Overtaking India, Indonesia is now leading the world in new coronavirus cases and deaths. A mix of denial and dysfunction led to a catastrophic surge of infections in the world’s fourth most populous country. Wary of the economy, President Joko Widodo resisted calls for a lockdown to contain the virus. He bet instead on an ambitious mass inoculation program that is administering a million doses a day. But limited access to supply of effective vaccines is setting Indonesia back in this race against time.
A Devastating Health System Collapse
Since June, the number of new daily coronavirus cases in Indonesia has soared from a weekly average of 6,000 to 40,000. Deaths are up tenfold from 150 to over 1,500 per day. In total, Indonesia has recorded more than 3.5 million cases and 100,000 deaths since the pandemic began. These official figures are based on testing rates that are among the lowest in the world.
Experts warn that the actual caseload in Indonesia could be as much as eight times higher than what the government reports. Seroprevalence studies estimate that at least 10 percent of Indonesia’s 270 million residents have already been infected with the coronavirus.
The true scale of the current outbreak is evident from the devastating collapse of the health system. Community health centers and hospitals are completely overrun. More than 2,900 people have died in isolation at home, unable to find medical help.
Those admitted to hospitals are struggling to get care due to dwindling medical supplies and staff shortages. Thirty-three people died at a major public hospital after it ran out of oxygen. To make matters worse, an alarming number of health workers are getting infected, despite being fully vaccinated. Thousands of doctors and nurses are in isolation. At least 380 died in the month of July.
Not reflected in these numbers is the helplessness felt by millions of Indonesians seeking care for their loved ones and the exhaustion experienced by those who are trying to respond. Civil society groups connecting patients with hospital beds and oxygen tanks are overwhelmed with requests. Volunteer undertakers are working overtime to collect the dead, only to join long queues at cemeteries.
Past the “Worst-Case Scenario”
Indonesia is currently under emergency restrictions that limit travel and set capacity caps on businesses across major metropolitan areas. Due to uneven enforcement, the government’s predicted worst-case scenario of 40,000 cases a day has already been breached for several weeks in a row. Epidemiologists estimate that if strict mobility restrictions are enforced, the daily case rate would peak at 200,000. Otherwise, Indonesia could be looking at 400,000 cases a day.
The geographical spread of the virus is of urgent concern. The present wave crushed the health system across the islands of Java and Bali that are far more developed than the rest of the country. Now, the more remote outer regions are registering daily spikes in new cases and hospitals are running out of essential supplies.
The protracted health crisis also has severe implications for the Indonesian economy, which is reeling from its first recession in twenty-two years. The World Bank recently downgraded Indonesia back to a lower-middle-income status. Over the past year, 1.6 million people have lost their jobs and 2.75 million have fallen below the poverty line. Despite government pledges for social aid, resistance to restrictions on economic activity is growing among Indonesia’s poor.
Denial and Dysfunction
How did Indonesia get here after avoiding a massive outbreak for eighteen months? Government officials are quick to blame the highly transmissible Delta variant that now accounts for nearly 95 percent of new coronavirus cases in the country.
Scientists contend that the new variant has only accelerated an already high level of community transmission that accumulated over the past year in the form of a “silent outbreak.” Indonesia’s relatively young population delayed a surge in severe cases, but misplaced priorities and data denial have prevented the government from using this lead time to prepare for an outbreak that had long been predicted.
Widodo views the pandemic primarily as a threat to economic stability, rather than a public health crisis. This thinking is reflected in the composition of his pandemic response team, which is dominated by business interests. It is hard to think of a country other than Indonesia where the minister for economic affairs is in charge of fighting an infectious disease.
The health ministry, which should be leading the pandemic response, has been persistently sidelined by Widodo’s own policies. It took him nine months to dismiss the controversial health minister, who is widely criticized for bungling Indonesia’s initial response to the crisis. Even after appointing a new health minister in December 2020, Widodo relegated him to the secondary role of a deputy chief in the pandemic team.
