The work of traditional and government midwives in Southeast Sulawesi
Simone Alesich
My mother was a dukun, but I didn’t want to become one. It is very demanding work. You can be called upon at any time, day or night.
(An elderly woman in Buton) Women assume most of the responsibilities for healing work in rural Southeast Sulawesi. Two types of women healers, the biomedical, government-trained mid-wife, or bidan, and the traditional healer and birth attendant, the dukun, between them provide the majority of healing services in rural villages. Healing can be con-sidered an extension of women’s work and women’s roles in the Indonesian state, and in the local communities where the healers live and work. In examining heal-ing work in rural areas we are encouraged to reconsider the notion of work, and how it can be defined and experienced in different ways. The type of work performed by these women healers differs significantly from women’s labour force participation in predominantly urban areas (see Hay 1999). In particular, the dukun’s position as a healer is not so much a job as a personal identity in the village where she lives, and a way of interacting with others. The same can be said at least in part of the bidan, since she must also live and establish social relationships in rural villages.
The Indonesian Department of Health plays an important role in the training of both bidan and dukun, and in determining their relative importance vis-à-vis the state. This was particularly apparent in the New Order period of government (1966–98). The history of maternal health service provision in rural villages in Indonesia is long and convoluted. The literature (e.g. Cholil et al. 1998; Hunter 1996) indicates that the late Dutch colonial period was the earliest time when an effort was made to coordinate birth attendant services in a centralized manner in the archipelago. The state has embraced, and rejected, the skills and knowledge of indigenous/traditional or village healers at various times since then. The colonial era saw the first effort to train midwives to replace healers in village areas, with the establishment of a ‘School for Indigenous Midwives’ in 1852 (Cholil et al. 1998).
Subsequently, the colonial regime conducted training of indigenous healers in bio-medical practice. After independence in 1945, and particularly during the New Order period, policies established by the Dutch were continued in various forms by the Indonesian state. In the 1970s the national midwife scheme was disbanded and
emphasis was placed on hospital deliveries for all births (Geefhuysen 2000). Later, the Department of Health began to train traditional healers (dukun) in biomedical practice (Grace 1996). The government midwife programme was revived by the Department of Health in 1989, with an estimated 56,000 ‘young midwives’ (bidan) placed on government contracts between 1991 and 1997 (Geefhuysen 2000: 63).
Biomedical training of dukun was phased out during the 1990s. While many of the changes to the maternal health service programme in Indonesia have been made in response to current global trends, as well as the perceived failure of previous schemes, this programme of maternal health training has had a significant impact at the local level in rural villages across Indonesia.
Southeast Sulawesi is a sparsely populated, relatively poor province of Indonesia, which has received scant attention in both academic literature and gov-ernment programmes. Like many provinces of Indonesia, it is on the outskirts of 62 Simone Alesich
Figure 4 Bidan Nila.
development, with mostly rural inhabitants working in subsistence and cash-crop farming. The two villages where I conducted fieldwork are in fairly remote, rural areas at two ends of the province.1One is a Butonese village, in the mountainous area between the port city of Bau Bau and the new district capital of Pasarwajo. The village does not share the sea-faring reputation of much of Buton, and villagers mostly farm dry rice and corn, and make arak (a type of liquor distilled from the lontar palm). The other is a Tolaki village up near the border with central Sulawesi province, and about 100 kilometres from the coast. It is a flat area, ringed with high mountains. The young men collect rattan and villagers farm dry rice and mung beans along the wide river nearby. Both villages are in ‘uplands’ areas, far from the coast; both are far from subdistrict health centres (pusat kesehatan masyarakat – puskesmas) and both have government midwives living in their villages. Southeast Sulawesi has historically been neglected by health services from the national gov-ernment (Kristanto et al. 1989) although it has been involved in the various waves of midwifery training.
Dukun and Bidan 63
Figure 5 Dukun Hana.
At the time that I conducted fieldwork in 2004, approaches to training traditional and biomedical midwives were changing yet again. Government midwives were being recalled for additional training by the district Departments of Health across Southeast Sulawesi province, partly in response to a general concern that the mid-wife placement scheme had not produced the reduction in maternal mortality for which the Department had hoped. After the end of the New Order period, the process of decentralization began to change the way that the state interacts with rural villages, with the new structure of the Department of Health placing much greater responsibility on district (kabupaten) health offices, for example, for train-ing and budget allocation. This chapter is written within the context of the current training situation, with reference to the historical context outlined above.
