Merapi's Picture in Century

Merapi eruption on 2010 is not as big as last time. On 1930 eruption, Merapi's have killed 1370 people in 13 village. Vulcanologic center has recorded big mount Merapi's eruption on 1961, 1984, 1994, 2006 and 2010.

Even its a dangerous and have evidence that Merapi's eruption has potential to kills many people but yet, still have a village 6km away from top of merapi's. What will government do?

1930

Merapi's eruption on 1930's, it rupted hot cloud and ashes

1370 peoples killed in 13 villages around foothills Merapi

1961

On 7-8 Mei 1961, ashes cover village till the top of the houses. 

Hot ashes and cloud burned 10 villages

1984

Merapi erupted on 1984

1994

Merapi's eruption on 1994

2006

Satellite photo  

Hot ashes slide down the hill

 2010

Merapi's eruption followed by lightening, sounds of Merapi's eruption can be heard more than 25km

Lava

Effect of Merapi's after big eruption on 2010, it cause a crack on it

Once upon a time ~

Yogyakarta is a student city, known as DIY (Daerah Istimewa Yogyakarta) cause it is the only region that control by Sultan. Mount Merapi is located 27-32km from here is one of the most active volcanoes in the world. On 6th of March 2010, I have the oppurtunity to go hiking (it takes around 2hours) and see Merapi from different view. Seriously, it is breathtaking and take our breath away (tiring but exciting) 

                                      

Our journey start at 3.30 a.m.

It is used to be so peaceful....

Now

after 1st eruption, mosque stand still but collapse after few eruption

Cows also suffer from burning

one of houses in jakal km 25 (25 away form Merapi)

The chronology of disaster

Pathophysiology of disaster

Hazard -  potential to cause harm or something that contain energy that can cause destruction. For example, Mount merapi that contain energy ( ashes, lava), when it erupt it can cause death and destruction

risk - is a likelihood to harm. It is different from hazard. For example, a low exposure to something that is highly hazardous, may result in a low risk. Mount Merapi is highly hazardous but risk if death is depends on geographic location, nearer to mount merapi increase the risk

event - it is a realization of hazard, still yet not a disaster. It is call an event when its happened ( Mount Merapi erupt)

impact - it is a contact of event and society. impact can happen to human or to the environment. For example, ashes of mount merapi reach till Jalan Kaliurang Km 35 (35km far from Merapi)

damage- caused by a sudden impact. Harm or injury to property or a person, resulting in loss of value or the impairment of usefulness. Merapi eruption on 2010 cause more then 200 people die, Many village a covered by ashes, destruction of infrastructure and houses. It cause them to lose their poultry and agriculture. 

disaster - sudden ecological phenomenon of sufficient magnitude to require external assistance, change of social function and cause destructive effect. Mount Merapi eruption cause high damage that needs assistance from outsiders. Helps come from internal and external, from other region including other countries.

Refferences :

1. Lecture notes Week 5, Conceptual Framework of Disaster and Disaster Management, by dr. Hendro Wartatmo

Wanna work in Malaysia?? Think first

"Working oversea" --> it sounds cool rite, especially when someone ask you about the payment, about life in a new country, then you will explain and make it look nicer. Hehe... Before you guys wanna know about what's happening for medical doctors in Malaysia, let me talk about international trades in services first because it is sort of related. So, basically it has 4 types which are

• cross-border trade - Any good sold by a seller in one country and bought by a buyer in a separate country. Simply means like you're shopping using an e-bay. You live in Jogja and purchasing clothes in UK. So, without going there, you still can have clothes that made from UK (sometimes written in tag --> made in thailand)
• consumption abroad - describes the process by which a consumer resident in one country moves to another country to obtain a service. For example, I'm Malaysian, live in Malaysia and go to Thailand to have a plastic surgery there.
• commercial presence - The service is provided within A by a locally-established affiliate, subsidiary, or representative office of a foreign-owned and — controlled company. For the ‘same’ company which has commercial presence in another Member's territory (Intracorporate Transferees). Means that Company X is well establish in America, so they set up a new hospital in Jogja for the native to have the services without going abroad.
• natural presence -A foreign national provides a service within A as an independent supplier (e.g., consultant, health worker) or employee of a service supplier (e.g. consultancy firm, hospital, construction company). Means that a specialist from Indonesia work in Malaysia

