A convoy of ambulances arrives to bury suspect coronavirus victims at Tegal Alur public cemetery in West Jakarta on March 26. (JG Photo/Yudha Baskoro)
Total War on Coronavirus
BY :PRIMUS DORIMULU
APRIL 03, 2020
Jakarta. This is not just another virus. The novel coronavirus or Sars-CoV-2 and the disease it causes, Covid-19, is extremely deadly and easily transmittable between human beings or even from the remains of victims. More than 1.5 million Indonesians may contract the disease without serious measures being deployed to break the cycle of the virus, without adequate supplies of personal protective equipment or without sound medical services.
You can potentially catch the virus by simply holding a door handle previously touched by an infected person. If after that you touch your nose, mouth or eye, the virus will find access to your respiratory system.
This is why washing hands – as everyone should know by now – is key to avoid the transmission of the virus. You have to get used to a new social habit: carry soap or hand sanitizer with you wherever you go.
Wearing a face mask is another effective way to prevent infection when you are in public places or in a meeting with other people. Japan is able to minimize Covid-19 transmissions because its citizens love wearing face masks when going outdoor. A face mask protects you from droplets when people around you cough or sneeze.
Indonesia has now joined the global fight against coronavirus. Like in any other type of war, citizens must follow the commander, focus on a single goal and fight together to defeat the enemy.
The government should take a more aggressive approach in leading all the country’s available resources to engage in some crucial efforts. First, to break the cycle of Covid-19 at all costs. Second, to increase hospital capacity in handling infected persons, especially patients in critical condition. Third, to prevent a further decline in people's purchasing power.
Any citizen, no matter who, must realize that we are all in the same boat. If one gets into trouble, they will have an impact on the other people on the boat. Everyone must make a contribution to defeat the coronavirus according to their expertise and ability.
The government has not imposed a lockdown to break the cycle of the virus. President Joko "Jokowi" Widodo opted to order a large-scale social distancing policy, locally abbreviated as PSBB, to be implemented strictly. If it doesn't work, the government will declare a civil emergency.
PSBB and Civil Emergency
On Monday, President Jokowi announced the government had decided to implement large-scale social distancing to be accompanied by a civil emergency. The following day, he issued a government regulation on the acceleration of Covid-19 mitigation to get the policy into force. He also issued a presidential decree on public health emergency related to Covid-19.
Both regulations state that Covid-19 is a disease that poses threat to public health and must be handled according to the regulations.
The government also issued a regulation in lieu of law (Perppu) on state financial policies and financial system stability to help the country cope with the Covid-19 pandemic – now deemed also an imminent threat to the national economy and financial system.
The new regulation allows the government to increase spending even if it potentially triggers a deficit of more than 3 percent of the GDP. This flexibility applies only during the Covid-19 emergency and its recovery period which spans until the end of 2022.
In combating coronavirus and easing its economic impacts, the government is allowed to take cash from surpluses in certain budgets, social funds, education funds, funds raised by public service agencies and parts of its participating interests in state-owned enterprises.
The government may also issue recovery bonds for private companies, SOEs, individuals and the central bank as lender of last resort.
The government regulation on large-scale social distancing effectively rules out any plan for a nationwide lockdown. President Jokowi stressed that regional governments aren't allowed to impose policies that contradict the central government's directives.
A large-scale social distancing imposes restrictions on many aspects of life in affected regions to prevent the spread of Covid-19. To declare it, a regional government must get a permit from the health minister.
Not a single district has received approval from the health minister until Thursday.
Jakarta Governor Anies Baswedan said he had requested a PSBB status to the minister but hasn't received a reply.
The 2018 law on health quarantine defines PSBB as restrictions on certain activities by a community in an area suspected of suffering from an infectious disease.
Covid-19 has affected all but two provinces in Indonesia. Only East Nusa Tenggara and Gorontalo has not reported any case.
A lockdown has been ruled out because it may result in massive financial burden to the government.
Article 55 of the law stipulates that the central government must shoulder the costs of basic needs for all people and their pets and cattle in the affected area during the lockdown period.
