Yodi Mahendradhata* – The Indonesian government seems to be transitioning from its pursuit of an elimination endgame in its fight against COVID-19 to a scenario premised on civil cohabitation.
There have now been over 4.1 million confirmed COVID-19 infections and over 133,000 COVID-19-related deaths in Indonesia as of 2 September 2021. The government expects that the pandemic will become endemic in 2022 as people's immunity against the virus increases along with the acceleration of the COVID-19 vaccination program.
'Endemic' refers to the constant presence or usual prevalence of a disease or infectious agent in a population within a geographic area, according to the US Center for Disease Control. Endemic COVID-19 should present a less significant threat to the health of the Indonesian population as most people will be protected against severe symptoms and resurgences when endemicity is reached, especially if the latter are contained via regular testing and outbreak tracing. Whether it was HIV, tuberculosis or another disease, endemicity has been the natural progression of many infections in humans.
Over 89 per cent of the 119 immunologists, infectious-disease researchers and virologists across 23 countries interviewed as part of a recent Nature Magazine survey indicated that it is very likely that COVID-19 will become endemic. To adjust to this situation, the Indonesian government is currently preparing several measures including controlling community activities and people's behaviour by implementing health protocols; accelerating the formation of herd immunity; increasing health capacity and infrastructure evenly in all regions; monitoring the distribution of virus variants, and developing a long-term public health resilience plan.
The expectation that COVID-19 will become endemic in Indonesia implies that the virus will not disappear from the country. Conversely, a sufficient proportion of the population is expected to gain protective immunity through vaccination and natural infection. As a consequence there will be much less transmission and even fewer COVID-19-related hospitalisations and deaths.
But we don't know yet when COVID-19 will become endemic in Indonesia. Experts estimate that it could take a few years or even decades to reach a steady state of endemicity.
The shift to endemicity is determined by many factors such as the transmissibility of the virus, patterns of contact within communities that allow spread and the strength and duration of immune protection from natural infection and vaccination. To make things even more complicated, the patterns in Indonesia will likely differ considerably among regions as there exist heterogeneous COVID-19 epidemiological patterns and responses across the archipelago, not to mention variable vaccine availability and uptake.
The path that COVID-19 might take in Indonesia on its way to becoming an endemic virus is evidently challenging to predict. But the Indonesian government does have some control over it. At least in the next year or two, Indonesia should continue to reduce transmission through implementation and adherence to proven public health measures. At the same time, the government should increase healthcare capacity to manage future surges until enough people have been vaccinated, the population achieves herd immunity or the severity of infections lessens drastically.
Most importantly, the government's strategy to curb COVID-19 must expand beyond biomedical and technical actions to engage with broader political, social and economic factors that influence the spread of the virus. Indonesia should fight COVID-19 via a whole-of-government approach, incorporating all sectors, engaging key stakeholders at multiple levels – including local authorities and communities – and building on clear and solid coordination.
In the absence of such an approach, instead of endemic terrain, Indonesia may be heading towards hyperendemic territory, with persistent, high levels of disease. Instead of civil cohabitation, Indonesia may instead enter into a conflagration scenario, locking the government into persistent emergency management mode. The Indonesian government clearly should not lower its guard too early given the unpredictable nature of COVID-19.
[Yodi Mahendradhata is Vice Dean for Research and Development in the Faculty of Medicine, Public Health and Nursing at Gadjah Mada University, Indonesia. This article was published by East Asia Forum.]