JAKARTA IN STATE OF EMERGENCY, the dilemma of pulling Covid-19 emergency break

Traf c in the Hotel Indonesia roundabout (15/09/2020) is sparse, unlike the usual dense traffic during work termination hours. (Photo: Rayi Gigih/IO)

IO – Since late December 2019, the world has been grap- pling with Coronavirus Disease 2019 (Covid-19), said to be caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, previously dubbed 2019- nCoV. The virus was rst diag- nosed in a seafood market work- er in Wuhan, China, and has spread throughout the world, until the World Health Organi- zation (WHO) nally declared it a global pandemic on March 11, 2020. Based on a global tally per September 13, 2020, con rmed Covid-19 cases have reached 28,938,095, with the death toll at 924,558.

Indonesia is one of the coun- tries most severely affected by the pandemic. Based on data of Covid-19 Handling Task Force on September 12, 2020, con rmed Covid-19 cases are 214,746 and death toll at 8,650. Jakarta is the province with the highest caseloads in Indonesia, at 52,840 cases or nearly a quar-

ter of the total national tally. The novelty of this disease, coupled by limitations in pub- lic health system, has caused widespread panic among the general public. Various policies were implemented to reduce the virus’ rate of transmission, one of which being the implemen- tation of Large-Scale Social Restrictions (PSBB).

PSBB is often associated with lockdown. Lockdown is a term often used to describe an effort to control the spread of infection within a certain area, which requires restriction on access or mobility. However, the de nition of lockdown itself is still vague and there is no glob- ally accepted consensus. The implementation of lockdown in each country or region has different protocols. Lockdown severely limits economic activ- ities, whereas PSBB according to the Health Minister Regula- tion No. 9/2020 is a limitation on certain activities and peo- ple’s mobility in an area sus- pected of being infected with Covid-19 to prevent further

infection, the recommendation of which is to be made by heads of local government. PSBB com- prises shutting down school and of ces and restrictions on religious activities, activities in public places, social and cultur- al activities, transportation ser- vices and other activities related to defense and security. PSBB, in a nutshell, aims to keep the economy running while putting a number of restrictions (health protocol) in place to prevent the spread of Covid-19.

The rst total PSBB was im- plemented in Jakarta in three periods –April 10-23, April 24 – May 22 May, and May 22 – June 4 during which the public is re- quired to follow health protocols to contain the transmission of Covid-19. Outside activities are limited, as per Governor Regu- lation No. 33/2020. The total PSBB was then changed to tran- sitional PSBB starting on June 5, and was extended ve times before nally reverting to total PSBB on September 14. The im- plementation of the transitional PSBB has actually resulted in an increase in the number of cases, at a rate of 2,000 – 3,000 con- rmed cases per day.

Public opinion is split be- tween the “health-versus-econ- omy” argument. Assuming that the economy can recover with- out rst bringing Covid-19 un- der control is illogical. The high number of cases will strain al- ready-thin resources. Health should be the priority; then the economy can recover, because humans are the economic ac- tors.

The current condition in Ja- karta is worrisome. In the past week, the number of Covid-19 positive cases has increased rap- idly, reaching more than 1,000 per day. Central Jakarta, West Jakarta, North Jakarta, South Jakarta and East Jakarta are now in the red zone category, while Thousand Islands regency is agged orange. The death rate, while still below national and global gures, is rising rapidly.

This has put extraordinary burden on limited isolation beds and Intensive Care Units (ICU) at referral hospitals. As of September 9, based on data from the Jakarta Health Agency, 77% of the total 4,053 isolation beds for Covid-19 patients are fully occupied and 83% of the total 528 ICU beds are lled. The availability of ICU beds is of particular concern, because they are needed to treat patients in critical condition. It should be noted that the relatively low number of Covid-19 deaths pres- ently is due to adequate isolation rooms and ICU capacity. If this capacity quickly lls up with new Covid-19 patients, the death rate would increase dramatical- ly. This does not even include deaths in non-Covid patients whose treatment is “neglected” due to the spike in Covid-19 pa- tients.

Currently the local govern- ment has increased the number of referral hospitals and isolation beds. But this must also go in tandem with the increase in the number of health workers, med- icines and all supporting equip- ment.

