Author: Lenny L. Ekawati, DPhil student at Linacre College, Oxford, and Project Coordinator at the Eijkman-Oxford Clinical Research Unit in Jakarta; and Benidiktus Delpada, Independent Researcher.
“Don’t return home (for the annual celebrations at the end of the fasting month of Ramadhan)!” was a recent recommendation by Indonesia’s President to prevent the spread of COVID-19 to areas outside of Jakarta and major cities, the epicentres of the pandemic in Indonesia.
Why are visits home forbidden this year? The main reasons are because (1) the Virus SARS-Cov-2 can attack anyone, and the number of positive cases in Indonesia is still rising daily; (2) the use of public transport, such as bus, planes, boats and trains make it impossible for travellers to maintain physical distancing so that the risk of spread during travel is very high; (3) travellers from an area classified as a ‘red zone’ (i.e. with many cases of COVID-19), such as Jakarta, can become carriers and infect elderly family members in their villages of origin.
Having learnt from China and Italy, the Indonesian government was eager to remind people of the fact that older people and people with chronic illnesses are at heightened risk of experiencing severe or even fatal manifestations of the virus. Reminders by the government about how to protect older people from infection are being echoed daily. If you think about it, the recommendations are not complicated: We are encouraged to stay at home, and if we must leave the house, we should use a form of transport which is not crowded; we should wash hands regularly with water and soap and always wear a mask. After returning home, masks should be taken off, hands and feet washed, and clothing changed. Not difficult, or is it?
The concept of social distancing which underlies much of this advice is based on an epidemiological understanding of how disease spreads from person to person. However, as in many other parts of Indonesia, social distancing becomes a challenge in Nusa Tenggara Timur (NTT), a collection of islands in Eastern Indonesia. Why? Because the culture of NTT is well-known for being friendly and warm, tolerant and communal. Social distance is anathema. In this context, how public messages are conveyed and the choice of words become important. The desired social distancing is not coterminous with not socialising but keeping a physical distance between people and avoiding crowds.
Feeling sad, depressed, worried, confused, afraid or angry during a pandemic is normal. In an effort to implement the advice to stay at home, while still interacting and socialising with elderly relatives or friends, younger family members are being encouraged to telephone, use video calls or social media like WhatApp groups or Facebook. Older people who are not familiar with mobile phones or internet technology are expected to feel the impact of the pandemic more deeply, starting with the emergence of loneliness, anxiety right up to depression. In Nusa Tenggara Timur, information about such issues is still rare, and there is a clear need for research about the experience of older people in connection with emotions, worries, fears or even trauma of death in this part of the world.
The provincial government in NTT has two routine social assistance programmes, the so-called ‘Family Hope Programme’ (PKH) and the essential food items (sembako) support for members of society who are less fortunate, including older people and those with disabilities. To date, only around 2,000 of the 36,000 elderly people in NTT have received assistance from the government. The cash or essential items are distributed via post offices, old people’s homes or local authorities.
Members of the police force in NTT (Eastern Indonesia) distribute essential food items during the pandemic
In connection with the coronavirus epidemic, the regional government of Alor island has newly made use of the so-called village fund for two purposes. (The village fund, or dana desa, is money from the central government given to local communities for community development and empowerment programmes.) First, to buy essential food items which are then sold cheaply in locations which can easily be reached by local inhabitants. This is being done in order to prevent people from gathering in traditional markets which often become a source for the spreading of the disease. Second, to distribute cash support for families in need in 76 villages. Meanwhile, in 102 other villages, families in need receive cash assistance of Rp. 600,000 [approx. £35] per month from the Family Hope Program (PKH) and Ministry of Social Affairs assistance.
Despite these programmes, there are older people in Alor who refuse to accept government support in the form of staples and essential items, because they are still capable of working the land and growing local food like cassava, bananas, corn and beans. As one older woman put it: “I have to make the effort myself. God gave me 10 fingers so that I can work.”
An elderly resident of Alor refusing government help during the COVID-19 pandemic
Another interesting encounter involved a small foundation giving support in the form of staples. This foundation was confronted with complaints by elderly transgender people (waria) who had lost their jobs during the pandemic. They deserve attention because, on the one hand, the regional government does not allocate support for them because many don’t hold an identity card (KTP). On the other hand, as transgender persons, they face difficulties arranging health insurance and accessing health facilities. Moreover, if infected by COVID-19, they are highly vulnerable to experiencing stigma and discrimination by the society around them.
In the face of the pandemic, the government requires resources which are flexible in order to carry out tests on the vulnerable population, such as older people. In guidelines published by the government, it says that if an older person has symptoms of the virus, they should quarantine. Their health status has to be evaluated by medical staff, and if their situation worsens, the older person must immediately be moved to the hospital for further care. Furthermore, the procedure for disinfecting the older person’s house has to be done by a health authority or other competent body. The problem is that these helpful and specific guidelines collide with local realities in Eastern Indonesia, which is an area that is poor and under-resourced. Health facilities in NTT are very limited, hence the likelihood is high that not all cases of COVID-19 among the older population can be handled properly.
Similar problems arise with routine medication normally consumed by older people who have a chronic illness such as asthma, cancer, diabetes, stroke and hypertension. In normal times, older people can routinely obtain their necessary medication. But during this pandemic, any visits on their part to hospitals or primary health clinics (puskesmas) for check-ups or to pick up medication increase the risk of their exposure to the virus. Help from health workers, health volunteers and staff at elderly primary health services is very much needed by older people during this difficult time.
Older people who live with the younger generation during this pandemic have many advantages. Why? Because younger people can help older people with chronic illness to visit primary health centres or can collect their routine medication for them. Aside from this, the younger generation can leave the house to shop for daily needs so that older people can remain at home. Indeed, local reports confirm the important role that younger people have in supporting the older generation and reinforcing the advice for them to keep safe. Less encouraging is the fact that young and middle-aged people seem to be more affected by the pandemic, not least indirectly via the loss of work.
Lastly, the recommendation by the government to work from home, learn from home and conduct religious worship at home brings positive effects. During the fasting month of Ramadhan, families spent more time together at home and praying together strengthened the bonds between family members. Many religious leaders supported this by saying that personal and family health is the primary responsibility, more important than worshipping together as in other years. However, some people still chose to loosen their commitment to ‘staying at home’ with the argument that communal worship brings greater rewards. In the lead-up to the end of Ramadhan, the situation became much laxer in many places, as people started going out more and shopping in preparation for the Idul Fitri celebrations. Roads and markets became crowded with traders and shoppers, without continuing to pay heed to the physical distancing rules.
There is cause for worry that the violations of the recommendations for preventing the spread of disease during the end of Ramadhan and the ensuing festivities will result in an increase in COVID cases within the next few weeks. As the saying goes, what we do today will define our tomorrow. Who knows until when? Some Indonesians have greeted with dismay the President’s recent statement that “we need to make peace” with the virus and adapt to a new normal. Given that Indonesia is still facing a rise in cases and fatalities, this adjustment of the message from ‘stay at home’ to ‘live side by side with the virus and remain productive’ seems premature.
Disclaimer: The views expressed in this article are personal and do not represent the views of Eijkman-Oxford Clinical Research Unit or Eijkman Institute for Molecular Biology.