Indonesia Can’t Keep Up With Its COVID-19 Cases

JAKARTA AND BANDA ACEH, Indonesia—Nearly 18 months into the coronavirus pandemic, Indonesia overtook India as Asia’s epicenter of new cases on July 13, with a massive third wave driven by the supercontagious delta variant. Trust in Indonesian President Joko “Jokowi” Widodo’s handling of the pandemic has plummeted. This month, the country passed another grim milestone: joining just a few others that have recorded more than 100,000 COVID-19 deaths.

Although Indonesia’s new daily cases have dropped significantly in recent weeks, the delta variant is still spreading beyond Java, the most populous island, to remote parts of the archipelago with limited health care infrastructure. The actual number of cases is likely higher than the official data indicates: Indonesia’s testing rate is among the lowest in Southeast Asia, and its daily death toll—down from its worst levels in July—still remains the highest in the world.

Meanwhile, the business-friendly Jokowi appears eager to move on. In his annual State of the Nation speech on Aug. 16, the president emphasized striking a balance between health and the economy. Despite partial restrictions, community mobility has returned to pre-pandemic levels in Indonesia’s more populous areas, leading the World Health Organization to urge the country to again implement measures to reduce transmission.

As Southeast Asia emerges as a COVID-19 hotspot, the crisis in Indonesia shows how slow vaccine rollout and unequal distribution are shaping the next phase of the pandemic. Most rural areas have significantly lower vaccination rates than more populous regions, according to Ministry of Health data. While over 42.3 percent of residents of Jakarta and 31.4 percent of residents of Bali were fully vaccinated as of last week, the rate was only 10.6 percent nationwide. Furthermore, Indonesia is one of the biggest purchasers of the Chinese Sinovac vaccine, but its efficacy against the delta variant has been called into question amid the current surge.

Without equal access to vaccines or proper test-and-trace policies, Indonesia faces significant community spread in outlying regions, overburdened health care facilities, and even the possibility of a new variant. Despite the seeming downward trend in recent caseload figures, the country is still in the throes of a crisis.

Within weeks, coronavirus cases had risen sharply, and Kudus descended into disaster. More than 400 people died between May and mid-June, though the real death toll is likely higher. “Many people died—two or three people every week in my village alone,” Badawi said. “Every day you heard ambulance sirens echoing on the street, and mosques from villages around the city announced funerals.”

The latest surge exposed Indonesia’s vulnerability to more contagious variants, particularly its lax test-and-trace protocols. Indonesia’s daily testing rate has lagged behind other countries’ throughout the pandemic. Even as test positivity rates reached 30 percent in July, the number of tests administered each day began to fall, in part due to hesitancy. At the start of the pandemic, the government managed to escape culpability for allegations that its screening missed virus carriers. But as hospitals filled up in July, it found itself in the spotlight for mismanaging the pandemic response.

Rebecca Meckelburg, a lecturer in development studies at Satya Wacana Christian University in Central Java, said that local health centers were only testing people with symptoms or those who had been traveling. “What you should be doing [is] testing really close contacts of each confirmed COVID case,” she said.

Indonesia’s testing capacity is uneven: More than half of its laboratories are located on Java.

As the outbreak has spread to other islands, the quality of official data has raised concerns among experts. Dicky Budiman, an Indonesian epidemiologist at Griffith University in Australia, called it “illogical.” “The death rate is high, [but] the coverage of regional testing in Indonesia is meager,” he said, suggesting that the test positivity rate is a better indicator of the surge than the daily case rate. As with vaccinations, Budiman added, Indonesia’s testing capacity is also uneven: More than half of its laboratories are located on Java.

In Aceh province, on the northwest end of Sumatra, the decrease in official case numbers does not appear to reflect the reality on the ground. Its testing capacity is one of the lowest in the country. Meanwhile, hospitals in the capital of Banda Aceh are filling up: Between 80 and 100 percent of beds are occupied, according to official data. Misinformation is rampant, and people have ignored restrictions, even in the city. Although the provincial government has deployed police to monitor cafes and other gathering places, many people go maskless and ignore social distancing protocols.

Marwan, a professor at Syiah Kuala University and the chief of the COVID-19 task force there, who like many Indonesians only goes by one name, said that officials have struggled to communicate the severity of the crisis to residents. Meanwhile, certain community figures deny the virus exists. “After one year the situation is not getting any better. The people are tired of the situation,” Marwan said.

Political and social factors have also exacerbated the crisis outside of Java. A long history of separatism has made many residents of Aceh and West Papua provinces distrustful of the government and reluctant to follow any policy issued by Jakarta, including emergency restrictions. This history has encouraged some vaccine hesitancy: A West Papuan activist told Foreign Policy that some people have refused to take the shot out of fears that it is a weapon against Indigenous communities.

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The spread of the delta variant paralyzed health facilities throughout Java. On July 3 and the morning of July 4, local media reported, 63 patients died due to insufficient supplemental oxygen at the Central General Hospital Dr. Sardjito in Yogyakarta province. The hospital denied the report, but sources confirmed the oxygen shortage to Foreign Policy. “The nurse explained to the patient next to me that they reduced the pressure of the oxygen to save the supply,” said Tuti Istikmalil Hakimah, a patient treated for COVID-19 at the hospital who witnessed the panic in the isolation unit.

In July, the minister of health identified oxygen distribution beyond Java as Indonesia’s main challenge in the weeks ahead. In West Papua, where hospitals have now begun to treat COVID-19 patients in overflow tents, that scenario is already playing out. Fansca Titaheluw, the acting director at Provita Hospital in Jayapura, said that the hospital has reduced its capacity due to oxygen shortages. “We can’t open all the beds, so we decided to treat patients with very severe conditions only,” she said. “Otherwise, we’re in a difficult situation.”

Limited hospital capacity means that many Indonesian patients are dying at home.

The limited hospital capacity means that many Indonesian patients are dying at home. LaporCovid-19, an independent site that collects data from volunteers and journalists, recorded over 3,000 deaths in self-isolation from early June through Aug. 7. That figure does not include people who died in ambulances, while trying to find health facilities, or while waiting in line in the hospital. “The number of the deaths do not represent the real-time number in the field. So [it] could be higher,” said Irma Hidayana, the platform’s co-founder.

As with Indonesia’s testing data, the official coronavirus death toll has come under scrutiny. For example, a Reuters report in July showed how a corner of a Jakarta cemetery filled up in just 10 days. Although the city recorded a significant increase in public funerals, there was still a large gap between the total number of deaths and those that were officially recorded as due to COVID-19. (The government later acknowledged a technical error in the data.) LaporCovid-19 has found more than 19,000 deaths that were reported by city and district governments but were not registered in the national government’s reporting system.

Budiman, the epidemiologist, has raised concerns about Indonesia’s current trajectory, including the potential for a new and even more contagious variant in Indonesia, particularly given low vaccination rates—a threat that Jokowi acknowledged last week. Budiman hopes that the government will embrace a more aggressive test-and-trace regimen, recommending antigen tests over PCR tests in outlying regions. But he remains wary of another spike: “If areas outside Java cannot be handled, the outbreak will return to Java.”