The New York Times has cottoned on to the unpredictable glories of Indonesia. But they’ve got it just that little bit wrong. Here’s what they have to say about US President Obama’s childhood minder:

“His nanny was an openly gay man who, in keeping with Indonesia’s relaxed attitudes toward homosexuality, carried on an affair with a local butcher, longtime residents said. The nanny later joined a group of transvestites called Fantastic Dolls, who, like the many transvestites who remain fixtures of Jakarta’s streetscape, entertained people by dancing and playing volleyball.”

If Obama’s nanny was playing volleyball on teams like those that now take on the cops behind the Melia hotel, he was not an openly gay man, she was a waria, or transgender. As you can see from the photo above, waria live as women — they even do the whole beauty pageant thing. She probably didn’t carry on an affair with a butcher — it’s more likely she was “married” to him. Indonesia’s attitude to homosexuality in the late sixties was not relaxed, it was unbelieving. Waria, on the other hand, are just a part of society; in some provinces, though not Jakarta, Waria is an accepted gender on the all-important national ID cards. Finally, transvestites don’t hang around the streets singing. They hang around the streets cruising for people who will pay them for sex.

Still, nice to see the Times ticking the “exotic diveristy” box as best it can.

Salaam kepada pembaca di tannah air kita. Kalau seandenya ada di Jakarta hari Minggu ini (Tanggal 3 Oktober), ayo ikut skrining khusus film baru Madame X, di Senayan XXI, Jam 9.30 (blerch!). Di minta 250,000 rupiah; dana akan digunakan untuk mendamping kawan2 waria yang perlu di rawat HIV. Satu di antara setiap tiga waria penjajah seks di Jakarta sudah perlu bantuan; untungnya ada kelompok waria seperti Yayasan Sirkandi Sejati yang kerja secara rajin untuk membantu komunitas tersendiri. They need your help, so please support them. Apalagi, dari trailer, kelihatannya Madame X adalah film yang norak habiiiiiiiiiiiiis, berarti tentu saja lucu dan berhasil. It should be fun!

When I was here six months ago, Health Minister Siti Fadillah Supari stomped on American scientists who’ve been trying for decades to help Indonesian colleagues build world-class research skills. The move played well to the growing Xenophobia of a minority of the population. But as rallies of flag-waving campaign louts brought Jakarta’s slothful traffic to an absolute standstill last week, she went one better. She worried aloud that foreign pharmaceutical firms were using Indonesian children as testing grounds for dodgy vaccines. Sadly, the vaccines she called into question were some of the most effective on offer: hepatitis B, chicken pox, rubella and typhoid. While Indonesian paediatricians fumed, nationalists rallied around the ambitious minister, saying a review of foreign vaccines is long overdue. Supardi’s own staff have been desperately backpedalling, basically admiting (“without elaborating” that the comments were little but political votemongering.

I’m not one to be too upset about being critical of Big Pharma when it’s warranted, but in this case it’s clearly not. The gossip in Jakarta is that Supardi is not anti Big Pharma, in any case. She justs thinks Indonesian businesswomen (and men) rather than foreigners should profit from the drugs the government buys. Shutting out foreign vaccines creates a market, in theory at least, for Indonesian firms such as Kalbe Farma, whose “Indonesia can do it too” press conferences are graced by the Minister.

I find it mildly ironic that Supardi gets such a good ride out of her anti-foreign demagoguery. Other members of her party think that pro- foreign sells better with the electorate than anti-foreign: they’re surfing the Obama wave in search of votes.

Thanks to Astry for this poster. There’s a fantastic collection of election posters on Astry’s blog, If you think Obama is kitsch, check out the candiadates who pose with David Beckham and Che Guevarra…

” I did not ask my students to give a definition of pornography. I asked them to give examples of what they considered pornographic. … Some examples my students gave: Playboy magazine (which is so puritan here that more skin can be seen in the Indonesian version of Cosmopolitan), prostitution and striptease (there are already laws concerning these), pornographic movies, photos and literature, adultery (in the sense of pre and extramarital sex), kissing in public, Inul’s form of dangdut and miniskirts. From these, we cannot deduce a clear definition. Many students gave examples concerning male desire for the opposite sex and the consequences of this desire, like rape, for example.”

