Indian J. Pediat., 29 : 381, 1962.

PEDIATRICS IN INDONESIA * SUTFDJO D]akarta

Geography Indonesia is a country consisting of more than 10,000 islands. It lies Southeast of tile Asian M a i n l a n d and Northwest of Australia. It is a tropical area and has almost all kinds of natural resources only a few of which have been brought into production. T h e population at present totals 96 millions, with an annual increase of approxilnately two millions. T h e main islands are Java, Sumatra, Kalimantan (Borneo) and Sulawesi (Celebes). T h e y are all mountainous. One of the smaller isl'mds, Bali, often called the Isle of Paradise, is world-famous because of its beautiful music, dances and wonderful panoramas.

General Health Conditions T h e m a i n health problems, as commonly found in developing countries, are malnutrition and infections. The Indonesian G o v e r m n e n t is doing its utmost to reduce the shortage of protein and calories by increasing the local production of foodstuffs containing protein such as fish and soy beans and by importing milk-powder and rice. * From The Department Djakarta, Indonesia.

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T h e incidence of malaria and yaws has significantly decreased as a result of tremendous efforts made by the Department of H e a l t h in eradicating malaria from endemic areas, and tile treatment of yaws throughout the country. Indonesia is a newly i n d e p e n d e n t country and is at the m o m e n t still struggling to throw off all b a d effects of colonialism. T h e financial and economic sitt~ation is at present not too good, b u t it is hoped that by increasing the national production conditions will improve in the near future. Since the proclamation of independence, progress has definitely been achieved in the field of education in all its aspects. T h e n u m b e r of undergraduates in all universities now totals 50 times as m u c h as in prewar days. In m a n y areas the prewar percentage of 90 for illiteracy has dropped to a mere 5 per cent.

Medical Education A steady increase of the d e m a n d for medical treatment by qualified doctors is observed in all parts of the country and a m o n g Feople of all kinds of social levels. T h e d e m a n d for doctors, paramedical personnel, hospitals and medicines is increasing steadily and in providing -them the G o v e r n m e n t has f d k e e p

382 INDIAN JOURNAL Ole[ PEDIATRICS pace with the rapidly growing population. Indonesia now had ten medical schools, of which only four are mature and have an o u t p u t of about 250 new doctors a year, the remaining six are still in their early stages (ff development. T h e total n u m b e r of medical doctors is now 2000.

Child Health About 3000 mother and child health centres, which annually increase by 300, are scattered all over the country. I n these centres mothers and expectant nlothers are given advice, children are given immunizations, while skim or soy milk are distributed to mothers and children in need of them. T h e work in such centres is carried out: by general practitioners, who arc assisted by midwives and specially trained nurses School-health control, however, is only carried out in bigger towns due to a shortage of doctors and paramedical personnel. In general sick children are hospitalized. In smaller towns they are taken care of by general practitioners. Pediatricians are only available in the bigger towns. T h e i r n u m b e r at present totals approximately 100. T h e following only refer to the aeitvities in the children's d e p a r t m e n t of the Medical School of the University of Indonesia in D jakarta, the oldest medical school in-the country. T h e children's deparunents of other medical schools are more or less replicas of that in D jakarta. T h e general aim of the medical education is to produce doctors who can cope with any emergency, even when they are placed in remote areas. I n the children's d e p a r t m e n t under~ a d u a t e s are taught the basic knowledge of pediatrics" alad publir health sufficient

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for their daily practice. I)itticult cases are referred to pediatricians in bigger towns.

Apart from the provision for teaching material for undcrgl'aduates, the children's d e p a r t m e n t is Ineant for the training of pediatricians. T h e course lasts three years which students have to spend in internship. G r a d u a t e pediatricians arc sent abroad to Western countries for a period of six to 19 months in order to get more knowledge arid experience. W h e n they return h.ome they are sent to other towns or to other medical schools to act as consultants or instructors. All lectures are held in the Indonesian language, but since English and G e r m a n are already compulsory subjects at the J u n i o r High School and subsequent schools, Indonesian intellectuals read and speak those language too.

