IO – On the 31st of March 2020 the President of Indonesia declared a state of public health emergency in Indonesia as a result of the situation created by the coronavirus SARS-CoV-2 (which causes COVID-19). The President then issued Government Regulation number 21 of 2020 and this together with Decree number 9 of 2020 of the Indonesian Minister of Health provides regions, towns and provinces with the right to ask the Minister that a state of Large Scale Social Restrictions or Pembatasan Sosial Berskala Besar (PSBB) be declared in their area. Jakarta Governor Anies Baswedan led the way by having the nation’s capital declared in a state of Large Scale Social Restrictions as of the 10th of April 2020. This was followed by several towns and regencies in West Java. To date Jakarta has extended the period till the end of May 2020.
On the 24th of April the Minister of Transport, Budi Karya issued Regulation number 25 of 2020 restricting all passenger transport to and from abroad as well as between different parts of Indonesia. Flights were grounded, ships were docked, trains were stopped and roads were closed. Transportation was limited to cargo and important services. A few exceptions were made for foreign residents returning home or Indonesians stranded abroad returning home as for example Indonesian crews of cruise ships returning after their ships were shut down.
The cruise industry worldwide is currently in a state of collapse due to the virus. Pak Peri who is a government official at Bali’s main sea port explained that returning cruise ship crews usually arrive by air and disembark in Bali where they are immediately quarantined in hotels or government buildings. The government then contacts their home towns to check whether their village or town has facilities with which to place them in isolation for 2 weeks. If they do they are sent home. If not they serve their two week quarantine usually in a hotel in Bali. Most areas use hotels to quarantine people suspected of perhaps having contracted the virus and the government pays for these. This is to try to provide the hotel industry which has also been devastated by worldwide travel restrictions, some form of income.
Governments all over the world face the same problem , namely should they try to restrict their populations in order to protect them from the virus which is far more dangerous and with a significantly higher death rate than the usual flu or common cold or should they not impose restrictions or very limited ones in order to save the economy? It is a great dilemma especially in developing and newly emerging countries where the choice can be dying from the virus or dying of starvation.
The situation is an extremely difficult one and many seeing the years of good work in the economy being rapidly whittled away, worry about their livelihood and with cabin fever rampant especially for those alone in an apartment and far away from loved ones as Lebaran approaches, the question of the day is how long will this situation last? When can we go back to living normally again?
Recently, Lieutenant General Doni Munardo who heads the government’s COVID-19 Rapid Response Task Force (also known as Gugus Tugas Percepatan Penanganan COVID-19) provided an answer to this question when he said, “We do not know when the corona virus pandemic will end. Life will go back to normal when a vaccine has been found against the virus.”
He said that Coordinating Minister of the Economy, Airlangga Hartanto confirmed that as long as we do not have a vaccine yet the situation remains unsafe and the new normal for the next few months will be social distancing, wearing face masks and hand washing and where necessary Large Scale Social Restrictions.
So what is the situation regarding vaccines?
The most promising vaccine undergoing clinical trials at the moment is that being tested by the University of Oxford. Head of the Oxford research team, Sarah Gilbert also headed the team that discovered the SARS vaccine and building on the SARS vaccine is what has made it possible for them to move so quickly in finding a COVID 19 vaccine. They began human clinical testing in April and hope to know the results by early June. If the results are as good as expected then Britain plans to have 1 million vaccines produced by September of this year.
Bill Gates has said that nations should not wait for a vaccine to be ready before negotiating for it and preparing to build the plants for it. India is certainly doing so. The countries with the ability to produce the most vaccines are Europe, India and the United States. India has already negotiated with Oxford and will be producing 4 million vaccines each month at a price of five US cents per vaccine. If the vaccine proves successful Sarah Gilbert and her team surely deserve to be nominated for the Nobel Prize for Medicine at the very least.
What should Indonesia be doing to prepare for a COVID vaccine?
