The Indonesianization of Social

Vivek Neelakantan PhD student, The University of Sydney, Unit for the History and Philosophy of Science

Abstract

The purpose of social medicine, which began in Europe as an academic discipline during the Second World War, was to investigate the correlation between specific factors such as age, gender, race, heredity, economic circumstances, domestic environment, occupation and nutrition on health. Almost a decade later, Indonesian physicians applied social medicine ideas to promote public health in a country characterized by weak state intervention. These physicians eschewed the narrow correlation between poverty and ill health but reinterpreted social medicine within the Indonesian social context with its entrenched patriarchal system and cultural preferences. The wider theme explored in this article concerns the emergence of social medicine in twentieth-century as a critical reaction to Dutch public health policies. The article examines the partnership between Indonesian physicians and the post-colonial state and their shared vision on state-guided social medicine, but does not explore why social medicine failed to usher in a transformation of the nation’s .

Keywords: Social medicine, Pembangunan, nutrition, famine

Introduction on family stability, a patriarchal system, and cultural choices pertaining to food-affected Social medicine began as an academic health outcomes. This article depicts the discipline in Europe at the time of the Second emergence of social medicine in twentieth- World War with the aim to investigate the century Indonesia as a critical reaction to Dutch correlation between specific factors such as age, public health policies. The article contains three gender, race, heredity, economic circumstances, sections. The first section offers a chronological domestic environment, occupation, nutrition, account of social medicine in the late-colonial and environment on health and disease (Ryle, period and during the Indonesian Revolution. 1948: 9-12). Nearly a decade later, Indonesian The second section surveys the Indonesian physicians such as Raden Mochtar applied discourse in social medicine immediately after social medicine ideas to promote public health independence. The third and final section in a country where the public health system devotes attention to the specific problem of was under-resourced and marked by weak population growth and child health. state intervention. These physicians eschewed the narrow correlation between poverty and ill health and reinterpreted social medicine within the Indonesian context with its emphasis Vivek Neelakantan 75 The Indonesianization of Social Medicine

Colonial medicine and decolonization criticize colonial health measures that would later serve as a blueprint for health policies Medical initiatives in the during the Soekarno era. A major bone of Indies before the nineteenth century were contention between the Indonesian nationalists limited to curative care, catering primarily and the Health Service in the Volksraad was to the European population in major cities the administration of the anti-plague campaign such as Batavia, Semarang and Surabaya. which involved both puncturing the spleen However by the nineteenth century, the colonial of corpses to detect disease and rat-proofing authorities introduced smallpox vaccination as of houses. The former action was held by a preventive public health measure. The Civil many Muslims to violate Islamic injunctions Medical Service of the Netherlands Indies related to the sanctity of the body after death (renamed Public Health Service in 1925) had (Abeyasekare, in: Chandler & Ricklefs [eds], launched disease eradication campaigns against 1986: 9). The Indonesian members of the , yaws, hookworm and plague and Volksraad campaigned to make the Health was entrusted with the task of implementing Service more responsive to the needs of the quarantine, intensive hygiene schemes, medical colony. I will briefly examine the contribution research, the training of doctors and of Abdul Firman gelar Maharadja Soangkoepon although anti-plague measures were resented (Volksraad delegate from North ) by the indigenous population. This section and the nationalist physician Abdul Rasjid discusses the dynamic nature of colonial who envisioned an Indonesian alternative to public in the Netherlands Indies, the dominant colonial health model that in the unpopularity of health measures such as the 1930s focused largely on prevention of vaccination, popular resistance, and the way infectious diseases. health became absorbed in the anti-colonial Maharadja Soangkoepon was critical of the struggle. In the process, colonial public health high cost of in the Netherlands measures were subject to nationalist criticism. Indies which left the poorer section of the Between 1912 and 1940, the portion of Indies population in the rural areas without the public budget in the Netherlands Indies access to Western medicine (Maharadja allocated to health service ranged between 2.5 Soangkoepon &Abdul Rasjid, 1938: 156- and 5 per cent but showed a declining trend 60). He encouraged individual initiatives to for much of the period as health received only promote hygiene and sanitation in rural areas, about half the amount spent on police and a task which could be well accomplished by less than one-ninth of the expenditure on enlisting Indonesian physicians better placed defence (Abeyasekare, in: Chandler & Ricklefs than their Dutch counterparts in determining [eds], 1986: 4). Health was an issue on the existing health needs. Abdul Rasjid argued nationalist agenda. The Volksraad (People’s that medicine not only affected physical but Council) was created as an advisory body by also spiritual well-being of the person and the colonial government in 1918; it fell under could be studied from scientific, religious and the jurisdiction of the