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Health and Medicine in Soekarno Era Indonesia: Social Medicine, Public Health and Medical Education, 1949 to 1967 COPYRIGHT AND USE OF THIS THESIS This thesis must be used in accordance with the provisions of the Copyright Act 1968. Reproduction of material protected by copyright may be an infringement of copyright and copyright owners may be entitled to take legal action against persons who infringe their copyright. Section 51 (2) of the Copyright Act permits an authorized officer of a university library or archives to provide a copy (by communication or otherwise) of an unpublished thesis kept in the library or archives, to a person who satisfies the authorized officer that he or she requires the reproduction for the purposes of research or study. The Copyright Act grants the creator of a work a number of moral rights, specifically the right of attribution, the right against false attribution and the right of integrity. You may infringe the author’s moral rights if you: - fail to acknowledge the author of this thesis if you quote sections from the work - attribute this thesis to another author - subject this thesis to derogatory treatment which may prejudice the author’s reputation For further information contact the University’s Director of Copyright Services sydney.edu.au/copyright Health and Medicine in Soekarno Era Indonesia: Social Medicine, Public Health and Medical Education, 1949 to 1967 Vivek Neelakantan Thesis prepared in fulfilment of the conditions for the PhD Unit for the History and Philosophy of Science University of Sydney 2014 Health and Medicine in Soekarno Era Indonesia: Social Medicine, Public Health and Medical Education, 1949-1967 Vivek Neelakantan Abstract In 1949, newly-independent Indonesia inherited a health system that was devastated by seven years of warfare resulting from three-and-a-half years of Japanese occupation and four years of revolutionary struggle against the Dutch. The country suffered from an acute shortage of physicians, and those few physicians were mostly concentrated in the large urban centres where a minority of the population lived. Additionally, the Indonesian Ministry of Health had to cope with the resurgence of epidemic diseases such as smallpox and endemic diseases such as malaria, tuberculosis and yaws. The Ministry of Health had initiated a number of symbolic public health initiatives—both during the Indonesian Revolution (1945 to 1949) and during the early 1950s resulting in a noticeable decline of mortality. These initiatives fuelled the newly-independent nation’s confidence because they demonstrated to the international community that it was capable of standing on its own feet. The early 1950s were thus a period of great optimism in Indonesian public health. Unfortunately by the mid-1950s, Indonesia’s public health program faltered due to a constellation of factors (a) political tensions between Java and the Outer Islands; (b) administrative problems particularly as the provincial and local governments implemented health policy but depended on the centre for the disbursement of finances; (c) political deadlocks; (d) corruption; (e) rampant inflation; and, (f) political instability. The optimism that characterised the early years of independence paved way for despair. The Soekarno era could therefore be interpreted as the era of bold plans and unfulfilled aspirations in Indonesian public health. This thesis relates the history of health of post-World War II Indonesia to the political history of the 1950s and critically examines the way in which promoting the health of the population became closely related with nation-building. Beginning 1950, Indonesian physicians appropriated military metaphors associated with the revolutionary struggle for independence in order to depict campaign against malaria, tuberculosis, yaws and leprosy as a struggle against the ‘big four’ endemic diseases that drained the overall vitality of the population. They i conceptualised disease eradication as symbolic battles that would lead to further victories of the nation such as those against poverty and illiteracy. In the post-World War II era—characterised by military rivalry between the US and USSR—the US in its bid to countervail the growing influence of USSR in newly-decolonised nations viewed the prevalence of poverty and disease as the breeding grounds of communist ideology. The US perceived the political significance of supporting disease eradication campaigns in developing countries as an attempt to lead these countries to a Western-style model of development, which made participation in these campaigns an essentially political act. Indonesian leaders were aware of the political ramifications of accepting foreign aid for the nation’s public health programs. They sought to cautiously balance the country’s ambitions of safeguarding