in rapid sequence with some mistakes, upside down for instance, and say anything that was not connected to the slides. In addition, you can put a picture of a naked woman in between.

When it is time to present your bad presentation, try to be bored. Do not wear unusual clothes, keep your eye from the audience, and mumble or read your presentation. You can use complex sentences with wrong grammar and wrong emphases so the audiences do not understand and try to torture them using too many points.

Finally, a really bad presentation leaves no question from the audience, but if there is, never put an answer in your reply, or after a long talk, simply ask “Does that answer your question?” In the end, with this guide and some experience, you can make “an outstandingly bad presentation”

From Smith, Richard, 2000, How Not To Give A Presentation, British Medical Journal,;321;1570-1571

Research ethics committees was set up because researcher usually have an agenda to work on their research, therefore they have a shift in moral from right-based point of view to a more emphasis on goal-based, duty-based moral¹. Therefore, to balance this view, I agree that we need an external view so the right-based moral is balanced between the other two moralities. This is where a health research ethics committee comes in place.

According to Foster¹, some researcher thinks the health research ethics committee are a counterpart body for finding mistakes done by the researchers. Actually, the health research ethics committee are more as a consultative body where researchers can have a better ethical judgement on what they have done in the research. With the committee consists of professional and layperson, they can give a balanced view on ethical matters found in a research. Consequently, researcher can have an ethically sound research, which is required in many publications and by many stakeholders nowadays.

Although the committee gives an insight for the researcher, this does not mean that morality is the only concern for the committee and researchers have no concern over morality. Because the health research ethics committee is only as a consultative body for researcher to get an ethical clearance, researcher still have the duty to implement ethical measures in their research. The responsibility is still on the shoulder of the researcher, nevertheless the health research ethics committee also have the responsibility to any ethical consequences of the research.

Framework for ethical review

There are three approaches, as mentioned above, to make moral decisions for ethical review; they are goal-based morality, duty-based morality, and right-based morality¹. These three approaches can be explained into a list of questions to help the analysis of ethics when an ethical committee decides whether it is reasonable or not.

These questions¹ are

Goal-based questions

• What question is the research project deal with?
• Is the purpose of the research good and desirable?
• How will the research complete that purpose therefore the results are trustworthy?
• How will the results of the research be disseminated?

Duty-based questions

• Are the procedures for the research participants risky?
• Is there a balance between risks?
• Are the risks greater than minimum risk?

Right-based questions

• Is there a consent sought from potential research participant?
• What are the procedures to obtain that consent?
• How will confidentiality be appreciated?

The development of research ethics committee

The development of research ethics committee is only recently started in the twentieth century. The Nuremberg Code was drawn after the trials in Nuremberg, 1946, of Nazi doctors who had conducted experiments on concentration camp. These codes consist of principles, but notably is the requirement of informed consent taken from human participant before the research started¹. Without the consent of the participant, a research is not considered ethical. Although this consent is needed, some people interpreted it that the consent does not have to be in written form. Therefore, they claim that they can have consent by simply an oral agreement, based on conversation or interview.

The next step is when World Medical Association chart up the Declaration of Helsinki in 1964. This started the revolution in medical research, where in the developed country, research conducted have to be under the supervision of ethical board. This was implemented in a law constituted in European countries, US and Australia. Following that, many district health research ethics committees were set up in those countries¹. This model then was also set up in the developing world, since there is no other model for health research ethics committee available. Although I agree that there are no a given set of model for the right health research ethics committee, for now this is the accepted model for a health research ethics committee.

The donors of research and research journal soon realised the importance of research ethics committee. It becomes a rule that a journal should not publish research without research ethics committee approval. This also leads the requirement of committee-approved research from pharmaceutical companies¹. We shall see that the need of a good health research ethics committee is a requirement for researcher to get their works published. Therefore, in relation to the following, to promote researches done by developing country, we also need health research ethics committee in place.