Governor-General and humanist considerations. Rasjid’s view of the Dutch parliament. The Volksraad was not health embraced not only a narrow defence a legislative body and not all members of the against disease but engaged broadly with socio- Volksraad were democratically elected. A few economic aspects affecting overall well-being by prominent Indonesian nationalists, especially emphasizing health conditions of rural areas physicians, were represented in this advisory in . Medicine anchored in body, for instance Abdul Rasjid. The Volksraad Western science but adopted to the way of life served as a platform for the nationalists to 76 Lembaran Sejarah, Vol. 10, No. 1, April 2013 in colonial Indonesia was essential to promote Although medical initiatives in the acceptance of basic hygiene. Nationalist leaders Netherlands Indies before the nineteenth such as Maharaja Soeangkoepon and Abdul century had been largely oriented to curative Rasjid thus used the Volksraad as a political care, such measures proved expensive towards forum to criticize the nature of colonial medicine the end of the nineteenth century as the in the 1920s and 1930s. archipelago suffered a severe shortage of skilled The Conference in 1937 medical personnel. Given the constraints of the approached the question of rural hygiene from acute shortage of skilled personnel and financial an interdisciplinary perspective involving resources, the Health Service concentrated collaboration of medical professionals with on the control of epidemics while leaving sanitary officers, architects, engineers, individual treatment of the individual to private scientists, and agriculturalists. The conference enterprise, in particular the missionary and acknowledged that preventive medicine was estate . Such measures did not enlist a cost-effective way of improving health in the co-operation of indigenous people. Asian countries (League of Nations, 1937: 42). Between 1942 and 1949, Indonesian Such an approach implied tracing the socio- public health faced formidable challenges: economic causes of ill health. The conference the Pacific War, including the Japanese recognized that overpopulation was correlated occupation of the archipelago as well as the with a high rate of infant mortality. A poor Indonesian Revolution (1945-49), both causing diet, low standards of living, and oppressive a considerable dislocation of health services. land laws were regarded as causative factors During the Japanese occupation, health was a for malnutrition that raised infant mortality. tool of military propaganda. Public health was Therefore, scientific research on nutrition centralized under Japanese command in and demonstration of the nutritive value of whereas the Outer Islands were neglected. certain foodstuffs through village lectures could Indonesian physicians such as Abdul Rasjid help mitigate the problem of malnutrition in and Boentaran Martoatmodjo - now getting Asian countries. The conference acknowledged more responsibility than ever - envisioned an that good health was a part of overall well- Indonesian alternative to Western medicine. being. Decentralized health delivery to rural They began to define what was at stake for the areas (focusing on preventing disease) was health of the Indonesian nation by advocating a cost-effective public health measure for improvements in the standard of living of the which the rural public had to be educated population through a programme of increasing through practical hygiene demonstrations. population, reducing the high rate of maternal The Bandung Conference was revolutionary in and infant mortality, nutrition, and ensuring perceiving public health as a cog in the wheel cost-effective measures to promote preventive of rural development, addressing sensitive health through use of jamu (Indonesian political issues such as land reform in colonial traditional medicine). countries, and placing villagers at the forefront Subordination of public health to the of the development process. The delegates to Japanese military forces, appropriation of 50 the Bandung Conference saw public health as per cent of the rice harvest for the military a means towards nation-building. Nationalists (Gunseikanbu), and forced labour of such as Gandhi were inspired by the ideals of were responsible for starvation deaths which rural reconstruction and incorporated them in went unreported in contemporary magazines their thinking. and newspapers (Sejarah Kesehatan I, 1978: 71). The Japanese realized that ill health was a Vivek Neelakantan 77 The Indonesianization of Social Medicine constraint to economic productivity among the by reducing import of Western medicine which Javanese labor that would eventually thwart dried up during the Japanese occupation. success of the Japanese mission of establishing Japanese attempts to promote jamu were a ‘Greater East Asia Co-Prosperity Sphere’ in superficial as there was no access to Western Southeast Asia. The Central Office of Public medicine during the war. They therefore had Health under the Japanese (Eiseikyokutyo) was to negotiate a solution that kept everyone entirely focused on a Djawa Sehat (Healthy happy. They used jamu as a tool of political Java) campaign with a massive effort to propaganda. eliminate framboesia (yaws) using salvarsan Soon after the Japanese occupation shots, although the implementation of the of the archipelago ended in August 1945, actual disease eradication was entrusted to Indonesian medicine was marred in political local authorities suffering an acute shortage of uncertainties resulting from the Indonesian budget and medical supplies. Revolution and Dutch attempts at reoccupation Martoatmodjo - unlike the Eiseikyokutyo of the archipelago. The two Dutch military which had used public health as a tool of interventions – in 1947 and 1948/49 - caused political mobilization of the population - displacement of the