Jakarta is currently in a state of emergency, facing a rising death toll, limited isolation beds, and the lack of ICUs. There needs to be an increased sense of aware- ness and urgency that we are in a health and economic crisis. A solution to deal with both the crises needs to be found now.

The action taken by Jakar- ta Governor to implement an “emergency brake” policy by re- storing the rst PSBB is aimed at curbing the transmission rate of Covid-19, which steadily in- creased during the transitional PSBB period.

As a consequence, several ac- tivities will be restricted, includ- ing educational institutions (re- placed by online learning), of ces (replaced by work from home), religious activities in places of worship, activities in public fa- cilities, reducing the capacity of public/private transportation, including online motorcycle tax- is. Only 11 business sectors are allowed to operate with strict health protocols, namely health, food, energy, communication & information technology, nance, logistics, hospitality, construc- tion, strategic industries, public utilities, and basic services and industries designated vital na- tional objects.

The question now is how effec- tive will the “emergency brake” policy be in slowing down the Covid-19 infection. If we look at the of cial data, the previous PSBB implemented from April 10 – June 4 was successful in re- ducing the number of cases. In March 2020, the actual transmis- sion rate (Rt) of Covid-19 in Ja- karta was 4, meaning one infect- ed person is able to spread the virus to four other people. With the implementation of the PSBB, this gure declined. In the period May 4-17, the value was 1.08 – 1.11. By June 5, it decreased fur- ther to 0.99, indicating that the outbreak was under control. The rate began to increase again to 1.3 after the PSBB was relaxed.

Another indicator is the daily positivity rate indicating the per- centage of people who test posi- tive using the PCR swab method. Data from the Jakarta Health Agency which can be accessed on www.corona.jakarta.go.id/id showed the daily positivity rate on April 10 at 7.1%. This gure was trending down during PSBB implementation (4% on May 22, then 3% on June 4). When tran- sitional PSBB was implemented, the positivity rate began to in- crease again. By the end of the transitional PSBB Phase One (August 27), the daily positivity rate was 9.4% and as of Septem- ber 10 it jumped almost twofold, to 15.8%. This increase could be

due to two factors, namely, more specimens were examined and the number of infected people was increasing.

This proved that during the relaxation of PSBB in the tran- sitional period and the low-level of public obedience in following health protocol have contribut- ed to the increase in infection and caseloads in Jakarta. The “emergency brake” policy, which put in place the same or even stricter level of restrictions, is expected to suppress the trans- mission rate and number of cases. It is also hoped that this measure will be able to prevent the collapse of the public health system in Jakarta. Otherwise, it is highly likely that there will be over ow of Covid-19 patients in Jakarta. This is not an exagger- ation, because many hospitals have been strained by the in- ux of Covid-19 patients. Also, many health workers have lost their lives ghting the invisible enemy. Based on data from the Indonesian Medical Association (IDI) per September 13, 115 doctors have fallen victim na- tionwide, with 13 of them from Jakarta.

The death of medical person- nel must not be taken lightly, because of their vital role in combating the outbreak, espe- cially considering the relatively low ratio of doctors per popu- lation in Indonesia, which is 4 to 10,000 population. With the death of 115 doctors, it can be said that 287,500 people have

lost doctors due to Covid-19. Training a doctor takes a long time and enormous resources. Complicating the matter, many doctors who have died are sub- specialists, some even lecturers and professors. The material and immaterial losses incurred are enormous. In addition, losing doctors will adversely affect the quality and capacity of health- care facilities. It is feared that this could have a domino effect on our battle against Covid-19.

The role of healthcare facili- ties, especially hospitals, is so central because they not only treat Covid-19 patients, but also patients suffering from other ail- ments. Many chronically-ill pa- tients are afraid to visit a hospi- tal for fear of being infected with Covid-19. The government’s well- worn “mantra” of “safety through health protocols” is for many people an abstract concept: they see lack of or no synergy between the central government, local government, and the communi- ty in dealing with the pandemic.

Other countries that have been quite successful in dealing with the pandemic include Hong Kong, Singapore and Taiwan. Since the rst cases were identi- ed on January 23 in Hong Kong and Singapore and January 21 in Taiwan – all of them import- ed cases – the local government immediately imposed strategic policies.