My analysis will consider the bidan and dukun as representing two different types of healing in Southeast Sulawesi, one type of healing sponsored by the state, and the other produced locally. The state has projected particular ideas and prac-tices of women’s work in the area of health, resulting in the female-dominated bidan phenomenon. The state has also redefined the role of the dukun according to state-sanctioned definitions of local healers. These state-sanctioned ideas draw on idealized concepts of the community and ‘the village’ in Indonesia (e.g. Bowen 1986; Li 2001; Warren 1993). Such state models of the village are often contested at a local level, and increasingly so in the decentralized era. This has implications for the roles that the bidan and dukun play in the local community. I will begin by considering in turn the dukun and bidan in my two field sites, the type of work that is performed by each, and how they interact with their clients, the state and the vil-lages where they live and work. I consider how their work has changed over time, and discuss the implications of this for women’s own understandings of their work and the roles they play in rural Southeast Sulawesi society. One important aspect of healing to consider is the connection between the healer, healing practices and the patient. Healing work cannot be separated from membership of a particular community, a healer’s relationship with her clients, and connections to other parts of her life.
Healing as work
Healing can be classified as ‘work’, in a fashion similar to factory labour or rice production. Analyses of labour in industrial economies place a great emphasis on productive work for a wage. This has been challenged by feminist scholars, who argue for unpaid work, such as housework, to be included within the definition of
‘work’ (Bullock 1994; Pringle and Game 1983). Adkins (1995) elucidates the dif-ference between ‘manufacturing’ and ‘service’ work, demonstrating that the latter is a growing area within the labour market, and one dominated by women. Part of the service provided to a client includes an aspect of the identity of the worker – such as her reputation or her rapport with clients (see Urry in Adkins 1995: 8).
Healing can be seen as a type of service work, where the person of the healer and her relationship to the client is much more significant than in other types of (pro-ductive) work. Moreover, the work of the healer itself has particular attributes 64 Simone Alesich
which the healer carries into the rest of her life, and her working and non-working lives inform one another. A large proportion of healers in Indonesia are women, and their healing role is seen by the community, and the state, as compatible with their identities and designated functions as women.
The healing practice of the dukun, the female traditional healer, is an integral part of her identity and relationship with others in rural villages. Dukun are expected to be available at any time, day and night, and remuneration for their services is often nominal or symbolic. The dukun has an important position in rural society as a pow-erful figure who can summon spiritual authority and heal people. She is related to many of her clients, who explicitly use this familial connection to seek her services.
She is descended from a family of dukun; thus her practice can be classified as an inheritance, and a woman descended from dukun often faces much pressure from the community to become one herself. She is trained by elders of that dukun family in a form of apprenticeship (see also Laderman 1983). In the area of childbirth, both the dukun and bidan are variously entrusted with the responsibility of ensuring the well-being of the mother and child. The bidan embodies the government health sys-tem and the authority of the government in the village. According to the govern-ment, the bidan is responsible for attending all births in villages, with the dukun only present as an assistant. However the ideals and practice of village health are embodied in the dukun, and her behaviour reflects the strength and authority of local health practice within the village. A majority of villagers express a preference for having a dukun attend births, whether or not the bidan is present. Yet the prac-tices of both healers are ambiguous, since they are affected by both the authority of the state and the local community where they live.
For women in rural areas of Indonesia, working for some form of remuneration complements their other responsibilities as mother, wife and housekeeper.
Although some women in Southeast Sulawesi work as waged labour in the forestry industry or road construction, for example, a large proportion of women work in occupations where they can concurrently look after children, their husbands and their households. This includes operating small shops from their houses or nearby markets. In both villages where I lived, small shops (kios) in the front of houses were a frequent sight. These are primarily – and sometimes solely – the responsi-bility of women (see also Indraswari 2005). Healing is one such occupation which dovetails in with other areas of women’s lives, since the typical work venue is her own, or another villager’s, house. However dukun work can be very demanding, such as when a dukun is called to attend the birth of a woman in a distant field (kebun), and she must be available to assist women in labour at any time.
The Dukun
Dukun Hana welcomed me into her house in some embarrassment, commenting on its shabby appearance, before offering me a chair in the front room. Her grandchil-dren played in the front yard and around our feet a number of small kittens mewed and explored. Hana is a Tolaki woman of probably about 50 years of age, who has lived in the northern part of Southeast Sulawesi province her whole life. She is a Dukun and Bidan 65
senior dukun in her village, called to assist births not only here but in a number of villages across the province where her skills are known. Hana laughed as she told me stories of births that she had attended and of her own labour, in the way of older women who are confident in their own society, able to laugh at their own actions and to proclaim that they sailed through their labour with ease. Extending her own lack of concern with pain, Hana told me about a recent accident where she had been badly hurt, and ‘nearly died’, when she left the village to assist a woman in child-birth some hours away. She smiled at me again, and walked into the back room to prepare a placenta for burial.
