Risks for an India scenario?
IO – The world has grappled with the Covid-19 pandemic for more than a year, but unfortunately not even one country has managed to bring it under control. Although there has been a decline in case numbers, many countries have actually seen a resurgence, as what we are observing in India. In early 2021, India claimed it had managed to suppress its daily Covid-19 infections, but now the country is in the midst of the worst Covid-19 crisis.
The second wave of Covid-19 in India is increasingly worrysome, as the pandemic now seems to target many of its younger population. It has been breaking global record in terms of highest daily caseloads and death toll, with news of medical oxygen scarcity, hospitals beyond capacity, and mass cremations. And more disturbingly, decomposing bodies suspected of being Covid-19 victims floating down the Ganges, India’s holiest river.
One of the causes of this devastating second wave was the public’s neglect to implement health protocols, due to the euphoria of vaccines and massive gathering of people during religious celebrations and regional elections. In fact, India’s vaccination campaign is still much slower than expected – less than 10% of its population has received their first dose and less than 2% the second dose. This lag is astonishing, because India is home to the world’s largest vaccine producer, the Serum Institute of India. In addition to low vaccine stocks (considering its vast population), the vaccination drive has yet to prioritize the population segment most at risk, namely the elderly and slum dwellers.
When India experienced what many has called the “Covid-19 tsunami”, its neighboring countries – Nepal, Bangladesh, Pakistan – have also seen a resurgence of cases, as do Latin American countries Brazil and Chile, as well as countries in Southeast Asia. The health ministry of Laos is seeking additional supplies of medical equipment and medicine, as their caseload surges 200-fold a month. Lao Prime Minister Phankham Viphavanh has imposed a lockdown in the capital and halted international flights on April 22, after identifying a Covid-19 cluster linked to Thailand. According to The Bangkok Post, Thailand’s public health ministry reported 2,041 new cases and 31 deaths on Monday (3/5/2021), which was almost double the number of two days before. A number of hospitals in Thailand are now under tremendous strain due to sudden spikes in Covid-19 patients. More alarmingly, it was reported that 98 percent of the new cases were the more contagious new strains. Meanwhile, Bloomberg reported that there have been 11,974 cases and 604 deaths in Cambodia as of Saturday (2/5/2021).
Covid-19 cases in Malaysia and Singapore have also been on the rise. Singapore now has 11 active cases, with Changi Airport among the largest cluster with 46 cases. Prime Minister Lee Hsien Loong wrote about his concerns over the new cluster and untraceable local transmission. Other than conducting more tests, Singapore has implemented a number of social restriction rules to reduce transmission. Meanwhile, the Malaysian government has again imposed a national lockdown, starting on Monday (10/5), its third thus far. In fact, there is a hospital bed crisis in ICU wards across the country. Prime Minister Muhyiddin Yassin declared that the lockdown policy will stay in place until June 7. During the lockdown, strict restrictions will apply on residents traveling between states or districts, with crowd-pulling activities banned.
Mutant variants
As it enters its second year, the pandemic has become more dangerous, due to an increase in mutated virus strains which are believed to be more transmissible and deadlier. These new variants are suspected to be behind the latest surge in Europe, India and Brazil.
There are several variants so far: the first found in the UK, Brazil and South Africa, all different from that of the original Wuhan strain. They are able to infect faster, potentially cause more severe illness and reduce the effectiveness of the vaccine.
Variant B.1.1.7 was first discovered in the UK in the fall of 2020. As of December 2020, B.1.1.7 has spread globally, with cases detected throughout Europe, North America and Asia. The Indonesian health ministry said that B.1.1.7 is 50-74 percent more transmissible. However, Head of the Eijkman Institute for Molecular Biology Amin Soebandrio said that the existing Covid-19 vaccine is still effective against the B.1.1.7. Then there is B.1.3.5, the second variant, first discovered in South Africa in October 2020. By end-2020 it had spread to the UK, Switzerland, Australia and Japan. The third, P.1, was first discovered in January 2021, when Japan reported four cases traced to visitors from Brazil. (FIGURE-1)
The latest variant, B.1.6.1.7, is found to have double spike mutations, namely E484Q and L452R.
Over the past few months, these “super mutants” have been the dominant strain in the Indian state of Maharashtra. Now they have been found in at least 17 countries. Many experts believed that this new variant is responsible for the explosion of cases in India.
When new variants were first reported in Britain, South Africa and India, many people in Indonesia thought that they were “distant”, but the facts were that the virus was able to jump across borders and continents rapidly. So far, seven variants have been identified in Indonesia, namely D614G, B.117, N439K, E484K, B1525, B.1617, and B.1351. They are thought to be 36-75% more transmissible than a previously circulating virus. The distribution of cases involving the new variants in Indonesia are: B.1617 (1 case in Riau Islands and 1 in Jakarta), B.117 (2 cases in North Sumatra, 1 in South Sumatra, 1 in Banten, 5 in West Java, 1 in East Java, 1 in Bali, 1 in East Kalimantan) and B. 1351 (1 case in Bali). (FIGURE-2)
Will Indonesia see the likes of India’s Covid calamity?
Director General of the World Health Organization (WHO) Tedros Adhanom Ghebreyesus urged countries to be vigilant for a potential spike in global cases and said that what happened in India may also occur in other countries as well, if the outbreak is not well-contained.
Indonesia should also learn from the experience of other countries, such as India and Malaysia, because we may go down the same road; in fact, Indonesia has several factors that can amplify the risk.
