I am Dr. Kinari Webb, founder of a health clinic in Indonesia that works with communities to stop illegal logging with health care incentives. AMA!

How do you make the finances work, if you're often paid in other-than-cash?

Great question. The handicrafts we sell for cash. The seedlings and manure we use for reforestation. This works because in the funding world it is vastly easier to get money for reforestation than for health care funding. So we can use the grant money for purchasing seedlings to "buy" the seedlings from the health care side of our work. When people pay with labor it makes everything we do cheaper. But actually most people choose to pay with cash -- they just love that they have this option because it means that they never have to worry about affording care. They never have to log to pay for health care. It should also be noted that the prices in our clinic are very low. It costs about what a bowl of soup costs to see a doctor.

Would you please Explain, in laimance terms, what "illegal logging" is?

Ah! Thank you for asking that. Where we work, "illegal logging" is logging within Gunung Palung national park. By law, that is not allowed and could theoretically lead to arrest although during the first five years of our program there weren't any arrests and since then there have only been two. The trick is that this is not just "illegal" in the eyes of the state but also something that the local communities do not want to do. In one survey we found that 100% of the loggers wanted to quit. The people see the forest as the source of their water, a source of medicines, and a home for the animals. They also have a cultural understanding that logging can lead to disease. One man told me that when they used to log they would push all the disease down from the hills to the village and people would get sick. Interestingly, there is evidence that might back this up since logged forest has a much higher rate of malaria-carrying mosquitoes.

laimance

"Layman's"

I can't help but think this is more or less extortion.

I'm all for ending illegal logging, but it sounds like they're saying, "stop logging or we won't set your broken leg, and you may end up dying because of it. Almost certainly lame for the rest of your life."

Withholding--or the threat of withholding--necessary medical care because someone is doing something illegal is at best unethical, to me.

I caught the story on NPR last night.

But it's more like, if you come from an area where illegal logging is happening, you pay the normal price for healthcare that you would anywhere else in the country.

If you come from a place where illegal logging has stopped, you get a 70% discount.

Trying to get the local populace to put pressure on the people that are doing the logging.

Exactly, but actually our "normal" price is still lower than the cost in the city two and half hours away which is where people would have to go otherwise. So our un-discounted price is doubly less expensive because you also don't have to pay as much for transportation.

No one is every denied care. I agree, that would be totally unethical! Everyone can always pay with non-cash means and what you have to understand is that when this idea was introduced in the original radical listening meetings the communities loved it. There were two aspects they loved: first it wasn't charity. They were trading something valuable with the world community for something they wanted. Second: they loved that it might help them get the few cheaters to stop. All over the world, there is a concept called the tragedy of the commons. It means that when a resource is available to everyone, some people may chose to exploit it to the detriment of others. They loved that this method might help get their neighbors to stop. And, it would be wrong if we weren't offering an alternative to logging. 100% of the loggers wanted to stop. They just often couldn't because of the need to pay for health care and often because they didn't have other skills. So when we listened to communities and provided the two things they asked for -- health care and training in organic farming -- they were able to stop. And they have! 52% of the previous loggers are now farmers and they tell us that they are making more money than when they were logging. With the few remaining loggers, who often don't own land, we are also now working with them to help them start micro businesses. We want everyone to have health care (and they do), we want the forest to be preserved for their well being and the well being of the world (and that is happening), and we want people to do better economically (and that is also happening!). It truly is win-win. Not lose-lose.

Coming from a woman who wants to travel and make a difference in the world, what did you have to sacrifice or lose in order to achieve your successes?

I worked for seven years without a salary and life was not always easy but, actually, I feel like I gained much more than I lost. It's impossible to count the value of getting to see individuals and a community transform. And it was the same way for me. I had to face really hard things but in that process, I was able to do the difficult personal work that is the foundation for being all that we can be. It will always be a work in progress, but I feel blessed by the work I've gotten to do and most especially by the people I've been privileged to travel this path with.

I heard some destitute people only seek medical help when they are severely debilitated. So, what is the worst case you have seen at the clinic and what is the most common chief compliant?