If implemented strictly, a large-scale social distancing can deliver results, especially if the National Police and the Indonesian Military (TNI) are involved to enforce it.
The police and the military have representative offices until the smallest unit of administration at the village level. Governors, district heads and mayors can be in charge in their respective areas.
When the situation degenerates into "beyond normal," the government will declare a civil emergency, President Jokowi said. Restrictions on people's movement and public gatherings will be imposed more strictly by involving police and soldiers.
Civil emergency is stipulated under a 1959 law on state of emergency. The president as the highest commander of the armed forces may declare the whole territory or parts of the Indonesian territory to be in a state of danger that carries an imminent threat to public safety, and accordingly decide a civil emergency, a military emergency or a state of war.
The coronavirus pandemic does pose a danger to the country so civil emergency is an option.
"We keep monitoring the situation to see if a civil emergency is necessary. The government must be prepared for the worst," the president said on Wednesday.
The home affairs minister has also issued a circular on the establishment of Covid-19 task forces at the regional level, led by governors and district heads. The police and the military have given their full support to the task force heads.
The law on state of emergency stipulates that the civil emergency leader is authorized to ban people from entering public buildings, residential areas or public squares for a certain period. Authorities may also limit outdoor activities and conduct body searches on suspected persons.
Parts of the large-scale social distancing policy have been in place before it was adopted, including the calls to work and study from home. People have also been encouraged to avoid religious congregations. The new government regulation has served to make this call even stronger.
At the time of writing on Thursday, the Covid-19 pandemic has affected 203 countries. There are 963,339 positive cases, 49,199 deaths or 5.1 percent of the total cases and 185,067 recoveries or 21 percent of the total cases around the globe.
The coronavirus has taken its toll on the US, the one remaining superpower with all its technological advances. There are now 216,722 cases in the US, more than in any other country in the world.
Italy is in a distant second with 110,574 cases, followed by Spain with 110,238. China, where the virus originated, reported 81,589 cases.
New cases in China keep falling, but the opposite has been occurring in the US, Italy, Spain and Iran. During the last 24 hours on Thursday, Spain saw 6,120 new cases.
Italy suffers the highest fatality rate and also sees the most deaths in the pandemic so far. According to official figures on Thursday, 13,155 people had died from Covid-19 in Italy, or 11.9 percent of total cases.
Spain reported 10,003 deaths or 9 percent, the US saw 5,140 fatalities or 2.4 percent while the death toll in France has reached 4,032 or 7 percent.
The death toll in those four countries has surpassed that of China, who recorded 3,318 deaths or 4 percent of its cases.
Germany meanwhile reported 962 deaths or 1.2 percent of its total cases.
The US, Europe and parts of Asia have become the new epicenters of the Covid-19 pandemic.
Indonesia has attracted global attention for the government's lack of transparency and alleged underreporting.
Indonesia is also among the high-risk countries due to its low hospital capacity.
The actual number of cases and deaths is very likely much higher than what the government reported in its daily briefings because it never conducted nationwide tests.
On Thursday, the government reported 1,790 cases accumulatively, the number growing rapidly in just around one month if we recalled that there were only two confirmed cases on March 2.
Of that figure, 170 have died, or 9.5 percent of the total cases. The fatality rate continues to beat the recovery rate, which stood at just 6.3 percent. There are reports that many people who developed Covid-19 symptoms had failed to get proper medical treatment.
The epicenter of the Covid-19 epidemic in Indonesia encompasses Greater Jakarta, which also includes Depok, Bogor, Tangerang and Bekasi.
Confirmed cases in Jakarta alone have risen to 897 or 50.1 percent of the national figure as of Thursday.
Combined with the figures from its satellite cities, Greater Jakarta accounted for 65 percent of Covid-19 cases across Indonesia.
According to an estimate, the actual number of infections in the archipelago has surpassed 200,000.
Many infected people could have gone undetected due to the lack of testing. The official number is just the tip of an iceberg since only a certain group of people have access to the government-sanctioned tests.
