Community Participation: The Way Forward
In my experience, gotong-royong or community participation is a strategy for working with the community to accomplish public health goals in a short space of time for the benefit of the community. Community participation is most effective when the community themselves see the need for it. But for the long-term community participation, it needs commitment, both human resources and financial from both the stakeholder and the community, more so the stake holder.
The spirit of gotong-royong could be traced back to a few public health programmes implemented by the Medical Department in a few landmark programmes. They were the Ulu Dresser Schemes in the early 1950s, the Rural Health Sanitation Programmes in the early ‘70s and the successful ongoing Village Health Promoter Programme since its implementation in 1983.
The Community Gotong-Royong Kliniks1 of the Early 1950s, 1970s and the 1980s
In early 1950s, when the health department saw the need for medical care in remote areas, they invited participation from the communities by introducing the Ulu Dresser Scheme. Qualified youths were recruited. But on the part of the villages, they had to provide a work station for the Ulu Dresser. Hence, clinics that were built through community efforts had been designated as gotong-royong kliniks or sub-dispensaries. I saw the remnants of the buildings built during the Ulu Dresser times at Long Panai, Long Bedian, Long Seridan, Long Lellang and Bario. All have been demolished except at Long Bedian where it is now a community centre. The one at Long Seridan is tucked in behind the upgraded clinic while the one at Bario had been claimed back by a villager.
This construction of community clinics continued into the 1970s when the government decided to fast-track the medical service provision needs. Medical Auxiliaries2 were quickly enlisted to fill the gap. Gotong-royong kliniks came up at Beluru on the Marudi side and on the Miri side at Bekenu, Batu Niah, Suai Tegaging and Jambatan Suai. The timber boom of the 1980s saw the construction of kliniks at Long Miri, Long Pillah, Long Naah, and Long Jegan. While some of the clinics were eventually replaced by government buildings as at Bario, Long Lellang, Long Bedian, Long Bemang and on the Miri side at Batu Niah, Suai Tegaging and Jambatan Suai, some villages without clinics are still hopeful that the government would build new clinics for them.
The Rural Health Sanitation Programme of the 1960s
The Rural Health Improvement Scheme Programme of the 1960s was a programme initiated by the Medical and Health Department in an effort to eliminate diarrhoeal diseases in villages which did not meet with initial success. The targeted villages for the improvement of sanitation gave lukewarm response. The villages in the past consisted of longhouses. They were dependent on river for their water needs. Although animals were reared but they were free to roam. Animals may reared under the homes. There were no proper drains under the longhouse and as a result, pools of water from the household accumulate underneath their longhouse. Rubbish were indiscriminately disposed. Motivating the villagers to reorganise their homes was no easy task. But when the Medical Department came up with the gravity feed water supply system initiative, the villagers became more receptive. They could see the benefits from it. Throughout the construction period, there was overwhelming support and involvement from the villagers. The men were actively carrying and laying out the pipes, clearing the path of the pipes, constructing the dam under supervision, and the womenfolk were cooking and providing food – it was a fiesta. In a week, the project was completed and water started to flow to their biliks3. The village became more organised, animal stock were kept away from the longhouse and the surrounding area was cleaner. The success in the implementation of the gravity water supply project catalysed the villages to be more organised and with much improved sanitation. Also the project paved the way for more similar projects in other villages.
Modern Day Construction of Gravity Feed Pipes in Miri Division
The gravity feed water supply system is essentially a system consisting of mountain streams that is dammed and tapped by means of connecting pipes to reach a village. The stream flow is tested for adequacy with enough head for the water to reach the various longhouse and its biliks. The construction involved careful planning and calculations for the length of pipes required. The villagers contribute their part by identifying the source of the mountain stream and purchasing connecting pipes from the main pipes to the biliks. The effort in installation was communal and subsequent maintenance was by the village committee.
Set in modern-day Sarawak, a gravity feed water supply system was planned at Long Puah in Ulu Tinjar. The gravity feed project started on 16th August 2011 and took 3 weeks for completion. Long Puah had a dismal history in being the beginnings of a cholera outbreak in a remote faraway area deep in the interior jungles of Ulu Tinjar in 1994. When I personally visited the village then, I found that the gravity feed pipe was leaking along its way under the latrines of the longhouses. The deteriorated sanitation and obnoxious odour from the latrines risked the village to diarrhoea diseases. After “cleansing” the village with lysol and promotion of personal hygiene done, the lysol odour floated in the village for a time. Minor rehabilitations and restorations were done to the pipelines. The gravity feed remained functional for a period but sometime in 2010, the villagers requested for replacement as the system was no longer functional.
When a pipe gravity feed water supply system was proposed, the villagers and its kampong committee were very cooperative and were eager to start work. When work started, with the villagers coming out in full force, the system was completed very quickly. For their efforts and ours, it was decided that the local Yang Berhormat Dennis Ngau would officiate the launching of the project.