Barriers and problems known in the present health research ethics committee

One of the problems here is monitoring on the work of these committees. Several countries have a set of regulation that monitor the work of health ethics committee from a government agency. Others only based on multi-centred review on research. However, the most important is these committees have to give reasons on their judgement¹. For me this is the best way a health research ethics committee could work in developing countries, where there are still limited law and regulation to conduct ethical review on health research.

Some of the problem relates to the committee is the balance between those who understand on scientific research but also with those who understand to be independent of the research in question². Therefore it is important to make sure that professional and non professional has voices in the health research ethics committee.

There is also a need of the health research ethics committee to present their annual report as part of their monitoring and evaluation. This is needed so they can improve their function in the health research².

There is also the need of public interest and pharmaceutical interest². The public is the reason why the ethical committee comes in the first place. The research committee have the responsibility to the public on their judgement. If they approve unethical research, the public will question the judgement of the ethics committee. However, the accountability of the ethics committee to the public must not forgo the confidentiality of research. These also apply when dealing with the interest from pharmaceutical companies.

Health Research Ethics Committee in Developing Countries

Developing countries in this essay are those countries who have just recently adopted the ethics model from developed country. Although the model from the developed country is not known to be the best model, nevertheless the scientific community have to follow that for the requirement for publishing journal and pharmaceutical industries.

While health research ethics committee was only recently has a strong position in developed countries, their counterparts in developing countries are only beginning to build up. These ethics committees usually started in universities where research done primarily and the need to address the ethical raised from this research come from this community too. These university-based ethical committees usually formed after researcher needed an ethical approval so they can implement their research in their own country. Since there are limited understanding on ethical framework on a research (although not on morality), their work have been not as satisfying as their counterparts. Also since there is only limited to almost no power of the health research ethical committee, made developing countries a good place for research without much concern for ethical barriers³. Even though there are laws regulating these, sometimes laws and regulation still have no jurisdiction over some ethical problem.

Health Research Ethics Committee in Indonesia

Indonesia is only recently starting their framework on bioethical research. Many research centres in Indonesia doing research based on researcher ethics, which is goal-based and duty-base morality. However, the need of a health research ethics committee comes eventually. The author’s institutions in Indonesia once faced with the requirement of an ethical approval for a community development research. Since we are the only academic medical institutions in the region, they requested an ethical review for their research. This is the condition where eventually health research ethics committee were needed in developing countries.

The regulation on health research ethics in Indonesia was drawn up since 1995⁴.  This government regulation deals with all matters related to health research and development. To implement this, the Ministry of Health set up a Ministerial Decree on National Health Research Ethics Committee in 2002⁵. This set of regulations is the starting point for setting up the health research ethics committee in Indonesia. Although research in Indonesia is still mostly at the early stage, at least we can be sure that a good practice in research is starting to take place in Indonesia. We just have to make sure that the implementation of this regulation is going to take place.

Nevertheless, there are still some problems regarding setting up health research ethics committees in Indonesia. From the report of Health Research Agency from Department of Health, Republic of Indonesia, there are at least 26 health research ethics committees in Indonesia, mostly from Faculty of Medicine or part of Medical Ethics Committee in a hospital⁴.  Since research were mostly conducted in universities in Indonesia, it is not surprising that health research ethics committees were founded in these institutions. The earliest records in the health research ethics committee was in 1984 where it was founded in University of Indonesia. The problems regarding health research ethics committee are described in the following.

A burden to research community?

There are ethical problems come up with the health research ethics committee in Indonesia. Some of the barriers for an ethical committee to work in Indonesia are recognised⁴. Firstly is the concept of bioethics or their implementation in research is still differs from one committee to the other⁴. Research by Indonesian science community is still developing. They came from different background or even different specialty. Yet this is still the professional-only committee, without any layperson involved. Mostly is about limited knowledge about ethics in research. Some of the human resources needed is only concentrated in several cities in Indonesia, while regional ethics committee have to use the only available resources they have. Research is done mainly in these areas, mostly in Java Island, while their counterparts in another region in Indonesia have no better access to knowledge in bioethics.

