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INDONESIAN DOCTOR DIVES INTO RACE TO EDUCATE COUNTRY ABOUT AIDS

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Dr. Tuti Parwati has just spent a grueling day meeting with international public health officials, tending to AIDS patients and preparing a speech for top members of the Indonesian government.

Now, after sunset, she's talking with construction workers at a camp in Denpasar, the largest city in Bali. A slight, well-dressed woman, Parwati may look out of place in these surroundings. But she's comfortable delivering her message, which pulls no punches: The workers must practice safe sex to avoid catching AIDS.Parwati, an Indonesian physician and AIDS researcher, is trying to help her country stop the spread of AIDS, acquired immunodeficiency syndrome. So far, Indonesia, a country with 195 million people - the fourth highest population in the world - has one of the lowest rates of HIV, the human immunodeficiency virus that can lead to AIDS. At the beginning of 1994, just 198 people were reported with HIV, and 51 of those had AIDS. Those numbers translate to about 20,000 to 40,000 people infected with HIV, say public health officials. In comparison, the United States, with a population of 249 million, has 339,000 reported AIDS cases and approximately 800,000 people with HIV.

If Parwati succeeds, say international public health officials, the island nation could become the first in the world to slow the spread of the deadly disease. They say Indonesia could serve as a model for other Asian countries that still have low levels of HIV.

The biggest boost to Parwati's campaign may come later this year, when a five-year $40-million effort funded by the United States, Australia and Germany, will go into effect. The United States, which is contributing $15 million to $20 million, has listed Indonesia as one of 15 priority countries to assist in stopping the spread of HIV.

Indonesia, made up of more than 13,000 islands, 6,000 of which are inhabited, is the world's largest archipelago. Two-thirds of the population live on Java, the world's most densely populated island, and Bali, the small adjacent island that is the hub of the country's tourist industry. Nearly one-third of Indonesians live in cities. Bordered by Malaysia, the Philippines, Papua New Guinea and Australia, Indonesia stretches across 3,200 miles and three time zones, from Sumatra in the west to Irian Jaya in the east.

"HIV already has broken through into the heterosexual community in India and Thailand," said Paul De Lay, a physician and technical adviser to the U.S. Agency for International Development's HIV-prevention program. "An epidemic of HIV in Indonesia would have a major impact through-out the Pacific Rim," with little hope in stopping the disease's spread throughout Asia.

IN NEIGHBORING Thailand, a free-flowing sex industry has caused the number of HIV cases to skyrocket to an estimated 500,000 in a population of 55 million.

Although Indonesia and Thailand have some of the same risk factors, Indonesia has two advantages, said Don Douglas, director for PATH, private international aid organization in Indonesia, and who spent seven years in Thailand. "Thailand had a large pool of low-income drug users," he said. "Here, drug use is rare." Indonesia also benefits from a smaller and out-of-the-way network of prostitution that is not socially accepted.

Parwati woke up to the HIV problem in 1987 when the Indonesian government sent her and several other health workers to Australia to study what was then assumed to be a disease confined to tourists. After visiting AIDS patients in a Sydney hospital, Parwati realized that 195 million Indonesians were also at risk. She returned, she said, "wanting to spread information on how to prevent AIDS to everybody as soon as possible, as loudly as possible, to tell people AIDS is coming and there is no cure."

First, she set up a system to analyze random blood samples to track the infection's spread in Bali, an island of 3 million. Working with U.S. AID public health officials, she identified those groups most at risk - male and female sex workers, homosexuals, students in tourist academies and employees in the tourism industry. Then she set up education programs to reach them.

Today, Parwati, who is chairman of the tropical and infectious disease department at Sanglah Hospital in Denpasar, Bali's largest city, heads Citra Usadha Indonesian Foundation, a nongovernmental organization that sends case workers out every day and night to talk with people. Parwati's workers hand out pamphlets and condoms and organize peer support groups. She has made a point of working through existing social structures and mobilizing the leaders of those structures to make HIV prevention a priority. The information they provide could mean the difference between life and death for some on the street.

The program has been expanded to more than 30 communities across the country that work with their own high-risk groups. These include construction workers, truckers who drive and ferry cargo across many of Indonesia's 13,000 islands, low-income married women whose husbands work away from home, oil workers, sailors and people who are exposed to Thai fishermen.

"Parwati's program model is among the most innovative in the world," said Tom Coates, chairman of the steering committee for social and behavioral studies at the World Health Organization's Global Program on AIDS. "The idea of using existing social structures and persuading the leaders of those structures to get behind prevention efforts hasn't been done much in other countries. But it's still hard to make HIV a priority when there's still such a low prevalence."

Public health officials with the WHO and U.S. AID say that for Indonesia to succeed in stopping HIV, it must go beyond Parwati's grass-roots programs to set into place an effective campaign at the national level.

With the prodding of Parwati and other enlightened public health officials, the Indonesian government is making progress. It gathers and publishes regular reports from 12 of its 27 provinces, and it is defining the behavior of high-risk groups and setting up small education projects.

The country's Communicable Disease Research Center in Jakarta is strengthening its testing laboratories and beginning to track the spread of HIV and other sexually transmitted diseases in 15 major cities. And 22 government officials sent by U.S. AID to Thailand to learn first-hand about the disease "all came back converted" to the need for urgency, says a senior U.S. AID official in Jakarta.

But any massive, high-profile education campaign in schools, health clinics or the media must still overcome considerable opposition to public discussion about sex-related topics. The opposition comes from the basic religious conservatism of Indonesia, similar to that of the United States. Although Indonesia is often described as a Muslim country - and it is has the largest Muslim population in the world - it has four other major religions: Hindu, Buddhism, Protestantism and Catholicism. Islam, the predominant religion, is not the fundamentalist type practiced in some parts of the Middle East. For example, Indonesia has a stated policy of equality for women, and few women cover themselves from head to toe.

THE COUNTRY'S conservatism led officials in the Department of Immigration to refuse basketball star Magic Johnson's visit to Indonesia for a one-day, AIDS fund-raising event last January. And, just as in the United States, explicit television advertising of condoms is not permitted. Although more people are using condoms, say U.S. AID officials, the current rate is still a dismally low 5 percent, and it will be years before any behavioral changes alter the rate of HIV infections.

"We are dealing with a lot of misinformation and prejudices," said Suriadi Gunawan, director of the Communicable Disease Research Center and a physician who studied at Johns Hopkins University."But if we give the clergy good information, we can change their beliefs." In fact, it was Indonesia's religious leaders who were instrumental in reducing Indonesia's population rate from 5.1 to 2.1 in 20 years, a feat no other developing country has matched. And already, said Gunawan, officials in the ministries of religious affairs and education are considering ways to incorporate HIV education programs into the curriculum.

International aid, such as the five-year, $40 million program expected to begin later this year, will be a big boost to the fight against AIDS. The money for Indonesia will go into surveillance, laboratory equipment and training, national education campaigns, beef-ing up government health facilities, and to develop more programs like Parwati's.

Nevertheless, Indonesia faces an uphill battle against AIDS. "We need hundreds of Tuti Parwatis," says Douglas. "In terms of a large national education program that takes advantage of the mass media, we're years away."

Six years into the battle, Parwati says she's committed to the long haul. But she's worried. In the last year, the doubling time of reported HIV infection has dropped to six months. "When we look at the beginning of the five-year curve in Thailand, Indonesia's is similar," said Parwati. She rolled her eyes and sighed. "We have to be optimistic. Because we've started early, we may at least slow the spread of AIDS."