Manalah Mungkin

Menikah mungkin menjadi satu-satunya keputusan yang pernah saya ambil dalam hidup yang jauh dari keegoisan, paling tidak begitulah nampaknya saat itu. Untuk seorang yang punya ambisi untuk menaklukan dunia, menikah tampak seperti satu-satunya checkpoint yang tidak berhubungan dengan cita-cita saya. Seorang yang punya impian sebegitu tinggi, mungkinkah ia menikah dan menyerah terhadap mimpinya, begitu kata teman saya kala itu.

Mereka tidak tahu bahwa saya berpikir sebaliknya, bahwa pernikahan yang saya pilih untuk lakukan adalah batu loncatan lain untuk impian saya. Bukankah seorang butuh kestabilan emosi dan finansial, untuk dapat mengembangkan dirinya lagi? Agaknya teori hirarki kebutuhan begitu terpahat dalam hingga saya selalu menjustifikasi seluruh tindakan sesuai dengan ajaran teori itu. Teori hirarki kebutuhan bilang  bahwa kestabilan keluarga dan cinta adalah kebutuhan dasar yang harus seorang penuhi sebelum ia dapat mencapai tahapan selanjutnya untuk menjadi beruang, berprestasi dan yang paling tinggi, untuk diakui.

Maka menikahlah saya dengan seorang laki-laki pilihan saya sendiri, seorang yang begitu penyanyang, pengertian dan bermimpi dengan ‘hemat’. Satunya-satunya hal yang ia inginkan adalah untuk memiliki keluarga yang bahagia. Kesederhanaan mimpinyalah, yang sebenarnya membuat saya begitu hilang kendali atas perasaan saya sendiri. Tidak pernah saya membayangkan ada seorang yang keinginan terbesarnya hanyalah untuk mendapatkan kebahagiaan dalam keluarga yang ia bina kelak, sesuatu yang begitu langka dan ‘mahal’ di dunia yang materialis.  

Namun orang boleh berangan, dan Tuhan berkata lain, jika memang Tuhan benar adanya. Pernikahan membawa angin lain pada laki-laki saya. Ambisi saya yang terlalu megah dan meluap-luap telah meracuni asanya yang suci. Tidak butuh waktu lama untuk saya bisa menyulutkan cita-cita lain dalam hatinya. Untuk yang pertama kalinya ketika saya bertanya apa yang ia cita-citakan di masa depan ia menjawab ia ingin menjadi sesuatu, bukan sesederhana membina keluarga bahagia. Manalah mungkin saya yang selama ini telah menitikkan nila pada air jernih dalam periuknya, berani untuk tidak mendukung ia yang akhirnya punya keinginan yang lebih muluk seperti manusia yang lain? Manalah mungkin saya yang suka mengejeknya karena ia punya cita-cita yang begitu ‘rendah’, bisa mempertanyakan padanya mengapa pada akhirnya ia memutuskan untuk mengganti cita-citanya menjadi ‘lebih tinggi’?

Apa boleh seorang yang telah berjanji dalam hidupnya, untuk akan selalu setia menemani dalam suka dan duka, dalam mimpi yang rendah ataupun tinggi, tiba-tiba berbalik arah dan menyesali keputusan hidup bersamanya? Apa boleh seorang yang telah begitu yakin ketika pertama memulai tiba-tiba tidak berani maju karena tiba-tiba teman seperjalanannya mengajaknya ke arah yang lain, menuju cita-citanya bukan cita-citaku? Apa boleh seorang yang telah mengenalkan, menanamkan dan menyuburkan suatu benih tiba-tiba memilih untuk tidak lagi menyemai dan memanennya, malahan berusaha untuk mencabutnya dan menjadi puas setelah lahan itu kembali kosong?

Begitu naif sebuah keinginan manusia yang tidak pernah menduga betapa berat menjaga ikrar kehidupan bersamanya di awal, padahal ia tahu bahwa pada manusia tidak pernah ada yang tetap kecuali perubahan. Begitu bodoh seorang awak kapal yang berpikir bahwa keakuannya yang lebih besar akan mengalahkan keakuan kapten kapal dan memanipulasinya untuk bisa mengantarkan ia di pulau yang ia inginkan.

Tapi apa mau dikata, begitulah kehidupan bersama yang walaupun pondasinya adalah cinta, temboknya hanyalah batu bata dan atapnya hanyalah genteng belaka. Memangnya ada di dunia ini seorang yang cukup kaya untuk bisa membangun rumahnya semata berbahan dasar cinta? Toh, jika cinta sebenarnya hanya dibutuhkan untuk pondasi saja mengapa harus menghamburkan cinta untuk membuat satu rumah? Jika seorang punya cinta yang berlebih-lebih, mengapa ia tidak membuat dua, tiga, empat atau sepuluh rumah berpondasi cinta, bertembok batu bata dan beratap genteng yang lain?

Sekarang mimpi untuk memiliki keluarga bahagia tidak terdengar lagi sebagai mimpi yang hemat dan sederhana. Terlebih ketika tidak satu pun di antara kami yang ingin memilih untuk menjadikannya sebagai daftar urutan mimpi pertama kami. Nyatanya berapa keluarga yang benar-benar bahagia? Apakah semua keluarga dimana kedua ayah dan ibunya berhasil mencapai cita-cita duniawinya benar adalah keluarga yang bahagia? Apakah keluarga yang berumah asri dan nyaman, bermobil mewah lebih dari satu, beranak pintar dan sehat adalah keluarga yang bahagia? Kini tidak ada lagi yang bisa saya tanyai tentang arti sebuah keluarga bahagia karena ia yang dulu begitu mengerti mungkin juga sekarang sudah lupa akan mimpi-mimpinya yang pernah membuat saya jatuh cinta. Entahlah.