population and interrupted advocated a comprehensive health programme medical supplies. The government of the that envisioned raising the standards of living Republic instituted the first Indonesian Ministry of Indonesians through a reduction of maternal of Health under leadership of Dr. Boentaran and infant mortality, malnutrition, and chronic Martoatmodjo, but it was unable to implement tuberculosis by way of a comprehensive a coordinated health policy due to the two Dutch programme of health education in schools military interventions. The Ministry of Health (Berita Ketabiban, 1944: 46). Martoatmodjo was relocated to soon after the first attributed the high incidence of tuberculosis military intervention. in Indonesia during the Pacific War to the poor From its inception, the Republic’s Ministry of nutritional status of the Indonesian family Health prioritized upgrading of the qualification where per capita consumption of protein rich of paramedical personnel in order to tackle the food was sub-optimal. acute shortage of physicians. The Rockefeller Indonesian physicians such as Abdul Rasjid Foundation supported training of personnel now began to rediscover the scientific value of such as vaccinators, public health instructors, using jamu in delivering cost-effective sanitary and malaria campaign officials in Magelang prophylaxis in rural areas of the archipelago where from 1946 the office of the division of although such remedies were rarely used by hygiene and health education was located. Indonesian doctors. Jamu was dismissed as This office began to enlist the cooperation of ‘unscientific’ within the Indonesian medical local people in the establishment of a rural establishment as it could not be subjected to hygiene service which was active in promoting scientific verification (Seno Sastroamidjojo, health education. However, because of the in Madjalah Kedokteran Indonesia, 1956: 18). ‘Madiun affair,’ and the second Dutch military Prior to 1942, not many scientific articles had intervention, the activities of rural hygiene been published on djamu. Promoting use and services came to a premature ending (Raden research of Indonesian traditional medicine in Mochtar, 1953). The main feature of the public health was perceived within a section health education work in Magelang, which of the Indonesian medical circle (for instance had begun as a health demonstration unit, was Abdul Rasjid, R.M. Abdoelkadir) as a means the campaign against soil and water pollution, of nation-building and to achieve self-reliance enlisting the support of villagers in improving 78 Lembaran Sejarah, Vol. 10, No. 1, April 2013 water supply and mobilizing joint action on critically examining the Indonesian perspective health issues. Prior to the first Dutch military on public health, disease eradication, national intervention, paramedical personnel in the health services, and how nutrition ought to be Banjumas regency in Central Java pursued incorporated into a broader framework of ‘social guerrilla warfare against the Dutch forces. well-being.’ In 1948, the Rockefeller Foundation gave President Soekarno’s version of financial aid to the amount of Rp. 165.000 to pembangunan, based on what was feasible, left a pay sanitary workers in Yogyakarta. Particular deep imprint on the development of Indonesian Indonesian initiatives in public health during social medicine in the 1950s. His version the Revolution included setting up rural reflected the newly decolonized archipelagic hygiene demonstration units. nation’s aspirations for a brighter future based on the proposition that the Indonesian nation Indonesian thinking on social medicine possessed immense physical and psychological strength since the independence struggle In the post-war period, the World Health (Soekarno, 1965: 196). The basic pillar of Organization (WHO) has been especially pembangunan’s was the doctrine of , influential in shaping social medicine thinking the philosophical foundations of the Indonesian in newly decolonized nations in Africa and Asia. nation enumerating respectively belief in one The WHO argues that public health is part God, just and civilized humanity, democracy, of a wider programme of social development. and social justice for all Indonesians. The Consultants within the WHO, for instance principle of ‘social justice’ for all Indonesians C.E.A. Winslow, claim that advances in public was reflected in Soekarno’s concern about health cannot be undertaken by curative ensuring Indonesia’s self-sufficiency in rice that medicine alone but require improvements in would lead to fulfilment of one of the most basic water supply, housing, sanitation, nutrition, needs (food) for all Indonesians. Soekarno’s and conditions of work. Post-war thinking on version of pembangunan embraced the idea of health in Indonesia after independence broadly kemerdekaan (freedom) that stood for multiple reflected the WHO definition of health which possibilities in the 1950s, including prosperity, states that health is not merely an absence human dignity, and physical and spiritual of disease but also a state of physical and welfare for all Indonesians. Pembangunan in psychological well-being. Public health in the the 1950s was associated with achieving the Soekarno era was loosely associated with the highest standard of living for every Indonesian, ideology of nation-building (pembangunan). investment in human skills, and achieving an In that way, Indonesians refashioned the idea equitable distribution of wealth. Soekarno’s of developmentalism inherent in the WHO pembangunan was internationalist in the discourse to fit Indonesian conditions. The true sense of the word, evaluating successful Basic Indonesian Law of 1960 ‘On Health’ socio-economic models functioning elsewhere (Undang- Undang Nomor 9 tentang Pokok in the world, and adapting them to Indonesian Pokok Kesehatan) broadly reflects the synthesis conditions. The internationalist aspect of of the WHO definition with the Indonesian pembangunan was evident in Indonesian vision of furthering the goal of a socialist newspapers such as Pos Indonesia and English society. In this section, I broadly examine the newspapers such as Times of Indonesia. In contributions by Seno Sastroamidjojo, Raden the following sections, I examine whether Mochtar, Soetopo, Johannes Leimena and Soekarno’s version of pembangunan translated Poorwo Soedarmo to shaping the thinking on into positive health outcomes. Indonesian social medicine during the 1950s by Vivek Neelakantan 79 The Indonesianization of Social Medicine