When Covid-19 tests are conducted nationwide, the results may raise eyebrows.
A health expert who asked to remain anonymous said 70 percent of Indonesia's more than 270 million people could contract Covid-19 and the death toll might surpass 1.5 million unless there were concrete measures to break the cycle of the virus.
When that happens, hospitals across the country will not able to deal with the number of patients flocking to their emergency wards.
Cancel Idul Fitri Exodus
There are three main issues that must be dealt with simultaneously in the fight against Covid-19: breaking the cycle of the virus at any cost, increasing the capacity of hospitals across the country and conducting proper actions to prevent people's purchasing power from plummeting.
Breaking the cycle of the virus is not something that can be negotiated. People should follow the government's instruction to cancel their annual Idul Fitri exodus, or mudik, to their hometown in late May.
If they insist on returning to their hometown, they should self-isolate upon arrival for 14 days, during which they must avoid physical contact with anyone else, including family members.
Sticking to this method will require contributions from all elements of the community. The government's Covid-19 Task Force head Lt. Gen. Doni Monardo has called for residents in Greater Jakarta to push back their mudik trip until the outbreak is over.
It is estimated that the number of undetected coronavirus sufferers is way higher than the official number of people who have tested positive for the virus.
Many people who contracted the virus remain asymptomatic, or develop only mild symptoms similar to seasonal flu. They become silent carriers and increase the pace of transmissions.
All people who have had contact with positive patients or come from affected areas like Greater Jakarta must self-isolate and undergo tests when they travel to other cities.
Around 15 million residents in Greater Jakarta will leave for their hometowns during the Idul Fitri holiday, the biggest holiday for Indonesian Muslims.
Thousands have already departed although not for a religious reason. They were forced to leave the capital after losing their jobs when the restrictions on movement and public gatherings were put in place.
The number of unemployed people will increase significantly once the large-scale social distancing policy is implemented in urban areas.
The temporary closure of malls, restaurants, cafes, entertainment spots and other non-essential premises increases unemployment claims, primarily among people working in the informal sector.
At the same time, airline, land transportation, hospitality and tourist businesses have already endured a severe downturn during this difficult period.
Calls for work and study from home have hit the informal sector hard. Taxi drivers and motorcycle taxi riders have lost much of their income. Salaries for many informal workers have been delayed.
They cannot afford their rents in the cities and do not have enough money even for food. These are the group of people who insisted to return to their hometown where they can at least find shelter.
This is the reason why President Jokowi has been extra cautious in making his decisions. The government doesn't want to issue a strict ban on people returning to their hometowns.
The government has announced a Rp 110 trillion ($6.7 billion) social safety net program as part of a stimulus package to ease the economic impacts of the epidemic. However, the fund is not intended for people who choose to remain in Greater Jakarta and other big cities during the Idul Fitri exodus.
This is a complicated dilemma. Allowing people to return to their hometowns in droves will increase the spread of Covid-19, but banning them from doing so will incur a huge financial cost to meet their basic needs as they stay – with restricted mobility – in urban centers.
"Test, test, test," World Health Organization director-general Tedros Adhanom Ghebreyesus has repeatedly called in the wake of the pandemic.
Apart from imposing physical distancing and providing supplies of personal protective equipment, it is very important for the government to have a real picture of the outbreak through massive tests.
Without a significant number of tests, nobody knows for sure the extent of the Covid-19 outbreak in Indonesia. The current figure announced by the government is just the tip of an iceberg.
Sources said that even before March, many Indonesians had contracted Covid-19 and some died from it. The more the tests are conducted, the better the government can get prepared.
At the initial stage, Indonesia used around 150,000 rapid testing kits imported from China. The limited number means that only selected individuals could get tested. The rapid tests can deliver results in 10-15 minutes. But their accuracy is questionable especially on asymptomatic persons.
People who have had contact with positive patients and those returning from affected countries are required to have the tests.
The rapid test detects the level of antibody, which is naturally produced by the human body during an attack by pathogen bacteria or a virus. But it cannot tell unequivocally that the infection was caused by the coronavirus.