Asian trading

Ok, now you have a clear picture in trade services? So, if you, a doctor not yet a specialist, wanna choose the last option (Natural presence) and working in Malaysia, you must consider those things list down here :) 

Malaysian Govt Doctors Criteria
Criterias for becoming a Malaysian Govt Doctor. Theres no need for an aptitude test. Students should consider these requirements: 

1. No life outside medicine; this includes dating, sports, clubbing, chores for your parents and visiting the toilet 
2. Not to live with your parents. Move out ASAP as they will never understand the ludicrous working hours that u go through. Furthermore, chores are not suitable for u as to rule No. 1. 
3. Not to be married until completion of all 4 years of Govt Compulsory service as u will be transferred left and right to some of the most remote Govt clinics in Malaysia. Having wife and kids to follow you to your new working area may increase high level of stress on all parties. Furthermore, if your spouse is a Govt Doctor, he/she will also be transferred away from u and no matter what appeal is made, KKM will put up a deaf ear (unless u have big cables or of a certain skin color). 
4. If married, no to have children until u finish all 4 years of Govt Compulsory service, as to which u and your spouse will not have much time for your child/children or they end up not recognizing u and refer the Indonesian maid as their mother (change in language patterns commonly follow). 
5. To obtain life insurance once your govt service begins as there is not many claims for accidents during work. Don't be fooled, Doctoring in Malaysia is hazardous. 
6. Able to withstand 36 hours of non stop work and stress without mistakenly labeling Left for Right or uvula for vulva (or Volvo S40) 
7. To buy a car with complete safety features which includes multiple airbags, ABS, EBD, side-front-rear-top-parallel and diagonal impact bars and seat belts to ensure survivability if u are involved in an accident because your driving resembled a drunkard maniac after working in the hospital for 40 hrs non stop. 
8. Constant supply of coffee 
9. Nicotine Patch as u will have the urge to start smoking due to overwhelming stress 
10. Interest in watching medical sitcoms such as House MD, Scrubs, ER, Grays Anatomy and Chicago Hope to inspire u to continue your life as a doctor as the exciting things u see on TV does not resemble the real life of a Malaysian govt doctor. 
11. Not to have any pets or plants (not even cactuses) as u will have no time to feed or care for them and eventually all will end up in your mortuary. 
12. Able to endure the stench of your own sweat as to when 36 hours "on call" does not permit u time to bathe or freshen up. 
13. Able to carry on working without food or water over 15 hours. If during fasting month, able to break your fast with water for injection as u had no time to buy food. 
14. Able to come to work with fever/cough/illness or physical disability (sprained ankle etc) as to which doctors do not deserve MCs. 
15. Able to stand scolding, destructive criticism, kiss ass behaviors, racial bias, finger pointing, scape goating, and in competency from your superiors. 
16. Able to withstand the jealousy when your friends call u up for some fun and ur stuck in the hospital during on call. 

So, still consider to work in Malaysia :)

Refferences :

1. lecture note Week 1, International Health and Decentralization, by Dr. Yodi Mahendradhata

Brave Soldiers

The word antibiotic comes from the Greek anti meaning 'against' and bios meaning 'life' (a bacterium is a life form).' Antibiotics are also known as antibacterials, and they are drugs used to treat infections caused by bacteria. Bacteria are tiny organisms that can sometimes cause illness to humans and animals. The singular word for bacteria is bacterium. We can assume bacteria as an enemy and antibiotic as a brave soldiers.

