Government indifference to dengue outbreak in Indonesia

By Dragan Stankovic
19 April 2004

At least 634 people have died so far this year in Indonesia from an outbreak of dengue fever that is the worst in years. As of April 13, the number of cases stood at 54,176, surpassing the total for the whole of 2003 and affecting 30 of the country’s 32 provinces. The number of deaths is twice the figure at the same time last year. In all, 743 people died from the disease in 2003.

According to Rita Kusriastuti, coordinator of an anti-dengue team: “The dengue fever outbreak is still far from over. The rainy season is not yet over and is expected to end sometime in May.” The hardest hit areas are densely populated cities such as the capital Jakarta where 12 million people live.

The actual number of cases may be far higher, as the official statistics only cover public hospital patients. Many of Indonesia’s 220 million people cannot afford to go to hospital and are forced to suffer at home without professional medical care.

Dengue is a debilitating and prolonged mosquito-born disease that causes high fevers, haemorrhaging and, in some cases, can lead to a sudden and fatal collapse of blood pressure. The World Health Organisation (WHO) warns that without proper clinical management the fatality rate can rise from 1 percent to 20 percent.

While dengue fever strikes Indonesia each year during the rainy season, some years are worse than others. Even before this year’s outbreak began, there had been warnings of a rise in infections, which appear to occur in cycles of four to five years. The last major epidemic was in 1998.

Yet the Indonesian government took no action. President Megawati Sukarnoputri finally made a statement on national television on February 26, but only after a TV station broadcast footage of her nervously giggling when asked to comment about the outbreak. Facing an election, she was forced to respond to criticisms over the government’s failure to respond quickly enough or to provide aid.

In her statement, Megawati offered little government assistance, but simply appealed to hospitals to accept patients regardless of their background or ability to pay. By early March the government had spent just $US5.9 million to fight the disease throughout the archipelago. Its promise to employ tens of thousands of nurses had not been carried out.

Hospitals indicate that their personnel are exhausted and the epidemic is spreading. Dr Tjandra Yoga Aditama, nursing director at the Persahabatan Hospital, said that in the first three days of March there had been 71 cases of dengue fever, compared to 50 cases for all of January. Other reports describe hospitals as war zones with patients sleeping in camp beds in any available space—corridors, hospital mosques and maternity wards.

Dr Aditama told Channelasia.com that the health system was unprepared for the outbreak. “The problem is the number of cases is increasing, very high. So our staff is quite fatigued, but they are still working very hard. Some of the nurses, they should be home at 4 p.m. but they go home at 10 p.m. Some of their husbands are complaining, but that is what they have to do. We are asking the government to give us more nurses and doctors. But anyway, we can still handle the situation—we’re working hard to.”

Indonesia’s Health Minister, Dr Achmad Sujudi, has tried to deflect the criticism, by pointing to an increase in the number of mosquito breeding sites. He said that a large number of construction projects came to a halt, particularly in Jakarta after the Asian financial crisis in 1997-98. The unfinished buildings collected pools of water where the mosquitoes bred. He also blamed increased amounts of rubbish in urban slum areas.

Unlike malaria, there is no prophylactic drug to prevent a person bitten by an infected mosquito from contracting the disease. But the mosquito population can be controlled by spraying with a mixture of insecticide and diesel fuel—a practice known as fogging. As the dengue outbreak began to spread, a number of people complained to the media that their areas had not been sprayed.

According to WHO officials, there are on average around 500,000 cases of dengue fever worldwide each year and, officially, 12,000 deaths. WHO estimates that the actual number of fatalities could be twice as high because of the large number of people in the affected countries who cannot afford hospital treatment. In 1998, a dengue pandemic affected 1.2 million people internationally, and preliminary data indicates that the figure may have been comparable in 2001.

A growth in international trade and travel has led to the rapid spread of the disease over the last half century—from a few countries in Asia and South America to 100 countries today. WHO has identified poverty and the lack of basic urban infrastructure—drainage, piped water and sewerage—as major causes of increasing number of cases, along with population growth and the growth of urban shanties around major cities in so-called Third World countries.

As in the case of Indonesia, governments have done little or nothing to eradicate the disease—except when it affects the economic interests, or political fortunes, of the ruling elite.