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Paying for healthcare with trees: win-win for orangutans and communities

  • In 2016, the Bornean orangutan (Pongo pygmaeus) was declared Critically Endangered by the IUCN. Orangutan habitat is fast disappearing due to deforestation caused by industrial agriculture, forest fires, slash and burn agriculture, and logging.
  • One of the most important remaining P. pygmaeus populations, with roughly 2,000 individuals, is in Indonesia’s Gunung Palung National Park. Alam Sehat Lestari (Healthy Nature Everlasting, or ASRI) is partnering with U.S. NGO Health in Harmony and effectively reducing illegal logging in the park via a unique healthcare offering.
  • When communities were asked what was needed to stop them from logging conserved forest, the people answered: affordable healthcare and organic farming. Expensive medical costs were forcing people to log to pay medical bills, while unsustainable agricultural practices depleted the soil, necessitating the use of costly fertilizers.
  • The two NGOs opened an affordable health clinic, and later a hospital, offering discounted medical service to communities that stop logging. Forest guardians, recruited in every village, encourage people to curb deforestation. They also monitor illegal activity and reforestation, while offering training in organic farming methods. And the program works!
A baby orangutan. Orangutans are listed as Critically Endangered and on the brink of extinction. An innovative NGO program in Borneo offers a discount on healthcare to communities that reduce logging in conserved forests, protecting key orangutan habitat. Photo by Rhett A. Butler

“I’m a dentist by training,” says Monica Nirmala, executive director of Indonesian non-profit Alam Sehat Lestari. The name translates to “Healthy Nature Everlasting,” and the organization, known by its acronym ASRI, is a remarkable trailblazer in community-led conservation focused on protecting the forest habitat of Bornean orangutans.

But, a dentist? Nirmala’s background isn’t as incongruous as it might first seem: ASRI, and U.S.-based partner organization Health in Harmony, have made a skilful intuitive leap, and are successfully connecting human health with rainforest conservation, or, as they say, “saving the rainforest with a stethoscope.”

Their work is urgently needed: Last year, the Bornean orangutan (Pongo pygmaeus) joined the Sumatran orangutan (Pongo abelii) in being declared Critically Endangered by the IUCN. Orangutan habitat is fast disappearing due to widespread deforestation driven by the expansion of industrial agriculture — particularly oil palm production. Add to that threat the risks from Bornean forest fires, slash and burn agriculture and logging, and its easy to see why P. pygmaeus is on the verge of extinction.

The revised IUCN classification was based on studies showing the loss of 98,730 square kilometers (38,120 square miles) of habitat between 1973 and 2010, with a further loss of 57,140 square kilometers (22,062 square miles) predicted by 2025 — that’s a total land area greater than the U.S. state of Georgia.

Even worse, more than half of remaining orangutan habitat has been degraded by logging, while thousands of the animals are hunted each year, primarily for their meat. If nothing is done, the population is on track to decline by more than 80 percent between 1950 and 2025 — a timespan that represents just three generations, according to the IUCN’s assessment.

A vision test at the ASRI clinic. U.S.-based Health in Harmony and Indonesian partner organization ASRI provide affordable healthcare to communities, reducing the need for logging. They also offer reductions in medical costs to communities that are taking steps to reduce their encroachment on Gunung Palung National Park, home to a major orangutan population. Photo by Roni Bintang

Hope human and wild

One of the most important remaining populations, with approximately 2,000 individuals, is in Indonesia’s Gunung Palung National Park, just south of the equator in the province of West Kalimantan.

Although the preserve is formally protected under federal law, enforcement is largely absent, so the 900-square kilometer (347-square mile) park suffers encroachment by loggers and local agriculture. It is here that ASRI and Health in Harmony are pulling together to ensure a brighter future for Borneo’s great apes.

Health in Harmony founder, Kinari Webb, credits an undergraduate year spent studying Indonesia’s orangutans at a remote rainforest field station as the catalyst for her work: it was during this time in 1993, she says, that she became aware “that human and environmental health are inextricably intertwined.”