Secondly, ethical problem found by the health research ethics committees are in the use of informed consent. While informed consent is already widely used in medical procedure in hospitals in Indonesia, their use in health research still have to be recognized. Most of researches conducted in these institutions in Indonesia are still taking consent based on oral agreement only, without any printed form. This will give a drawback, especially for research in vulnerable populations.

Thirdly, almost all university health research ethics committee are working for medical faculty, limiting their work only for research in medicine. Only some works with other health institutions, such as faculty of health sciences, pharmacy and others.

Another problem is that it is still hard to work on research without insufficient support and funding, which is mostly comes from the government. Most still agree that lack support and funding from the government are essential in the recent condition in ethics committee in Indonesia. Although the government of Indonesia regulate an ethical clearance for research, the realisation for this is still not monitored. Some only see the ethical clearance as an unnecessary part of research. However, few centres have maintained proper consultative action of the health research committee. This lack of resources also includes no standard framework for health research ethics committee in Indonesia. While it is recognized to have good morality in research (which in this case duty-based and goal-based morality), there is no concept of what are the steps needed to be taken to have an ethical approval for research.

Finally, even though there are still no visible legal charges regarding ethics in research in Indonesia, taking the lesson from the awareness of people in Indonesia regarding ethics in clinical medicine, health research ethics committee should prepare the research community on dealing with ethical matters.

Other recognised problems within health research ethics committees in Indonesia are the lack participation of layperson in the committee and the gender proportion of in the committee.

The concept of medical and health research is somewhat only limited to certain community, in this case the medical clinician and academician. Involving layperson in research of medical and health is still hard to implement in Indonesia. The committee usually required those who understand the goal of research. According to Siegler⁶ it is unethical to delegate this responsibility to people who did not understand (although his article focuses primarily in the ethics for doctor-patient relationship). However, a layperson should give an insight on the right-based morality without the bias of research goal.

Another problem is the inequity of gender proportion in health research ethics committee. While there is an increase of the number of women in health research ethics in Indonesia, their participation in health research ethics committee is still limited. Even though in Indonesia, women are becoming closer in gender equity in health profession, their places in the health research ethics committee is still limited. In a research by Hyder et al.³, they found that in developing countries, most researchers were middle aged male with part time basis as a researcher.

I think in Indonesia we have to put more women in the health research ethics committee, since some health research actually focused in child and women health in Indonesia. A more balanced committee will give a balanced view and can give more insights into the ethics of health research.

Advantages for research community

Although to have a health research ethics committee is considered a burden for developing country such as Indonesia, there are several advantages to have a working system of health research ethics.

As mentioned before, with the health research ethics committee working with the research community in Indonesia can give a credible predicate for research done in Indonesia. Since an ethical approval is needed for research, the health research ethics committee should also have accountability for their given approval to the research. In turns, this will increase the credibility of the health research ethics committee, a win-win solution for both researcher and ethicist.

Another advantage is increasing publication in internationally recognised scholarly journal from Indonesia. This will also recognised by other stakeholder, eventually such as pharmaceutical or biotechnology company.

Finally, the advantages to have a good health research ethics committee is to increase the partnership between developed and developing countries, as mentioned by Varmus and Satcher⁷. With a good health research ethics committee, Indonesia can have better access to knowledge and information for their research.

Steps to be taken for Indonesian health research ethics committee

There are recognised steps needed to be taken by ethicist in Indonesia for the implementation of the health research ethics committee⁴. One of them is setting a common understanding on health research ethics for all research community in Indonesia. Another step is to set up common guidelines for health research ethics committee for Indonesia so we can have common procedures when dealing with ethical matters and also promoting new health research ethics committee in regional provinces. I think these guidelines are the most important part. When comparing to other national health research ethics committee such as Australia’s National Statement on Ethical Conduct in Research Involving Humans, these show what we have to achieve in Indonesia for a better research.