Seno Sastroamidjojo was a leading social Indonesian economy, Sastroamidjojo reflected medicine expert in Soekarno’s Indonesia. the idea of pembangunan or nation-building. Sastroamidjojo’s vision of social medicine At the time of the transfer of sovereignty in serves as a vantage point to examine how 1949, Indonesian doctors lacked an indigenous social medicine ideas were adapted to an vocabulary for the terminology of social Indonesian context, considering that he had medicine. Indonesian social medicine had, an eclectic educational experience, ranging according to Sastroamidjojo, developed its own from a pesantren (Muslim boarding school) identity considering the archipelagic diversity in Grabak (Java) and STOVIA in of the nation in terms of culture, religions, and (graduate of 1916) to specialist training in manners. For the effective delivery of social gynaecology and social medicine at Amsterdam medicine in rural areas, there was a pressing University, training in midwifery at Berlin need to orient the medical faculty towards University, venereology at Budapest (Hungary), village social life (Seno Sastroamidjojo in social medicine at Stockholm, subsequently Madjalah Kedokteran Indonesia, 1956: 20). serving as a for the Health Service Mochtar became head of the Department of the Netherlands during a brief interlude, of Community Education in the Ministry working as a private practitioner in Jakarta of Health soon after 1949. He served as for six years, later as a surgeon at the Billiton Professor of Public Health in the Faculty of mining company. His international training Medicine at the newly established Universitas conditioned his outlook on social medicine. He Indonesia in Jakarta and was also a visiting was indeed a translated person. faculty member at the univerisities Gadjah According to Sastroamidjojo’s philosophy, Mada (Yogyakarta), Airlangga (Surabaya) social medicine was a synthesis of sociology and Hasanuddin (Macassar). He reiterated and public health. He classified poverty and WHO thinking of the 1950s that health was illiteracy as enemies of Indonesian society, not merely an absence of disease but rather a perceiving social security as an insurance state of physical, psychological and social well- against injury at the workplace. He was of the being (Raden Mochtar in Madjalah Kedokteran conviction that without social insurance the Indonesia, 1957, no. 7: 141). Environmental WHO definition of health - as ‘not only absence factors affecting population well-being were of disease but also a state of psychological and inadequate housing, and nutritional diseases social well-being’ - would be become redundant. such as kwashiorkor. Public health was a Sastroamidjojo’s understanding of the WHO means to alleviate human suffering. Public definition of health was shaped by eugenics. He health was not an isolated pillar standing on believed that for producing a strong and healthy its own but anchored in public welfare, the generation, the medical examination of couples rights of labor and the humane care of the before marriage for venereal diseases was mentally ill. According to Mochtar, public necessary (Seno Sastroamidjojo in Madjalah health was a means to achieve the dignity of Kedokteran Indonesia, 1956: 17). For the mankind. Society was not homogeneous. Social eradication of venereal diseases, sex education variables affecting access to community health before marriage was necessary. The high rate services included gender, age of the population, of oedema among Indonesian infants in the nationality, religion and occupation. 1950s was, according to Sastroamidjojo, due Mochtar believed that public health to a shortage of food. A malnourished child education was a means to improve health mirrored the poor health of the economy. By indicators by inculcating hygienic habits. linking malnutrition to the poor state of the This implied efforts to improve socio-economic 80 Lembaran Sejarah, Vol. 10, No. 1, April 2013 conditions of the masses and was a way for the community participation, was crystallized in community to identify its health needs (Raden the concept of Puskesmas (Pusat Kesehatan Mochtar in Madjalah Kedokteran Indonesia, Masyarakat, community health center) in the 1957, no. 11: 341). Health education was an late 1960s. The full realization of Mochtar’s active process. The health educator had to ideals on primary health care in the 1950s was convince the public that health was one of the probably inhibited by the waxing and waning of basic necessities of life such as food. Health Indonesia’s parliamentary institutions, lack of education necessitated a coordinated approach coordination between the centre and provinces between various levels of government: central, on financing health projects, and the Darul provincial and district. Health education Islam insurrection in in 1956. consisted of imparting a ‘one-way method’ Johannes Leimena served as minister of message involving communication of the Health from 1947 until 1956, except during message through films, lectures, newspapers, or the first cabinet of (1953- the radio. The ‘two-way Socratic method’ was an 1955). Leimena’s pressing task was to rebuild important pedagogic technique for public health Indonesia’s health