Two months ago, in the rural Chinese city of Wuhan, several stall vendors at the Huanan Seafood Wholesale Market began displaying signs of severe upper respiratory infection. At the turn of the year, the first death from the then mysterious Wuhan pneumonia was reported in a 61-year old man after almost two weeks in intensive care at a Wuhan hospital.
Fast forward one month and the outbreak has spread to over 29 countries, affecting over 69,000 people and causing close to 1,700 casualties within the space of seven weeks. The WHO has declared it a Public Health Emergency of International Concern (PHEIC), and many countries are on red alert for potential carriers and new cases.
China is by far responsible for majority of the positive cases with 68,508 cases as of February 17, leaving 355 cases spread out between the other 28 countries. Singapore has seen 75 cases, followed by Japan with 59, Hong Kong with 57, Thailand with 34, South Korea with 29, and sub-twenty case-counts spread out across the globe. Every major Asian country has been hit with this outbreak, except for one notable exception: Indonesia.
Indonesia is a huge archipelago of 17,508 islands spread over the span of 5,300 km from Sabang in the Indonesian west coast to its eastern perimeter in Merauke, which is just one thousand kilometres off the northern tip of Australia. To fathom how colossal this country is, its wingspan covers the entire road distance from Finland to Morocco, bypassing 6 countries in the journey.
And unlike Russia, this country isn’t quite as sparsely populated. With a population size comparable to 50 Singapores, it is the 4th most populated country in the world with 265 million inhabitants, according to this 2019 census, just shy of the USA, who has 67 million more people.
By mere virtue of statistical probability, it seems highly unlikely that a country as big and as close to the outbreak epicentre as Indonesia would see zero cases two months and 70,000 infective incidents into this global pandemonium.
According to this news piece, the closest Indonesia has been correlated to the disease was a Chinese tourist who recently flew in to Bali from Wuhan, came back, and was tested positive for the 2019-nCoV in his homeland on February 5. Officials believe that the subject may have gotten the virus when he returned to China, as the incubation period of virus is understood to be from zero to 24 days.
Singapore, a country with a population of 5.6 million has seen 72 cases up to this day (published 17 February 2020), meaning the incidence per 100,000 inhabitants is 1.28. In comparison, Hong Kong scores 0.77, Taiwan 0.08, France 0.02, and Sweden at 0.01. Indonesia has, well 0.
To put distance into consideration, Indonesia is 3,488 kilometres (2,167 mi) away from the disease epicentre in Wuhan, comparable to Singapore which is separated by 3,432 kilometres (2,132 mi). Singapore has identified more than 6 dozen cases whereas Indonesia has identified 0. And forget 3,000 kilometres, there are countries thousands of kilometres further from Indonesia that’s been affected by this disease. The USA, Canada, Finland, and Sweden just to mention some.
And being home to cities and islands that are known popular tourist destinations, Indonesia’s flight volumes compare to that of other countries. Bali, back in January, flew in 5,000 people from China every single day — that’s at least 150,000 people flying in and out of this bustling international hub, roughly one-fourth the size of the entire Macau population — a country that has observed 10 cases to its name so far.
Moreover, Indonesia isn’t particularly the most hygienic and health-conscious nation in Asia, let alone in the world. Health screening in an Indonesian airport, as reported by a friend of mine during his recent travel from and to Singapore, is almost non-existent. The experience was diametrically opposed during his re-entry back to Singaporean territory, as he noted that a thorough and conservative health exam was mandatorily performed in every individual stepping foot onto Singaporean soil.
When all the facts are laid out, it seems like Indonesia’s evasion of this list is an event of epic miraculous proportions. And this contemplative notion is bound to a laundry list of questions, not only from people within the country, who are concerned for their own safety, but also from curious on-lookers around the world.
Why has Indonesia seen 0 cases in the midst of a novel pandemic?
How have they managed to achieve this despite their lack of vigilance?
Could there be something else that we’re not seeing in Indonesia?
There’s no way we can answer everything in this single article, but I’ve pieced together information from a number of credible sources — both local and international — that I hope would at least provide insight and a sense of direction at addressing these questions.
“The fact remains that Indonesia does not have a positive case of the 2019-nCoV.” — Terawan Agus Putranto
Is the government hiding something?
As much as fears of potential concealment have stirred the nation, nobody in the vast majority of the crowd can really speak of fishy backroom activity, though concerns have risen on social media over the possibility of a politically-driven concealment.
A friend told me that there is zero knowledge within the Indonesian public regarding a positive 2019 n-CoV case. “If they are hiding something, then they’re doing an exceptionally good job at it,” as I quote from this person, who chose not to reveal their name.
Indonesian Health Minister Terawan Agus Putranto disclosed in a recent cabinet meeting that “In the age of social openness, nothing is being concealed.” He then adds, “The fact remains that Indonesia does not have a positive case of the 2019-nCoV.”
As quoted from a piece by The Guardian, one senior former diplomat in the country, who did not want to to be named, said he did not believe official assertions that no cases had been found. “There’s a tendency to hide or gloss over serious problems in the top levels of the government,” he said. “I’m a bit concerned.”
Are cases being undetected here?
