(Illustrated by Gimbar Maulana)
How to Flatten the Covid-19 Curve in Indonesia
BY :WIKU ADISASMITO
APRIL 17, 2020
Watching the world news today can feel like living inside of a Hollywood movie about a major outbreak. Sadly, that's exactly where we are right now: desperately trying to build an arsenal to fight a fast-spreading, invisible enemy.
But there's still a possibility for a happy ending: Covid-19 can be defeated with a focus on putting people first.
There are many lessons we can learn already from other countries' experiences – including their failures.
Governments around the world have been caught off guard by the fast-developing pandemic, forced to scramble to implement measures to contain and mitigate the Sars-Cov-2 or coronavirus, a novel virus about which we learn more every day.
What Indonesia can do is take on all those new data, the good and bad experiences of other countries and adapt the global outbreak response into a customized Covid-19 mitigation strategy for a complex, geographically diverse country.
We know there's no one-size-fits-all solution and that's why we're stepping up a coordinated response to halt the pandemic through a focus on saving lives and preventing further transmissions.
Where Are We Now?
As of the second week of April, a month after the first two positive Covid-19 cases were reported in the country, there has been an exponential increase in the number of confirmed cases to over 5,000.
Worldwide, the virus has infected over 2.1 million people and killed over 140,000 of them.
The grave situation has forced Indonesia to declare a national disaster, which means there is a genuine threat that has put 270 million lives – the country's total population – in danger.
Following the example of other countries, we must try to "flatten the curve" of the pandemic – basically preventing a sharp peak in infections from overwhelming the health system, among others by encouraging good basic hygiene and physical distancing behaviors.
Experts predict the end of this month may be when new infections peak. Other modelers say it may be May. Whatever happens, to ensure the curve is flattened we need to continue these behaviors.
Our most vulnerable – the elderly and those with compromised immune systems – depend on that flattening of the curve. Our health workers depend on it. Our communities and economy also depend on it.
Look at what happened in Italy, Japan and the US when infections are not slowed in time.
We're all in this together and must do our part to slow infections here in Indonesia, in every province, in every village.
Are We Too Optimistic?
While waiting for the good news from virologists at home who have been working hard using the latest data to understand the nature of the virus, the government has set May 29 as the end of this unusual health emergency.
But are we too optimistic?
In reality, the virus sets its own timeline, but we can shorten that timeline with hard and smart work, including strong coordination across all sectors.
The real objective of setting up a timeline is to visualize the end in mind, forcing us to meet milestones (and obstacles) along the way.
We can start by focusing on the hardest-hit communities to understand how Covid-19 has spread.
Test, Test, Test
The best way to unmask Covid-19's progress through our communities is through massively scaling up tracing, testing and treatment. Rapid detection of new cases is critical to pinpoint more intense health efforts to stop local transmissions.
Provincial administrations in Java and Bali have rolled out various innovations in testing people for Covid-19.
Fintech and app-based companies have also managed to lure people to get themselves tested.
West Java alone has tested more than 10,000 people, and over 90 percent of the results came back negative.
True, the serological rapid tests most of them use are not perfect, molecular tests in labs are needed to verify the results.
Over 70 labs in Indonesia are now prepared to carry out this humongous task using the gold standard method: Reverse Transcription-Polymerase Chain Reaction (RT-PCR).
Up to April 15, more than 33,000 samples have been tested. More than 80 percent came back negative.
Around 5,000 who tested positive for Covid-19 were immediately sent to health facilities specifically designed to treat them.
Prior to taking swab samples, thousands of epidemiologists had searched for people who have had contacts with positive Covid-19 patients.
By doing this, we found over 11,000 people with Covid-19 symptoms and hospitalized them.
Around half of them have tested positive and the rest are waiting for their results.
Yes, we still have a huge homework in expanding our lab capacity to enable quicker tests to determine the fate of these "patients under observation" (PDP).
But robust case tracing and detecting have made our testing work more strategic and efficient.
Moreover, targeted testing produces data that help us quickly funnel more support and supplies to the places that need them the most.
How to Stop Hospitals From Buckling Under Pressure
To prevent our health system from buckling, health staff have been trained to triage for three categories of patients: those without symptoms, suspected cases and confirmed patients.