infrastructure which had been education consisting of discussions on matters destroyed during the war and the Indonesian of public health initiated by public health Revolution. As a result, Indonesia experienced officials with schoolchildren (Raden Mochtar in an acute shortage of doctors, paramedics, and Madjalah Kedokteran Indonesia, 1957, no. 11: hospitals. Implementing a coordinated health 346). Mochtar thus envisioned the public as an plan to address acute shortages of personnel and active partner in the health education process. achieving a synchronization of decrees issued by For sensitizing future medical practitioners the centre with local governments proved highly to social conditions in the rural areas, the challenging since the Indonesian Revolution Universitas Indonesia introduced a course on had produced a federal state structure in which preventive medicine. the demarcation of public health responsibilities In 1959, Mochtar served on the advisory between the central governments on issues such committee of the Department of Health in the as financing campaigns against communicable municipal government of Jakarta. He argued diseases became a rather thorny issue. Leimena that a disease did not exist in isolation but was was faced with the arduous task of achieving rooted in social, environmental, psychological, coordination between and within different and physical factors. To illustrate his argument levels of government. Newly independent on the environmental impact on disease, Indonesia had inherited the legacy of the Dutch Mochtar used an example from an Indonesian health system which largely emphasized the family (Pos Indonesia, 23 June 1959). A child prevention of communicable diseases such as aged six, living with his/her grandparents (the plague, smallpox and cholera. Yet, curative care parents having divorced) suffers from asthma was largely managed by Christian missionaries, and hookworm. The grandfather is uneducated private estates (particularly in Sumatra), and but earns a modest income to support the family government polyclinics, mainly in major cities. with at least two square meals a day. However Leimena conceptualized Indonesia’s health the child suffers from asthma as a result of policy in terms of integrating preventive and stress due to family tensions. Stress was a social curative health care through five-year plans. factor affecting health and well-being. At the time, Leimena’s vision of integrating Mochtar’s ideals of achieving the highest preventive and curative care seemed a far- possible standard of health through cost- fetched dream since the government lacked effective preventive measures emphasizing Vivek Neelakantan 81 The Indonesianization of Social Medicine funding for such a project (Johannes Leimena, in achieving an equitable distribution of food 1980: 59). in Indonesia proved overambitious as the Leimena’s logic was that disease and Ministry of Public Distribution was unable to poverty constituted a vicious circle. A sick achieve coordination with the departments of person became poor and this impoverishment Agriculture, Transmigration, and Labour. accounted for further disease. Improvement Poorwo Soedarmo was an alumnus of the of the socio-economic conditions of the people London Postgraduate School of Public Health alone could ensure the development of a basic and later a faculty member of the Medical standard of health. A healthy nation was School of the in reflected in the physical and mental well-being Jakarta. His publications on nutrition largely of its inhabitants (Johannes Leimena, 1956: 9). dwelt on the issue of kwashiorkor in Indonesia. As a minister of Public Distribution, Leimena He had observed that during the colonial period, perceived that an adequate quantity and quality children afflicted by kwashiorkor or marasmus of nutritious food was critical to the health of were labelled as ‘indolent’. Since then, the pregnant women, children and ensuring the word ‘indolent’ came into usage as an epithet productivity of workers. However Leimena to describe the diseased indigenous body. He perceived the question of nutrition through has noted in his autobiography that nutrition the lens of scarcity. He held that Indonesia’s forms an important indicator of the quality of achieving self-sufficiency in rice was the most the nation (Poorwo Soedarmo, 1995: 35). He effective way means to overcome nutritional advocated that a food policy for Indonesia had to and calorific deficiencies. Indonesia’s per capita take into account the rate of population growth, consumption of rice per person per year was 84 percentage of dependent population, and a food kg prior to the Second World War and 93 kg in balance sheet for the Indonesian population the late 1950s. However, Leimena observed, which would take into account the nutritional Indonesia was experiencing a population requirements for the ‘average Indonesian.’ He growth at 1.7-2 per cent per year in the 1950s had observed that in several islands of the which outstripped its food production (Leimena archipelago, particularly in Java, Madura, in Berita Kementerian Kesehatan Republik and , self-denial of food was regarded as Indonesia, 1959: 5). Indonesia compensated its a virtue. As a result, people from Java, Bali, shortfall of rice production through imports. or Madura were reluctant to talk about food Leimena was of the opinion that Indonesia could scarcity. become self-sufficient in rice by maximizing Ensuring a minimum quantity of rice production and distribution to feed its ever- for each person was also regarded as a basic growing population. He envisioned building entitlement of the Indonesian citizen. While Indonesia’s capacity in rice production through a stable Indonesian currency could meet intensification of paddy cultivation in Java and Indonesia’s growing rice requirements, there extensive dry land farming of paddy in the