Read the rest here.

If you don’t know what Inul’s form of dangdut is, you’re in for a treat. (It’s so compellingly trashy that I’m not allowed to embed the viedo.)

Michael tells the story more patiently than I’d be able to. As several people pointed out, including Dharmawan, Willem and Catherine. Read. Really, please read. What Michael doesn’t say is that Indonesia has pocketed more than US$ 400 million in foreign taxpayers’ money to deal with HIV so far, and has another US$ 130 million from the Global Fund on the table. And it can’t even assure treatment in the big, well-funded, teaching hospitals designated to provide ARVs. No need to point out that treatment is the EASY bit, the big, politically popular success story. People need it because we fail so badly on the cheaper, easier prevention services, like making sure that kids who inject heroin in Indonesia don’t also inject HIV. If it doesn’t make you angry that we’re using your money so badly (if you’re a European or North American tax payer) or serving your needs so poorly (kalau seandenya anda orang Indonesia, apalagi orang Indonesia yang terinfeksi HIV…), this blog’s no place for you.

As the Jakarta Post pointed out yesterday (in a profile that called me a “raging dinosaur” — a compliment, I think) I was wrong to dismiss Indonesia’s “anti-pornography” bill as so silly it would never get passed. (It did.) I had the same reaction when I heard several weeks ago of a bill to implant people with HIV in Papua with microchips. The brain-child of an Indonesian doctor who has served for years in the country’s easternmost province of Papua, it was too silly even to comment on. Apparently, I was wrong again.

The Post now reports that the bill has the support of local legislators, and may be passed into law. Not all people with HIV will get silicone implants, you understand. Just those who are “sexually aggressive”. Who qualifies as sexually aggressive? “Aggressive means actively seeking sexual intercourse,” the good doctor, one John Manangsang, is quoted as saying. Oh, so perhaps that is everyone, after all.

Predictably, and entirely appropriately, HIV activists are railing against the bill. So are many others, including Papua’s former Vice Governor Constant Karma, a very sensible vet whose position as head of the provincial AIDS council may be threatened because Dr Manangsang’s bill reserves the post for a medic such as, oh, himself perhaps. I’ve got nothing to add to their cries for common sense. This sort of nonsense is hardly worth commenting on from a public health point of view. But I think it might give pause for thought to those who are pushing rapid decentralisaton and local democracy as a development model.

Until 1999, Indonesia’s 13,000 islands were held together by one of the most centralised administrations in the world. Then, by fiat of the erratic and short-lived president Habibie, it decentralised, virtually overnight. Not to the level of the then 27 provinces, but to the level of the then 300-and-something and now 400-and-something districts (the total changes almost monthly as local luminaries seek to consolidate their power and their bank balances by heading up a new district). Pimps of decentralisation sell it as taking decision-making closer to the people — making administrations more responsive and accountable to the electorate and the tax-payer. Which is all well and good, provided you have an educated and informed electorate, and an administration which is willing to listen to them rather than to impose absurd (and sometimes populist) measures at will.

One hopes that the people of Papua will take their leaders to task for suggesting daft measures such as electronic implants. But Papua’s literacy rate is just 72%, against an average for the rest of Indonesia of well over 90%. It’s HIV epidemic is very different, too. In terms of patterns of both infection and sexual behaviour, it looks a lot like East Africa, circa 1992. Men who buy sex are most likely to be infected, but unlike the rest of Indonesia (where drug injection and sex between men compete with commercial sex to spread HIV) there is every indication that patterns of sexual networking may support the spread of the virus beyond high risk groups and their immediate sex partners. Most importantly, perhaps, the people of Papua have been too long accepting bad government. Bringing bad government closer to the people does not make it any better.

For the last couple of weeks, I’ve been saying with some confidence that there was no way that Indonesia’s parliament would actually pass the anti pornography bill which has been 10 years in the making. The spirit of pluralism is of necessity deeply rooted in Indonesia; with so may religions, languages, ethnicities, people have to tolerate one another just to survive. Of course political inertia is almost as deeply rooted as pluralism, so it sometimes takes people a while to wake up to the fact that a few noisy zealots are whipping them towards the brink. But once at the brink, once faced with the possibility that all-important pluralism will actually be undermined, they would rise up, speak out, push the zealots back into their lairs, I reasoned.