Menyoal Kodrat Laki-Laki dan Wanita

Setelah 50 tahun lebih Simone de Beauvoir menulis tentang wanita yang selalu menjadi warga kelas dua dalam the Second Sex, tibalah pada masa kini dimana emansipasi dianggap sudah tidak diperlukan lagi. Masa kini dimana hak wanita kini sudah ‘lebih’ diakui di mata laki-laki hingga membuat laki-laki yang hidup di jaman sekarang menjadi laki-laki yang lebih ‘toleran’ dan ‘adil’ dibanding laki-laki di jaman Beauvoir atau RA Kartini. Hak untuk mendapat pendidikan, hak politik untuk dipilih dan memilih, serta hak mendapatkan penghasilan yang sama dengan laki-laki untuk beban kerja yang sama, sekarang akhirnya sudah dikembalikan pada empunya hingga kini pertanyaannya adalah apakah wanita telah sampai di ujung perjuangan emansipasinya?

Banyak yang berkata bahwa emansipasi itu sudah menjamur dan tidak diperlukan lagi, diikuti dengan penyebutan contoh-contoh keberhasilan perjuangan emansipasi wanita Indonesia, salah satunya adalah terpilihanya Megawati Soekarnoputri untuk menjadi Presiden RI tahun 2001-2004. Tapi apa benar wanita Indonesia sudah memiliki pilihan dan kesempatan yang sama dengan laki-laki?

Dengan modal IQ yang rata-rata sama, wanita dibekali ketekunan yang lebih tinggi dari pada laki-laki, tapi cukup mengherankan bahwa hanya sedikit wanita yang bisa sampai pada puncak kariernya. Terlebih jika melihat ranking IPK tertinggi pada kelulusan yang biasanya didominasi oleh wanita, tidakkah terbersit pikiran untuk bertanya apa yang sebenarnya terjadi hingga mereka pada akhirnya tidak dapat mempertahankan pencapaiannya untuk tetap berada di puncak klasemen?

Mungkin salah satu alasannya adalah sampai saat ini wanita tetap dihadapakan pada pilihan untuk memilih antara karier dan keluarga. Hasri Ainun Besari seorang yang dikenal sangat pandai di kelasnya dulu hingga kepandaiannya dianggap setara dengan BJ Habibie, yang kelak menjadi suaminya, oleh guru-gurunya semasa di sekolah, adalah seorang dokter lulusan Fakultas Kedokteran Universitas Indonesia. Selepas lulus menjadi dokter umum, Ainun, yang selanjutnya lebih dikenal dnegan nama Ainun Habibie, melanjutkan pendidikannya untuk menjadi dokter spesialis Anak di Universitas yang sama. Sayangnya, setelah menikah dengan Habibie, Ainun harus rela berhenti dari pendidikannya dan memilih untuk mendampingi Habibie terbang ke Jerman. Di fase hidupnya yang selanjutnya Ainun yang rindu untuk dapat mempraktekkan keilmuannya, kembali menjadi dokter setelah mendapat restu dari Habibie sehingga bekerja lah ia di suatu Rumah Sakit di Jerman. Namun, baru beberapa saat bekerja Ainun memutuskan untuk menyerah menjadi dokter, kali ini untuk selamanya, karena tak tega melihat anaknya yang tidak terurus. Ainun kemudian lebih dikenal kiprahnya sebagai seorang istri dan ibu yang penuh cinta kasih dan pengertian yang terus mendampingi suaminya hingga di akhir hayatnya, dibanding sumbangan dan pengabdian di bidang keilmuannya. Pilihan Ainun dianggap sebagai hal yang wajar karena ia mengikuti kodratnya sebagai wanita, yang terlahir untuk setia dan welas asih bukan untuk melakukan pekerjaan yang lain.

Wanita yang bekerja sering disalahkan karena anak-anak yang tidak terurus atau laki-laki yang selingkuh. Istri yang sibuk bekerja dan menjadi kurang perhatian pada suami adalah pembenaran yang umum didengar dari laki-laki yang berselingkuh. Mungkin seorang boleh bertanya, seberapa besar perhatian yang sebenarnya dibutuhkan laki-laki hingga ia tidak mungkin berselingkuh? Bukankah seorang laki-laki yang sudah berpoligami malah cenderung untuk terus dapat menambah istrinya? Apakah benar kerinduan belaka ataukah keserakahan yang tidak diakui semata yang menjadi alasan utama perselingkuhan?

Mungkin di antara kita banyak yang heran, pada jaman yang sekarang sudah ‘setara’ ini, mengapapengguguran kandungan lebih sering pada bayi perempuan daripada bayi laki-laki? Mengapa banyak orang yang menolak kontrasepsi dengan alasan menunggu kelahiran seorang putra? Mengapa banyak yang lebih mengidamkan kelahiran bayi laki-laki daripada bayi perempuan? Seorang laki-laki tidak pernah dihadapkan pada pertanyaan apa yang akan ia pilih antara karir atau keluarga, semata-mata karena ia adalah laki-laki.

Laki-laki tidak akan pernah disalahkan karena anak-anak yang kurang perhatian atau keluarga yang carut marut. Bukankah tugas utama laki-laki adalah untuk mencari nafkah? Bukankah laki-laki terlahir untuk lebih berpikir daripada merasakan? Bukankah wajar bila laki-laki yang giat bekerja lalu tidak dapat mengurus keluarganya? Bukankah itu kodratnya?

Kodrat adalah garisan takdir yang secara umum telah didogmakan agama secara membabi-buta pada penganutnya, percaya tidak percaya, ya harus percaya. Baik itu Al-Qur’an, Al Kitab, Tripitaka, dan kitab-kitab lain yang pernah ditulis sebagai panutan agama, wanita selalu digambarkan sebagai makhluk yang menjadi lem pada cangkir bukan teko yang memberi air. Tidakkah anjuran ini terdengar sangat memihak ketika kita tahu bahwa para nabi yang menyampaikan ajarannya adalah laki-laki? Mungkinkah mereka menyampaikan sesuatu yang tidak menguntungkan bagi kaumnya? Lalu apa yang dapat kita jadikan bukti, jika Tuhan memang ada, bahwa perkataan itu adalah perkataan Tuhan yang tidak memiliki keberpihakan ketika dalam agama tertentu Tuhan dikenal berjenis kelamin pria? Tidakkah sedikit pun itu mengganggu kita bagaimana sejak jaman dulu panutan yang kita taati tanpa bertanya mungkin saja sengaja dibuat untuk menguntungkan kaum lain dan menundukkan kaum yang lainnya?