Antibiotics generally work in one of five ways. These are:

• Inhibition of nucleic acid synthesis (e.g. Rifampicin; Chloroquine)
• Inhibition of protein synthesis (e.g. Tetracyclines; Chloramphenicol)
• Action on cell membrane (e.g. Polyenes; Polymyxin)
• Interference with enzyme system (e.g. Sulphamethoxazole)
• Action on cell wall (e.g. Penicillin; Vancomycin)

Antibiotic Ressistant
Antibiotics are important medicines that help fight infections caused by bacteria. Because bacteria are clever they adapt and find ways to survive the effects of an antibiotic. The more we use antibiotics, the more they become "antibiotic resistant" so that the antibiotic no longer works. This means that antibiotics are becoming less effective at fighting infections.

Mechanism of bacterial resistant

• target alteration - alteration of Penicilin Binding Protein(PBP)—the binding target site of penicillins—in Methicillin Resisstant Streptococcus Aureus (MRSA) and other penicillin-resistant bacteria.

• enzymatic inctivation - enzymatic deactivation of Penicillin G in some penicillin-resistant bacteria through the production of β-lactamases.

• decrease access to target - by decreasing drug permeability and/or increasing active efflux(pumping out) of the drugs across the cell surface

• miscellaneous - some sulfonamide-resistant bacteria do not require para-aminobenzoic acid (PABA), an important precursor for the synthesis of folic acid and nucleic acids in bacteria inhibited by sulfonamides. Instead, like mammalian cells, they turn to utilizing preformed folic acid.

Antibiotic Stewardship

An effective antimicrobial stewardship program, with appropriate drug product selection, dosing, route of administration, and duration of antimicrobial therapy, in conjunction with a comprehensive infection control program has been shown to limit the emergence and transmission of antimicrobial-resistant microorganisms.

Tools for good antibiotic Stewardship

• Guideline
• Restriction
• Area specific practices
• Combination treatment - Indication is to prevent emergence of resistant organism, polymicrobial infections, synergism, decrease toxicity and for severe or very severe infectious

It is not necessary to prescribe antibiotic in common cold patient. Most colds last about two weeks and end with a cough and coloured sputum. You need to see your doctor if your cough lasts more than three weeks, or you become very short of breath or develop chest pains, or you already have a chest complaint. Even if a cold goes to your chest, it is still unlikely that you would need an antibiotic but you should see your doctor if you are worried about your symptoms.

Refferences

1. http://www.scq.ubc.ca/attack-of-the-superbugs-antibiotic-resistance/

2. http://www.ashpadvantage.com/podcasts/handouts/07568.pdf

3. Lecture Note Antibiotic Use In hospital, Consequence and role of Drug Formulary in Controlling Drug use by dr Iwan

Ada apa dengan PUSKESMAS

Prior to Declaration of Alma Ata in 1978 regarding Primary Health Care (PHC), Indonesia has developed various forms of PHC in some regions. So, Puskesmas basically is a other name of PHC in Indonesia

went to Puskesmas Kota Gede II during block 1.6

All things that you need to know about... PUSKESMAS

1. Puskesmas??? What is it, sounds so weird....

• Functional health organization unit
• Public health development center
• Building community participation
• Provide comprehensive and intergrated services to the community under its coverage in the forms of  principal activities

2. I live in rural area, where can I find this PUSKESMAS?

 Part of or the whole sub-district (kecamatan), depending on:

• Population density (~30,000)
• Areas (~district head office)
• Geographic (extended to have supporting-Puskesmas/Puskesmas Pembantu or Puskesmas Keliling)
• Infrastructure (personnel and facilities) part of or the whole sub-district (kecamatan)

 Especially for big cities (population > 1 million) = Puskesmas Pembina:

• Coverage: sub-district
• Population: 150,000
• Referral and Coordinating several Puskesmas Kelurahan (village-level)

 Suppoting facilities

• Assistant Puskesmas (Pustu) 
• Mobile Puskesmas (Pusling), 
• Village birth attendance cottage (Polindes) - Village Midwives (BdD).  