FIGURE-2
First, a large population and under-resourced healthcare system that can quickly buckle under a surge of cases. Indonesia is also still very weak in terms of testing and tracing. Our close contact tracing ratio is still between 1:4 and 1: 5, not much different from last year. So, the current decline in cases could be a ticking time bomb.
Secondly, Indonesia’s socio-cultural conditions are also similar to India’s. Societies in both countries are deeply religious. Many clusters in India originated from religious festivals, one being from the Hindu bathing ritual in the Ganges or Kumbh Mela where more than 1,000 people were infected and started up a “super spreader” event.
Currently, Indonesia is also facing an alarming period, after the increased activity and mobility in the lead up to the holy month of Ramadan and Eid al-Fitr (Lebaran). Even though the procedures for conducting tarawih (evening Ramadan prayer) have been issued, there is no guarantee that tens of thousands of mosques will follow the strict health protocols. Shopping centers and traditional markets were also crowded ahead of Eid. This was complicated by the annual homecoming exodus (mudik), which despite the government’s ban, has often been violated. After all, exodus within urban agglomeration was still permitted. The family gathering ritual during Eid is also a cause for concern, as it can easily form a “transmission cluster”. Meanwhile, there is a palpable sense of complacency among residents, compared to last year. This is evident in recent weeks from the diverse new clusters emerging, from office clusters, “fast breaking” clusters, tarawih clusters in Banyumas, exodus clusters in Pati, and takziah (comforting the bereaved) clusters in Semarang. This happened amid stunning news that of 6,000 exodus travelers randomly tested for Covid-19 at 300 checkpoints, 4,000 were found to be positive.
Based on official data, number of new cases has stagnated, slightly fluctuating between 4,000-6,000 per day. This is worrying as there was a decline in cases after reaching the peak of the first wave in late January. The government must be vigilant because it is feared that another spike might follow.
Limited vaccine stock and the use of low-efficacy vaccines, compounded with still-low vaccine coverage are sources of concern. President Jokowi is targeting 70 million Indonesians to get a jab by July 2021; however, the realization still lags far behind. Judging by the latest data from the National Covid-19 Handling and Economic Recovery Committee, as of May 6, 2021, 12.9 million people have received their first dose of vaccine and 8.31 million people the second dose. A far cry from the expected milestone. (FIGURE-3)
Returning migrant workers and foreign nationals have also contributed to the increase in cases. Thousands of migrant workers enter Indonesia daily through several international airports, and their arrival is not accompanied by any robust quarantine system.
They are at high risk of bringing the new VOC (variants of concern) from other countries. As have been reported, as many as 200 Indonesian migrant workers (TKI) from Malaysia who had just arrived in Indonesia via Batam, Riau Islands, tested positive for Covid-19. The Riau Islands Covid-19 Handling Task Force regularly conducted swab tests on 14,000 migrant workers who had entered via port of Batam and Tanjung Pinang. Data from the Soekarno Hatta Airport Immigration Office found that 454 Indian nationals entered the country in the period of April 1122, including 135 Indian nationals admitted on KITAS (limited stay permits) on April 21. Meanwhile, of the 127 Indian nationals who entered Indonesia on April 23, 2021, 12 tested positive, at a time when the Covid-19 pandemic in India is raging.
Lax government policies can also contribute to the looming Covid-19 storm. Policy inconsistencies have an adverse impact on grassroot implementation, because law enforcers will be confused in interpreting the policy. Violation of regulations can potentially increase the risk of a runaway outbreak, especially post-Lebaran. This is because policy inconsistencies will defeat the effort to impart norms as part of a wider social awareness. One example of policy inconsistency is when the government banned the mudik (Lebaran exodus), but encouraged local tourism as part of an economic recovery driver. Also, allowing foreign nationals to enter Indonesia. We can see that there is a double standard, leading to weakening of social control and failure of Covid-19 handling during Lebaran in 2021. Meanwhile, the “exodus culture” is a major economic driver for local economy and business establishments and street vendors along the major routes traversed by travelers. And among the series of activities during Lebaran, at least one day is dedicated to sightseeing. However, when done during the pandemic, it can become a weak link in the handling of Covid-19.
Patience and vigilance
So far, the government policies related to Covid-19 handling have not been robust and solid, but instead, contradictory and counterproductive. This has only served to confuse and frustrate the public further in their implementation. In policymaking, the most important thing is consistency. When a policy is seen as conflicting it often fuels a sense of injustice or confusion in the community. The rationale behind the policy should also be well-communicated, so it is better understood by the people. The success of a policy will hinge on the wider participation of the community in the form of compliance with standing regulations. The public should be involved in policymaking because they play a vital role in impeding the Covid-19 transmission chain. Thus, the government should not create inconsistent and confusing policies; otherwise, there will be resistance and refusal to comply on the part of the public. Of course, we don’t want the public to further distrust the government as this will be disastrous during a pandemic situation.
Furthermore, the public still needs constant reminding to carry out the 5M health protocols – mask wearing, hand washing, social distancing, crowd avoidance and mobility reduction – because this will form a strong defense against Covid-19. It is hoped that the public can be patient and stay aware that there are many people vulnerable to Covid-19, because immunization coverage is still low. If we neglect to carry out health protocols, the potential for transmission will increase, resulting in more new variants. The grim image emanating from India should be a powerful reminder that no one in the world is truly safe until everyone is safe. (Drg. Tince Arniati Jovina, MKM)
Drg. Tince Arniati Jovina, MKM. Policy analyst at the Indonesian Health Ministry’s Research and Development Agency. She holds a Master’s Degree in Public Health from the University of Indonesia (UI)