The dukun, or traditional healer, is a common figure in rural life in Southeast Sulawesi. Indeed, women with specialized skills in attending births in villages are found across Asia. They have been generalized by development literature into the category of ‘traditional birth attendant’, which ignores the specificity of their roles in the communities where they work (see Pigg 1995). Dukun is an Indonesian term for this type of healer, a woman who attends birth, among other healing services.
Confusingly, dukun is also a term used widely in Indonesia, and historically in anthropological literature, to refer to sorcerers and magical practitioners (see for example Geertz 1964). Some authors have used local terms, such as belian in Lombok (Hay 2005) to remove the confusion used by the term dukun. Since my fieldwork was conducted in two different areas of Southeast Sulawesi, the local terms for dukun differed: osando in Tolaki and bisa in the Wakaokili dialect used in the Buton village.2
The demanding nature of dukun work in Southeast Sulawesi villages means that it tends to be performed by older women, who have lesser responsibilities for chil-dren and the household. Dukun are typically past the age of having chilchil-dren, ‘usu-ally between about 50 and 70 years of age’ (Grace 1996: 151). Older dukun are greatly revered for their experience and knowledge, referred to as dukun senior.
Being married, with children, and generally older, dukun escape the condemnation that women in some societies have in terms of working outside the normal occupa-tions of women (in child rearing and household tasks). Their status as older women, and mothers, means that they are able to leave the village to attend births (in other villages or in distant fields), and to work at night as well as during the day. This can be considered less acceptable for younger women (for a discussion of the problems of night-time work see Nilan and Utari ch. 7 of this volume).
I visited Hana’s latest client in her front bedroom: a young unmarried woman, the dukun’s niece, who had fled to her aunt’s house to give birth because she had concealed her pregnancy from her parents, fearful of her father’s reaction to her pregnancy. I later watched as Hana washed the new baby’s placenta carefully, using water, salt and dried mango (a type of asam or sour dried fruit) before wrap-ping it in a white cloth (white cloths are also used for burial) to bury it. The placenta was buried by a man, since the baby was a boy. The placenta is referred to as kakak – older sibling – and it will guard the baby against illness as it grows (for discus-sions of the meaning of the placenta in other parts of Indonesia, see Grace 1996;
Niehof 1985; Parker 2002). The dukun prepares the placenta for burial as part of her role in assisting women, usually relatives, with the birth process. The authority and 66 Simone Alesich
healing skills of the dukun can challenge the lack of authority women generally hold in village society. In this case the dukun harboured her niece in her house, pro-tecting her from the violent intentions of the girl’s father. Such a role may be desta-bilizing to the male-dominated social order in villages in Southeast Sulawesi.
The education and training of dukun lie outside the formal government system:
dukun are trained in a type of apprenticeship with an older dukun, often a member of their own family (see Grace 1996; Laderman 1983). Laderman outlines in some detail the rigorous apprenticeship of a dukun in Malaysia (where she is called a bidan kampung), which has many regional similarities to dukun training in Indonesia. Dukun in the village learn a number of specialized skills which are com-mon to dukun in Indonesia more generally; these skills include herbal or traditional medicine, spiritual healing, massage and birth attendance. Laderman argues against assumptions that dukun are untrained, suggesting that it is ‘an expression of cultural bias in favour of formal schooling over apprenticeship’ (1983: 119). While there are a few male dukun in Southeast Sulawesi, the majority are women and it is generally seen as inappropriate for a man to deliver a baby, ‘unless he is a doctor’, as one informant commented. The birth process is considered the preserve of women. It is almost exclusively female dukun who brace the legs of the woman giv-ing birth, assist in delivery and sit in the birth room. As older women too, dukun attend births having experienced childbirth themselves, and are therefore seen as the appropriate people to guide younger women and impart their knowledge of post-partum care. A number of dukun have commented that attending births caused their own childbirth labours to be particularly severe, one Tolaki dukun saying,
‘attending births is a pamali (something forbidden). When I attend births the sick-ness of other women transfers to me, making my own labour more difficult.’
Although knowledge of spiritual and traditional medicinal practices is held by a number of people in the village, dukun are set apart by the extent of their knowledge and experience (Hay 2005). A dukun must be skilful in wielding ambivalent spiri-tual power to help their clients (Slamet-Velsink 1996). When attending births, dukun use their spiritual knowledge and experience to protect the woman and her child’s spiritual and physical health. Grace argues that dukun ‘speak the same lan-guage, literally and metaphorically’ as their clients (1996: 164), offering reassur-ance to the woman giving birth on a number of levels, in a way that cannot be duplicated by the bidan. This link between spirituality and health is important in traditional health practice, since ‘health represents cosmological harmony’
(Aragon 1992: 333). The prayers that the dukun chant in Southeast Sulawesi are Islamic, and dukun like Hana have strong connections to Islam. Hana competed in Qur’an recitation competitions as a girl, although she does not hold a formal posi-tion in the Islamic faith, since these are reserved for men. Islam is linked to local beliefs in Southeast Sulawesi, as it is in other parts of the country.
