COVID-19 – perspectives of an Indonesian family doctor

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview: 19th March 2020

Number of confirmed cases at time of interview: 309

Number of confirmed deaths at time of interview: 25

Total population of Indonesia: 264 million people

Today, I am speaking to Dr Erfen Suwangto, family doctor in Jakarta, Indonesia, and also Chair of the young doctors movement of Asia Pacific, the Rajakumar Movement. I know Erfen from when I met him at the WONCA Asia Pacific Conference in Kyoto last year and I have always been struck by his kindness but also his relaxed nature – the Indonesian personality.

Some of the awesome guys from the Rajakumar Movement. From L to R: Wee-Sian (Australia), Erfen (Indonesia), Mel (Philippines), Loretta (HK) and your truly

Indonesia is the largest archipelagic country in the world and is the home of six major religions – Islam (87%), Protestantism, Roman Catholicism, Confucianism, Buddhism and Hinduism. Religion plays an important role in many Indonesians’ lives which could be critical to the response to COVID-19. As we speak, there was an inauguration of a Christian bishop; there’s a big Hindu event coming up; a large Islamic event was cancelled this week but not before many people have travelled from all over to attend. This is slightly worrying in terms of transmission and spread in the near future. Further to this, many religions have communal prayer and we have seen religious establishments being the focus of super-spreading in other countries, like South Korea. Indonesia is probably behind us, the UK, on the prevalence curve so we are both wary of what is yet to come. I ask him whether religious leaders will play a major role in the response and he feels that it would be variable. There will be some who believe that this is God’s will and there are others who recommend more sensible practical measures. As community leaders, they would be perfect conduits to disseminate information but this will depend on their belief system and would need to be negotiated tactfully. For the local population, I can also imagine not being able to practice your faith, and all the social elements that go with it, will also be challenging. The peak is predicted to be around the Muslim new year, Eid, which will be difficult as most people will want to travel across the country in order to go home and spend it with their families which may accelerate the spread again. Imagine being told that you can’t go home and see your loved ones during the Christmas period which would be the the European equivalent of this national holiday.

Erfen is a family doctor in a private clinic and they have had to close for the foreseeable future because they cannot keep their staff safe. There’s just not enough hand sanitisers, masks and soap (which have been out-of-stock for two weeks) for adequate infection control. He talks about the fact that he has tried to import some equipment from abroad but unfortunately the bureaucracy involved is another level. The Health Minister is Erfen’s friend (and also a military doctor) and is saying that this is something that needs to be addressed and made easier. The government hospitals, however, will remain open and there is a sense of duty for the staff to remain there. He’s quite worried already by the high mortality rate (8%) and suspects it’s due to the lack of resources – both equipment and human.

Interestingly, the COVID-19 response is being headed by a disaster management team which kick into action when needed, like in the 2004 earthquake and tsunami. This is led by the military which is fascinating given that the country is still finding its feet as a democracy after 30 years of military rule that ended only in 1998. Erfen thinks that the population may draw some comfort from the military presence as many people see it as a the ‘good old days’ with a bit more order. At the moment, those who come back from high risk countries are ordered to self-quarantine for 14 days (NB see bottom of text for etymology fact about why we call it “quarantine”). If symptomatic they call a number and an ambulance arrives at their home to take them away for swabbing. He also mentions that some people are covertly going to clinics to get tested so as to avoid the stigma and also to get faster results. This seems to be breaking some self-isolation rules but I’m not sure if the awareness in the UK is much better.

Similarly to the UK, Indonesia’s strategy is to postpone lockdown until they need to in order to protect the local economy. I know that people criticise public health policy taking into account financial concerns but I know already from my non-medic friends that they have real worries about redundancy. I’m sure this virus will have ripple effects for years to come and, as family doctors, we need to look at the long game. We’re the first ones in and the last ones out. Erfen and I also talk about the difficulties of enforcing a lockdown. I know my friend in Turkey has mentioned people socialising in the pharmacies “picking up their medications”; and there has been several news articles discussing the number of fines handed out in France for breaking lock-down rules; and Spain is also struggling with people wanting to smoke outside or walk their dogs in public. Erfen is worried about the religious who would want to pray together but also the poor who want to work. I think most of us family doctors share this concern about our most destitute and what impact this will have economically and on their health. We can only hope that all our governments do something to protect businesses and the people. We also talk about how COVID-19 can give false positives for dengue fever which is something that our Singaporean colleagues have found. He says that the symptoms are very different so it’s pretty easy to identify the false positives but it’s quite an unusual finding! I definitely didn’t know that the largest dengue specialty hospital was in Jakarta and they take referrals from across South East Asia. New fact of the day!

Erfen says something that really strikes me in our conversation which I had never considered. He says that the Indonesians are accustomed to suffering. With the high levels of infectious diseases (300 TB deaths a day and a current dengue fever epidemic in East Indonesia) and the number of natural disasters (remember the tsunami in 2004), COVID-19, he feels, is being overlooked by the public. With death and loss being such a part of life, I can see why this is being perceived as less of a public health emergency in Indonesia than it is in Europe and I can also see why people are religious and rely on seeing it as God’s will. He also talks to me about the Indonesian psyche. I’ve always thought Erfen as kind, patient and incredibly relaxed but he laughs this off saying that, amongst Indonesians, he would be considered very serious. He says that his people are accustomed to suffering but they are also accustomed to being together. He feels that good relationships define the Indonesian people and he says that “it’s hard to feel lonely here”. I love this because in the UK, we have a loneliness epidemic, both amongst the young and old which will only be exacerbated by the social isolation. I wonder if that is why we have so much COVID-19-related anxiety in the UK because we feel alone. We both feel that this pandemic will bring out the worst and best in people and will be a test for the public’s values and humanity.

I send love and respect to the healthcare professionals in Indonesia who have managed to get back on their feet after so many disasters.

I managed to not smile for about 15 seconds to partake in this recreation of Charlie’s angels at Inari-jinja with Erfen. NB I don’t usually wear a suit to go hiking but I didn’t have time to get changed!

Why is quarantine called quarantine? It is derived from the Italian word for 40 – quaranta. During the Black Death in the 14th century, European sailors who had visited Venice had to self isolate for 40 days as a rule which became known as a quarantine.

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