3. What services can I have in Puskesmas, did they provide massage for a numb shoulder?

For all gender and age, from conception to those dying

• Promotion
• Prevention
• Cure/treatment
• Rehabilitation

Primary programs of PUSKESMAS

• Maternal and child health 
• Family planning
• Nutrition improvement
• Environmental health
• Communicable disease eradication
• Treatment, including emergency condition
• Public health education / promotion
• School health program
• Sport health
• Public health nusing

4. There are increasing cases of dengue in my village, what Puskesmas will do??

 Functions:

• Public health development center
• Building community participation to
• promote healthy life behaviors
• Provide comprehensive and integrated health care services

 Activities:

• Stimulating the community to do self-help activities
• Informing the community to search and use the locally available resources effectively and efficiently
• Technically assisting the community for medical content, medical and health referral without rising any dependency
• Providing direct health services to the community
• Collaborating with other related sectors in implementing the health programs

 Roles:

• As a technical implemental institution, it shall have a managerial capabilities and long-term vision to improve the quality of health services
• In planning, managing and evaluating
• Using and updating related information techniques to improve the comprehensive and integrated health services

5. Who works in PUSKESMAS?

Organization Of Puskesmas

6. Can Puskesmas handle severe cases?

 Type of referral system:

• Medical referral (diagnostic and treatment) - patient consultation, sending specimens and inviting special health personnel
• Health referral (promotion and prevention) - epidemiological survey and eradication of outbreaks, food aids, investigation of food poisoning, special aids during disaster and displaced  opulation/refugee, clean water, technology and laboratory

Refferences

1. http://staff.ui.ac.id/internal/140102741/material/Puskesmas.pdf

Surveillance

The World Health Organisation (WHO) define “surveillance” as the systematic ongoing collection, collation and analysis of data and the timely dissemination of information to those who need to know so that action can be taken. In other words, the epidemiological surveillance is necessary to plan, single out, manage and evaluate the actions relevant for the management of population sanitary status. In particular, the main tasks of surveillance systems may be summarised as follows:

• to monitor the sanitary status dynamics with the aim of intervening with timely preventive measures,
• to evaluate measures already implemented in relation to disease prevention and control,
• to optimize the use of available resources.

Surveillance is first and foremost a process for producing information that will trigger, inform or be used to evaluate defined public health (or clinical) action. If there is no clear and immediate link between the information output of an activity and existing or planned public health action then it is unlikely that the activity is surveillance.

Surveillance Types

1. Passive 

• definition - the most common form of surveillance, health authorities take no action while waiting for report forms to be submitted. It is also a potentially misleading term, since case reporting is not a passive activity for the reporter, who must complete the form.
• advantage - less costly than other reporting systems, data collection is not burdensome to health officials, and the data may be used to identify trends or outbreaks if providers and laboratories report.
• Limitations - non-reporting or under-reporting, which can affect representativeness of the data and thus lead to undetected trends and undetected outbreaks. A positive test may not be reported to prevent the stigmatization associated with STD, because of a lack of awareness of reporting requirements by health care providers, or the perception on the part of the health care provider that nothing will be done. 
• Incomplete reporting -  (i)reflect lack of interest, surveillance case definitions that are unclear or have recently changed, or changes in reporting requirements. (ii) Result of the patient not being willing to provide the information or hardware/software systems that cannot capture the information in databases.

2. Active surveillance

• definition - involves outreach by the public authority, such as regular telephone calls or visits to laboratories, hospitals, and providers to stimulate reporting of specific diseases.
• it places intensive demands on resources, implementation of active surveillance should be limited to brief or sequential periods of time and for specific purposes.
• It is a reasonable method of surveillance for: (i)conditions of particular importance - to document a suspected outbreak, or to augment timely disease intervention or epidemiologic investigation (e.g., for congenital syphilis in certain jurisdictions); (ii) episodic validation of representativeness of passive reports and as a departure point for enhancing completeness and timeliness of reporting (e.g., lab visitation programs to ensure all reactors reported);( iii) diseases targeted for elimination or eradication (e.g., smallpox, syphilis).
• Operationally, active surveillance includes visits or telephone calls to such key reporting sources as clinicians or laboratories by public health authorities on a regular or episodic basis to elicit (or verify) case reports and/or reviewing medical records and other alternative sources to identify diagnoses that may not have been reported. It is generally employed when it is expected that more disease is in the community than is shown in the passive surveillance systems.