Bahkan menurut bahasa Jawa, wanita adalah singakatan dari wani ditata atau berani untuk diatur. Kitab-kitab Jawa tidak ada yang ditulis oleh seorang wanita, besar kemungkinan karena wanita tidak pernah mendapat pendidikan dengan alasan ujung-ujungnya hanya disuruh untuk mengurus suami dan anak. Pemikiran yang kita anggap bodoh pada masyarakat jaman dulu tapi ironis kalau kita tahu bahwa sekarang para sarjana, para insinyur, para dokter, para pengacara memilih untuk menelantarkan karirnya dan kembali pada kodratnya untuk mengurus anak dan suami. Pilihan yang sesuai kodratnya.

The Idea of Happiness

Happiness is a state of mind which cannot be defined exactly as its idea is dissimilar for each person. Though every life’s goal is to find happiness, everyone lives their life differently according to their own perception. Needless to say, that our idea of happiness defines our life path.

For the ambitious, life is like a ladder and the goal is to arrive at the top floor. Claiming high position or title is their idea of happiness. I am one of those people. All my life I have kept seeking to advance. I can’t help the anxiety creeping to my mind once I stay calmly in a step ladder. Since I was a child, accomplishment has become my way of asking for gift. I wasn’t born in a wealthy family. Each time I had something that I wanted, I needed a good reason to ask. Becoming a winner was my biggest shot.

There was also time, when I merely joined competition because of the prize. Sometime I wanted to buy my own goods without asking to my parents. Joining a competition could be really profitable. By paying a small amount of money at the registration, I could get as much as ten times of my ‘early infestation‘ once I became the winner.

Winning is addictive. There is this exciting mix of feeling that I feel once I succeed. I feel invincible, proud and the most important, happy. There is no feeling superior to happiness. Sometime I think that to be able to survive, we only need to be happy but, such a good feeling never last long. A tiny misfit can ruin it easily. Thus, I need to win again.

My idea of happiness leads me to see this life as a competition. Every day, I am fighting to not losing. I need to win to feel happy. It gets me higher than most of my friends, yes. But it feels really exhausting sometime.

Idea is not fixed, it keeps evolving as people grow and interact with their surroundings. Mine of happiness will transform too, someday.

Disgraceful Young Or Elder?

Politeness has long became elder favorite subject of critisizing young generation. They love to say how most of adolesecent and young adult’s skill of communication are lacking, not in the term of uneffective communication but manner degression. In the country where manner is considered superior than matter, a new generation who use simplified interaction are often disregard.

Elder wants to teach about manner so bad that they incorporate this subject in formal teaching formed under school curricula. Art, Culture and Skill (SBK) is a subject in primary to high school which teaches Indonesian culture in not only form of art but also in form of life skill (communication included). I don’t object the teaching of SBK in school since what I know from my litlle brother textbook, it looks like a fun informative cultural rich subject. However, such life skill of communication should not be taught formally as it is human’s natural ability. Sooner or later they will be able to do it.

The main goal of communication is to deliver and receive messages. Form of communication itself are varied depended on multiple factors. Whichever form of communication used, they are all considered good as long as it can effectively send intended messages. However, people in Indonesia are more interested in manner heavy rather than matter heavy. Sweet flowery talks are considered better than meaningful straightforward talks. Those who talk short are considered as rude and disgraceful. Perhaps, it becomes one of the reason why our officials are smart talker instead of hard worker.

In fact, cultural heavy communication form has been responsible for many airplane crashes in 1980s and 1990s. Quoted from Malcolm Gladwell book, Outliers, between these years Korean Air were crashing so often because miscommunication between flight attendants. Korean, like Indonesian, are strictly bound to their traditional culture, even in modern aviation industry. One of the cockpit conversation from the crashed plane, recorded in Black Box, found that Korean Air co-pilot were keep using ‘code’ of disagreement to show his objection of captain decision, instead of straightforward talking. Unfortunately, the captain did not understand his co pilot true meaning and kept doing his wrong approach, the plane crashed as a result. This is a life and death situation where people are faced in fight or flight state. But bizarre enough, even in this kind of circumstances, Korean flight attendant were still tightly follow their cultural order of communication, resulting in wrong received messages.

Have thoroughly understood the lying problem, Korean Air then reformed itselves by switch its staff training and improved its way of communication so that there will be no more ‘taboo’ words to say to the captain for the greater good of flight. Following this breakthrough, in 2006 Korean Air was given Phoenix Award by Air Transport World in recognition of its transformation.

Communication obstacles are also occured in medicine due to its hierarchaly structured arrangement. At the top of the chain is professor, folowed by senior consultant then junior consultant then residents then intern then medical students at the bottom of the chain. But in other acclaimed chain, senior nurse is placed above resident, followed by general nurse then intern then medical students. By this form of hierarchy, message is transported carefully from chain to chain, don’t dare skip any of it if you don’t want to be labelled as rude brat. Also important to be noted that, you need to first use flowery sweet talk to begin every conversation with everyone on the chain, upper or lower. Being rude brat can get you in trouble and will make you kicked out from any possible social interaction.

Medicine is one of the field that mostly faced with life and death decision but strangely practice in calm aristocratic way. It is necessary to rapidly response and decide on any given cases, especially emergency. Ideally in this kind of circumstances, politeness should be taken aside and straightforward (though may also be rude) talking supposed to be considered as prime. In the utopion world, any social uncomfort following this out of order socially structured interaction will be forgotten and forgiven.

Culture is our society’s color. It should festives our interaction with others, not isolate us and enstrange ourselves inside a list of allowed or unallowed manner accroding to politeness. Elder should be wiser in seeing this matter, instead of being easily offended by minor misconduct. It is necessary to preserve our culture in young generation yet, exaggerated way of preserving will further distance the young from the elder. As a consequence, young people may be sick of their own culture and grow out of it completely. So tell me which one of them is more disgraceful?

