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‘It’s Too Late’: In Sprawling Indonesia, Coronavirus Surges

The 1,340 Maluku Islands are a long way from anywhere. So remote are these Indonesian isles that the country’s most famous novelist was imprisoned there in a gulag that was actually an archipelago.

But the coronavirus is stalking the farthest reaches of the planet.

The first case of the virus in the Malukus was confirmed in mid-March: a hardware technician who had journeyed from Indonesia’s most populated island, Java. With the central government loath to impose a national lockdown, local officials took matters into their own hands, instituting quarantines and limiting flights and ferries.

It didn’t work. Twenty-five medical workers at one hospital in Ambon, the biggest city in the Malukus, have tested positive for the coronavirus, even though none had contact with Covid-19 patients there. A hat vendor with no history of travel to other Indonesian viral hot spots became sick and died in early May, signaling that community transmission had begun.

Over the past week in Maluku Province, positive coronavirus tests have increased by double digits each day, with limited testing — only around 600 people have been tested — surely obscuring the true caseload.

“We didn’t expect it to happen this fast,” said Kasrul Selang, the head of the coronavirus task force in Maluku Province. His wife has tested positive for the coronavirus.

ImageAn isolation room for coronavirus patients in a Jakarta hospital this month.
Credit…Willy Kurniawan/Reuters

The world’s fourth most populous country, Indonesia offers both a cautionary tale for how dithering leadership can thwart public health and a medical puzzle for why an unprepared nation’s hospitals have so far not been overwhelmed by the virus.

With thousands of islands straddling a section of the Equator wider than the continental United States, Indonesia has counted on its sprawling archipelago and youthful population to slow the deadly spread of the virus. But with sharp caseload increases in far-flung regions like the Malukus and full-blown outbreaks on more populated islands like Java, Indonesia’s luck may be running out.

In early May, Indonesia had recorded fewer than 12,000 cases of the coronavirus, with around 865 deaths. By Thursday, the number had increased to 24,538 confirmed cases and 1,496 deaths. Health experts say even this doubling of cases reflects the limits of testing rather than the true caseload.

In an alarming glimpse at what could be runaway transmission, a random sampling of 11,555 people in Surabaya, the country’s second largest city, found last week that 10 percent of those tested had antibodies for the coronavirus. Yet the entire province of East Java, which includes Surabaya, had 4,313 officially confirmed cases as of Thursday.

“Massive infection has already happened,” said Dono Widiatmoko, a senior lecturer in health and social care at the University of Derby and a member of the Indonesian Public Health Association. “This means it’s too late.”

Yet even as the country’s caseload accelerates, the Indonesian government has said that national coronavirus restrictions, already a scattershot effort, must be relaxed to save the economy.

Credit…Juni Kriswanto/Agence France-Presse — Getty Images

“If people don’t eat and they get sick, it will be worse,” said Joko Widodo, the president, at a briefing for the foreign news media.

There is widespread concern among public health experts, however, that Indonesia’s health care system will break down if the coronavirus spreads as intensely as it did in the United States or Europe.

Worryingly, more than half of Covid-19 deaths in Indonesia were of people below age 60. In the United States, most deaths have been among the elderly. The relative youth of the victims in Indonesia, health experts say, hints at hospitals that are unable to provide the kind of lifesaving treatment offered in other countries.

And epidemiologists fear an even bigger surge in cases next month. Last week, in a country with the largest Muslim population in the world, millions of Indonesians gathered to pray and travel at the end of Ramadan, the Islamic holy month. In the capital, Jakarta, more than 465,000 vehicles left the capital during the holiday period, according to a toll operator.

While the Indonesian government announced some coronavirus travel restrictions in late April, they have not been enforced rigorously, critics say. Loopholes abound. Airport staff have complained about entire families, including children, flying under exemptions meant for business travelers.

Modeling by epidemiologists at the University of Indonesia forecasts that up to 200,000 Indonesians may require hospitalization for the virus because of Ramadan-related activity.

Achmad Yurianto, the spokesman for the National Covid-19 Task Force, said that he expected a surge in confirmed cases beginning next week because of all the holiday movement.

Credit…Heri Juanda/Associated Press

Because Indonesia’s testing rates are the worst among the 40 countries most affected by the virus — 967 per 1 million people, compared to 46,951 per 1 million people in the United States, as of Wednesday — Indonesians, especially those with asymptomatic or mild cases, are unknowingly spreading the virus, infectious disease experts warn.