Webb decided to study medicine in order to return to Indonesia to “do a combined health care and conservation program. Though I didn’t know at that time exactly what [that program] would look like, what I did know was that the local communities would have a better idea than I ever could what the solutions would be for protecting the forest.”

Gunung Palung National Park, in West Kalimantan, Borneo. The 900-square kilometer protected area is home to one the largest remaining populations of Bornean orangutans (Pongo pygmaeus). Photo by Cam Webb

Subsequent experiences working as a medic in Aceh after the 2004 tsunami “solidified for me how critical it was to listen to the communities [I was working in], and to ask them what they saw as the solutions,” Webb says.

When Health in Harmony asked the communities surrounding Gunung Palung what was driving them to log the conserved forest, and what it would take for them to stop, the answers that came back were surprising but compelling: affordable healthcare and organic farming. Extremely high medical costs were forcing people to turn to logging to pay their healthcare bills. Exacerbating that problem: current agricultural practices depleted the soil, necessitating the use of expensive fertilizers and leading to slash and burn agriculture on the edges of the park.

This “radical listening” approach, first applied by Health in Harmony in their earliest involvement in Borneo, is now a fundamental strategy of the NGO’s work. “The amazing thing is that we have found stunning consistency in what communities in a given ecosystem will decide the solutions are. And they do this independently,” reports Webb. “And what we found is that when we actually do what they say: it works! Logging has dramatically declined around Gunung Palung, and [local] people are wealthier and healthier.”

The entrance to Gunung Palung National Park, a preserve which suffers from illegal logging. An innovative community conservation project is working in communities adjacent to the park to address one of the main drivers of logging: the need to pay for expensive healthcare. Photo courtesy of Health in Harmony

Trees for treatment

Once they had detected the root of the deforestation problem, Health in Harmony set out to find a cure: in 2007 the NGO established a clinic in the town of Sukadana to the west of the national park. ASRI was formed to run the project locally with Monica Nirmala now serving at its head.

Today, the clinic not only provides high quality healthcare that is affordable to all, but actively rewards communities that reduce logging, or stop altogether, with further reductions on the cost of treatment. Forest guardians, recruited in every village, encourage others in their community to reduce logging. The guardians also monitor illegal activity and reforestation efforts, and offer training in organic farming techniques.

“The forest guardians are so proud of the work they do, and many have come up with very creative ways to help folks stop practices that are destructive of the forest,” says Webb. “The thing you have to understand is that the forest guardians come from every one of these villages, and they have known the loggers their entire lives.” In fact, many forest guardians are ex-loggers.

This locally driven initiative is paying off, for the forest and for patients visiting the clinic.

“[C]ommunities that are not doing any logging during a given 3-month period of time [get] a 70 percent discount on their [medical] bills,” Webb says. “Villages that border the park, and are still logging, get a 30 percent discount — just for agreeing to try to decrease logging. Villages that have dramatically decreased their logging get a 50 percent [healthcare] discount.”

A tree nursery containing seedlings of local species that are used to reforest critical corridors of habitat between larger expanses of forest. Seedlings are among the most popular forms of currency used to pay for healthcare, and can even be drawn on as a sort of healthcare savings account. Photo by Chelsea Call
Not only is healthcare made affordable, but people can pay for treatment with seeds and seedlings, which are then used by ASRI in reforestation projects to restore orangutan habitat and improve the environmental conditions of the watershed. Photo by Chris Beauchamp

What’s more, patients can barter for treatment — with tree seedlings, seeds and compost serving as just some of the accepted currencies. These payments are used in turn to fund another of ASRI’s projects: reforesting corridors of critical orangutan habitat.

“The most favorite non-cash payment option is seedlings,” Nirmala says. “[P]atients can also [create] a ‘savings account’ at ASRI’s clinic by banking their seedlings for future healthcare needs.” It was this option for non-cash payments that first drew Nirmala to ASRI, because it “aligned with my desire to give healthcare access to the under served community in rural Indonesia.”