Empathy As Foundation of Medical Practice

I'm currently working in pediatric ward and reading a book written by a sick person. It's more than enough for me to start thinking about doctor and patient relationship. I am used to see sick people, watch somebody fight their last battle and announce death to the family. Sickness and death for me are like regular paperwork lied in office table. It's merely work. But sometime in some 'idiosyncratic' days, I cannot stand not to overthink or overfeel it. This is the worst thing you may do as a doctor, beside misdiagnose.
During medschool, I learn about empathy. It is defined as the act to understand someone's feeling and behave appropriately upon it without getting ourselves involved either at heart or mind. If you, somehow, share the same feeling as your patients or their families and overwhelmed by it, that is called as sympathy. Doctors must not become sympathic to their patients, empathic is the farthest we may go, since growing sympathy is exhaustive and able to interfere our feeling and therefore, fogs our judgment.
However, sometime I have idosyncratic days of empathy and it happen when I witness relationship of pediatric patients and their parents. It is hard to limit the growing of sympathy when you are in a ward filled with loveable creatures and their constant guardians who hold hands and whisper kind words or sing lullabies. At this point, you may be wonder how sharing parents' feeling of these sick kid will lower medical care given.
Growing sympathy is dangerous not because it makes doctor deliver lower quality of healthcare, in fact it makes doctor become more motivated and hardworking. As consequences, they will provide over the top care, run more diagnostic test, give better or more medicine. All of these sounds good, though it is not. Overdiagnose is as bad as underdiagnose, and overtreatment is as equally as dangerous as undertreatmemt. Wu ji bi fan (物极必反), said Jackie Chan to Jaden Smith in Karate Kid movie, which can be translated "As soon as a thing reaches its extremity, it reverses its course. Things will develop in the opposite direction when they become extreme," or simply means "too much is bad".
Overdiagnose is relatively new problem in medicine. In older time, people will only seek doctor during life and death condition. Yet, today a kid with 6 hours of fever will be brought by their parents to ER for fear that their kid may have hemorrhagic fever. It is a good precaution to be alarmed of what fever may lead. We should congratulate government's health promotion center for this. However, 6 hours onset of fever will not change anything in terms of body response, which is mostly used in detection test, therefore the kid's lab test will be false negative. There are some tests that measure antigen (existence of substance other than our body component, for instance virus) which allow faster detection in lab. Nevertheless, even this test need 1 day window period to appear positive. If however, doctor who treat this kid develop some sympatic feeling, he may be order some lab tests, which is expected to be negative, and expose this kids to unnecessary harm.
The worst consequences of overdiagnose is overtreatment. In our 6 hours onset of fever kid with negative test result, an overcaution doctor may prescribe her/him not only with fever lowering drug but also with antibiotic which most of the time is unnecessary as most infection in children is viral. This is a double preventable unnecessary harm.
Overtreatment is not merely doctor's fault. Parents also contribute to it by becoming overcaution and demanding. Being overcaution about their kid's condition is parent's job, but usually parent doesn't stop there. They goes further by asking for certain drug prescription, antibiotic most of the time. Though doctor knows that antibiotic will only be useful for bacterial infection, facing this kind of parent can alter their decision. Drug is toxic if it is not targeted for the right condition. Even if it is given for the right disease, the adverse effect still can not be avoided. Therefore, drug use should be administered really carefully by weighing their harm and benefit.
Looking at this doctor and patient's pattern of relationship should increase our awareness of possible conflict of interest in medical care by unexpected parties. Whomever interfere doctors' judgement, either it's themselves or patients, should not be taken lightly. Every patient should be managed with best available treatment. Even if it means that doctor should isolate their own feeling or ignore patient's exaggerated worry.
Empathy can be seen as solution for this issue. It open windows of possibility of budding doctor patient relationship in just the right amount so that it won't affect any judgement.
Empathy can be taught in medschool and it is best given with small frequent dose. It means that empathy should be put continuously in every module with short amount of hour. Students may get bored and thus, lazily join the course. However, eventually after the end of medschool, they will find its beneficial effect in delivering medical practice. Thus, I encourage all medschools to incorporate this teaching in their curriculum. 

The Falling of A Knight

Today is the day we will all remember as the day of the falling 'Knight'. Television and online media brought us to witness how ambition overtakes and ruins senses of a great man. Prabowo was a great man, until he became so overwhelmed with his toxic obsession of being the man of the country.

Born and raised in well educated family, Prabowo grew up to be a smart kid (found out recently that his IQ test scored at about 150). With his good look and charming attitude, it was enough for him to be a womanizer. During his time in army, he was a very dedicated and respected soldier. He even was able to earn promotion almost every year. Of course, we can not forget the fact that at that period of time, he was the son in law of the president. But still, our former 32 years long President must have seen something in him, he wouldn't choose anyone for the 'affectionate' position out of the blue.

He though was not perfect. There were several scandals linked with him. He was mentioned to be the man responsible for the disappearance and death of '98 reformation activists. As a consequence, he was dismissed from the army in his peak career as a Lieutenant General. He was then divorced with the president's daughter, blaming different political view as reason. He moved on though, left the country and started to build his career as a corporate giant. He succeeded.

However, his shining path in entrepreneurship didn't resonant in his political career. Though his founded political party shone out during its first and second time in general election, it didn't get him the vice president crown at first try and president at his second and last try. His failing last attemp resented and wounded him badly.

Instead gentlemanly step back and accept his lost, he had prepared comprehensive rejection for the election result. First, he declared signing off from the election as a rejection of result. Second, he declared to cancel his previous statement of walking out from the election, knowing that he wouldn't be able to sue anyone behind his lost. Third, he reported unfair conduct of election to constitutional court. Before officially entering his report, he confidently stated that there were vast amount of evidences, size of tank, supporting his claim of unfair election, though his real evidences handed to the court was one bundle of paper, size of a toy tank. The court rejected his claim. He once again lost.