was also a fear among policy-makers that rice Outer Islands as a means to achieve berdiri imports would compromize Indonesia’s self- kaki sendiri (to stand on one’s own feet). sufficiency. Leimena perceived Indonesia’s nutritional problems through the lens of the Pancasila The population controversy and child ideology which includes social justice for all as health one of its tenets. He focused the state machinery By 1953, world population had grown by towards ensuring an equitable distribution of 10 per cent since before the Second World War food by maximizing rice production. His plan as a result of improvements in public health, 82 Lembaran Sejarah, Vol. 10, No. 1, April 2013 for instance vaccination against tuberculosis. the functioning of maternal and child health This had contributed to reducing death rates policies in Sweden. Dr. Saroso had observed but birth rates continued to rise, particularly that the family planning programme in Sweden, in developing countries in Africa and Asia, incorporating birth control, was successfully contributing to the problem of diminishing per executed through district health centres. capita availability of food. The premise of the She was very outspoken in a radio broadcast WHO and FAO that the world’s population from Radio Republik Indonesia about using was a source of potential human capital found birth control as a means to prevent maternal support among Indonesian policy-makers. mortality. Vice President Hatta was outraged at Indonesia’s first Five-Year Plan unequivocally Saroso’s open advocacy of family planning as he signalled that Indonesia’s population was found such a discussion offending the cultural growing at an alarming rate but planners were and religious sensibilities of Indonesians divided on economic and religious grounds although he had perceived that Indonesia’s whether to use birth control to lower the rate growing numbers put pressure on the per capita of population growth. availability of food (Hull & Hull, 2005: 4). In 1953, Soetan Sjahrir - the Socialist party In the early 1950s, Soekarno faced several leader who had served as Indonesia’s foreign pressing challenges as the nation’s first minister and as first prime minister negotiated president such as forging national unity in the the with the Dutch in wake of regional uprisings, conflict between the 1947 – was disillusioned about the , the religious groups and the communists, leadership’s inability to address pressing and tackling economic problems such as poverty economic problems such as the food scarcity and food scarcity. The question of addressing caused by its ever increasing population (Times the problems created by Indonesia’s rising of Indonesia, 31 March 1953: 4). population did not capture the President’s The first Five-Year Plan (1956-1961) had attention in the early 1950s. Soekarno stated acknowledged that Indonesia had an unusually that Indonesia could easily support a population high rate of population growth, with nearly two- of 250 million and that the most pressing thirds of the population concentrated in Java. problem for Indonesia was to provide housing Yet, the Plan was coached in alternate versions and jobs for the people. Therefore, foreign of the pembangunan ideology which argued that journalists perceived that Soekarno argued in Indonesia’s surplus population would serve to favor of a link between population growth and harness the country’s natural resources. On economic development. Foreign journalists the other hand, every increase in the national in the 1950s tended to represent Soekarno income would be neutralized by an increase as ‘pro-natalist’ although Soekarno was able in population. The discussions in the early to accept the logic of birth spacing in order to 1950s boiled down to two propositions (Hull & protect the health of mothers (Hull & Hull, Hull, 2005: 3). First, poverty and high fertility 2005: 12). As the nation’s president, he did continued to kill mothers. Second, poverty could not want to be seen accepting advice from be overcome through economic planning. These foreigners on population control and advocating propositions had widely different implications family planning programmes associated with on the question of how the government should immorality (Hull & Hull, 2005: 13). address the question of poverty. Soekarno had observed that Indonesia’s Dr. Julie Sulianti Saroso, technical director population was growing at the rate of one of Maternal and Child Health in the early million per annum in the 1950s which increased 1950s, was awarded a WHO Fellowship to study the pressure of population on land, particularly Vivek Neelakantan 83 The Indonesianization of Social Medicine in Java. Subsistence agriculture alone was Mohammed) to justify that coitus interruptus unable to fulfil the food requirements of an as a means of family planning was permissible ever-expanding population. On the tenth in the greater common interest of preventing anniversary of Indonesian independence, on 17 maternal mortality. August 1955, Soekarno stated: Ia adalah satu Indonesian newspapers such as Pos bangsa jang biologis-dinamis (The Indonesians Indonesia and English-language newspapers are a biologically dynamic nation). In order such as Times of Indonesia reflect the to achieve the Javanese ideal of loh djinawi, internationalism of the Soekarno era, in 1959 subur kang sarwa tinandur (such fertile critically evaluating the success of family that everything one sows, grows), Soekarno planning programmes elsewhere, for instance argued that it was necessary to resettle Java’s and Malaya (Singapore). Such an approach ever-increasing population on the Outer was at odds with the Indonesian government’s Islands through a programme of transmigrasi preoccupation with domestic concerns such as (transmigration) and at the same time the deterioration of parliamentary institutions increase productive capacity