Conclusion

In conclusion, Indonesia is still at the development stage for ethical consideration in health research. There are still many problems for health research ethics committee to work in Indonesia, from lack of resources and support, gender equity, lack participation from layperson, to the unsupportive condition of research in Indonesia itself. I think, before a set of standard guidelines were put up by the national committee, many regional health research ethics committee have different concept to rely on the ethical of health research. After this task is completed, we can expect that several barriers, such as gender equity, involvement of both professional and laypersons, and others regarding health research ethics committee in Indonesia will be solved.

References

1. Foster C. The ethics of medical research on humans. Cambridge: Cambridge University Press, 2001.

2. Evans D, Evans M. A decent proposal: Ethical review of clinical research. Chicester: John Wiley & Sons, 1996.

3. Hyder AA, Wali SA, Khan AN, Teoh NB, Kass NE, Dawson L. Ethical review of health research: a perspective from developing country researchers. J Med Ethics 2004;30(1):68-72.

4. Health Research and Development Agency Department of Health Republic of Indonesia. Situation analysis and mapping of health research ethics committees in Indonesia: Executive summary: Department of Health Republic of Indonesia, 2005.

5. Ministry of Health Republic of Indonesia. Keputusan Menteri Kesehatan Republik Indonesia tentang Komisi Nasional Etik Penelitian Kesehatan. In: Department of Health Republic of Indonesia, editor, 2002.

6. Siegler M. Ethis Commiitees: Decisions by Bureaucracy. In: Kuhse H, Singer P, editors. Bioethics: An Anthology. Oxford: Blackwell Publishers, 1999:587-590.

7. Varmus H, Satcher D. Ethical Complexities of Conducting Research in Developing Countries. New England Journal of Medicine 1997;337(14):1003-1005.

Menurut Statistics Indonesia, sebuah situs yang dikelola oleh Biro Pusat Statistik, di Indonesia berdasarkan sensus terakhir tahun 2005 ditemukan 109.613.519 pria dan 108.472.769 wanita. Di Kalimantan Timur sendiri ditemukan sebanyak 1.486.179 pria (saya salah satunya) dan 1.354.695 wanita. Itu artinya perbandingan pria dan wanita sebesar 101:100 untuk Indonesia dan bahkan 109:100 untuk Propinsi Kalimantan Timur. Bahkan untuk skala yang lebih kecil, Kota Samarinda misalnya, punya perbandingan 106:100, sedangkan untuk skala Dunia, menurut CIA, badan intelejen Amerika Serikat dalam The World Factbook menyatakan untuk tahun 2009 diperkirakan sebanyak 3.412.990.488 pria dan 3.377.071.728 wanita.

Dari tampilan di atas dapat kita lihat bahwa secara keseluruhan di dunia jumlah laki-laki lebih banyak dari pada wanita. Namun demikian pada beberapa negara memang jumlah wanita bisa lebih banyak, misalnya di negara-negara yang sedang berkecamuk perang, sehingga angka kematian pria lebih besar, misalnya di Somalia. Di lain pihak pada negara-negara tertentu laki-laki jauh lebih banyak seperti China akibat One Child Policy-nya, atau India dengan tingginya infantisida bayi wanita akibat resiko biaya mahar yang tinggi, atau akibat imigrasi pria dewasa seperti pada banyak negara-negara Timur Tengah.