At this point, you may have predicted what follows, unacceptance and accusation of court side taking. I don't know if this will be the end of his long neglect, but sure it is the beginning of his rock bottom sliding. Losing would not make anyone losing sympathies, but being a childish unsportive adult will. Furthermore, instead of going from hero to zero, he's going into minus if he continues blinded by his ambition.

There's an analogy of road to success and road to acceptance as mountain climbing and descending. It is easier going up than going down as you are drived by the motivation to get to the prize at top of the mountain. It makes you ignore soreness in your legs. But once you arrive at the top and start to go down, your journey become more dangerous as you are already exhausted and suddenly turn to be more careless. Your legs are all cramping, you already run out of food but you have to control the gravity pulling. Thus, most of explorers who fail were found in the descending track.

Mr. Prabowo is in his road of going down. It may be hard, but sure it is not impossible. In fact, he has through 2 out of 4 acceptance stages, denial and anger. Later, he will be in depression stage, tough it is usually last the longest. He will some day there in the last stage, the sweet acceptance.

My prayer is with you, Pak.

What I (un)Learn During Internship - Part 2 (Abusing Social Insurance)

Since January 1st, 2014 Indonesia has finally implemented its new national social health insurance system (SJSN) with goal of realizing health for all. The new funding system aims to deliver accessible and affordable health care for every Indonesian, living everywhere in the country. 

Social insurance has long been admired to cover all Indonesian, regardless their economic and social status. However, before the realization of SJSN, only the poorest and least fortunate households were covered by social insurance, under Jamkesmas, Jamkesda and Gakin, while the middle class people who were not eligible for these insurances were forced to pay healthcare by out of pocket funding. According to their economic status, most of Indonesians can be classified as middle income people, thus out of pocket spending shared the biggest health financing source in this country.

Middle income people do not own enough money to keep purchasing for health care, thus if they continue this habit of health spending they will finally be 'exhausted' and overwhelmed by it. To cut this suffocating condition, Indonesian government then decided to reform its health financing system by implementing new national social insurance with universal health coverage as the main goal.

For 8 months long since it first runned, most of Indonesians are still unregistered for the insurance. In fact, there are less than 20% of citizenz covered until now, still we are far from our dream to provide health for all. Nonetheless, misconduct from healthcare provider has been able to be spotted in many places, including the hospital where I am posted during my internship. One of its massive wrongdoings lays in how it overclaim diagnosis. 

As a secondary health care provider, scheme of the new social insurance in it is to receive costumized financing from health insurance provider (BPJS) according to disease diagnosis as listed in INA CBGs. If you have certain disease such as severe head trauma, the allocated fund for your case is Rp 8.000.000. It means that the cost of treating you from laboratorium test until surgery cannot exceed this amount whereas such case usually may spend about Rp 12.000.000 in your hospital. If you (by using healthcare) exceed this amount, like Rp 4.000.000, 00 higher in this case, your hospital will suffer financial loss. Imagine if it happens over and over again, the hospital will not be able to endure it and will collapse as a result. 

By this means, the hospital should manage each case cost efficiently in order to survive. Unnecessary tests and treatment should not be administered to patients, generic drugs should be chosen over patents. However, old habits hard to die. Some hospitals (including the place I'm posted in) keep operating ineffeciently, yet they know the consequences. As a result, they cheat their way out by putting more diagnoses so that the social insurance will cover higher amount for them. How brilliatnly despicable.

This problem should be seen as systemic problem, rather than one hospital management misconduct. Doctors are not innocent. They take part in this corosive act, by growing preferences in prescribing patent over generic drugs. If their reasons to do so is because the generic isn't available yet, it doesn't make sense since most of their drug choices have long been invented after their patent runs out. Even if they argue that patent drugs are better than generic, this isn't correct either. They are identically the same, made with the similar substances. I don't see how they can be more superior than the generic. Their superiority claim might only lays in their pamphlets and brochures brought and spread to the doctor's office by the med reps.

Patients aren't guilty free either. They often encourage doctors to prescribe expensive drug with belief it has better effect, whereas it is purely precipitated by placebo effect. There's a study by Branthwaite and Cooper which find that packaging effect has beneficial effect in enhancing pain relief. Even more interesting, another study exhibited that pain relief drug was more potent when subjects were told it cost more ($2.5) than when they were told it cost 10 cents.
However, even if doctors finally agree to compromise and decide to use generic over patents, the hospital has marked up drug prices some extra rupiahs for all social insurance patients.

This is how complex the problems are. Everybody takes part in abusing social insurance.

The last disturbing fact that I can provide you is that once BPJS delivered funds for the claim, each people work here enjoy extra money since received funds exceeds their real expenses.Imagine if this is how social insurance is conducted in most places, Indonesiay will declare bankruptcy in no time.

Here some things that I will be doing if I were anyone important:

• carry out audit each month for every social insurance providers
• place at least 2 BPJS officers in every providers to make sure fair play
• forbid doctors to prescribe patent drugs where generic drugs available
• deliver massive education for public awareness of similar drugs effect between generic and patent
• include healthcare providers, doctors, and patients in SJSN and BPJS feedback and evaluatio

Last but not least, if all of mentioned above have been done eventually but show no significant improvement, hire a shaman and ask him to put a curse on everyone who conduct cheating. Problem solved.

What I (un)Learn During Internship – Part 1 (Boss Based Medicine)

Problem with medicine is its uncertainty. Everything in it keeps evolving; widen disease definition, new drugs, new diagnostic test, new surgical method, and so on. What is considered as beneficial today may be classified as harmful tomorrow. Thus, in order to prevent patients from harm of outdated medical practice, experts develop new approach in practicing medicine, Evidence Based Medicine (EBM).

I learned about it when I was in medical school. It was the module where you were taught about how to read a paper, assess validity of a trial, and find answer of clinical query. At the end of the module, I was equipped with the ability to criticize journals so that I can be more careful in seeking answers through all the available evidences.

EBM training aims to help doctors provide tailored up to date medical practice based on the latest available evidence. This skill is expected to assist doctors in their lifelong learning of medicine. So when we have graduated for 30 years long, our knowledge can still be equally up to date compared to fresh graduates. That's the dream. However, what happens in reality (as in hospital, clinic, etc, other than teaching hospital) is not as beautiful as how it should be. If teaching hospital was a city zoo, the other hospitals would be Amazon.