Clinical Pediatrics T h e activities in clinical pediatrics take place in the children's d e p a r t m e n t which has a capacity of 300 beds. If we hear i n m i n d that D jakarta has a population of three millions, this means a shortage T h e d e p a r t m e n t is actually a part of the city's general hospital which has to serve the whole p o p u l a t i o n of Djakarta. Patients mostly come from the lower income class. Those who are economically better situated prefer the more expensive private hospitals. H e n c e the outpatient d e p a r t m e n t of the children's deIzartment is always overcrowded. T h e doctors in charge have to spend ahnost the whole m o r n i n g on routine examinations. An average of 70 patients a day for each doctor is considered normal. A visit by 700 to 800 patients a day is not uncommon. Only severe cases are admitted, due to the shortage

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of 13eds and paramedical personnel. T h e admitted cases are continually checked by the interns who are under constant and close supervision of older and more experienced members of the medical staff. T h e s e interns have to report regularly on interesting and difficult cases. Each report should be accompanied by references to all literature pertaining to the case and should be delivered before the doctors of the children's d e p a r t m e n t or before the entire medical staff of the hospital. Once a week a reference day is held in order to keep up with the huge a m o u n t of contemporary literature in pediatrics from abroad. T h e teaching of undergraduates in pediatrics takes a total of 14 weeks to complete, of which 6 weeks are included in their fourth year in which they get theoretical instructions as well as instructions on the preliminary examination of patients at the bedside. T h e other six weeks in which they should only concentrate on getting practical experience, are included in their fifth year. T h e entire medical school curriculum has six giades lasting a )'ear each. T h e students are divided into sm~ll groups intensively supervised by senior instructors. At the end of their term each has to pass one or more examinations. Most of the time of the staff members in charge of the children's d e p a r t m e n t is actually consumed by the routine examination of outpatients and of admitted cases, and by the teaching of under-graduates. Nevertheless, an effort is being made to do surveys and research work. Although these are carried out on a small scale, some results have already been achieved. Surgical cases are still referred to the surgical d e p a r t m e n t of the hospital, but it is the aim to set up a centre

including such items as children's surgery, radiology, neurology, psychiatry, etc. Such a centre will u n d o u b t e d l y be of utmost importance and will benefit both the patients and the doctors in charge. In fact a step in this direction has already been inade and separate subdivisions of hematology and cardiology have been in existence for some years. I t has been stated earlier that only 9serious cases are admitted to the departmerit. As a consequence of t h i s , t h e mortality rate of several diseases is very high. Another causative factor is that these patients are usually a d m i t t e d in a bad nutritional condition, w h o as a rule come l r o m the lower income class a n d are already in a state of deterioration. Malnutrition is commonly f o u n d a m o n g the outpatients. Unfortunately, not every case can be admitted. Mild cases, established as such by clinical examination are treated by the polyclinic and given skim or soya milk. Tuberculosis is still a terrible e n e m y to the Indonesian child. Primary cases are handled in the polyclinic. Only subprimary tuberculosis patients are admitted in an isolated ward. Tile mortality rate of tuberculous meningitis for instance is still about 50 per cent. Other diseases include diarrhoeal disorders, encephalitis, infectious diseases, inborn errors of m e t a b o l i s m , avitaminosis, virus diseases, etc.

Social Pediatrics I t has been mentioned before that the main activities in this field are centred a r o u n d the m o t h e r and child health eentres established t h r o u g h o u t the country. T h e children's d e p a r t m e n t in Djakarta has such a centre. Once a week the outpatient d e p a r t m e n t of its bmlding is transformed into a centre

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which only healthy infants and toddlers are allowed to visit. T h e i r mothers are given advice in matters of feeding and hygiene. Immunizations, however, are not compulsory. Vaccinations against smallpox and imlnunizations against diphtheria, pertussis and tetanus, and against cholera, typhoid and paratyphoid fever are routine. Although smallpox vaccinations are not compulsory, practically they are. T h e Departnlcnt of Health has specially organized teams whirh do these smallpox vaccinations covezing the whole country. Specially trained personnel visit the villages and imnmnize the people. In case all epidemic breaks out in a certain area, a large scale vaccination campaign is immediately started and patients are isolated and treated ill barracks. B. C. G. vaccinations are provided only by the Municipal Health Department. Only infants and children who have had definite contact with tuberculous people c.an be sent for vacci. nat_i_0n. The children's department has another mother and child health centre in a suburb in D jakarta. T h e proceedure is the same as those in the

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D jakarta centre. This suburban c"entre, however, provides material [or surveys and research in the. sense that here the homes of the children who visit the centre can be easily visited and data can be obtained as to the children's actual food intake, the state of cleanliness of their surroundings, their education etc. T h e result of such a survey in living conditions can be checked with the conditions o[ health of the children concerned. This is thoroughly done at the mother and child health centre. Other social activities consist of the operation of institutes and training eentres for physically disabled children, for the blind, the deaf and mutes. Those are Government-run institutions and are mostly established in towns other than D jakarta. Private organisations have established many homes for orphans in a great number of towns, but there is only one home for mentally retarded children for the whole country, namely, the one in D jakarta. Undernourished school children are sent to vacation camps in the mountains at regular times to regain health and strength.