3. Sentinel Surveillance

• Sentinel surveillance involves the collection of case data from only part of the total population (from a sample of providers) to learn something about the larger population, such as trends in disease. 
• advantages - (i) less expensive to obtain than those gained through active surveillance of the total population, and the data can be of higher quality than those collected through passive systems. This is because it is logistically easier to obtain higher quality information from a smaller population.(ii) Sentinel surveillance systems may be useful in identifying the burden of disease for conditions that are not reportable, or behavioral characteristics that are of sufficient public health importance to merit monitoring. 
• vulnerability - not being able to ensure the representativeness of the sample selected 
• Candidates for sentinel systems might include: human papilloma virus, herpes simplex primary infection, congenital infection, or other adverse outcomes of STDs. 

4. Lab-based reporting

• a surveillance system in which the reports of case come from clinical lab instead of healthcare practitioners/hospital

5. Universal case report 

• a surveillance system in which all cases of disease are supposed to be reported 
• Additionally, case reports received by the public health authority may require further action to ensure completeness, proper case classification, and partner management.

Ideal Surveillance System

Information Cycle
1. Collection 

• long or short term - Long-term data although in some cases essential, e.g. in time series analysis, is often prohibitively expensive in terms of both labour and monetary cost. However, long-term data collection is critical, if the modeller is to attempt to perform a time series analysis to account for seasonal, cyclic or secular trend in the respective populations and infection patterns. Time series analysis is also useful in quantifying parasite or vector development and maturation (Mullens and Lii, 1987).
• longitudinal or cross sectional
• retrospective or prospective in nature. 

2. Collation 

• the assembly of written information into a standard order. One common type of collation is called alphabetisation, though collation is not limited to ordering letters of the alphabet.
• Although computers have been available and heavily used in the developed world for several years, they have been in limited supply in many of the lesser developed countries. As a result, the data from these lesser developed countries typically exist on paper.

3. Analysis & Interpretation

• For epidemiological modelling will depend on the question of interest. Appropriate analyses could include case-control or cohort studies, or they may focus on the quantification of the estimation and significance testing of specific population and disease dynamics parameters. Analyses may also be made in order to specify the appropriate distribution of these parameters to be used in a simulation model.

4. Dissemination/Utilisation

• Once the appropriate data have been collected, collated and analysed, what is the appropriate form(s) in which they should be disseminated? Meaningful dissemination of these data and analytic results could occur in at least two ways. The first is to make the data available, in a collated from, to all interested scientific researchers. This method has recently been adopted by the National Animal Health Monitoring System, which is a livestock health surveillance system operated by the United States Department of Agriculture (USDA-APHIS/VS).

Purpose and Uses of Surveillance

• estimate magnitude of the program 
• determine geographic distribution of illness 
• portray natural history of a disease 
• detect epidemics/ define a problem 
• generate hypothesis and stimulate research 
• evaluate control measure 
• monitor changes in infectiuos agent 
• detect changes in health practice 
• facilitate planning

Refferences :
1. http://www.cdc.gov/std/program/surveillance/4-PGsurveillance.htm
2. Lecture note Week 2, Surveillance, Response and the Role of Public Health Informatics by dr Luthfan Lazuardi

How Indonesia's Health Care System Let Me Down

by Jason Tedjasukmana/Jakarta

Published in Time Magazine

I never thought I would let the grim stories I'd heard about Indonesia's health care system turn me into one of those expats who left the country at the slightest hint of a sore throat. I may have been skeptical of undergoing any major procedure in the country where I've been living since 1994, but I was pretty confident local doctors could handle a run-of-the-mill condition like vernal conjunctivitis. I was wrong.

