Death by a Thousand Cars

JAKARTA, Indonesia — It’s nearly 10 a.m. when the women of 118 receive their first serious emergency call of the day. A man is down in West Jakarta, bleeding with serious injuries after being knocked off his motorcycle in a traffic accident.

For a moment, the staff of 118 — Jakarta’s version of 911 — shine. The operators, five women who wear identical black headsets over their flowing hijabs, are experts in navigating ambulance drivers through the capital’s chronically congested streets. A woman in a floral hijab scribbles down details on a worn legal pad and then checks her computer screen to find an ambulance idling nearby. She calmly explains the situation to the driver while the call center’s in-house doctor, Kelvin Riupassa, stands by.

Riupassa, 36, began working with the city’s ambulance division in 2011. She knew she wanted to go into medicine after her father died of cancer when she was just a teenager. “It made me want to become a doctor to help people like him,” she says. Riupassa spent six years cutting her teeth in emergency rooms and in a remote region of the Indonesian province of Papua before joining the city ambulance division. The division, which is called Ambulans Gawat Darurat (AGD) in Indonesian, or Emergency Ambulance, seemed like the perfect home. Now an old hand, Riupassa thought that by working with the ambulance service, she could help save the kind of patients for whom, by the time they got to the emergency room, it was too late.

But the division is stretched thin and severely underfunded. AGD only owns 43 ambulances for a city of about 10 million. When I visited the division’s threadbare headquarters in northern Jakarta last August, nearly half of them were garaged, either because they needed maintenance or because of a policy to keep some vehicles parked and at the ready in case of a large emergency. With little more than two dozen ambulances left to patrol an area roughly the size of Chicago, but with almost five times the population, average response times have soared to 37 minutes, according to AGD data. The same trip takes an average time of 10 minutes in the United States. In Japan, an ambulance arrives on the scene in about seven minutes.

Few are willing to chance the wait. Minutes after an ambulance is dispatched to the scene, the panicked woman on the other end of the line, who Riupassa says is responsible for the traffic accident, cancels the order. Instead, she tucks the patient into her car and speeds toward a public hospital.

“Our ambulance was already going there.… It was only a few kilometers away, but they didn’t want to wait,” Riupassa tells me. “It’s common. If there is a serious accident somewhere, they don’t want to wait to meet us.”

Even for a megacity in a developing country, the scale of dysfunction in Jakarta’s ambulance service is enormous.

The Jakarta police say more than 1,000 people died in traffic accidents alone in 2010 (the most recent year with data available). That’s more than double the amount of traffic fatalities in the South Korean capital of Seoul — a city roughly similar in population and area to Jakarta — and some 250 more fatalities than Bangkok, which has about 2 million fewer people, according to the Japan-based International Association of Traffic and Safety Sciences. And experts warn that thousands more die of injuries and illnesses like heart attacks or strokes that could have been treated by a well-staffed ambulance service. Indonesia’s surgeon association estimates that adequate emergency response could save as many as 4,000 lives a year in the capital alone.

Jakarta has the hallmarks of a city in ascendance. Construction cranes work day and night as new office towers rise in the capital’s downtown business district. The government broke ground on a $1.5 billion mass rapid transit line in October 2013 — the first in an integrated transit system that seeks to alleviate what has become one of the world’s most congested cities. Property prices continue to rise, and the city’s middle class still crowd the capital’s posh restaurants despite a weakening Indonesian rupiah. The city’s new governor, the brash 49-year-old Basuki Tjahaja Purnama, seems committed to accelerating Jakarta’s push toward modernization, embarking on a polarizing plan to replace the city’s tin and plywood slums with subsidized apartment buildings and centralize the city’s iconic roving food vendors — an effort the city says will reduce health risks but that critics contend will leave the poor even worse off.

But the sprawling Indonesian capital is also straining under the weight of a rapidly growing population and decades of patchwork development. The pitfalls of progress in Jakarta lend an air of almost Sisyphean tragi-comedy to the government’s best efforts. The city’s public order agency demolishes blocks of illegal roadside food stands only to have the vendors rebuild in the same spot weeks later. The recent construction of a $3.5 million bus terminal was marred by a critical design flaw: Its driveway is too small to actually accommodate large buses. And a law requiring all vehicles to carry at least three people in order to drive on main thoroughfares in order to reduce congestion has only spurred an underground economy of for-hire passengers who amass roadside before rush hour. Such incidents accumulate and take their toll: The eminently quotable Purnama told the local press once that Jakarta was like a person who “waited until they had to defecate and then built the toilet.”

