The Fading Voice of Doctors in Pandemic Policy
The widely circulating reports about preparing vaccinations against Covid-19 have given rise to optimism and anxiety at the same time amid the protracted pandemic.
This handout photo taken and released on August 11, 2020 by Presidential palace shows President Joko Widodo (C) visiting the Bio Farma Pharmacy that produce vaccines for COVID-19 coronavirus in Bandung, West Java. - Indonesia on August 11, 2020 launched human trials of a Chinese-made coronavirus vaccine with some 1,600 volunteers slated to take part in the six-month study.
The widely circulating reports about preparing vaccinations against Covid-19 have given rise to optimism and anxiety at the same time amid the protracted pandemic. Some people are so optimistic that they are convinced that a vaccine will mean the end of the pandemic.
As someone who works every day at a hospital and still has time to read various medical journals and media reports, this writer still finds it hard to understand the present circumstances.
Nine months since President Joko Widodo announced the first patients to test positive for Covid-19 in Depok, the number of confirmed Covid-19 cases has kept increasing until today. Worse still, public fear over the pandemic is waning. Ignoring the health protocols is commonplace. This is even more so the case because the regional elections have not been postponed despite the warnings from different circles. In fact, the pandemic will no go away, even though we might be bored of it.
For doctors who are engaged daily in treating Covid-19 patients, the masses’ ignorance of the health protocols is extremely hurtful.
“You dare to be laughing together in a large crowd. Actually, you’re likely to come to us later as patients with severe Covid-19,” these wary doctors may wish to tell these people.
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Officially, the number of new cases is averaging 4,000 per day. This is an unusually high number, never mind that many other cases may as yet be unrecorded. The current situation worsens the condition of the “last bastion” against the virus, that is, the health workers. The Indonesian Medical Association (IDI) has noted that 136 doctors and 130 health workers died in mid-October 2020 while carrying out their Covid-19 treatment and management duties.
The IDI mitigation team has even recorded that 1,267 of resident specialist doctors had been confirmed with Covid-19 infection at 11 a.m.
Exhaustion, minimum personal protective equipment (PPE) and fully packed hospital wards have increased the exposure of physicians and health workers to the virus. The IDI mitigation team has even recorded that 1,267 of resident specialist doctors had been confirmed with Covid-19 infection at 11 a.m. Western Indonesian Time on 19 Oct.
Under such distressing circumstances, we are still seeing people seizing the bodies of family members who died of confirmed or suspected Covid-19. The media still publish frequently reports on hospitals that are surrounded, ambulances that have been forced to stop, and health workers who are upbraided and driven off by the patient’s family.
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We do understand that the patient’s family may be in shock and their emotions may be unstable. However, some have even thrown feces at health workers. This is entirely difficult to understand. The situation has certainly caused much difficulty for health workers in managing and treating their patients.
Wavering policy
We are overwhelmed, but still find it hard to admit this. The question arises, has the Covid-19 response been misguided?
The government has formed several task forces. Initially, the President formed the Covid-19 Rapid Response Task Force under Presidential Decree (Keppres) No. 7/2020. Later, it issued Keppres No. 82/2020 to dissolve this task force and replace it with the Covid-19 Handling Task Force. This task force falls under the Covid-19 Handling and National Economic Recovery (PC-PEN) Committee.
An employee works on the production line of COVID-19 coronavirus vaccines at the Bio Farma Pharmacy, which will produce the vaccine early next year with a production capacity of 250 million vaccines a year, in Bandung, West Java on August 12, 2020. - Indonesia on August 11 launched human trials of a Chinese-made coronavirus vaccine with some 1,600 volunteers slated to take part in the six-month study.
The government has apparently wavered several times in implementing the large-scale social restrictions (PSBB). When the number of confirmed cases surged, the government promptly warned us to get ready for the reinstatement of the full PSBB.
But when some regions tried to apply strict restrictions to curb local transmissions, Economic Coordinating Minister Airlangga Hartarto responded by opposing the measures, asserting that the economy must continue to run and to avoid causing a panic by imposing strict restrictions.