Subjugation of public health imperatives to economic targets bred dysfunction. From the beginning, Widodo ruled out costly lockdowns to contain the virus. But climbing infection rates made this position untenable. Over the past year, his advisers have fumbled with one containment policy after another, leaving behind a dizzying trail of acronyms.
The government initially implemented large-scale social restrictions that set capacity caps on transport and businesses in affected regions, instead of closing them down. But mass confusion ensued when ministers sparred publicly over sectoral details and governors tussled for authority.
Instead of disciplining his subordinates, Widodo loosened the restrictions and began propagating the idea of a new normal. He urged Indonesians to “make peace” with the coronavirus until an effective vaccine became available.
Confronted with another rise in cases after the New Year, the government announced “micro-level social restrictions” that used a neighborhood zoning system to enforce mini-lockdowns, based on reported infections in each area. This scheme bypassed governors and tasked neighborhood leaders with enforcing quarantine and capacity caps, in accordance with local needs.
When cases began soaring in June, the health minister pushed for a lockdown to prevent an imminent collapse of the health system. Widodo disregarded this advice and insisted on keeping to the micro-measures that did not “kill the economy.” The present surge eventually forced the government to impose emergency restrictions on travel and nonessential businesses in July. But these rules were relaxed within weeks, and Indonesia is now back to implementing micro-restrictions.
Neighborhood-level interventions to control the coronavirus were successful in countries like Taiwan and Vietnam because they were supported by robust health surveillance to pinpoint outbreaks. Indonesia’s attempt to replicate these measures failed due to a deep disregard for data.
A year into the pandemic, Indonesia’s testing rates remain woefully low and tracing capacity is almost negligible. It is conducting just sixty tests per 1,000 people, when the Philippines and Malaysia with much lower infection rates are doing three and ten times the number of tests, respectively.
Widodo is not at fault for trying to avoid harsh containment measures that could plunge millions into poverty. But concern for the economy does not explain why his government did not invest in building high testing and tracing capacity that could have reduced the need for such extreme measures.
Part of the problem is flawed policy design. Indonesia allocated $400 million for coronavirus testing. But local governments have used only 3.8 percent of this budget, in order to keep their case counts low and evade zone-based restrictions mandated by the micro-measures.
The bigger issue with health data is political. Public health experts warn that national-level data are routinely manipulated by officials to justify the government’s pro-business policies. This was apparent in the recent decision to ease restrictions on business activities, based on a slight decline in new cases, which was in fact driven by a drastic reduction in tests and data entry backlogs.
Race to Vaccinate Impeded by Limited Supplies
The government’s poor handling of the pandemic is taking a toll on Widodo’s personal credibility. Having taken a hands-off approach, he routinely gave his cabinet two-week targets for controlling the pandemic and then made televised appearances to admonish them for failing. As the crisis drags on, he is under growing public pressure to rein in the business interests in his cabinet and implement stricter containment measures.
Widodo seems determined to avoid this path and is betting instead on an ambitious vaccination program to stem infections. Since he launched a free public vaccination drive in January, 7 percent of Indonesians have been fully inoculated and another 17 percent have received their first shot.
Low vaccine stock, bureaucratic hurdles, and poor communication about the halal status of vaccines slowed down the initial rollout. Misinformation on social media platforms that amplified rare vaccine side-effects also created distrust.
In May, however, the fear of a looming health crisis and large shipments of vaccines helped push past logistical hurdles. Tragic news about overrun hospitals and isolation deaths also lowered vaccine hesitancy among the public.
Of the nearly 70 million shots administered to date, the first 23 million were given over 100 days, the second 23 million took 50 days, and the last 23 million were delivered in just 25 days. The health ministry estimates that it can dispense up to 5 million jabs a day if effective containment measures can relieve pressure on overwhelmed health facilities.