of land through a and the government’s perception of family modernization in agriculture (Soekarno, 1965: planning as an international aid intervention 221). Soekarno had approached the population infringing upon Indonesia’s sovereignty. A Pos problem through a vision of transformation of Indonesia article dated 5 July 1959, screamed Indonesia’s economy from a colonial economy Bahaja Besar jang Mengantjam Asia: Kenaikan based on estates and subsistence agriculture Penduduk Sangat Tinggi, Sudah Perlukan to a self-supporting socialist economy capable Diadakan Sistim Pemandulan (Asia needs of standing on its own feet (berdiri atas kaki drastic steps to curb population growth). sendiri), based on industrialization. The rate of population growth in Indonesia In 1959, Dr. Hadji Ali Akbar had published was seven times the corresponding figure in an article in Madjalah Kedokteran Indonesia Europe. It outstripped the nation’s capacity to on birth control in order to address the medical, produce food, thereby raising fears of starvation political, economic, and religious reservations (bahaja kelaparan) (Pos Indonesia, 5 July in Indonesia against birth control through 1959). In India, 25 per cent of the population a Malthusian lens. According to Akbar’s was undernourished. In the state of Madras, argument, the world’s population expanded at the then Congress government had introduced a rate of 25 per cent per decade in the 1950s a cash-based incentive for couples practising leading to a fear of ‘population explosion’. Nearly family planning. Elsewhere in Southeast Asia, two-thirds of the 900 million children worldwide the People’s Action Party in Singapore had in the late 1950s suffered from inadequate introduced family planning in the late 1950s, nutrition. One of the commandments of the accompanied by a comprehensive programme Koran proclaims that every person shall have that served to improve the quality of life of a right to food and shelter. But population children through enhanced nutrition, and growth outstripped food supplies, particularly education. in Indonesia. Therefore, birth control was a Family planning was a controversial issue necessary measure to improve the quality of that divided the Indonesian physicians in the life of children. As most Indonesians were of the 1950s. Although advocated by Indonesian conviction that life is sacred from conception, newspapers such as Pos Indonesia, based in they found it hard to accept the economic urban centres such as Surabaya, such articles rationale of birth control. Therefore, Akbar had limited readership in the 1950s. cited from the Hadith (sayings of Prophet 84 Lembaran Sejarah, Vol. 10, No. 1, April 2013

A related issue in social medicine in in cooperation with the BKIA. The pilot project Indonesia at the time concerned child health, of enlisting dukun for childbirths was initially a matter generally subsumed under the broad implemented in the Yogyakarta region and met umbrella of population health. A representation with success during the period 1953-1961 in of the post-colonial Indonesian child and the preventing maternal and neonatal mortality. way child health and survival influenced On the whole, enlisting the cooperation of discussions about social medicine form missing dukun to prevent maternal mortality was elements in the historiography of Indonesian largely unsuccessful as the dukun refused to medicine of the Soekarno era. register for the training program provided by The idea of instituting maternal and child the government fearing competition from the welfare in independent Indonesia was the BKIA midwives. According to the Division of brainchild of Professor M. Soemedi who had Maternal and Child Health estimates for 1961, earlier worked on a Rockefeller hygiene project Indonesia’s population grew at the rate of well in Java prior to the Second World War. In 1948, over one per cent annually whereas there were the Ministry of Health under the Republican only 50 midwives entering the health services, government had set up health advisory bureaus a figure grossly insufficient to keep pace with to achieve coordination between maternal the country’s rapidly rising population. and child health. They were rechristened as The fervor of the Indonesian Revolution Balai Kesedjahteraan Ibu dan Anak (BKIA). continued to have an impact on health policies Kesedjahteraan, loosely translated into English during the Soekarno era. Nation-building as welfare or happiness. In 1949, the BKIA was held synonymous to character building. implemented maternal and child health Children were perceived as agents of social programmes in Indonesia that embraced both transformation, constituting Manusia Indonesia rural and urban areas (Gambiro in Paediatric Baru (New Indonesians) in accordance with the Indonesiana, 1964: 136-7). However in the pembangunan (developmentalism) ideology. early 1950s, Indonesia faced an acute shortage The growth of a baby was in policy circles of skilled medical personnel, most noticeably regarded as a golden standard to assess the midwives. On average, one BKIA served a state of the Indonesian nation. population of 15,000, but these figures are The issue of child health was addressed misleading. Although on paper every subdistrict through a number of pilot studies, often would have one BKIA, in reality,the BKIA was undertaken with international support. In not fully functional in the Outer Islands, or the 1950s, the Southeast Asian Regional they were seldom visited by pregnant women. Organisation of the WHO (SEARO), and the In Central Java, only 26 per cent of expectant UNICEF initiated pilot nutrition projects in mothers visited a BKIA whereas in Indonesia to investigate the socio-cultural less than 10 per cent of women made use of the determinants of nutritional deficiencies through services of the BKIA. Rural areas in Indonesia dietary and nutritional surveys. The