As a consequence, the daily tally of new cases to date has remained very high, and the curve has not been flattened. Sadly, the economy still remains sluggish.
So it seems that the pandemic response is not being guided appropriately, without a single unified command or vision. The concerns of medical and health professionals have apparently not been taken into account. It even seems that policy is reflecting the voice of the medical world less and less. The threat of economic recession appears to be of a greater concern than the increasing spread of the outbreak and the rising death rate. As a consequence, the daily tally of new cases to date has remained very high, and the curve has not been flattened. Sadly, the economy still remains sluggish.
An interesting example has been presented in a media article, which quoted a local official as saying that the number of confirmed cases in their region had increased drastically because of increased tracing and testing.
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The official’s intension was to calm the local people. But his statement actually opened criticism from medical circles, that the published figures of confirmed cases had not been accurate so far, because of insufficient contact tracing and testing.
Logically, if contact tracing and testing were increased drastically, the number of confirmed cases would soar. Conversely, if contact tracing and testing were suddenly halted altogether, the number of confirmed cases would see a zero increase.
In such a situation, what is the responsibility of the medical profession in overcoming the policy confusion? Could we say that the medical profession is facing an identity crisis, especially in managing the pandemic? Is the pandemic response beset by ethical issues and conflicts of interest?
Professionalism in the medical field entails several basic principles, including capacity and skill, integrity, respect for patients, fair treatment founded on self-conviction and self-confidence, as well as avoiding conflicts of interest and corrupt practices. Developing, maintaining and upholding professionalism are fundamental to the medical profession in the fight against this aggressive virus.
In the field, medical professionalism can take various forms. In a hospital, doctors are charged with treating and managing patients based on a determination to help recover and restore their health. They manage patients with empathy and in complete observance of medical ethics.
Medical professionalism has been put to the test in managing the Covid-19 outbreak. With their limited numbers and whatever PPE that is available, doctors and health workers are working hard, day and night. They manage tens of thousands of Covid-19 patients, ranging from asymptomatic people (OTGs) to patients with acute or severe forms of the disease.
As Covid-19 is highly contagious, frontline doctors and health workers have become infected by the very patients they were treating. Physicians and health workers have thus been dying.
Listening closely to medical professional
Doctors not only treat patients directly. They have another task that is no less important, that of medical research. In the context of Covid-19, many doctors are involved in research to develop vaccines, drug therapies, medical equipment like ventilators, Covid-19 tests to replace the polymerase chain reaction (PCR) tests and other efforts.
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Some are studying the biological aspects of the virus, such as its chemical components and structure, its genome, character and virulence, and genetic mutations. These medical professionals belong to a silent group that work in solitary rooms, far from the noise.
The above is an example of the cross-sectoral and strategic role of medicine, in which medical professionals take part in formulating strategy and emergency scenarios for managing the health emergency. The government has set up a task force, later changed into the Covid-19 Handling Task Force to involve many parties. In the medical industry, the task force involves public and private hospitals, clinics, puskesmas (community health centers), private laboratories, pharmaceutical manufacturers, medical associations and many others.
It also involves even more nonmedical professionals, even members of the National Disaster Mitigation Agency (BNPB). Most recently, it was revealed that members of the State Intelligence Agency were also involved.
Are the inputs and concerns of medical professionals given ample consideration and then implemented, or does the task force merely listen to them or even ignore them?
Then, what is the role of medical professionals in the national Covid-19 response? Have professional associations like the IDI, the Indonesian Pediatric Society (IDAI) and the Indonesian Dental Association (PDGI) formulated a blueprint of the pandemic response? Are the inputs and concerns of medical professionals given ample consideration and then implemented, or does the task force merely listen to them or even ignore them?
Are the policy products and the implementation of the various Covid-19 programs dominated by health considerations or economic considerations? This is an important question from a doctor who spends his time taking care of Covid-19 patients all day while he worries and whispers prayers that his patients might get well soon and infect no one else.