The acceleration of Indonesia’s vaccination program offers hope, but the path forward is impeded by an acute shortage of doses. Just last week, vaccinations were temporarily suspended in some parts of the country when doses ran out. This setback comes at a critical time when the Delta variant is running rampant in rural areas and small towns and a large number of people are lining up to demand shots.
Behind Indonesia’s vaccine shortage is jarring global inequity. Hedging their bets, rich nations placed large orders with multiple vaccine manufacturers early on in the pandemic. The United States, EU countries, UK, Canada, Australia and Japan reportedly procured 1 billion extra doses of high-efficacy vaccines, effectively blocking developing countries from purchasing Pfizer, Moderna, and AstraZeneca.
The COVAX facility created by the WHO to facilitate equitable vaccine access inequity through a sharing scheme also fell behind on delivery targets due to funding gaps, rival buying from rich nations, and production problems during India’s second wave.
Rather than delay its inoculation program to wait for leading vaccine producers, Indonesia bet big on China’s Sinovac that promised early delivery on large orders. Sinovac comprises more than 50 percent of Indonesia’s total vaccine requirement of 426 million doses. Of the 151 million doses delivered between January and July, 90 percent are Sinovac.
In a bid to diversify its vaccine pipeline, Indonesia has signed deals with Pfizer, AstraZeneca, and Novavax for 50 million shots each. But these orders, placed in December, will only be available for shipping in small batches later this year.
An assured supply of vaccines from China was critical for Widodo’s plan for Indonesia to achieve herd immunity by the end of 2021. But in the context of the current surge of infections, overreliance on Sinovac has created two challenges.
First, the entire supply of Sinovac to Indonesia is in bulk form. The time and wastage involved in the fill-and-finish process makes it difficult to keep up supply with rapidly rising demand. The 124 million doses of Sinovac already received in bulk form are expected to yield 100 million shots, after accounting for wastage. Of these, only 65 million have been distributed for use.
Second, growing concerns about Sinovac’s efficacy threaten to further deplete Indonesia’s vaccine stock. Despite lack of transparency in trial data, Sinovac initially proved effective in reducing infection rates among 1.5 million health workers who were the first to get their shots. But a recent rise in severe and fatal infections among fully vaccinated doctors and nurses raises questions about its efficacy against the Delta variant. Adding to these concerns are recent studies that claim protection offered by Sinovac may only last up to six months.
In light of these developments, some countries such as Malaysia are phasing out Sinovac, while others including Saudi Arabia and UAE have been reluctant to accept it, even in travelers. For now, Indonesia is following the WHO’s lead in continuing with its rollout, while revaccinating its health workers with Moderna shots donated by the United States. The health ministry’s recently announced plan to administer a third Sinovac booster to the general public will further strain Indonesia’s vaccine supplies.
The United States, Australia, and Japan responded to the humanitarian crisis in Indonesia by donating a total of 9 million doses of vaccines for immediate use. While this short-term relief is welcome, it is not nearly enough to help Indonesia meet its current shortfall.
Vaccine Inequity Trap
The situation in Indonesia is dire. There is no way the government could have prevented an outbreak of the coronavirus altogether, but prudent management could have saved lives and bought more time for vaccinations.
Rapid mass inoculation is Indonesia’s best hope out of this crisis. However, limited access to vaccine supply is forcing Southeast Asia’s largest economy into an impossible choice between saving lives and livelihoods.
Other countries in the region share Indonesia’s predicament as they brace for a new wave of infections. Locked out of the global vaccine supply, they are left to fight the coronavirus with harsh mobility curbs, even as their economies stretch to the limit.
The recent commitment by G7 countries to share their surplus doses through COVAX is an encouraging sign. But donations, however generous, cannot meet the global demand for vaccines in the time frame required to prevent new variants from emerging.
Until wealthy nations heed calls for a technology transfer to enable local production of effective vaccines, developing countries like Indonesia will remain trapped in a cycle of costly lockdowns and deadly surges.