Internship is the first taste of real world for me and my colleagues, as fresh graduates. I captured (so many) misconducts of medicine during my first 4 months posting and the biggest problem lays in how patients diagnosed and treated.

Few weeks ago, there was a 60% burned surface patients who had been cared in ICU for 3 weeks. At that moment, she appeared to be lethargic with high temperature, high respiratory rates and high leukocyte counts. We also found some evidences of organ damage in her lab results. We were all agreed that she was in severe sepsis. In this kind of condition, there may be some beneficial use of corticosteroid.

Though its use remains controversial, but the last systematic review and meta-analysis published in JAMA on 2009 concluded beneficial effect on short term mortality outcome by low dose administration of corticosteroid. I then, suggested to her attending surgeon, the use of low dose corticosteroid to our patients.
 *Systematic review is a paper which review all other papers using clear method of inclusion and exclusion criteria while meta analysis is a study which pool all trial results, which included based on the previous systematic inclusion and exclusion, into one big spreadsheet and count the overall outcome together. Thus, systematic review and meta analysis provide strongest evidence among other type of studies.

However the attending surgeon who took care of this patient denied my idea of using corticosteroid and argued how corticosteroid would increase the severity of her condition since its effect in decreasing immune response and therefore it would make her more susceptible to infection. That sounded plausible, at first. But he didn’t aware that what actually made septic patients died was their immune reaction, instead of their infection.

Our body has the ability to defense our self from outsider such as, bacteria. When we recognize their invasion, we will automatically release our first soldiers, the innate immune system. Imagine them as cavilary soldiers with standard weapon. Later, these soldiers will call for other help, the chemoatractant (think of them as the army with radio connection which control distance weapon and control media). During all these activities, there is also undercover special forces among these armies who study the invaders tactic, known as adaptive immune system. Right after enough learning, these special forces will attack the invaders with specialized weapon according to their weakness.

If all our immune system response correctly and the bacteria is defeated, we will bnot be sick. However, sometime in special condition in which there are misresponse soldiers or too many enemies, our body will suffer from our overreacting and overactivating defense mechanism. The chemotractant will be released abundantly and therefore disrupt our body function. This is what happen in sepsis. What we need now is something to calm down our body reaction. Theoretically, corticosteroid which work in suppresing immune reaction will help our patients.

Evidence Based Medicine is designed for this kind of situation. When you are faced with life and death decision, looking through all previous trials are the only reliable ways. Unfortunately, this is where the attending surgeon is lacking. Rather than looking for evidences, he relied his judgement on basic medical knowledge.

This is what I actually find from the paper I mentioned before:

1. There is no significant different in 28 day mortality between patients administered with corticosteroid and control, RR 0.84, 95% CI 0.71-1.00; P=0.5; I2=53% in randomised trials and RR 1.05, 95% CI 0.69-1.58; P=0.83 (don’t be intimidated with these numbers, it only means that the result is not significant)
2. In the subgroup analysis, there is significant difference in 28 days mortality between patients received prolonged long term corticosteroid and control, RR 0.84, 95% CI 0.72-0.97, P=0.02 (it means that long low dose use of corticosteroid administration has significant protective effect toward septic patients).

For a dying patient, I think the result of this study is worth trying.

There are reasons why we do a lot of trials in medicine and why we practice medicine using Evidence Based Medicine approach. Our basic science of medicine is most of the time useful to help us diagnose disease but it is often misleading if we bluntly translate it into how we should manage our patients. In medicine, it is dangerous to continously feel intelligent enough or competent enough because, truthfully we can never be too smart in this field. What we thought theoretically correct are many times wrong in real practice. As mysterious as medicine can be, the wisest thing is might be to follow what the great Steve Jobs told us to do, “Stay hungry, stay foolish”. 

Freedom

Today is a special day for me as an Indonesian. It’s the anniversary of my country’s independence day. Sixty nine years ago, a baby just born and called as Indonesia. A new free country with thousands islands, hundreds different tribes and languanges, different kind of clothes even different type of food.

Freedom.

We all wants it. When I was a kid, I remember that I wanted to grow up so fast that I would have my own freedom. I imagined that it would be a lot of fun to be able to sleep late at night, skip my day nap, watch any TV shows without asking permission from my parents first, go to many places at anytime of the day without being called to go home. Being a grown up was great, that’s what I thought.

But, I was wrong.

 I didn’t know there was two kind of freedom, ‘freedom to’ and ‘freedom from’. What I dreamed as a child was to have a ‘freedom to’ while I didn’t realize that at that time I actually enjoyed the luxury of the other type, ‘freedom from’. In ‘freedom to’ situation, you can decide and do anything by yourself. No one is above you. You are in charge of your own life. But no one tells me that once I’ve got my 'freedom to’, I'm own my own. In the ‘freedom from’ condition, you are guaranteed to have no suffering. You are freed from discomfort, hunger or even dirt. When you’re a kid your mom will do all of those necessary things for you. You don’t have to decide what food you want to eat or how you will get it. You are freed from thinking. Even more important, you are freed from the complexity of life.

Most of the time, it is easier to live with ‘freedom from’ rather than ‘freedom to’ type. Puppet countries as known as commonwealth do not need to endure bloody war to gain their independence as they receive it as a gift. It’s not necessary for them to think about their country’s form, constitution, or even national anthem. Everything has been settled and prepared. Even before proclaiming their independence, they already have their head of country. To have a template to build a country, what a luxury. Those ‘freedom from’ countries are usually more developed than the ‘freedom to’ countries. Canada, Australia, are some examples. However, those so called freedom are fake. They are surrounded by walls, their choices are limited. They may never be able to have their own decision. There will always be advice or interference as the consequences of their non suffering. Nothing is free.

I was wrong again. ‘Freedom from’ is not that special.