When the result comes back negative, it doesn't mean that the patient is free from Covid-19, because the incubation period could take days.
On the other hand, a positive result doesn't necessarily mean that the patient has coronavirus. The antibody level may increase due to an attack by any type of virus.
By the end of March, 18,077 Jakarta residents have undergone the tests and 299 of them have tested positive for Covid-19. A number of affected provinces also have begun to conduct the tests.
The more accurate test recommended by the WHO is called a swab test, in which lab technicians took a specimen from the respiratory system for real-time polymerase chain reaction (RT-PCR).
But not every hospital in Indonesia is capable of conducting the swab test. Indonesia has only 13 medical laboratories, three of them belong to private entities.
Low Hospital Capacity
Hospital capacity in Indonesia is too low to handle a sudden surge in the number of patients during an outbreak. Problems have arisen even in the current situation, especially because only a few hospitals have isolation facilities to deal with infectious diseases.
Before the Covid-19 outbreak, the ratio of hospital beds in Indonesia stood at 1.04 per 1,000 people. China has a much better ratio of 4.3 beds per 1,000 people.
The ratio of the number of doctors and nurses per 1,000 citizens is also below the global standard, standing at a mere 0.3 and 1.2 respectively. China has two doctors and 2.7 nurses per 1,000 people.
To make things worse, Indonesian doctors and nurses must cope with limited supplies of PPE. Many hospitals have allowed their staff to wear used surgical masks due to limited stocks, as long as they don't share them with others.
According to government data released on Thursday, 14 doctors including 10 specialists have died after handling Covid-19 patients in Indonesia. Dozens of nurses were also among the Covid-19 fatalities.
In this situation, experts suggested that the government take firm actions to protect medical workers who treat Covid-19 patients at close quarters.
They propose seven policies that the government needs to consider to protect medical workers.
First, the government must make sure that the management of national health insurance BPJS Kesehatan pays off its debts to hospitals. Without enough cash in hand, hospitals cannot handle the increasing number of Covid-19 patients.
Second, the government must make sure that Covid-19 patients are allowed to use their Indonesia Health Card (KIS) under the national health insurance plan (JKN) to get hospital treatment without additional charges. The bills should be repaid immediately by BPJS to keep hospitals' finances in good balance.
Third, the Health Ministry, governors, district heads and mayors must get rid of regulations that hamper the establishment of new hospitals. In this fight against Covid-19, the private sector must receive the support they need to build new hospitals.
Fourth, the Health Ministry must revoke rigid regulations and bureaucratic red tapes for doctor's licenses. Doctors should be allowed to deliver services in different hospitals, not limited to the hospital of their employers, in handling Covid-19 patients over the course of six months.
Fifth, the government must make sure there are enough supplies of PPE for medical workers. Industry, trade and finance ministries should take measures against local PPE producers who keep exporting their products.
Sixth, all hospitals, be they state-owned, municipally-owned or private ones, must get state facilities in serving Covid-19 patients, from tests to treatment.
Lastly, the Health Ministry must involve medical students to join the fight as volunteers and provide them with high safety standards and good benefits.
There is no country that is fully prepared to deal with a massive-scale outbreak such as Covid-19.
China was forced to build makeshift hospitals in many places to accommodate patients. Many other governments also work very hard to build hospitals designated for coronavirus patients in a very short time.
Patients of this highly contagious disease must be isolated from other patients. Indonesia soon realized that three hospitals for infectious diseases – Persahabatan, Gatot Soebroto and Sulianti Saroso, all in Jakarta – cannot handle the rapidly growing number of Covid-19 patients.
The government is currently building a special hospital on Galang Island, Riau Islands Province, to treat Covid-19 patients.
Even the US is facing the same problem. President Donald Trump has instructed constructions of makeshift hospitals occupying several public buildings.
Patients in critical condition should get special treatments in high care units. Around 2.4 percent of Covid-19 patients advance to a critical condition, mostly people above 60 years old with underlying illnesses.
There are also patients who develop serious symptoms like breathing difficulties but are not in a life-threatening situation. They must be treated in intensive care. Around 13.9 percent of patients fall into this category.