On March 13, 2020 (around 50 days from when the rst case was identi ed), Singapore had187 cases with zero deaths (pop- ulation around 5.7 million peo- ple), Taiwan had 50 con rmed cases with 1 death (population around 23.6 million) and Hong Kong had 131 con rmed cas- es with 4 deaths (population around 7.5 million).
In general, the policies put in

place by the three countries cen- tered around:

  1. Travel restriction to pre- vent community outbreak
  2. Aggressive mass testing and contact tracing, strict lockdown
  3. Rigorous social distanc- ing, self-isolation and im- proving hygiene 

In implementing those poli- cies, each country follows a dif- ferent approach. Singapore, for example, imposed ight restric- tions as well as self-isolation upon arrival, building special isolation facilities, aggressive and extensive contact tracing, prohi- bition of large-scale gatherings, regular monitoring of worker health, compensation scheme for furloughed workers, and edu- cating the public on preventative measures. In Taiwan, there are sanctions and nes in place for violators.

The Indonesian government is not as strict in tackling the pandemic, as evidenced by its ever-changing policies. Likewise, the public are not as compliant and disciplined, as one can still see many not wearing masks and/or keeping safe distance when performing outside activ- ities.

A study in Beijing to examine the effectiveness of using masks, washing hands and maintaining social distancing found that us- ing face masks and disinfectants are highly effective (up to 80%) in preventing Covid-19 transmis- sion. On the contrary, frequent or close contact increased the risk of transmission by about 18 times. The study also found that there was a high risk of trans- mission from Covid-19 patients before symptom onset. Wearing face masks after symptoms doesn’t appear to signi cantly prevent transmission. In other words, it is crucial that everyone observe preventive measures such as mask wearing, social distancing and hands washing.

But one needs to keep in mind that wearing masks and social distancing is a last re- sort measure when one needs to perform urgent activities out- doors. It’s still best to do activity from home. The health sector should be prioritized in handling Covid-19. The implementation of PSBB, as part of the health policy will have a positive domino effect on other sectors, such as the economy, education, and social life. Health is essential because if people are healthy, society will function optimally.

The question then moves to how to deal with the Covid-induced economic downturn. Keep in mind that Covid-19 cases are growing exponentially, much faster than the rate of econom- ic growth when business activ- ities are as normal. The longer the transmission of Covid-19 is left unchecked, the steeper the growth rate of new cases will be.

Dealing with higher Covid-19 cases in the future will be far costly than suppressing its cur- rent growth, so the only logical step to take now is to do what it takes to reduce the rate of trans- mission, even though it means economic growth will suffer. The “Covid-19 debt” with high inter- est must be paid off before fur- ther investment can be made. If there is a one thing regrettable about the Jakarta Governor’s “emergency brake” policy, it is that it wasn’t enforced earlier.

Short term pain for long term gain, as the saying goes. This aptly describes the situation that is taking place in Indonesia, in particularly Jakarta. Covid-19 is a bitter pill that must be swal- lowed as quickly as possible so that the bitter taste doesn’t lin- ger in the mouth. Recessions are common in many regions and various sectors have been par- alyzed by this deadly disease. As an archipelago, Indonesia is facing an uphill battle compared to other countries. So long as the vaccine is not yet available, Covid-19 transmission must be prevented through total enforce- ment of PSBB and proper health protocols. The recommended approach is called 3T (Testing, Tracing, and Treatment) and 3M (wearing mask, keeping safe dis- tance, and washing hands).

It is time for Indonesia to unite together, helping one an- other and playing one’s role and responsiveness as much as possible. This is not the time to point ngers and indulge in prej- udice. If we can come together During this dif cult time, Indo- nesia will surely recover. Strict government and an obedient so- ciety are the keys to successfully overcoming this pandemic.

Dr Erlina Burhan MSc. Sp.P (K) is a pulmonologist with over 16 years experience in pulmonology and re- spiratory medicine. She is a faculty member of the Department of Pul- monology and Respiratory Medicine FKUI/Persahabatan Hospital (RSUP). She is also chairwoman of the Indo- nesian Society of Respirology (PDPI) Jakarta, and Head of the working group for infection PDPI and team leader of Covid-19 Treatment at Per- sahabatan Hospital. Concurrently, Erlina also serves in the Covid-19 Task Force of the Indonesia Medical Association (IDI).