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“The disaster is still coming,” said Dr. Pandu Riono, an epidemiologist who led the University of Indonesia’s modeling effort. “Even after many months, we still have leaders who believe in miracles rather than science. We still have terrible policies.”

The Indonesian government should have known better. For weeks, even as nearby countries recorded spiraling local infections, Indonesia’s leaders acted as if the archipelago were somehow immune to the coronavirus.

“They were in denial,” said Dr. Erlina Burhan, a senior pulmonologist at Persahabatan Hospital in Jakarta. She noted that she has already been falling asleep in exhaustion at her desk because of the deluge of coronavirus casework.

Indonesia didn’t confirm its first coronavirus case until early March. Neighboring Malaysia and Singapore recorded their first cases in late January.

Meanwhile, some hospitals, particularly on crowded Java, were logging big upticks in pneumonia cases with symptoms similar to Covid-19. But bodies were buried before coronavirus tests were administered.

The governor of Jakarta said hundreds of people had probably died of Covid-19 in the capital but were not part of any official coronavirus count.

Denial continued among Indonesia’s top leaders, even as a cabinet minister fell ill in mid-March. The nation’s health minister suggested that prayer could ward off the virus. Or maybe exercise and vitamins could do the trick.

Mr. Joko, the president, eventually admitted that the true situation wasn’t being shared with the public to avoid panic spreading across the archipelago.

Because national restrictions weren’t put into place until about a month ago, some provincial officials instituted their own travel bans, just as state governors did in the United States.


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  • Frequently Asked Questions and Advice

    Updated May 28, 2020

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Is ‘Covid toe’ a symptom of the disease?

      There is an uptick in people reporting symptoms of chilblains, which are painful red or purple lesions that typically appear in the winter on fingers or toes. The lesions are emerging as yet another symptom of infection with the new coronavirus. Chilblains are caused by inflammation in small blood vessels in reaction to cold or damp conditions, but they are usually common in the coldest winter months. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


In Maluku Province, the governor began limiting arrivals at the airport and big ports in late March, after the first case was confirmed there. About 6,000 outsiders were quarantined.

Credit…Firdia Lisnawati/Associated Press

But in a notoriously corrupt country, not everyone followed the rules. Even if official ports of entry were monitored, fishermen moved back and forth from the Malukus to viral hot spots like Makassar on the island of Sulawesi, where infections proliferated after a gathering of a Muslim revivalist group.

For each place like Maluku Province that tried to impose local discipline, others were proceeding as if life were normal.

“If they had restricted movement since the beginning, the disease would not have spread to almost all over Indonesia,” said Dr. Rodrigo Limmon, head of the Ambon branch of the Indonesian Doctors Association.

In the Malukus, medical staff resorted to using plastic raincoats from convenience stores for lack of proper equipment. Ambon, which was devastated by communal violence at the turn of the century, has only 25 ventilators. The Haulussy Hospital, where the 25 medical workers tested positive, was forced to close.

“If they get sick or die, how will we survive?” said Wiesye Pelupessy, founder of an Ambon civil society group that has been distributing personal protective equipment for local medical workers.

Some officials are hopeful that, for now, the virus hasn’t spread to the farthest-flung islands in the Maluku island chain. The southeastern Malukus have not yet recorded a single case.

There are other, even more unlikely, places in Indonesia that have avoided out-of-control epidemics. The tourist island of Bali had direct flights from Wuhan, the Chinese city that was the center of the initial outbreak. Even in March, holidaymakers were arriving in Bali from Europe and other places hard hit by the virus.

Yet Bali has had just 420 confirmed cases. Gusti Ngurah Mahardika, a virologist at Udayana University in Bali, checked in with local crematories to see whether more bodies were coming in because of the coronavirus. They were not.

“It is not the Indonesian habit to hug and to kiss,” he said, looking for possible factors that might have contributed to the island’s low caseload. The same cultural social distancing has been mentioned in connection with the relatively low number of infections in countries like Japan and Thailand compared with Brazil or Italy.

Nevertheless, public health experts in the Malukus are bracing for what many fear will be a new wave of cases following the post-Ramadan festive period. Over the weekend, local markets were packed with holiday shoppers.

Despite local government regulations limiting spiritual worship, the faithful flocked in Ambon last Sunday to celebrate the end of Ramadan. Few wore masks. So far, most of the region’s biggest outbreaks have been linked to superspreader religious events.

“In Maluku, we are lucky that we are islands,” said Meikyal Pontoh, the head of the provincial government health office. “But because this is already worldwide, we have to fight really hard and pray really hard.”

Credit…Mast Irham/EPA, via Shutterstock


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