When we first started our work nearly ten years ago, it was very common to see people come in at stages of disease that were just horrifying -- very advanced cancers with huge tumors, heart disease so bad that people couldn't stand, or tuberculosis that had turned them into skeletons. Thankfully it isn't like that anymore. People come in at much earlier stages and we are often able to cure them or refer them to the care they need. It is still nothing like in the developed world, but things are noticeably different and that makes me very happy. The most common diseases we see in the clinic are high blood pressure, diabetes, heart disease, lung disease (mostly from smoking) and tuberculosis. We also see a good bit of anxiety and depression. The way things work in the clinic is that all the patients are seen by Indonesian doctors. However, we also have volunteer physicians from around the world who come to learn from their Indonesian colleagues and teach them. They are available to consult and discuss cases if the Indonesian doctors have questions.

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There was a fascinating study in the slums of India that showed the rates of depression were exactly the same as in the US. Maybe it is just the human condition but my general feeling is that while it certainly occurs there, it is actually more common in the US. Once your basic needs are met, wealth has been shown to be negatively correlated with happiness. There doesn't seem to be much stigma associated with mental illness. And it is always a joy to cure someone with a diagnosis. Just telling people that they are actually well when they have a psychosomatic complaint is usually very effective.

Apa kabar? I heard your segment on NPR yesterday. What is your favorite Indonesian cuisine?

Baik juga! Terima kasih atas pertanyaan ini. Saya paling suka petai! Petai goreng atau dengan sambal. Enak!

I was struck by the story of the man who said “Why should I pay more than the others (for medical care) when I didn’t do anything bad in my village, I never was a logger?" Does this happen often? Is such a person's efforts to dissuade others from logging rewarded in any way?

Well, first of all, logging villages still get a discount just for bordering the park and working on decreasing logging. Those villages are called "Red" and they get a 30% discount. After a few years, in another round of radical listening we also instituted a "yellow" category for villages that had dramatically dropped their illegal logging rates but hadn't quite gotten to zero yet. They get a 50% discount. The green ones get a 70% discount. And remember, everyone can always pay with barter options so everyone can always access care. They just might have to pay with more seedlings, so more work on restoration can be done. We actually rarely get complaints and most people love the idea that the system helps encourage their neighbors to stop.

How do you know Radical Listening works?

The proof is in the pudding. During the first year of our program we spent over 400 hours listening to communities. We said, "You all are guardians of a precious rain forest that is valuable to the whole world, what would you need as a 'thank you' from the world community so that you could protect it?" They asked for high quality, affordable health care and training in organic farming. We did both of those things and sure enough, five years later the illegal logging had plummeted! I don't believe that outsiders can ever know what the most efficient and critical fulcrums of change are. Communities know that and my experience is that, by consensus, they can all agree what those issues are.

How much did the illegal logging plummet? I believe "anything you can measure you can improve", so what data has made Radical Listening a better approach?

We went from an estimated 1350 logging households when we started to about 450 after five years. Now, after 9 years, we are down to about 180 individuals! My experience is that this is a better approach because you are doing exactly the things that are causing people to destroy their environment. People were logging to pay for health care and because they didn't have the skills for an alternative livelihood. In addressing both of these things simultaneously, the effect was synergistic.

That is a really interesting way of doing development work within a community instead of ... I'm struggling with the right way to phrase this ... doing work "to" a community.

Have you seen this model used elsewhere successfully?

Exactly!! Most programs do work "to" a community. They come in with the idea that they know best -- and they DON'T!. Yes, I have see other programs do something similar. Check out Blue Ventures in Madagascar (https://blueventures.org). They have a similar approach that is also working amazingly well.

Do you see this model working in other places and capacities? Trading healthcare for not poaching...or something like that?

Absolutely! But only if the local communities are the ones that identify health care as a cause of doing something that they don't actually want to do. If you are a subsistence agriculturalist and are growing enough to eat, what do you need money for? A wedding, a house, and health care are often the critical things. But health care is the only thing that can't wait until you've collected money -- and that you will do anything to get. When we started 99% of the people wanted to protect the forest -- they just couldn't because they were missing critical knowledge and resources. The thing is that our experience in scouting out sites for replication, is that this story is very common and health care needs often drive over-exploitation of the environment.

Do you see this as a model that works? Would you look to replicate elsewhere?