We aim to quickly identify new cases and encourage people to stay home if they have mild symptoms, and if they become severely ill, seek appropriate care at a specially equipped referral hospital.
A centralized treatment facility with a capacity of over 2,000 beds has been set up. Add to that government facilities that have been turned into makeshift hospitals to provide an additional 1,500 beds. They will be used to treat patients with mild symptoms.
Critical patients are referred to some 300 state-owned main referral hospitals that can take up to 40,000 patients.
Stay Home, an All-Indonesia Effort
The goal of the massive scaling up of rapid diagnostic tests, coupled with telemedicine services managed by the Task Force since day one, is to keep people not showing serious symptoms at home.
And it works, many Indonesians have been carrying out their voluntary home isolation with heartening discipline.
What makes me proud as an Indonesian is that communities have got together to support people who have tested positive for Covid-19.
Neighbors, friends and work colleagues team up to provide food, financial aid even entertainment for the patients.
An all-Indonesia response does not just rely on the government – it's neighbors looking out for one another, helping you make the right decisions about your health.
Ten Thousand Tests Per Day
Works remain underway to beef up our referral hospitals and laboratories and support health workers to deliver quality care.
President Joko "Jokowi" Widodo has set the ambitious goal of testing 10,000 samples every day to deepen our understanding of the community’s burden of disease.
Soon this goal will be increased to 100,000 samples per day in a race against time before the peak of the outbreak comes.
Our biggest and most strategic investment, in terms of time and human resources, is spreading preventive messages that change behaviors.
Although the details may change as scientists learn more about this disease, the basics remain – keeping to good basic hygiene including frequent handwashing, wearing a mask to protect yourself and others when you leave the house and better still, stay at home.
Those who think changing the behaviors of at least 70 percent – the minimum number necessary for a popular behavioral switch – of a total of 270 million people who live on 13,000 islands and speak 400 local dialects within weeks is easy, think again.
It's a gigantic task, but it must be done.
PSBB and Behavioral Change
Since April 7, a large-scale social restriction (PSBB) has been imposed in Greater Jakarta, the epicenter of local transmissions, and in Pekanbaru, Riau.
To make sure people comply to the restriction, aside from law enforcement economic incentives are introduced.
The government has promised to provide a social safety net, including basic supplies, valued at Rp 600,000 ($37) per household per month.
An estimated 3.7 million households will receive this relief package for three months, starting in April.
The main objective is to ease the burden on residents who have lost their livelihoods due to the pandemic and to combat risk-averse behaviors.
Flattening the curve requires individual behavior changes, policies that promote healthy habits, supportive communities and attentive local governments who look out for everyone, but especially the most vulnerable people.
This behavioral change strategy will face its biggest challenge in the coming days when Muslims around the globe begin the fasting month of Ramadan.
At the end of Ramadan, in late May, authorities fear millions will embark on mudik, the annual Idul Fitri exodus to people's hometowns, and spread the coronavirus from urban centers to villages and remote areas.
Our risk communication and community engagement (RCCE) team has stepped up effort in convincing people that staying in Jakarta and other urban centers will be safer for themselves and for their families in their hometowns.
The government has been using mix-media channels, including live talk shows, media briefings and press conferences all conducted around the clock by teleconference from the National Disaster Management Agency (BNPB) headquarters' media center.
The effort has had some success. The Transportation Ministry's latest online survey shows that 99 percent of a total of 42,890 respondents on Java Island have knowledge about Covid-19 and 58 percent of them said they will cancel their mudik plans this year.
Villages around the country have set up their own quarantine measures, often requiring returning residents to spend 14 days at makeshift "independent isolation sites" before they can enter the villages, which help dissuade people from making the trips.
Together, Indonesians all over the country are ensuring our health and social systems are strong enough to handle the impact of the Covid-19 pandemic by laser-focusing on the best interests of the people and insisting on an all-Indonesia effort.
We've already gone past the "what if," "should have" and "could have" moments in this pandemic. Passing the bucket will not resolve anything. From this day forward, it's time for Indonesians to make wise, contextual and people-centered decisions.
What the world can do, is to collectively do the same things. We are all in this together.
Professor Wiku Adisasmito is the lead expert of the National Task Force on Covid-19 Rapid Response and Adjunct Professor of Infectious Disease and Global Health at Tufts University.