In April 2009, my right eye started to itch and turned red. My vision turned blurry, and I couldn't figure out why I was losing sight in that eye, so I went to see a general practitioner, who suggested I see a specialist as it looked as though the problem might be in the cornea. I followed his advice, and after enduring a merry-go-round of eye doctors in Jakarta, my eye continued to get worse. Weeks later, I decided to leave the country to seek treatment, but by then it was too late. The condition had already damaged my cornea. Doctors in Singapore, where many Indonesians go in search of better care, suggested a number of treatments, including a corneal transplant if the others failed to restore my sight. I opted for another opinion back in the U.S.

For me to say that Indonesia's health care system is inadequate is, well, far from adequate, so let me quote a former head of the Indonesian Doctors' Association. "We have no health system," Dr. Kartono Mohammad recently told a group of journalists. "There is no quality control." At a time when Indonesia is striving to reach the ranks of the BRIC countries, strong fundamentals and an economy set to grow around 5% this year have yet to boost the hopes of millions in need of basic, reliable health services. For 2010, the health ministry has been allocated $2.2 billion, which is a slight increase over last year but still half of what is generally spent by the defense department. Overall, spending on health comes in at less than 2% of the year's total fiscal expenditures estimated around $110 billion. "It's still not enough," admits Health Minister Endang Rahayu Sedyaningsih. "Of course it is not right yet, but a national health system is there."

That might come as a surprise to the hundreds of Indonesians that still die each year of tuberculosis, malaria, dengue fever and other treatable illnesses. As for myself, I wondered how something as treatable as vernal conjunctivitis, which generally afflicts allergy sufferers, could lead to blindness. I had to go back to the U.S. to find out what at least six doctors here couldn't decipher; a doctor in Michigan diagnosed my problem in five minutes. "You have a case of vernal conjunctivitis," the cornea specialist told me. "If your doctors over there had looked under your eyelid they would have caught it, or at least they should have."

In fact, they did look. A fairly senior doctor hastily flipped my eyelid but failed to notice anything, despite the development of bumps similar to cobblestones that were scraping my cornea every time I blinked. A simple steroid would have reduced the swelling (as it did once I was prescribed one in the States) but I was told over and over that steroid drops would make it worse. Instead, in addition to dozens of antibiotic and antiviral drops, the doctors in Jakarta "cleaned" my eye by scraping off a layer, hoping a new layer would grow over the damaged center that was now exposed like a scraped kneecap. The pain that ensued once the anesthetic wore off was like having shards of glass driven into my eye, yet it could have been mitigated with a bandage lens — a protective contact lens with no power, which I also never received.

Naturally, I thought about suing the doctors, an avenue which Kartono and other health care experts have warned me rarely pays off. "It is a very gloomy picture," says Ajriani Munthe Salak, a researcher from the Legal Aid Foundation for Health. The chances of winning a malpractice suit in Indonesia are slim, she said, and the chances of damages being paid even slimmer.

I had already told myself that I was fortunate to have the means to seek treatment overseas, and that I would not pursue legal action if my vision was restored. After nine months, thousands of dollars and a procedure performed by an American doctor, about 50% of my vision has been restored. The imbalance between the right and left eye, which has normal vision, causes routine dizziness and discomfort, but I remain optimistic that I will get my right eye back.

If I don't, though, I feel compelled to do something, not so much for myself as for the millions of Indonesians who are much less fortunate and have nowhere else to go. The more I ask about the doctors I saw in Jakarta, the more horror stories emerge. One person I contacted reached a settlement in a similar case, though it cost her an eye. Others feared the prospects of a legal battle similar to one endured by Prita Mulyasari, a working class Jakarta woman who dared to criticize a local hospital and spent months facing down its lawyers. She has become something of an icon for all that is wrong with Indonesia's health care system. I don't know what I'll do yet, but I commend Mulyasari for having the courage to challenge a system that has let so many people down.

Read more: http://www.time.com/time/world/article/0,8599,1964611,00.html#ixzz16wxOCULi