Yes! We are currently doing site visits throughout Indonesia to decide where to do next. Our wonderful replication coordinator, Kari Malen, has a great way of envisioning the best way to spread this model. She calls it the wheel method with hubs and spokes. The hubs are more intensive sites like the ASRI program around Gunung Palung but spokes could be less intensive sites. For example we are considering doing work at Bukit Baka Bukit Raya National Park. The situation is very similar there where people are logging to pay for health care. However, the population is not large enough for a full scale clinic, but we could potentially do mobile clinics from our current hospital. We see potentially doing other hubs in other parts of Indonesia like in Sumatra or Papua with spokes as well. We are also looking outside Indonesia. Know anywhere you think would work well?

Our goal is also not to do it all ourselves. We want to collect excellent data at every site we do and hopefully train others to do similar work all over the world.

Is this a clinic or a full blown hospital, if not do you ever plan for it to expand into one?

We have actually just completed the building for a hospital. The critical reason for this was that a population of over 120,000 people don't have access to C-sections and the maternal and neonatal death rates are very high. However, we are still looking for fundraising for the equipment to fill the beautiful new building. The other great thing about building a hospital is that it allowed us to join the government health insurance system which should be a source of more sustainable funding.

Also how does payment by labor work surely if there injured this is counter-intuitive and will cause them more harm?

We give everyone six months to pay. And actually, we never ask anyone about payment when they come in: we just take care of them. Then later they can work out how they would like to pay and over what time frame. It's not unusual if someone is hospitalized for a family member to help us do laundry or roll bandages while they are taking care of their loved one. In that way, they are already starting to pay for their bill while the patient is hospitalized.

Hi Dr. Webb! I'm curious how you like Borneo. Do you plan to live there for a long time... or forever? Is this your home now?

I love Borneo and in many ways it has become my second home but I believe that there is a role for founders and then one should move on and make way for the next generation of amazing folks whose skills are more aligned the needs of an organization as it grows. While I still spent 8 months there in 2016 as we finished the hospital, my plan is to spend less time in Borneo and more in the US doing fundraising, spreading the word, and helping the Health In Harmony team get ready for replication in Indonesia and around the world. I imagine I will always go "home" though on a regular basis to cheer the team on.

Is anyone ever denied healthcare if they can't pay?

No Never!!! See the note above where I just answered this question. This is so critical for me. Everyone can always pay with barter options and we give people six months to pay.

Can you tell us a bit more about Radical Listening, and why it is a good fit?

I am aware that as an educated person I was taught to think in boxes. I was taught to think of health care as somehow different from conservation and economics but the truth is that there are no real boundaries. When talking to communities that are experiencing these problems directly, they are well aware that everything is interrelated. I don't think it has to be a long process. We have found that even in just an hour and a half meeting, a group of people can come to consensus about what they need to protect the ecosystems in which they live. And the amazing thing is that in a given region we have found stunning consistency in the answers that groups of people come to. Health In Harmony (www.healthinharmony.org) has developed a training module for radical listening. If you are interested, please feel free to be in touch.

As the founder of Health in Harmony and ASRI, what would happen if you got hit by a bus?

Ha! Great question. I guess this is the thing I'm most proud of: I think very little would happen. A few tears and then everyone would get on with the work. I'm also not the only founder. We have another legal entity in Indonesia called Alam Sehat Lestari (ASRI). This organization was co-founded with me by an wonderful Indonesian woman, Dr. Hotlin Ompussunggu. She has also moved on to do similar work in another part of Indonesia (and she's still helping us scout sites for replication). Now Dr. Monica Nirmala runs the whole team of 106 staff in Borneo of whom only one is an American. She does a stunningly great job.

And at Health In Harmony we have a fabulous team of 8 folks being managed by Trina Jones who are preparing for replication, overseeing even more research to prove the model, spreading the word, and raising the funds to support ASRI. We have also just hired an incredible new Executive Director, Jonathan Jennings, who will start in January. He comes to us from Doctors without Borders where he is the second in command of the Canadian branch.

We are poised to expand. Probably I can be of help in this process but even without me I know the whole team would do an amazing job.

A donor recently visited the program in Borneo and he told me that he had originally supported us because he thought we had a great idea but now he could see that the genius of the work was in the incredible team that have been assembled. That is really the truth!