I was wrong.

There was indeed a little bit of rising up, most notably on the Hindu island of Bali, and in largely Christian North Sulawesi. And in the national parliament, 100 MPs rose up and walked out in protest before the bill was voted on. But none of this was enough to stop the bill being passed. I’m hoping that the law will be ignored, like so many others in Indonesia (laws against corruption, laws protecting the rights of factory workers and citizens in police custody, laws guaranteeing access to free primary education…). But its broad definition of “pornography” (basically as anything sexual, rather than anything related to sexual exploitation) is dangerous. The fact that it explicitly allows citizens (read: self-appointed vigilante groups) to take this fuzzy law into their own hands to defend the morals of the nation is more than dangerous, it is stupid.

But Indonesia has always been a country of contrast and compromise. Two other things happened at time the law was being passed that cheer me somewhat. The first is that Habib Rizieq Shihab, the leader of the obnoxious FPI or Islamic Defenders’ Front, the best known of the said self-appointed vigilante groups, was thrown in jail for inciting violence at a religious tolerance rally in June. The second, less significant but rather amusing in the circumstances, was that Kick Andy, Indonesia’s answer to Oprah, aired a whole hour and a half programme about sex, drugs and AIDS. In it, my friend Lenny talked about transgender sex work, Bhim demystified gay life in Jakarta in a no-big-deal kind of way, and I talked about anal sex and gave condoms to students on air. An HIV-infected sex worker described what her husband thought of her work and an extremely eminent doctor tore a strip off the government for allowing stocks of antiretrovirals to get run down to zero, despite sucking in millions of dollars from donors.

There may be no room for pluralism in the law, but it is still there in fact.

It’s the latest punch in a dust-up that has been running for months. It’s not actually about what the navy-run NAMRU does. It’s about politics, personalities and profit. US Secretary of Health and Human Services Mike Leavitt tapped the nail on the head in his extraordinarily candid and rather admirable blog.

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

Ibu Siti was chosen as health minister in preference to a previously favoured candidate because Indonesia’s president needed a woman from an Islamic party to tip his precariously balanced cabinet back from the brink of secular technocracy. She makes no apologies for taking an anti-Western stand at every opportunity. Most famously, she’s stopped giving flu samples to the WHO for analysis. In fact that’s probably why NAMRU got caught in the mess — it’s a WHO collaborating center. Supari has published a book “It’s time for the world to change! The hand of God behind the flu virus” in which she essentially argues that bird flu is a conspiracy cooked up in US military labs. Leavitt again:

Minister Supari, recently published a book in which she asserts the U.S. military is using influenza samples to create biological weapons. Secretary of Defense Gates was asked about the Minister’s accusation when he was in Indonesia this past February; he replied, “That’s the nuttiest thing I’ve ever heard.”

Of course that is loopy, and meant only for domestic political consumption. But the Indonesian cardiologist is not entirely wrong about another issue. Supari doesn’t think Big Pharma should make tonnes of money out of vaccines developed with samples from Indonesia, without Indonesians getting anything out of it. This makes Leavitt cross. Big Pharma needs the incentive of big profits if it is to continue to invest in research and innovation, he appears to say. But refusing to provide samples to help them achieve those profits also achieves robbing Indonesians and other people of an effective vaccine and thus good health.

In truth, Supari has a point. Her mistake is to reduce the equation to cash. What Indonesians need first and foremost is free access to any vaccines that are developed. Leavitt acknowledges that this is an issue, but brushes it aside. He’s wrong to. Bird flu is different from malaria and dengue fever and most other infectious diseases that affect developing countries, in that it threatens people in rich countries, too (HIV is one of the few other exceptions). That gives poor countries a tool which they can use to scratch away at an incentive structure that is chronically biased against investment in prevention in general and in prevention of diseases that affect poor people in particular. If Supardi learned to use that tool like a scalpel instead of a butcher’s knife, she might actually do something useful for both Indonesians and the world.