its political sovereignty in health with increased openness to international assistance in health administered through the channel of UN agencies such as the WHO and the UNICEF. Indonesia did not uncritically accept the recommendations of international aid agencies. Indonesian leaders elected to follow what I have characterised as the ‘Bandung approach’ to health: it adhered to a non-aligned foreign policy which sought to minimise the intervention of either the US or the USSR, solidarity in health with nations in a similar socio- economic position, and a creative appropriation of WHO recommendations in health to reflect the country’s unique demographic and epidemiological requirements. This study sheds light on the nature of sovereignty and postcolonial governance in Indonesia. The country’s sovereignty was more fissured than scholars have assumed. Political differences between Java and the Outer Islands were heightened as a result of these tensions, which affected policy outcomes. The fissured nature of Indonesian sovereignty was evident in the lack of coordination between the Ministries of Health, Finance and Education on one hand and the provincial governments on the other. This undermined the consistent implementation of the Leimena Plan for health—named after Indonesia’s most influential Minister of Health since independence, Johannes Leimena—and medical education initiatives across the archipelago. The Indonesian bureaucracy proved to be the biggest impediment in the effective implementation of public health. This thesis reveals the benefits of linking the historiography of postcolonial Indonesian medicine with the political history of the 1950s more generally. The synthesis of these two streams of historiography serves as a useful vantage point to examine how Indonesia managed to ii implement its health policy independently during the height of the Cold War with minimal external intervention. Although the achievements in public health during the Soekarno era (1949- 1967) pale in comparison to the authoritarian Soeharto regime (1967-1998), the holistic view of public health embraced by nationalist physicians during the 1950s that symbolically related health to nation-building form the backbone to the Ministry of Health’s Healthy Indonesia 2010 campaign implemented at the turn of the 21st century. Yet the realisation of these plans is still in jeopardy because of corruption, collusion, nepotism, and an inept bureaucracy, just like during the Soekarno era. iii In the memory of my late grandfather Mr N.N. Subramanian iv TABLE OF CONTENTS Abstract i Dedication iv Acknowledgements vi Special Note on Orthography and Translation ix Chapter 1: Introduction 1 Chapter 2: Appropriation and Transformation of Social Medicine by Indonesian Physicians 33 Chapter 3: The Bandung Plan for Health 77 Chapter 4: The Campaign against the Big Four Endemic Diseases 111 Chapter 5: Expansion and Transformation of Medical Education in Indonesia 188 Chapter 6: Science in the Soekarno Era 232 Chapter 7: Conclusion 262 Bibliography 271 v ACKNOWLEDGEMENTS It has been a long but very fulfilling journey. My interest in Indonesia began in 1998 as a high school student when the downfall of the Suharto regime made headlines in the international media and my interest in Indonesia has remained active since then. Events that stirred me in the direction of the history of medicine were more complex. In 2005, after earning a Master of Philosophy in International Studies from the University of Madras (Chennai, India) I happened to meet with Sanjoy Bhattacharya, now Professor of History at the University of York, at the Maharashtra State Archives (Mumbai) who encouraged me to undertake intensive study of Bahasa Indonesia and consult archival sources. In 2006, I was enrolled as a MA candidate in History at the University of Iowa and was selected for the prestigious Crossing Borders Fellowship that enabled me to pursue archival research at the headquarters of the World Health Organisation (WHO) and League of Nations Archives located in Geneva, Switzerland (mid- 2007). In 2008, I was awarded the All-Net Fellowship for less commonly taught foreign languages at the University of Iowa that enabled me to independently learn Bahasa Indonesia with the assistance of a tutor. My MA thesis assessed the history of smallpox eradication in Indonesia. In 2009, I was accepted in the PhD program at the Unit for the History and Philosophy of Science at the University of Sydney and was awarded a prestigious University of Sydney International Scholarship. Throughout my candidature, I have benefitted immensely from the guidance of Hans Pols and Warwick Anderson. As my primary supervisor, Hans has been enthusiastic about the project from the very beginning and introduced me to specialists in the field. I would like to thank Hans
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