Researchers at the Harvard T H Chan School of Public Health in the United States have suggested that Indonesia’s lack of confirmed cases “may suggest the potential for undetected cases”, as fears of air travel being a contributory factor to transmission of the disease from China.
This is especially true in the midst of the country’s apparent lack of vigilance in the surveillance and monitoring front, as reported by this article from Channel News Asia.
Quoting from a brilliantly-written recent article from the NY Times, two-time former vice president of Indonesia Jusuf Kalla, who is also president of the Indonesian Red Cross (Palang Merah Indonesia) said that “it was possible that the disease had already entered the country and that Indonesians might not recognise the symptoms as being that from the 2019-nCoV.”
“Singapore has a tight system, but even there the virus got in,” said Kalla. “It’s possible that there are infected people but here in Indonesia people think that it is only a regular fever or they think it is dengue fever.”
“We have all the equipment needed.” — Vivi Setiawaty
Is Indonesia unable to detect cases of the 2019-nCoV?
The 2019-nCoV can be detected through a myriad of techniques. The World Health Organization (WHO) reports that the most common method to detect the 2019-nCoV is through a molecular assay, which involves a rigorous process of virus concentration, nucleic acid extraction, then amplification by means of PCR, and finally comparing the results to a control, which in most cases is a SARS-CoV strain.
Minister Terawan, in the same press interview at the West Javan presidential palace, addressed concerns by claiming that “[Indonesia] has the kits to check to check coronavirus and they’re certified”.
The Health Ministry’s chief of biomedical research centre, Vivi Setiawaty has followed guidelines which were set by the WHO since late December, when the novel coronavirus strain was first detected.
“Ever since the outbreak occurred, the WHO has issued guidelines on how to detect the virus, and [they] indicated that Indonesia is deemed capable of detecting the coronavirus,” she said during a press conference on February 3. “We have all the equipment needed.”
What is the most likely reason for this phenomenon, besides luck?
Navaratnasamy Paranietharan, who is Indonesia’s WHO representative, said it appeared unlikely, as some have suggested, that the hot tropical climate could be a factor in restraining transmissions though more data would be required to be sure, as quoted from another article by Channel News Asia.
“It doesn’t make sense at this point whether that could be the reason why we don’t have coronavirus cases in Indonesia,” Paranietharan said.
Anung Sugihantono, who also comes from the Health Ministry, posits that immunity could play a role in curbing cases in Indonesia. “When we talk about hosts [of the virus], the immune system against the novel coronavirus is different from one person to another, one ethnicity to another. This is what we’ll be studying further, whether these factors have led to no cases being found in Indonesia,” Anung told journalists last Thursday (Feb 6).
“In terms of environment, we live in a tropical country and the people commonly have activities outdoors. Where these have influences in virulency must also be reviewed scientifically,” he added.
What’s the closest Indonesia’s gotten to a confirmed positive case?
One day before Valentine’s day this year, a 19-year old university student from the eastern Indonesian region of Maluku was admitted to a hospital after showing symptoms of the novel coronavirus.
This student, as reported by Jakarta Post, arrived in a nearby city in poor health following a visit to Malaysia, a country which has reported 22 confirmed cases as of February 17.
The patient is currently held at quarantine, and is awaiting test results from a lab in the East Javan city of Surabaya, which along with the capital of Jakarta, is the only 2 cities where the test is available at the moment.
Up to this day, Indonesia has tested 64 samples of suspected 2019-nCoV infections, upon which 62 came back negative, and an additional 2 are currently still being tested, including that of the 19-year old.
What happened to the 238 Indonesian citizens stranded in Wuhan?
Earlier this month, 238 Indonesian citizens were evacuated from the disease’s ground zero and taken into a 14-day quarantine in the Indonesian town of Natuna, where they are being actively monitored and observed for potential signs of infection.
Fourteen days later, none of them sustained signs of the infection, and all 238 people were subsequently flown back to their respective hometowns, where they were received by jubilant and relieved family members.
“We have experienced this many times” — Achmad Yurianto
How does the near-future look like for Indonesia?
In short, hopeful.
“We are not prepared to face a major outbreak, but we are prepared to prevent an outbreak,” says Achmad Yurianto, who is the Secretary of Prevention and Control at the Health Ministry. “We are not waiting for it to happen. We in fact have tightened prevention.”
He says that Indonesia is better equipped at monitoring travellers for illness due to a past history of the tragic Middle Eastern Respiratory Syndrome, which killed more than 858 people in 2012. Roughly 1.4 million Indonesians take part in the annual pilgrimage to Saudi Arabia, where there is a potential exposure towards MERS, and are therefore always screened on their return.
“We have experienced this many times,” he said. “Maybe other countries are not as diligent as Indonesia in dealing with this situation.”
It’s a bold statement from a country that’s still recording high death rates from tuberculosis, a disease that has mostly been eradicated in the western world.
“But we remain hopeful”, says Terawan. “We pray that no infected individual steps foot into our country, and we will perform proper surveillance as recommended by governing boards such as WHO and the CDC”.
The current census states that Indonesia has readied 100 hospitals across the archipelago, including three in Jakarta.