Tube Well Construction
During the 1997-1998 cholera outbreak occurring in the background of the dry weather influence of El Niño, there were zero inches of rain for in rural Miri for 6 months. Many villages which had been provided with water tanks had slowly depleting reserves and they were stingy with the usage of water. The rivers were at their lowest levels. A visit by high-level officers (the parliamentary secretary and top officers from the Ministry of Health) paved the way for introducing tube well drilling. A complete tube drilling machinery arrived and soon a “drilling team” was organised in Miri Divisional Health Office. Staff from Kedah Health Office who had experiences with tube well drilling came to Miri to train our team. During its peak period, the team was able to construct 14 tube wells in 7 villages in Miri Division alone. The drilling machineries cost RM500,000 which consists of a lorry and a drilling machine.
The first drilling at Rumah Gansol in 1998 was a success and is still pouring good potable water, even during the driest period.
One of the latest drilling was at Rumah Merudi where 11 of our staff and 34 villagers were involved. The drilling started on 14th September 2012 and completed 3 months later.
Training the Village Health Promoters (VHP)
This programme which was implemented in 1983, showed no signs of declining. Villages continued to participate in this programme. Villages participating in this programme would be given priorities over some health projects such as gravity feed, water tanks, etc. A stepwise approach with the final objective that every village would have a VHP. Steps involved included the visiting the kampongs, meeting the village committee and explain the programme. If agreeable, the village committee would have appointed their representative for the programme. About 20 representatives are appointed each time. The appointed representatives would then attend a 3-week course conducted by trainers from the Divisional Health Office Miri. Upon completion of the course, certificates are given and they went back to the community practising what was taught to them. There are no monetary benefits given to the VHP, but we compensated in reimbursement of fuel if they brought ill patients to the clinics. In addition, the VHPs who are active are eligible for free medical care.
Training had been conducted far and wide. We have had sessions at Long Bedian, Long Jeeh, Long Loyang, Bario, Lio Mato and also at Long Banga. In the Miri side, we had sessions at Bekenu and Ladang Tiga.
I had the services of Abdulhan Mohd, JM Monica Pantulusang, Robin Anyie, JM Lonnie, and JM Catherine Kinyang, JM Monica and MA Luhin and JM Leles Mering, who were passionate about their involvement.
Campaign Against Dengue in the 1990s
Canada Hill, Pujut Corner, the riverine squatters of Miri River, villages near the up-and-coming early industrial activities at Kuala Baram were hot seats of dengue in Miri town and its surroundings during 1990s and before 2005. The rapid development of Miri attracted local immigrants from all over Sarawak. The haphazard crowded living conditions with lack of inadequate water supply which resulted from improper storage of water in containers of various sizes were risk factors for dengue. In addition, the cleanliness left much to be desired. Rubbish, including tin cans for drinks and canned food were indiscriminately thrown. All that was needed for the mosquito to breed was a period of dry spell followed by rain. The health department was on standby mode, by then. The main control measures were just fogging and issuance of compound to offenders. But when the situation went out of control, with more victims claimed, we have to resort to interagency participation and also get the community to be involved. Hence, with that extra effort, on a Sunday, the local council will provide dustbin lorries to the Canada Hill, Pujut Corner and other outbreak areas thus, flushing out rubbish periodically. That spirit of gotong-royong was enough to slow down the spread of dengue, if not, to eliminate it.
Campaign Against Malaria at Long Jekitan 2012
The Silat area which lies deep in the primary jungle in south Baram near to the Kalimantan border, consists of a few settlements where Long Jekitan is located. There is a school, and only in 2013, a functional government klinik kesihatan was built. There were no malaria cases until 2005. But in 2008, the problem started and malaria spiralled out of control. Whatever control measures taken earlier had little effect. In 2010, cases of malaria recurred. The causes for the outbreak became obvious. There was a concurrent outbreak at Long Jekitan Long Keluan, Long San and Long Beku. Although Long San is a Kenyah community, there is a rumah sakai meant for the Penans only. While all the Kenyahs were spared from malaria, not so the Penans. Penans from the “triangular community” of Long Jekitan, Long Keluan and Long San were simultaneously affected during the school times. They soon brought back the disease with them and the outbreak prevailed in the respective communities. A reconnaissance visit to Long Jekitan revealed 18 ponds. The Penan huts were poorly walled with planks set apart. The ponds were dug to provide fish as a source of protein for the people back in 2008. Unfortunately, there were no large fish except for small fries. The vegetation in the ponds became the most suitable breeding ground for the mosquitoes and this helped malaria to propagate. Use of pesticides was not lethal enough to stop the breeding.