There will always be two sides of everything, there isn’t any light without shadow. What struck me the most is how hard it is to have a' freedom to' can be. It is a tough job with big responsibilty. If you mess up, you have to fix it yourself. If it is just ruling my body then fine. How hard it can be to handle one self. But governing a country with 250 million people in it who comes from thousand different islands and have their own culture plus without any help feom outside? That is tremendously difficult (look at my president before and after photo, you will see).

Not to mention, my predecessors built this country out of scratch. No template. It's not like there was any senior or expert that they could come to consult as it was everyone's first time. They could not make any mistake, because all of their efforts could be vanished over a night. I remember the story of deciding the proclamation day. The young generation had to force the old generation to proclaim Indonesia's independence on the next day, August 17th, as Japan already lost World War II, on 14th. The old did not want to hury because they remembered Japan's promise to give independence to Indonesia while the young saw no reason to wait longer. So the young kidnapped the key points person, Soekarno and Hatta, to force them to do so. The young won. We proclaimed our independence on August 17th, 1945.

Though my country is still struggling as a developing country. I feel lucky to be born here, in the country where differences are seen as a union. Luckier to know that I have every right to say anything that I want without any fear of being caught, and the luckiest of all, I can do anything mens can do (except, making girls pregnant).

Terima kasih. Dirgahayu Indonesiaku. Merdeka

Why Indonesia Should Legalize Abortion

(This article was featured in The Jakarta Post August 24, 2014 in opinion section printed and online http://www.thejakartapost.com/news/2014/08/24/why-indonesia-should-legalize-abortion.html)

On 21st July 2014, Indonesia government release a new regulation on abortion, PP No. 61/2014 which resonance with the previous higher constitution, UU 36/2009 tentang Kesehatan. In Indonesia, some regulation is a restatement of other higher regulation like PP repeats the stances in UU. Thus in term of content, the new PP on abortion contains no new policy. Abortion in Indonesia remains to be prohibited for most causes unless to safe mother’s life or preventing mental illness in rape victims.

Restricted law on abortion in Indonesia leads institutional safe abortion to be impenetrable to access. It leaves women in crossroad of choosing options available to terminate their pregnancy. If the safe one is restricted, the only choice remain is unsafe abortion. WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Among WHO Asia’ regions, South-Eastern Asia, in which Indonesia included, has the highest rate at 26 per 1000 women aged 15-44 who undergo unsafe abortion.

In Indonesia about 11-14% of maternal mortality (392 in 100,000 live births) is caused by unsafe abortion. It means there is 43-55 women death in 100,000 live births while there are about 4.5 million birth per year in Indonesia. Other studies estimate there are about 37 abortion in 1,000 women aged 15-49 years. Though the real number may exceed this estimation as most of unsafe abortion consider outlaw and become unrecorded, abortion causes (at least) thousands of mother dead each year.

According to WHO, one of the major causes of abortion is unmet need of contraception. There are about over 40% of pregnancies worldwide are unplanned, resulting from non use of contraception and ineffective use of contraception. In Indonesia, about 760,000 or about 17% of all live births is unwanted or unplanned. There are very limited studies provide information on what happen to these kids after they are born, whether they rise well by their parents with adequate nutrition and stimulation, whether they receive enough care and love during childhood or whether they simply neglected.

There was a Prague study regarding this inquiry which followed the development and mental well being over 35 years of 220 children whose mother had been twice rejected to abort the same pregnancy born in 1961-1963. In 1960s, women who wanted to terminate their pregnancy in Czech should first be agreed by some special commission. In the age of 9 years, children from unwanted pregnancies were paired with other 220 children born from accepted pregnancies. The follow up was conducted among the children at age 9, 14-16, 21-23, 28-31 and 32-35.

At first, children born out of unwanted pregnancies had similar birth weights and lengths, same chance of having congenital abnormalities and similar score on signs of minimal brain dysfunction compared to the accepted pregnancy children. However, as they became older the unaccepted pregnancy children develop more psychosocial problem. They had dropped out of school more and had obtained lower scores in school. The boys of unwanted pregnancy were significantly less sociable and well adjusted than the controls, when they got older they were less satisfied with their jobs, relationship and overall mental well being compared to the control. The gap was more significant between unwanted pregnancy women and control women in term of unemployment, unmarried status and parenting difficulties that required authority attention.

The study also includes siblings of unwanted men and women to minimize the confounding factor and it was found that the siblings did not show these psychosocial problems. The study concluded that retaining unwanted pregnancy entails an increased risk for negative psychosocial development and mental well being in adulthood. The result of this study, in part, turned the Czech government to abolish abortion commissions in 1986.

Looking at the magnitude of problem caused by unsafe abortion, it is necessary for regulators to start considering the importance of increase accessibility to legal abortion. This can be done by broadening the inclusion of allowed abortion in constitution. By loosening abortion law, unsafe abortion rate can be minimized and therefore reduce the number of maternal death and future mental health problem.

Despite the benefit, legalising abortion in Indonesia remains to be a major challenge. Most religion see abortion as a sinful conduct, an attempt of murder. Norm and religion remains the same from time to time, but people interact and change. In older time, religious group denied any use of contaception for birth plan but look how we are all benefited from it today. More economic growth, better human development index, and so on. Thus, sociocultural value should never prevent us from accesing better care of medicine

Blame It on The Girls

Man is defined as a human being and a woman as a female 

-Simone de Beauvoir-

I went to a seminar about adolescent sexual health today. It was a very interesting event with many well respected high authority figures spoke. They delivered remarkable presentations, flawless slide show with appropriate amount of jokes in the middle. But my eyes was locked into Jakarta's head of education department, not because of his head which start to bald and was mentioned in almost every minute during his speech, but because of how he reacted at a very sensitive issue.

Prior to his speech, there was a guy, the chief of Indonesia teacher association, who talked about the importance of education for adolescent and sexual problem related to the age group. I asked him about whether there was such policy of expelling pregnant students from school which happened quite often. According to chief of teacher, there wasn't any detail sanction or any instruction to expel them from school. However, they still have to leave school anyway since teacher's creativity to interpret basic school regulation for such immoral behavior is, sex before married (until pregnant or become viral sex tape), to receive highest punishment and be expelled from school, in order to prevent their friends from repeating it. In some schools, if the teacher hasn't kicked them out, they will voluntarily leave school as they feel shameful about it. The chief teacher's solution for this issue is to find way for these unlucky girls to keep continuing her study by sending her to other school or put her in Paket C. Fair enough.