Benefiting all

The positive conservation impacts are clear: the number of households logging in the park has dropped almost ten-fold, from 1,350 when the project started in 2007, to just 180 today. Reforestation of degraded corridors that connect with core areas of orangutan habitat is already producing good results; camera traps confirm that the apes are making use of this newly restored habitat. And they’re not alone: a range of other species have been recorded using the habitat corridor, including the threatened bearded pig (Sus barbatus), sunbear (Helarctos malayanus) and Horsfield’s tarsier (Tarsius bancanus), a small nocturnal primate.

“We were able to leverage the social capital gained through health services and the trust gained by saving people’s lives to educate, explore, and sometimes alter, local perceptions and behaviors towards forest conservation,” explains Bethany Kois, research director at Health in Harmony. “[I]n effect, we reduce the need for formal enforcement of the prohibition on logging and poaching within Gunung Palung National Park by providing a personalized, voluntary incentive for compliance with the prohibition.”

This novel approach, Kois points out, has succeeded in a country with among the highest rates of deforestation in the world.

At the same time, measurable health benefits are being received by more than 100,000 of the region’s people: “Infant deaths per 100 households declined from 3.4 to 1.1 over the first five years of the work,” says Webb. Patients who attend ASRI’s clinic are also “more likely to immunize their children, use birth control and less likely to defecate in the river,” says Kois.

Children taking part in a demonstration as part of the ASRI Kids program. Co-founder Kinari Webb described the results of the program as “stunning,” with all children learning for the first time that orangutans are uniquely found on Sumatra and Borneo — a fact that helps foster pride in country and instil the desire to protect rare wildlife. Photo by Chelsea Call
A member of the ASRI Kids program plants a seedling in a reforestation site. ASRI Kids is a conservation and health education project that is raising awareness about local biodiversity and the links between human and environmental health. It is also an important investment in the next generation and the future. Photo by Loren Bell

Another initiative is the ASRI Kids program, which aims to raise awareness and increase knowledge of forest and human health basics among the next generation. “The pre- and post-test results are stunning for these classes,” Webb says, with all children learning for the first time that orangutans only occur on Borneo and Sumatra, for example — knowledge likely to increase pride in country and care for the environment.

The program also expands children’s horizons. “The biggest thing I’ve noticed from the kids who started in these classes five years ago is that they now have a much bigger vision for what they might want to do with their lives, [aspiring to become an] architect, marine biologist, doctor, nurse or field guide,” she says with pride.

Meaningful work

Webb cites transferring leadership of ASRI to a 99 percent Indonesian team — almost all women — as one of the program’s many successes. And so strong is the appeal of their work that they are able to attract employees from across Indonesian Borneo and beyond, as well as locally.

One employee is Fransciscus Xaverius, known as Pak Frans, ASRI’s reforestation coordinator. Pak Frans worked previously on conservation projects in Central Kalimantan, but was attracted to ASRI’s combined focus on affordable healthcare and conservation, as well as by the technical challenges presented by reforestation of various types of degraded lands adjacent to the national park.

“I enjoy every process in planning, implementing and evaluation in regards to reforestation activity, as well as cooperation with various stakeholders,” says Pak Frans. “I feel satisfied when seedlings that we plant grow well,” transforming the previously burnt or cleared land back into forest, and delivering benefits to the surrounding community.

Pak Frans has never seen an orangutan in the reforestation plots, but he’s seen something arguably more tantalizing: “I have seen [an] orangutan’s nest in [the] reforestation area, that indicates orangutans have been in the site and made their nest to stay over[night]” rather than just passing through.