Many patients in critical condition couldn't be saved due to the shortage of life support equipment, especially ventilators.
People with mild symptoms ideally should be admitted to hospitals too, but they are treated as outpatients to reduce hospital loads.
We appreciate the government's quick move to transform the Athletes' Village in Kemayoran into a makeshift Covid-19 hospital.
Siloam Hospitals is among private healthcare operators who set up special facilities for Covid-19 treatments. Siloam has opened two facilities in Kelapa Dua and Mampang for Covid-19 patients.
Known Covid-19 cases in Indonesia involved people from the middle and upper classes. The number of confirmed cases will increase sharply when patients from poor families are detected.
Unlike the 1998 Asian financial crisis that hit big corporations and financial service institutions, the Covid-19 economic impacts destroyed nearly all sectors including small and medium enterprises.
In 1998, the informal sector remained untouched, providing a cushion for the national economic downturn.
A similar story occurred during the 2008-09 global financial crisis triggered by the subprime mortgage crisis in the US. The SME sector continued to show resilience despite a slowdown in financial services.
The Covid-19 pandemic triggered a multidimensional crisis. Many countries have predicted minus growth this year. The crisis is even more complicated in the sense that human lives are at stake.
Finance Minister Sri Mulyani Indrawati and officials of the Financial System Stability Committee (KSSK) have prepared two scenarios for "hard" and "very hard" situations.
If the spread of Covid-19 cannot be stopped immediately, Indonesia will arrive at a very hard situation where the economy will suffer a minus 0.4 percent growth.
But if the current mitigation measures work well in stopping the cycle of the virus, the economy will manage to grow by 2.3 percent, a hard situation given that the government has projected a 5.3 percent growth for the year.
Household spending, exports and investment will see a negative growth. Indonesia can only rely on government spending to keep the economy afloat.
For its handling of the Covid-19 epidemic and to prevent a weakening in purchasing power, the government has launched a Rp 405 trillion stimulus package; of which Rp 75 trillion will go to Covid-19 handling, Rp 110 trillion to social safety net programs and Rp 150 trillion to economic recovery efforts.
The rupiah has weakened to above 16,000 against the dollar, while share prices index at the Indonesia Stock Exchange has lost 28 percent between January and April 2. No one knows when we will hit rock-bottom or what it would be like.
When Will It Be Over?
The coronavirus outbreak began at the Chinese city of Wuhan in December last year. The potential danger of this virus became a global attention when Dr. Li Wenliang from a hospital in Wuhan shared his knowledge of what was then called the novel coronavirus with a fellow doctor on WeChat on Dec. 30.
The city began to report fatalities on Jan. 22. Dr. Li, who was first accused of spreading hoax by the local police, died on Feb. 7 aged 34. He was later confirmed of having been infected by a coronavirus patient under his supervision.
Indonesia woke up much later on, after the WHO declared a pandemic on March 11. Around 70 percent of the 7.8 billion population on earth are now prone to being infected by the virus.
Indonesia can get rid of the coronavirus entirely if every citizen has developed immunity to the virus. Certain people can stand against the virus without serious health risks, but their number is unknown.
Modeling by a group of mathematicians from the University of Indonesia suggests that the peak of transmission in the country might occur on April 16 and then gradually fade away between May and early June. The scenario is based on the assumption that strict social distancing measures are in place and people duly follow them by staying at home.
Without serious mitigation measures, the peak of the transmission will arrive later on June 4 and the outbreak will stay in the country until September.
There is also a third scenario predicting a peak on May 2 on the assumption that the measures are in place but only parts of the community are willing to implement them.
The key to break the cycle of the virus is public attitude.
"The solution is discipline to follow the command from our leaders," Covid-19 Task Force head Doni Monardo said.
Lack of cooperation from the public will turn any policy useless, even if a lockdown is in place.
Indonesia may take a lesson from the Japanese who strictly observe physical distancing and wear face masks everywhere. Businesses continue running and no people have lost their jobs due to the pandemic in Japan.