Indonesia should now already be taking steps to negotiate for the vaccine. Unfortunately, Indonesian ambassador to the United Kingdom, Rizal Sukma is under medical treatment at present. If the government has not already begun negotiations or have a completely different plan – as a former foreign minister as well as ambassador to the UK and alumni of Oxford University, Marty Natalegawa could well b e a good choice as special envoy to negotiate on Indonesia’s behalf.
Dr Bachti Alisjahbana is an internist and specialist in infectious and tropical diseases who practices at Hasan Sadikin and Santo Borromeus general hospitals in Bandung. He is also a researcher whose research takes on many epidemiological aspects. He says, “In preparing for a vaccine the government should now already act to prepare for it. The Oxford vaccine may be available by the end of the year and then it will need to be very rapidly distributed all over the country and rapid distribution of a vaccine in Indonesia has never been done before.”
Indonesia should also be preparing the necessary legislation for Indonesia to bypass the bureaucracy and legal hurdles that could well hold up a new vaccine for several years from coming onto the market here. In a state of public health emergency the rules for either importing the vaccine or producing it here could be relaxed for the sake of the health and economic well-being of the people of Indonesia. The government also has to set about procuring investors or loans if it does not have the funds needed to import or produce the vaccine. Plans should now already be prepared for raw materials, machines and construction of plants (if necessary) to produce the vaccine. It must obtain the experts required and train the staff needed to conduct vaccinations as well as set up a program and detailed plan to implement the vaccination program all over Indonesia.
Dr Bachti warns, “If Indonesia decides to try to produce the vaccine our industry is not in the same position to produce it as India. India probably has about 10 bio tech companies that could produce the vaccine but Indonesian only has Bio Farma and Kalbe and perhaps a few companies that produce vaccines for animals like Sanbe Farma that could maybe be used to help produce the vaccine.”
Is a vaccine the only possibility of ending the COVID-19 situation?
Another possibility for the COVID situation to come to an end is if a cure is found for the virus. At present the scientists of many nations are researching a cure for COVID19 and there are several very promising research programs being carried out on various drugs. One drug much in the news recently is remdesivir which was originally created as a cure for ebola. It has proven effective at inhibiting the growth of similar viruses causing severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Testing has shown it to be a drug that is effective when the patient is not yet severely ill and it can help reduce the recovery period. It is however very expensive. There are many other drugs currently being tested as a cure to the corona virus SARS-CoV-2 such as EIDD- 2801 which introduces genetic mutations into the virus’s RNA. As the RNA makes its copies, so many damaging mutations accumulate that the virus is no longer able to infect cells. In addition EIDD-2801 has broad spectrum activity against a number of diseases of public health concern, including SARS and MERS, influenza, chikungunya, ebola, and equine encephalitis (VEE and EEE). Also, it can be taken in capsul form unlike remdesir which needs to be taken intravenously. EIDD-2801 is however at present still undergoing human trials. Another possibility among the many drugs undergoing trials is Avigan, also known as the Japanese flu drug.
Dr Bachti explained that in Bandung amongst the drugs being used to treat COVID-19 are hydroxychloroquine, alluvia, remdesivir and interferon beta. Hydroychloroquine is of special interest to Indonesia because it is an anti-malarial drug that has been available very cheaply on the market in Indonesia for nearly 70years. “However its effectiveness is still being tested and Indonesia is taking part in multi-country and multi-centre trials coordinated by the World Health Organization called the Solidarity Trials which will probably show results in 3 to 6 months’ time.”
So, while waiting for a cure or a vaccine what can nations do?
Herd Immunity
Some countries have chosen the economy by opting for what is known as herd immunity meaning not to restrict their populations but allow them to intermingle so that as many as possible soon develop immunity towards the virus. The United Kingdom tried to do this but soon its hospitals were overwhelmed with patients and the UK was simply not ready to deal with such a situation as its health system was not equipped to deal with it. They had a shortage of COVID test kits, of hazmat suits to protect their medical staff, a shortage of respirators and hospital beds. With its death rate from corona virus rising to over 32,000 deaths, the UK has now become the country with the highest death rate in Europe. However, even before reaching such numbers its government was forced to declare a state of lockdown.