I decided on a two-pronged strategy for the control. The first strategy was a State-level effort to eradicate cases of malaria with the aim of “flushing” out malaria from the outbreak areas by sending teams every 2 weeks so that all the Penans who were affected were seen swallowing the malaria pills and be freed from malaria. The other strategy was engaging the community to eradicate the mosquitoes by clearing the 18 ponds. In doing so, I deployed the 2 village health promoter trainers4 and a Penan speaking community nurse. Their role was to win the hearts and mind of the Penans i.e. do home visits, treat patients, and culminating in gotong-royong effort to drain the ponds and emphasising on village cleanliness. One week after the VHPs arrived, a gotong-royong was held. Engagement of a timber camp nearby to provide a “piku” (mini excavator) to help drain the pond was enlisted. Manual draining of the pond was also done. By 25th October 2010 all the ponds were emptied of water and since then, according to the entomologist, there were no mosquitoes in Long Jekitan.
“Victory for all”!
Kem Kesihatan Ulu Baram 22nd and 23rd September 2012
When the Ministry of Health announced that we must do National Blue Ocean Strategy (NBOS) in unreachable areas in the Division, I already decided with whom to partner for this. Definitely, if health department were to do it alone, it would easily cost us a bomb! I decided to involve Samling Corporation as a major partner. The others who would be involved would be the Miri Hospital, Dental Divisional Office, Social and Welfare Department, the army, the police and the local representative.
We made a courtesy visit to Samling Corporation to see its manager and discussed the events and this was followed by a meeting at my office. Samling Corporation was more than willing to be co-host for the event as part of their corporate responsibility.
The event would be held at Kilo Ten Central Base Camp, located in the middle of primary jungle and which was about three-hour drive from Miri. In the meeting, Samling would agree to provide lodging and food for all the eighty staff involved. We had the cooperation from the army who was assisting with the transfer of medical and dental equipments, we had dentists from Pejabat Pergigian Miri and from the army, we also had specialists and staff from hospital Miri, we also had the police to provide security in the area, officers from the Welfare Department to promote their welfare schemes and we also had Samling to facilitate the movement of staff and equipment at the Central Base Camp.
The day the camp started, and for the next 2 days, there were a thousand patients. Patient came in for minor ailments, screening, and many flocked to the dentists.
On the second day, the local representative, Yang Berhormat Encik Dennis Ngau came to grace the occasion. The good thing about this is everyone was proud of their own success. For the Health Department, it was fulfilling the community health needs.
At the end of the day, all the participating agencies claimed victory for their effort and it paved the way for more health camps and smart partnerships to come in the Ulu Baram.
Mass Community Treatment for Filariasis in a Village at Rumah Barauk
Filariasis or commonly known as Elephantiasis, is a vector-borne disease caused by a bite of an infected Mansonia mosquito harbouring the infective microfilaria. Once it bites a human, the microfilaria in the human develops further into adult worms. The adult worms copulate and produce the larval forms of microfilaria. When the mosquito bites and sucks blood of the infected person, the larval microfilaria develops further in the mosquito. The adult male and female round worms reside in the lymphatics and may cause complications such as swollen limbs.
In Miri Division, there were not many persons with visible signs of elephantiasis. But the presence of microfilarial worms in the blood stream was a cause for concern. The drugs to free one of filariasis is albendazole and diethylcarbamazepine (DEC). Patients who have the filarial worms in the body may experience exaggerated unpleasant side effects due to the death of the filarial worms. Headache, dizziness, fainting, nausea, vomiting, bodyaches and diarrhoea are some of it. It is so crucial to explain the disease to the community members, especially the effects and complications if it is not treated. This includes managing the side effects of the drugs consumed if distributed.
It was a fine day until an individual from Sungai Entulang area came to seek treatment for fever in September 2013 at the nearest clinic which was at KK Tun Haji Openg. The Medical Assistant on duty decided to take a blood slide from the patient with the purpose to examine for blood for malaria parasite (BFMP). A laboratory technician at Divisional Health Office Miri analysed the slide and to his surprise, he detected filariasis worms. On the same day, a team was organised to do a night blood survey (NBS) on 505 individuals and 39 persons were found positive for filariasis. Treatment was not immediately given until discussions with the community were held.
It was rumoured that a villager had been apparently well the day before he died the following day after swallowing the drugs. With that as a fact, the mass treatment would not be as easy as envisaged, and the villagers must be convinced that the drugs are safe to be swallowed.
A meeting at the District office chaired by the SAO of Miri was held. Members included the village headman, the village committee, the headmaster of a primary school in that area and office staff from Miri Divisional Office. During the meeting, a briefing about filariasis was given by Dr V. Lugah and she also explained the need for treatment. The meeting also called for the villagers to be present for the mass treatment to be held over the following weekend.