The city’s health care system has not been immune from such growing pains. Jakarta rolled out an impressive universal health care scheme in 2012 that provides, among other things, all city residents with free ambulance transport to and from the hospital. Since then, 15 new hospitals have opened their doors. And while these new hospitals have the capacity to take on patients, the city failed to provide them with a dedicated fleet of ambulances — meaning that the burden of transport to these new facilities has fallen on the city ambulances. Instead of responding to emergency calls, the fleet spends most of its time delivering patients to and from routine medical care.

AGD is, in theory, an attempt to address a public health concern. The service was started in the 1970s to provide emergency care for Jakarta’s growing, but underserved, population. Since then, however, private ambulances have become a public relations tool for political parties, religious institutions, and powerful companies: All have their own emergency response divisions, which travel around the city wrapped in advertisements. (The newly-formed Perindo Party, founded a little more than a year ago, already has at least 78 ambulances to its name.) But health experts warn that these vehicles are under-equipped, more meant to look good than provide emergency care.

AGD was supposed to be different. As Jakarta’s only citywide emergency care provider, the ambulance division was initially tasked with providing needed pre-hospital care while rushing the patient to the emergency room. In reality, though, today’s AGD is a medical transport service. In an average day, AGD transports some 60 patients from city hospitals to their homes, outpatient centers, or specialists. Meanwhile, AGD’s paramedics and nurses respond to, at most, an average of three emergency calls a day.

“If you call our common control room, we try to send the nearest ambulance,” says Erizon Safari, AGD’s director. “But during the daytime hours, like today, almost all of our ambulances will be booked for patient evacuations. We now have 15 new hospitals. The government built 15 new hospitals, and they all have no ambulances.”

A series of large whiteboards filled with pending appointments panel one wall of the call center. “This is all for today,” Riupassa says as she gestures toward the wall of names and addresses. She asks if I would like to ride along on a patient transport that will take us from the northern reaches of the capital to a massive trauma center in the city’s center before we break off and the second ambulance continues to a nearby suburb. In total, the trip is expected to take more than an hour and is only one of nearly five dozen scheduled patient transport jobs already on the books. The jobs range from taking a seriously ill patient from a smaller hospital to a large teaching one to returning discharged patients from the hospital back to their homes.

Minutes later, we’re barreling down the dedicated bus lane in mid-afternoon with our lights blaring as driver Asep Dian Ristianto speeds to keep up with the small motorcade’s main ambulance. He swerves around a slow-moving car illegally driving in the bus lane and hops the curb back into the main lanes of traffic before we suddenly slam on the brakes. Four rows of rebar spikes stick out of the road surface directly in front of the ambulance, running the width of one lane of traffic; Jakarta’s roads are rife with such hazards. “That’s dangerous,” Riupassa remarks before suggesting someone report the spikes through a new smartphone app recently released by the city to collect incident reports.

Traffic is uncommonly light as we drive through North Jakarta, but it builds steadily as we head south. We soon end up idling in traffic, lights on, as Ristianto sporadically sounds the siren at an unmoving line of cars and motorcycles. Riupassa looks enviously at the bikes. AGD used to own a fleet of motorcycles that were a godsend for the beleaguered ambulance division. They were able to cut through even the heaviest traffic and were able to weave through the cluttered and congested side streets to provide care long before a transport ambulance could arrive. But the entire fleet fell into disrepair after a bureaucratic bungle failed to designate the vehicles as city-owned property; a mistake that meant AGD could use the motorcycles but could not pay to get them repaired.

She hopes the planned purchase of 10 new motorcycles by the end of this year will cut response times in half, as long as AGD can secure enough funding to keep them on the road. Funding remains a serious hurdle for AGD’s expansion plans. The service planned to purchase five motorcycles and 10 ambulances in 2015, but in the end they only had enough money to buy five new ambulances. The motorcycle division remains, at least for now, a distant dream.

Still, Riupassa is optimistic that plans to purchase at least 10 additional ambulances this year will materialize. She repeatedly mentions the new ambulances during our conversation. Riupassa says the office needs a minimum of one ambulance for every 10 square kilometers to cut response times to an average of 10 minutes per call. “I am optimistic that we can respond faster,” she remarks with a nod of her head. “Of course I am optimistic. That’s why I am still here. I tell all my staff, ‘An emergency can happen to any of us, to our families,’ so any time [we are on a call], we need to move fast.”