surveys were the dukun and the dukun bayi domains. showed that rates of malnutrition were related A dukun was able to attend up to six deliveries to socio-cultural practices such as dietary per week in contrast to three deliveries per preferences, schooling, and household income week per . However, the dukun were (social determinants of health), causing chronic untrained in hygienic practices. Therefore, a malnutrition in Jakarta and Lombok. pioneering attempt was made in Indonesia to In 1949, Poorwo Soedarmo and J.V. Klerks train dukun bayi in simple hygienic practices of the Nutrition Institute (Jakarta) with the with which they could carry out their profession support of UNICEF carried out a survey of Vivek Neelakantan 85 The Indonesianization of Social Medicine infants (both boys and girls) below the age of 3, engaged in the informal sector. Apart from school-going children under the age of 12, and ascertaining the age of the toddler and medical men in the age group of 12-20, 25-45, and 50- examination for tuberculosis, which would 60 years in order to assess their dietary status aggravate malnutrition, the study established a as a response to food shortage in Lombok due positive correlation between feeding habits and to the failure of rice harvest in 1949 (Poorwo malnutrition. Interviews with mothers revealed Soedarmo, in Poorwo Soedarmo, J.V. Klerks that poverty was not the most significant & W. Praenger [eds], 1949: 3). The nutritional determinant that influenced poor nutrition of surveys revealed that toddlers enjoyed better toddlers, although 75 per cent of the family nutritional status compared to their school- income was spent on food. The study discovered going siblings due to the higher allocation of that the health of the mother was not always food at the household level. Overall, the state positively correlated to nutritional disorders of nutrition of the working age group (25-45) among children as faulty feeding practices such was relatively favorable with only 11.5 per as a rice-based diet may have contributed to cent suffering from nutritional deficiencies a reduced nutritional intake. The nutritional as compared to 29 per cent in the 12-20 age surveys in Indonesia of the 1950s force us to group. The survey indicated that Sasak rethink the direct correlation between poverty households favored men from the working-age and malnutrition that was assumed to hold true group above women, toddlers and children in in policy circles of the WHO and Indonesia. the distribution of food. School feeding was implemented as an emergency relief measure in Conclusion 1950 to reduce under-nutrition among children but failed to achieve desired results due to The ideology of pembangunan a local food shortage in Lombok and a lower (developmentalism) influenced Indonesian priority given to school-going children in the understanding of health policies throughout allocation of food at the household level. The the 1950s. President Soekarno’s interpretation nutritional survey questioned the feasibility of of pembangunan ascribed agency to mankind emergency relief measures in ameliorating poor to surmount national problems. Indonesian nutritional status of the population without leaders acknowledged a correlation between addressing poverty, intra-household inequality, illness and low economic productivity. They and problems of rural indebtedness. appropriated the WHO definition of ‘health’ - health defined in terms of social well-being In 1952, the WHO commissioned a study of - into the Indonesian context. Consequently, chronic malnutrition among Jakarta’s toddlers health became a means to realize the aims which established a co-relationship between of a socialist society in accordance with the infant feeding practices at the household principles of Pancasila. level and kwashiorkor (Poorwo Soedarmo & H.A.P.C. Oommen in Madjalah Kedokteran Pilot studies on nutrition in Indonesia Indonesia, 1953: 229-49). This study examined undertaken by the Indonesian nutritionist the influence of the wider social environment Poorwo Soedarmo in 1949-1952, questioned the that contributed to poor feeding practices WHO thinking that perceived a vicious circle leading to chronic malnutrition. The sample between poverty and ill health. The studies population consisted of 146 untreated cases, of highlighted the need to identify structural which 127 cases were chronically malnourished, forces such as the patriarchal system, age, at the Central , Jakarta. These toddlers gender, and class in assessing the incidence of hailed from families whose parents were nutritional disorders and recommended health 86 Lembaran Sejarah, Vol. 10, No. 1, April 2013 education to bring about an attitudinal change Soedarmo, Poorwo, ‘Food Shortage in Lombok,’ in: in feeding habits. Poorwo Soedarmo, J.V. Klerks & W. Pranger This article offers a close examination of (eds), Lombok Food Problems. Surabaya: Van the partnership between Indonesian physicians Ingen, 1949. and the nationalist regime immediately after Soekarno, Dibawah Bendera Revolusi. Jakarta: independence, including their shared vision of Panitia Dibawah Bendera Revolusi, 1965. state-led social medicine. However, the article does not explore why social medicine failed to Newspapers reshape the Indonesian health system. The Berita Kementerian Kesehatan Republik larger theme of this article is the evolution of Indonesia, Vol. 8 No. 1, 1959, pp. 5-12. Indonesian social medicine in the twentieth Berita Ketabiban, 1944, pp. 43-52. century in a critical response to colonial health policy, a critical attitude by Indonesian Madjalah Kedokteran Indonesia, Vol. 3, No. 6, physicians towards WHO thinking and 1953, pp. 226-49; Vol. 4 No. 9, 1959, pp. 198- President Soekarno’s notion of social justice. 215; Vol. 6 No 1., 1956; Vol. 7 No. 7, 1957, pp. 140-54, No. 11, 1957, pp. 341-8. 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