Sweden did not close its schools or borders nor did it impose a lockdown or severe social restrictions on its population and it has fared somewhat better than the UK. This could be in part because Sweden has an extremely good health care system which is in a far better position to cope with the COVID situation than the UK. Also, their government did put some social restrictions into place and provided guidelines to their population. Then Swedish culture is – unlike the Italian culture – not a physically demonstrative one. Furthermore, Sweden has an extremely disciplined population that trusts its government and has followed its guidelines on social distancing in restaurants, shops and on the streets. Many people simply chose to stay at home.
Nevertheless, Sweden did not succeed in protecting its elderly population who are most vulnerable to the virus and after four months they currently have a far, far higher death rate than any other Scandinavian country – and it continues to rise. In fact, their death rate per capita even exceeds that of the United States. Swedish hospitals are starting to be overwhelmed and the army is now setting up field hospitals in major cities. Furthermore, Sweden’s economy has still suffered despite the lack of lockdown. The Swedish government is now seeking extraordinary powers from the Swedish parliament to impose further restrictions on its population and the Swedish Prime Minster says that thousands of Swedes may die of the disease. In a country with a population of 10 million some experts estimate that around 4 million may contract the virus.
So, what have the most successful countries done?
The most successful countries in dealing with the COVID-19 situation have been countries such as South Korea, Taiwan, Singapore, Germany and New Zealand. One thing that these countries have in common is that they prepared well in advance. Some like South Korea, Singapore and Taiwan have had experience in dealing with SARS and MERS and knew what to expect and what to prepare for. Others like Germany and New Zealand have good leaders who assessed the situation and planned ahead well. All of these countries also have good health care systems and a relatively educated and disciplined public which trusts its leaders. While waiting for a vaccine or cure for the corona virus these countries have practiced what is known as Testing, Isolating, Tracing and Treating or TITT.
TITT means that when a person is discovered to have contracted COVID-19 the government isolates them or treats them if they are displaying symptoms and it tries to trace all the people they have been in contact with during the last two weeks. This is not always easy if a person has for example been to a public place and does not know all the people he or she has been in contact with. Google and Apple have prepared an App and also an interface that governments can use in order to create Apps to help them in this form of people tracing. Australia has such an App called the COVIDSafe App.
Once these people have been traced they are either isolated which can take the form of self-quarantine at home if they show no symptoms or mild ones. If they become really ill then they are treated in the hospital. It is here that a good health care system comes into play as the better a country’s health care system is the less patients die.
Some countries such as South Korea immediately put TTIT into practice and did not have to implement a lockdown or even severe social restrictions. They already had a good TITT system in place due to their experience with SARS. Germany had to implement a lockdown but is rapidly building up its TITT system by carrying out an ambitious testing plan whereby they are testing 4 million people every week. This of course means that a country must also have sufficient test kits, laboratories to analyze the tests and sufficiently trained medical staff to carry out the tests as well as lab technicians to analyze the tests.
In Indonesia there are not enough test kits available to do so. Bio Farma has managed within two to three months to set up production of PCR test kits but the problem is a difficulty in importing reagents for the tests. Ideally, we would set up a plant to produce Taq Polymerase ourselves as it is produced in volcanic regions but this is currently not the case.
Dr Isabella Margie a GP in Jakarta says, “Vaccines may take time to be safe to give to people. What is most needed while we wait for one to be produced are excellent medical equipment and effective medicines.”
It is for example a lack of medical equipment such as hazmat suits and face masks to protect medical staff that has led to nearly 40 Indonesian doctors and nurses dying on the frontline of the COVID-19 war. The government has been rushing to try to produce these. The Governor of West Java says that factories there are now scheduled to produce 1 million face masks per day. The Ministry of Health has been guiding garment factories to produce WHO standard protective wear for medical staff and the Minster of Defense, Prabowo Subianto just purchased 1000 of the first ventilators produced in Indonesia.
It is a race against time as Indonesia waits for a vaccine or a drug to be produced against the corona virus. (Tamalia Alisjahbana)