Muhammad Yusuf, known as Jili, is an ex-logger from Sukadana who is now the organic farming facilitator at ASRI. “Logging is a high-risk job,” he explains when asked why he switched from logging to conservation. “Besides, as [a] human being, my conscience kept asking whether I did the right thing or not [when logging].” Now teaching organic farming, Jili cites his community involvement — simultaneously reducing logging while making farming more productive — as the reason why he has “never faced rejection from [the] community.… [T]he program is very simple, promising and sustainable.”

New reforestation sites are already growing well, and camera traps have shown that they are being used by a variety of wildlife, including several threatened species including bearded pig (Sus barbatus), sunbear (Helarctos malayanus) and Horsfield’s tarsier (Tarsius bancanus). Photo by Darya Minovi

For Sukadana-born forest guardian coordinator Hendriadi, known as Hen, working to enrich life in the community is what’s important. He values community-based projects because of their possibilities for shared knowledge and experience. “Especially when forest guardians and I [went] from household to household, there were new things I learned. I gained stories and understanding about the importance of conservation and life experience from [the] community itself.”

Scaling up

Webb sees replicating and expanding ASRI’s success as a priority. A newly built hospital and training center, opened late last year, is enabling ASRI to provide more extensive care, including greater surgical and emergency treatment.

ASRI director Nirmala says that she would like to see the program share its “model, approach and values to as many people that are interested in doing similar work [as possible]. The vision is to see flourishing win-win situations between communities and their environment, especially in poor and environmentally threatened areas.”

Webb envisions a wheel-and-spoke model as one fruitful avenue of exploration: “For example, we are considering a spoke to Bukit Baka Bukit Raya National Park on the border between West and Central Kalimantan. The population there is not large enough for a clinic (just a few thousand people), but these folks are often logging to pay for healthcare (both the cost of transportation and fees). Our thought is to be able to provide mobile clinics from ASRI to this location and thereby reduce the stress on the national park and the important orangutan population there.”

“Thus far, we’ve identified a handful of Indonesian protected or conservation forests that contain critical biodiversity, where poor human and environmental health are linked to poverty,” Kois says. “We’re working to understand whether, or to what extent, payments for environmental services — such as healthcare incentives, protected area enforcement patrols, ecotourism opportunities and sustainable farms — might act as an effective incentive system in these locations.”

Learning from ASRI’s many accomplishments will be a crucial strategy for shaping future endeavors, says Kois. In 2016, “we recognized that, while we knew our projects were working to effect positive change, we didn’t really understand how they were working. Because we aim to scale-up our model in other locations within Indonesia over the next five years, it is imperative that we learn the ‘how’ of what we do.” To this end, Health in Harmony has embarked upon an evaluation of the mechanisms behind ASRI’s positive impacts.

An orangutan caught on a camera trap in one of ASRI’s reforestation sites. Not only are orangutans moving through the newly restored habitat, a nest has also been found by the ASRI team, indicating the orangutans have spent the night there. Photo courtesy of ASRI/Health in Harmony

Promise for tomorrow

“People really do seem to have hope and that is a wonderful thing,” Webb concludes. “They can see now that life can get better. I was recently talking with a farmer who told me that 80 percent of the farmers in his village had now switched to organic methods.”

“At first I thought that couldn’t possibly be true, but the more he talked, [the more] I realized it probably was. He said they are making much more money too,” and credited ASRI’s trainings for the shift in behavior and for the healthier soil from which the community is now benefiting.

When it comes to orangutans, Webb is equally optimistic in outlook. “There is no question that habitat protection is the absolute key. With so much loss of forests, the national parks (that are also seriously threatened) become even more critical. And the thing is, that win-win solutions are totally possible — we just have to listen to what the communities [say are] the solutions to stopping logging.”


With thanks to Syufra Malina, ASRI’s executive secretary, for her translations of the interviews with Pak Frans, Jili and Hen. 

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The newly built community hospital and training center which will allow ASRI to expand its healthcare offerings to include surgery and emergency care. Health in Harmony hopes to soon expand its healthcare-conservation model to other sites in Indonesia where medical needs, poverty and environmental threats are intertwined. Photo by Indra Lim


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