Rasio seks pada manusia ini sudah menarik perhatian berbagai ilmuwan sejak dahulu. Charles Darwin, bapak Evolusi, sudah mencatat beberapa rasio seks pada komunitas tertentu dan disajikan dalam buku The Descent of Man. Yang menarik adalah rasio seks pada saat lahir, natural sex ratio, pada manusia umumnya sebesar 105:100. Mengapa hal ini bisa terjadi? Apa yang menyebabkan bayi yang dilahirkan sudah memiliki kecenderungan, meskipun tidak terlalu besar,  memiliki jenis kelamin laki-laki? Mengapa di Indonesia lahir sebanyak 9.983.140 bayi laki-laki dibanding 9.608.600 bayi perempuan pada awal tahun 2005?

Hal ini dijelaskan oleh Ronald Fisher pada tahun 1930 dalam buku The Genetical Theory of Natural Selection yang menyatakan pada awalnya rasio seks natural pada kondisi evolusi stabil itu adalah 1:1. Penyebabnya dapat dijelaskan oleh W.D Hamilton sebagai berikut:
1. Anggaplah suatu saat jumlah kelahiran bayi laki-laki lebih sedikit daripada kelahiran bayi perempuan.
2. Akibatnya bayi laki-laki ini lebih besar peluangnya kelak untuk kawin (karena lebih mudah berpasangan) daripada peluang kelak kawin bayi perempuan (karena ada kemungkinan tidak mendapat pasangan akibat bayi laki-laki yang lebih sedikit)
3. Akibatnya, orang tua yang membawa gen yang bersifat mendukung kelahiran laki-laki lebih besar peluangnya memiliki anak cucu dari pada orang tua dengan gen yang bersifat mendukung kelahiran perempuan.
4. Akibatnya gen pendukung kelahiran laki-laki lebih tersebar luas dalam populasi
5. Dan jumlah bayi laki-laki menjadi lebih banyak … hingga akhirnya hal yang sama terjadi pada sisi perempuan.
6. Akibatnya rasio keseimbangan 1:1 tercapai.

Nah, lalu mengapa kita memperoleh rasio seks natural sebesar 105:100, bukan 100:100 seperti kata Fisher? Ternyata penyebabnya adalah “biaya hidup” yang dikeluarkan oleh orang tua pada bayi laki-laki lebih kecil dibanding pada bayi perempuan. “Biaya” ini bukan hanya dalam artian uang, namun segala macam sumber daya yang dihabiskan oleh orang tua pada sang bayi hingga dewasa. Mengapa biaya ini lebih kecil pada laki-laki? Bukan karena laki-laki jarang dimanja, namun karena angka kematian anak laki-laki lebih besar dibanding angka kematian anak perempuan. Di Kalimantan Timur saja, angka kematian bayi laki-laki sebesar 45,17, sedangkan perempuan hanya sebesar 34,56 di tahun 2000 (data dari Statistics Indonesia), sedangkan angka kematian anak balita di Indonesia sebesar 36,0 untuk balita laki-laki dan 31,0 untuk balita perempuan (data dari WHOSIS). Karena lebih banyak anak laki-laki yang mati, akibatnya peluang bayi laki-laki untuk kawin kelak lebih besar, termasuk juga dalam menurunkan gen yang mendukung kelahiran laki-laki. Itulah sebabnya mengapa kelahiran bayi laki-laki lebih banyak dibanding kelahiran bayi perempuan.

Menurut konvensi PBB tentang status pengungsi tahun 1951, yang disebut pengungsi (refugee) adalah orang yang

“... owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of their nationality, and is unable to or, owing to such fear, is unwilling to avail him/herself of the protection of that country.“

Tadi sedang kuliah tentang etika penelitian terhadap pengungsi,  pas lagi break temen di samping, dari papua nugini, aja k ngobrol, dia bilang setelah belajar gini koq kayaknya enak jadi pengungsi, dan dia mau jadi pengungsi …
Trus dia bilang coba Indonesia nyerang Papua Nugini aja biar dia jadi pengungsi.

Terlepas dari sangat tidak mungkin Indonesia menyerang Papua Nugini, keinginan untuk jadi pengungsi (arti sempit, ngga mencakup internally displaced person seperti pada tsunami Desember 2004) ngga pernah terlintas dalam pikiran.