The differences in spiritual healing between Butonese and Tolaki villages reflect local differences in cultural practices and spiritual beliefs. These different types of spiritual powers are employed by the dukun to protect her client, the birthing woman, from harm. Dukun not only protect pregnant and labouring women from spirits: their spiritual healing extends to other types of spiritual disturbance in
Dukun and Bidan 67
village society. For example, a Tolaki man who kept seeing the ghost of a dead per-son, and fainting, was ritually washed by a dukun to cure him of this disturbance.
Dukun Hana explains, ‘The bidan and the dukun must work together. The dukun does not know how to inject people with syringes, and the bidan does not know how to perform spiritual healing (tiup-tiup).’ While some bidan may make an attempt to cater for spiritual needs when attending births (Parker 2003), this is not generally seen as typical by villagers. Village women who give birth in hospital, for example, do not observe the same post-partum practices as women who give birth in the home, and their recovery is assisted by pharmaceuticals from the bidan rather than traditional remedies, such as washing with hot water, by the dukun.
Dukun work is not something that can be set aside at the end of a day: it is an important aspect of the way that dukun define their relationships with others and establish their identity in the village. As a vocation which is inherited, dukun are aware from an early age of the expectations placed on them to follow in the foot-steps of their elders. As the quotation at the start indicates, one woman from a fam-ily of dukun resisted the pressure from the community to become a dukun, arguing that the work was too demanding. This is a story common to other parts of Indonesia, such as Bali (Connor 1983: 62–3). Within a Southeast Sulawesi village, there are particular families of healers – although all villagers seem to be related to a dukun in some way, even if only through marriage or via a distant relation. In some cases, a dukun from a neighbouring village will be preferred to attend a birth over a local dukun due to a closer familial connection with the family concerned.
68 Simone Alesich
Figure 6 Birth ceremony attended by dukun.
Hana was frequently called to attend births in her natal village, some hours distant.
Virilocal residence is common in Southeast Sulawesi, and women retain links to their own village. In the case of polygynous marriage (also common in Southeast Sulawesi), some wives may remain in their natal villages after marriage.
There have been a number of efforts to train dukun in government-sponsored biomedical practice since colonial times in Indonesia. Currently, the Indonesian government advocates dukun training in non-clinical skills, particularly training in her relationship with the bidan. Dukun have responded to recent government pres-sure for non-clinical training in a number of ways. Some have attended the training and continued to practise as before. Others have relished the new knowledge and potential opportunities that this training has provided, particularly younger dukun who lack authority in terms of their own dukun practice in the village. A senior dukun, Hana has strenuously resisted any government training, declaring proudly that she has not attended any training sessions at any time, now or in the past. Hana is one of the most-respected dukun in her community, which is reflected in the patronage that she has in the village as well as praise from the health establishment.
However, she feels dismissed by the government health system, and she is acutely aware of their interest in limiting her role in attending births. She said that the puskesmas (subdistrict health centre) ‘told me I am the best dukun. But they do not listen to me, they don’t give me the equipment I need, that I ask them for.’
The healing practices of dukun and bidan are remarkably different, including their understandings of healing and their relationship with the community. One key concept in dukun practice is the idea of matching a treatment to the patient. This is often referred to in Indonesian as being cocok or ‘compatible’. While the bidan will usually dispense some sort of medication to each patient – often just vitamins – the dukun tailors the treatment of each illness to the perceived cause, whether physical or spiritual, in conjunction with the patient’s ‘unique individual circumstances’ and their relationship to their environment, community and belief system (Slamet-Velsink 1996: 75). When villagers assisted me in one village when I was ill, they deemed Western pharmaceuticals to be more cocok for me, arguing that traditional remedies were less likely to be effective than medicine from my own world of Western biomedicine. For those villagers, I was connected to a different environ-ment, community and belief system to them, as evinced by my white skin, Christianity and status as a foreigner. This was further reinforced to them by the atypical nature of my illnesses, such as violent reactions to certain foods and fre-quent dizziness, which they did not experience.
The Bidan
As noted earlier, government training schemes for midwives have been in place in various forms in Indonesia since the Dutch colonial period. The most recent effort, from 1989 onwards, has involved a concerted placement of midwives directly in villages, rather than in health centres (puskesmas) or hospitals as in previous schemes. Bidan in both of the communities where I conducted research trained under the post-1989 midwife placement drive, which involved school-leavers Dukun and Bidan 69