Mr. head of education department, on the other hand, stated that it was unnecessary to help those girls to stay in school. It was their faults in the first place. He continued by saying that they probably enjoy their earlier sexual activity so it was no need for us to find solution for them. It was a jaw dropping moment. Who doesn't enjoy any sexual activity? Even the rape victim sometimes feel aroused. It was a physiologic response. We can't avoid it to happen. It's just how our body react to such stimulus, like nauseous if there's anything hit the back of our throat or coughing if there's any other than air tries to sneak in our respiratory tract.

What more surprising from his statement was what was following it, people's reaction. They laughed hard and clapped loudly as if the sky was falling. Falling and burying those unlucky girls alive.

Human reproduces sexually, if you remember your elementary school biology, so it's not possible for any woman to become immediately pregnant without a sexual partner (exception for Jesus's Mom). But it's funny how all the stigmas only attack woman while man are safe to continue doing whatever they want freely without being stigmatized. It's funny how we place woman to be the only criminal while they are probably the true victim. I'm not suggesting that we should also punish the man by kicking him out of school and screw his life, but what I'm trying to say is that if we can let the man live in peace, why can't we leave the girl alone? Why can't we just let her have the baby and let her stay school rather than creating her Armageddon?

One of the cause of maternal mortality in Indonesia is unsafe abortion, and most of it happen to unwanted pregnancy, the case with our unlucky girls. Afraid by social punishment and stigma, she chooses to terminate her pregnancy by having abortion, and since it's illegal in our country to have an abortion, she goes to an unskilled traditional midwife who merely know how to conduct the unsafe one, then our unlucky girls lose her life because of the unsafe abortion complication. It's society that should be blamed for the death of a girl for putting the label on her. When do we become so cruel? 

Woman are easily forced and scared especially under the dominance of man. They often aren't initiated the act of sexual contact, but most of the time should bare the consequences alone.

We might still remember that there was an unconscious woman in TransJakarta bus who was raped by 4 bus officers. The court decides to "sufficiently" sentenced the defendants with 18 months imprisonment. During the court session, the judges accused the victim of leading on those men by her choice of clothing. Oh poor the men for being enchanted by the unconscious woman. She must be a witch.

I cannot provide any conclusion or even a slight assumption to this issue as I still have no clue why this kind of thing happen in the country famous for its friendliness. Maybe it happens because our patriarchal society, maybe it happens because our religion teach us so, or maybe it's just happen becuase we're lack of love and humanity. Who knows. Wallahualam.

Science Irony

Recently, I read a few medical and science books. Two books that I read were written by Ben Goldacre, a very vocal idealist bright scientist from UK, titled Bad Science and Bad Pharma. The other book was a textbook of pharmacoepidemiology written by group of experts in the field. All of those books gather excellence evidences which criticise how we practice medicine today in term of industry interference and lost research data or inadequate drug study, though the last book doesn't say it straight forwardly.

When I read the books, I find how all of those problems in developed countries are too sophisticated and too advance to happen in my country. Problems like unpublished research data, inadequte reporting, or unnoticed long term adverse events of drugs are far beyond our ability as a country. Those problems are like fairy tale in the country where drugs are mostly still inaccessible and unaffordable. Today's most talked issue among physicians in developed countries, statin's long term side effect in geriatric patients, are somehow irrelevent with circumstances in my country where high cholesterol are still underdiagnosed and therefore undertreatment (following this sentence, I should have provided you with evidence, but there wasn't any data of how many people predicted to have high cholesterol and how many of them receive treatment. We'll talk about it later). To have such a long term side effect of expensive drug is luxurious for our people. Look how ironic this world can be.

Now let's talk about research. It's funny how Goldacre are resentful by many unpublished research data (most of them showed no significant benefit of new drugs, he's arguing that they intentionally unpublished to hide the findings thus it will favor the pharmaceutical industry), while researchers in my countries are struggling to publish their findings. Most of researchs in my country went unpublished as they were rejected by journal's editor. So that's just there hiding peacefully in the laptop. There was a moment when I was presenting my literature review on a med student championship, one of the judges, asked me why didn't I pick study from my own country while there is one Randomized Controlled Trial (RCT) that he aware had been conducted on my topic. Well, I've searched using all the available med research database, but there wasn't such study I find conducted in my country. This is a publication bias, not becuase it is unpublished but because it's insearchable. In that championsip, I decided to use a systematic review which (not so) surprisingly, doesn't contain RCT that the judge was talking about. Not even mention in the excluded studies.

According to Goldacre, many of product sellers in UK cherry picks research to back up their product selling. Cherry pick is an act where someone is selectively choose some studies which support their arguments, whereas studies can result in vary outcome. Thus, the best evidence isn't some researchs, it's a research that contains every previous studies (published or unpublished, in favor or against, significant or insignificant), it's systemmatic review and meta analysis.

In country where there are lack studies conducted in a year, and less academic journals and none of them are linked to Pubmed (biggest database of online medical studies), we have our own problem. We have data scarcity. We are unfindable. None of product sellers can cherry pick studies, which is good but devastating at the same time if we realize how lacking we are in science. We have a lot of intelligence talented scientist, some are brighters than those in developed world. However, they are forced to unscience and unsmart theirselves because of how my country treat them. There is no sufficient fund allocated for research, and if there's any only few of the research proposals selected and therefore the rest of them struglling to find their own funding, even some of them use their own fortune. Eventually, they have to choose, to stay in the country and taking regular less interesting job or to stay in the country and live as idealist scientist and live poorly or they can also choose to get out of the country and pursuing life of science abroad.

This toxic conditions leave my country in their biggest intellectual crisis. We keep arguing without evidence, we decide things without sufficient knowledge, we think we are the smartest because no one can prove we are wrong while the truth is we know nothing about our implausibility.