Mungkin karena pikiran kita belum bisa memikirkan cara menghadapi kekerasan dan penindasan yang hebat (tapi Indonesia juga punya ya, seperti dari Aceh dan Maluku). Atau emang sebenarnya Indonesia sendiri nyaman untuk ditinggali.

Kalaupun ada keinginan untuk mengembangkan diri, menjadi masayarakat dunia, rasanya ada cara yang lebih baik (meskipun ngga mudah) dibandingkan dengan menjadi pengungsi.

Aku baru dapet email tentang masalah bunuh diri di Indonesia. Ada asumsi yang keliru sih dari cara pengirim email itu menafsirkan beritanya.
Okelah

Aku coba cari beritanya, rupanya tentang peringatan hari kesehatan mental sedunia

Dari berita tersebut, dikatakan 50.000 orang di Indonesia berusaha untuk melakukan bunuh diri pada periode 2005-2007

hmm, darimana bisa dapet angka segitu ya?

Alasan bunuh diri yang utama adalah kemiskinan

tadi barusan chatting sama seseorang yang entah dari mana asalnya, tapi dia bilang, punya keponakan baru kelas 6 SD udah 2 kali mencoba bunuh diri gara-gara temannya ngga suka sama dia

… mahalnya biaya sekolah dan kesehatan, serta penggusuran

alasan kesehatan ya … ironis ya

Nah, data ini juga belum termasuk akibat overdosis obat terlarang yang mencapai 50 ribu per tahun.
41% berusaha gantung diri, 23% minum racun serangga

anehnya ada anjuran untuk pembatasan senjata api, padahal datanya ngga disebut

Daerah yang tinggi angka kejadian bunuh diri adalah Bali (121 kasus pada 2004) dan Kabupaten Imogiri (20 kasus pada 2004)

Pulung gantung ya …

Gimana cara mencegahnya? Pengenalan dini gejala depresi itu penting, tapi kebanyakan orang susah mengamati gejala bunuh diri.

Wah, pernah sih punya teman yang mau bunuh diri … meskipun menurutku caranya kurang ampuh.

Akhirnya diberi juga obat anti depresi

What do you think?

Referensi

Santos TW, 50.000 Orang Indonesia Bunuh Diri: Penyebab Utama Kemiskinan, VHRmedia.com, Jakarta, 8 Oktober 2007 – 16:56 WIB, http://www.vhrmedia.com/vhr-news/berita-detail.php?.g=news&.s=berita&.e=883

Kalau dilihat dari definisinya, kesehatan internasional, sama halnya dengan kesehatan masyarakat, mempertimbangan berbagai faktor yang mempengaruhi kesehatan masyarakat pada tingkat global. Faktor-faktor yang mempengaruhi kesehatan manusia masih berlaku di sini, genetik, lingkungan, kultur, politik, ekonomi, pelayanan kesehatan. Namun di sini kita bakalan melihat dari tingkat global: hubungan antar negara.

Orang yang berkecimpung di kesehatan global bakalan terlibat dalam berbagai keahlian, ngga sekedar kedokteran dan kesehatan, namun juga ekonomi, antropologi, komunikasi, manajemen, dan masih banyak lainnya. (Bahkan bidang ini juga bisa mempelajari masalah terorisme).

Namun saat ini kebanyakan masalah yang dipelajari di kesehatan internasional adalah masalah negara berkembang. Seperti kata seorang rekan, teori kesehatan masyarakat yang ada kebanyakan berlaku di negara maju. Belum banyak yang mempelajari kesehatan masyarakat di negara berkembang. Contoh saja dengan istilah double burden (beban ganda) yang dialami banyak negara berkembang.

What do you think?

Referensi

International Health. (n.d.). Encyclopedia of Public Health. Retrieved October 10, 2007, from Answers.com Web site: http://www.answers.com/topic/international-health