Despite the ambulance corps’ hardships, things have gotten better in recent years. Two years ago, AGD’s ambulances didn’t even have GPS trackers installed. Today, the small call center can see every city-owned ambulance in the field on its desktops or on any of the large flat-screen TVs that line one wall. The center’s staff keeps an eye on the fleet, offering advice on shortcuts and updates on traffic conditions as they dispatch drivers on calls. The governor now wants all private ambulances to install similar GPS units and respond to calls by 118 staff.

“Ahok is very concerned about the ambulances,” Riupassa says, using Purnama’s nickname. “Ahok is open-minded, and I believe he minimizes corruption in Jakarta so we can provide more public services.”

Her staff is professional and well-trained. The ambulances are outfitted with modern medical equipment and ample room for extra passengers. Riupassa is inquisitive on the ride, asking me as many questions as she answers. “Is health care expensive in the U.S.?” “Does the U.S. have a lot of corruption as well?” “Do corrupt officials go to jail?” She wants to go the United States, or maybe Japan, to study emergency response methods. “I want to see how many ambulances they have and how they get paid,” she says, pausing briefly to think. “Which one is better?”

When Aryono Pusponegoro, a prominent trauma surgeon, helped start the Jakarta ambulance division in the late 1970s, the office had only a single ambulance. “It was a joke,” he says with a laugh. Pusponegoro, now a professor and head of the Indonesian Surgeons’ Association, spent years building the capital’s 118 service, which started out as private organization that provided emergency transport for the capital’s residents. He says he was part of a small team of doctors who realized the need for a citywide ambulance service at a medical conference in 1969, after one of his peers lamented that 70 percent of deaths at the time were the result of traffic accidents.

But costs ballooned far beyond his budget: By the time he handed it over to Jakarta’s public health ministry in 2006, it cost some $74,000 a month to operate. Pusponegoro says he was paying to train a large staff, purchase medicine, and provide the kind of street-level emergency care that doesn’t exist today. But few patients could afford to repay the cost of their transport in a country where half the population lives off around $2 a day. The handover was meant to provide additional public funds for the cash-strapped ambulance division. Instead, the funding shortfalls continued, and the service’s fleet fell into serious disrepair.

“When we handed it over, it just collapsed,” he says.

Before the handover, AGD used to respond to emergency calls — delivering an average of 300 patients a year to Cipto Mangunkusumo, the city’s main trauma hospital, he says.

“[Today] if you get in an accident or anything, a heart attack or whatever, it is almost certain you are dead because no one is going to come to give you first aid,” Pusponegoro says. “The ambulance doesn’t go; that is the problem. It is sad, but that is the fact. Last year, only 12 [patients] arrived at Cipto hospital.… The rest are going straight to the morgue.” (Pusponegoro’s numbers couldn’t be verified by official data, but a surgeon at the hospital told me they seemed accurate.)

Pusponegoro is now attempting to start another ambulance service. “I’ve got to do it again because too many people have died,” he offers as a quick explanation before diving into the details. He plans on starting with a small fleet, only five ambulances and five motorcycles, concentrated in Jakarta’s business district during the day before moving to populated neighborhoods at night. He boasts that his ambulances — retrofitted Hyundai and Daihatsu minivans — cost about $25,000 to make; a fraction of the cost of the ambulances operated by AGD.

“I got the experience. I know how to do it. I know how to make it work,” he says. “The problem is I got no money.” The effort has turned Pusponegoro into something of a salesman. He spouts off ideas about services that could eventually subsidize a citywide emergency response. He talks about offering a “red carpet” service for wealthy Indonesians, about transporting blood and organs from hospital to hospital, and about whether he can cut a deal with the country’s public insurance provider.

In his 2011 book, The Silent Disaster: Disasters and Mass Casualties, Pusponegoro estimated that millions of people die nationwide from injury and illness because they can’t reach a hospital in time.

I’ve only seen two such deaths during my time in Indonesia. One was a police officer fatally shot near my apartment during a wave of similar killings back in 2013. The officer was splayed out on his back in the middle of a main road as a small crowd gathered. A few years later, I passed another man lying in the street, this one a motorist knocked off his motorcycle. He was motionless and bloody, and the crowd was directing traffic around the body instead of offering any help. I checked the papers later that week but found nothing about the accident. Such things rarely make the news in Jakarta.

Top image photo credit: BAY ISMOYO/AFP/Getty Images