An aside: NAMRU does make life rather easier for Supardi’s ilk than it needs to. It’s website borders on the jingoistic, as well as lying about relations with the Indonesian MoH. It’s a truly remarkable and wonderful institution, the cradle of many a wonderful Indonesian scientist, but it might want to hire some PR expertise. Any idea who might be good at this kind of trouble-shooting?

Let’s look at the last report UNAIDS issued, in December 2007. Confusingly, it also gave figures for 2007, but they’re not the same as the figures in the new report. The 2007 report revised previous estimates downwards quite a bit because of better data, largely from India. So it’s not fair to compare the numbers with the 2006 report. But we can compare them with the trend data given in 2006. I’ve pulled out the numbers, and here they are:

Yes, new infections have “declined” since their peak of 3.4 million in 1998. But they appear to be up on 2006. That’s probably an artefact of changing assumptions. The people living with HIV at the end of 2007 should be those who were living with HIV at the end of 2006 (33.27) plus those who got infected in 2007 (2.7 million, if you take the new figures), minus the people who died (2.0 million). By my calculations, that makes 33.97 million men and women, sons and lovers, kids and grandparents, accountants and circus performers and sex workers infected with HIV worldwide. So we’re missing nearly a million.

I understand that estimates change as better data become available, of course. I even bothered to read the UNAIDS backgrounder on methodology (pdf). But I’m still having trouble understanding how the arithmetic works on this one. I’m also wondering if it really worth the sweat of publishing estimates so often. Does the world really need a 50 page report in December 2007, and then another 357 pages seven months later, giving different figures for the same year? Is the marginal increase in accuracy worth the confusion and crushing report fatigue that I’ve heard from so many journalists?

If yes, it would be nice to have the differences explained. Perhaps more cogently than this explanation, which is given in the report: “Even though the HIV prevalence stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of ongoing new infections and increasing access to antiretroviral therapy.” Besides contradicting the headline statement that prevention is working in heavily-affected countries (i.e. Africa), this is arrant nonsense. Prevalence is the percentage of the population infected with HIV at any given time. It is the product of past rates of new infection (i.e. incidence) and death. The relationship between prevalence and “the actual number of people infected” is determined soley by the number of people in the population. If prevalence is stable but the number of people infected is growing, then it means that the population is growing, nothing else.

It’s worrysome too that Zimbabwe is singled out with Rwanda as a up-there-in-lights HIV prevention success story. The Zimbabwean government has been preoccupied with many things lately, but HIV prevention has not been top of the list. Data show that partner numbers have fallen, but anecdote suggests that it’s in large part because of the political an economic turmoil that has beset the country. Watching one’s father being beaten-up by Robert Mugabe’s goons doesn’t exactly put one in the mood for sex. It might make you want to go out and get plastered, and that might put you in the mood for sex, but with inflation at 2.2 million percent, beer drinking is no longer and option for lots of people. UNAIDS has in the past (rightly) suggested that good leadership is a crucial ingredient of successful HIV prevention. By giving the example of Zimbabwe so much prominence, are they now suggesting we should turn our attention to economic meltdown as a way of reducing multiple partnerships and thus HIV? It might work. The only year that we saw a substantial fall in the proportion of men buying sex in Indonesia was in 1998, the year the economy took a swan-dive off a dliff.

This kind of nit-picking is of course churlish. I sympathise with the writers of reports like this, caught as they are between the need to show that things are going well (so you should keep investing in HIV) and that the situation is dire (so you should keep investing in HIV). In truth, the key issue is not whether there are 2.5 or 2.7 million new infections. It is that somewhere between two and three million people are still getting infected every year with a completely preventable disease that we are spending over 10 billion dollars a year on. That’s a scandal that no amount of report-writing has been able to change.

Their discussion about the rights and wrongs of discrimination in toilets is interesting. But the “where to pee” debate masks something (to me) much more important: “where to go for health care”. When I was working with the fabulous Lenny Sugiharto and other waria in Indonesia, I learned that one of the reasons these “women with penises”/”other definition of your choice” had such phenomenally high rates of untreated STIs and other illness was that they HATED going to health services, and getting stuck in the men’s wards. Groups like Arus Pelangi are lobbying for less discriminatory attitudes among service providers, but there’s a hell of a long way to go.