Before the gathering a pre-survey was done about the villagers’ perception towards the illness and its treatment and that same night, a gathering was held at the village longhouse. The gathering drew a huge crowd of 664 people living in that area. The medical team was presented with three doctors, eight health staff and nurses in case of any untoward incident happen. There were speeches from the village head and messages from the Divisional Health Office followed. Soon after, the mass drug-swallowing session began with the health staff taking the drugs first and followed by the whole crowd. Later that night, we had some light community activity such as karaoke, ngajat and laughter.
The outcome was everyone swallowed the tablets, thus arresting the filariasis from further spread! The area was considered free from filariasis.
Launching the “World Leprosy5 Day” in June 2014
I was being practical when I decided to launch a national event “World Leprosy Day 2014” at Long Banga after Divisional Health Office Miri was given the honour to host the event. Leprosy is still prevalent in the remote areas around the Long Banga areas. Hence, to launch an event there would be the right thing to do. The presence of villagers from the several villages near Long Banga would promote information and awareness about Leprosy. I also reiterated that launching the event in urban Miri was a waste of time and effort as there had been no cases in Miri for the last 10 years. In launching the event, we had an ally in Sam Ling Corporation. Always reliable, the slightest of hint about the looking into the health welfare of the people in Ulu Baram will bring them forth to us. We also had a committee for launching the event at Long Banga, chaired by their village committee and we were only advisors. Whatever the committee requested, especially cash, we took note and actually gave the villagers whatever they wished for. For the people of Long Banga, it was an honour to have this function at their door step and also an honour to hold an event for a good cause.
Three events were planned, firstly to have a wakil kesihatan kampong course among the Penans from fourteen villages around Long Banga living in the Ulu Baram; secondly, to do a practical training session on how to detect leprosy and thirdly, while preparing for the launching, a health camp was also held. While the health department coordinated the effort in this programme, we also decided to include Samling Group of Companies, Welfare Department, Village Security and Development Committee of Long Banga and Yaw Teck Seng Foundation. The local Telang Usan Assemblyman Dennis Ngau was invited to officiate the event on 26th June 2014.
The launching was a success! There were a lot of smiling faces; everyone was at their best and the villagers were in their best traditional attire. Once again, community participation at its best!
Constructing A Gravity Feed Pipe System
A Gravity Feed Water Supply System
- A suitable mountain stream is identified and then dammed with a concrete wall of stones, sand and cement.
- A 4-inch diameter polypipe is laid out at the base of the dam before constuction of the dam.
- The pipe is channelled to the nearby longhouse for the distribution of the water.
Providing Water Via Tube Well Construction
Tube well for the village. It involves operating a drilling machine by trained personnel. Villagers took part in the spirit of community participation in helping to lay out the pipes and construction of a concrete storage pond, where the underground water is pumped into it. From there, water is distributed to the respective homes of the villagers.
The Village Health Promotor Programme
The Village Health Promoter was initiated in 1983. Every year, a training course for 20 volunteers is held. The VHP or Wakil Kesihatan Kampong, or WKK as the successful participants would called themselves, become members of the voluntary workforce of the Health Office to promote health in the villages.
Malaria Eradication At Long Jekitan
The strategy in eradicating malaria is treatment of affected persons, eliminating the presence of infective mosquitoes through spraying of the walls of the homes and removing the breeding areas. Another important part is getting the community to be aware of the mosquitoes and minimise exposed skin from getting bitten. After identifying the environmental threat (in this case the ponds), steps are taken to drain the ponds and to cover them if need to.
Kem Kesihatan At “Kilo Ten” Central Base Camp
It was an uphill task to set a carnival of health in the middle of the jungle where the main limiting factor was transport. But with the host, Samling Corporation, this was made easier. Security was further enhanced provided by the Police, and transportation of equipments and personnel by the Army trucks and the Samling transport.
Filariasis Activity At Rumah Berauk
Eradicating filariasis is not a difficult task. People in affected designated areas will only have to take the drugs once a year to render themselves free from the dreadful disease.
At Rumah Berauk, during one of the mass drug administration activity that occurred in the past, one of the villagers died after taking the said medication, which was not correct. This caused grave concern and only resulted in many villagers not complying to the swallowing of the drugs. Hence, through careful planning, the Health Office was able to persuade the villagers to take the medications and thus, was able to achieve a 100 percent compliance.
World Leprosy Day At Long Banga
This National Day Celebration is celebrated annually all over the states in Malaysia. When Miri was given the honour to host the event, I decided that it would be held where the disease is most prevalent. The function was held at Long Banga Community Hall. The village of Long Banga which is a Saban community, is about 400 kilometres from Miri and takes nearly 10 hours in a land cruiser.
By Faizul Mansoor, from the book A Community Doctor in Miri