In this file photo taken on July 21, 2020 a general view is pictured of the offices of British-Swedish multinational pharmaceutical and biopharmaceutical company AstraZeneca PLC in Macclesfield, Cheshire. - Pharmaceutical company AstraZeneca said on September 8, 2020 that it had "voluntarily paused" a randomized clinical trial of its coronavirus vaccine in what it called a routine action after a volunteer developed an unexplained illness.
The President has also formed the PC-PEN Committee, consisting of the Policy Committee that falls under the Economic Coordinating Minister, the Covid-19 Handling Task Force under BNPB Chairman Doni Monardo, and the Recovery and Transformation Task Force under Deputy State-Owned Enterprises Minister Budi Gunadi Sadikin.
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Some people have asked, why is the Health Minister or another medical professional not among the committee’s leadership? Remember that Covid-19 is a health problem. Are the committee’s polies dominated by the concerns of the medical profession or those of other professional fields, like economics, business, trade, or finance? The answer to this question will give an idea as to whether the central government is prioritizing public health concerns or economic interests.
In these circumstances, the medical profession should avoid any tug-of-war between sectoral and political interests, keeping in mind that national politics is still polarized and has not yet come back together. The medical profession should devote itself to the interests of humanity, the nation and the state, avoiding any tug-of-war between group interests. It must maintain close ties with all parties while also taking caution to keep its distance, as many controversies have arisen in terms of the pandemic response.
For instance, the presence of a high-level, non-health state institution in all sectors related to pandemic control or to the procurement of PPE and health equipment has generated controversy and speculation, as has the issue of imported vaccines versus red-and-white vaccines, and many others. There is an impression that the health emergency response is being treated more as a big, unrestricted business opportunity instead of a major undertaking to put an end to the increasing infections in all provinces in Indonesia.
The device uses a noninvasive method, and does not require taking any blood or nasopharyngeal samples from the test subject.
A striking example is the Genose invention by Gadjah Mada University (UGM). This device tests people only based on exhaled breath. It produces a positive or negative Covid-19 result in less than two minutes. Aside from the cost of making the device, the it costs less than Rp 1,000 per test per person. Yogyakarta Sultan Hamengku Buwono X has tried it. Why doesn’t the central government enthusiastically make use of the Genose in a mass testing program? This is far cheaper than the rapid diagnostic test that costs hundreds of thousands of rupiah per person, never mind the PCR swab test that costs millions of rupiah per person. The device uses a noninvasive method, and does not require taking any blood or nasopharyngeal samples from the test subject.
Using the Genose device in a mass testing program would increase the testing rate. Even if the device needs licensing, a device invented by the nation’s citizens should be facilitated. It is also not difficult to import of rapid test kits (the accuracy of which is still questionable). Indeed, if the low-cost Genose is used in mass testing, the other tests will obviously have difficulty competing against it. Is this the reason why the UGM invention has not yet been approved for public use?
Not to mention, the government has been insistent in ordering vaccines from several countries with differing prices, even markedly different prices of between US$5 and $22. In fact, none of these potential vaccines have succeeded in achieving effectiveness results above the standard (60 percent). The report of a patient who died after a vaccine trial raises another question.
The goods do not even exist yet, but a polemic has already been sparked, even a scramble to obtain them. Several hundreds of billions, even trillions, of rupiah have been spent on preordered vaccines on the Health Ministry’s plan to vaccinate 70 percent of the population, or 160 million Indonesians. News on the “red-and-white vaccine” has receded amid the fierce polemic over potential vaccines imported from other countries.
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Since Covid-19 control and management involves huge amounts of money, the voice of the medical world, the health issue, should be given greater attention. The medical profession must weight the scale so it returns to the medical side, so the strategic policy strategy for controlling the pandemic is more rational and measured in addressing the growing issues.
Djoko Santoso
By taking into account of the voices of doctors, the last bastion of the war on Covid-19, hopefully the transmission curve will soon decline and then flatten. When this happens, it is hoped that the curve of economic recovery will start to rise.
Djoko Santoso, Professor of Medicine, Airlangga University
