JAKARTA: The sun was already setting when Dr Yakub and his team of contact tracers were deployed to a densely populated neighbourhood in South Jakarta.
An elderly man had just died at his home and there were signs that he had contracted COVID-19.
The deceased had earlier tested positive in a rapid antibody test but he died before the result of a more accurate swab test was out, a process which could take a few days.
By the time they arrived at the man’s abode, it was packed with mourners from various parts of the Indonesian capital.
The presence of three men in hazmat suits came as a shock to the man’s relatives and friends, some of whom did not have a clue to the circumstances behind the man’s death.
“Immediately, there was silence the moment we arrived. It was tense. But we had a job to do,” Dr Yakub, who did not want to provide his real name for privacy reasons, told CNA.
The team tried to explain to the mourners that there was a high chance that the man had contracted COVID-19 and needed to be taken to a community health centre so he could be buried according to COVID-19 protocols.
The health workers also informed them that they were there to test family members and neighbours who might have come into close contact with the man.
The mourners were enraged. They shouted angrily at the contact tracers.
“Where is the proof?” Dr Yakub recounted one of them as saying. “You get paid for every positive patient you find, don’t you? You label every illness as corona, don’t you?”
The shouting quickly turned violent with the workers pushed and shoved around as well as being subjected to verbal threats.
“We were in our hazmat suits. It was hard to defend ourselves, so we retreated,” Dr Yakub said.
Days after, the deceased's test results came back, and indeed he had contracted COVID-19.
Dr Yakub and his men returned to the neighbourhood to test the man’s close contacts. This time, they were escorted by police and people from the local district’s office.
“Many of them also tested positive,” he said.
The Indonesian health ministry defines close contacts as anyone who had direct physical contact or face-to-face interaction of more than 15 minutes with a COVID-19 patient, within 48 hours before the first signs of the patient’s illness appear and the following 14 days.
The ministry is targeting to test 30 close contacts for every confirmed patient.
According to health ministry data, there were 20,481 recorded cases between Aug 27 and Sep 2. During the same period, 121,159 unique individuals were swabbed for COVID-19. This means that less than six people were tested for every confirmed case.
Even in Jakarta, health workers can only test an average of six contacts per confirmed case, the city’s health agency announced last month.
The ratio is even lower for other areas across the archipelago with some provinces testing less than one contact per confirmed case, according to data from volunteer group Kawal COVID-19.
There are many reasons why contact tracing is still low in Indonesia, Dr Yakub told CNA.
“Our work is much like a detective. When a patient tests positive, we interview them to see where the patient went and who the patient has been in close contact with,” he said.
“When they cooperate, our work is easy. The problem is they don’t cooperate sometimes. They won’t self-isolate, they won’t give any contact details. Our energy and time are wasted dealing with those kinds of people.”
Senior contact tracer Dr Mawar, who also refused to give her real name, said it takes a lot of patience to do contact tracing work.
“We need to have sympathy. It is already difficult for them to accept that they or their loved ones have contracted COVID-19. We cannot rush them when we conduct our interviews,” she told CNA.
“Then we contact the patient’s family, friends and colleagues, first through WhatsApp then over the phone.”
Dr Mawar, who has conducted contact tracing since February, said it can be a shock to have people in hazmat suits suddenly knocking on the door.
“That was what we did in the beginning. We arrived at their doorsteps unannounced on an ambulance. Our presence immediately caught the neighbours’ attention. We learned that people felt intimidated and won’t cooperate if they are treated that way. That’s why we call first and try to strike a conversation,” she said.
“After that, we try to be flexible. They can decide when and where they want to be tested. If they don’t want their neighbours to see us, they can come to the nearest testing facility or we can perform the swab test at a discreet location like a sports hall or the back of a mosque.”
Dr Mawar said despite her best efforts, there are people who refused to cooperate.
“I often got scolded. Maybe I caught them in a bad time or a bad mood,” she said.
“There are times when the number provided is not active. When that happens, we have no choice but to go to their known addresses. There are also times when they have moved elsewhere or try to hide from us by staying at a relative’s house or a hotel.”
SOME BELIEVE COVID-19 DOES NOT EXIST
Anggara Widyartanto, a public health student who became a contact tracing volunteer for a month, said up to 20 per cent of people he contacted refused to cooperate.
“If they were cooperative, I only had to spend 10 to 15 minutes talking to them. But if they were not, I could spend 30 minutes debating with them,” the university student told CNA of his experience volunteering at a community health centre in Surabaya, East Java.
Widyartanto said those who refused to be tested were afraid of being ostracised by people around them. Some, he added, were afraid of testing positive and being told to self-isolate, particularly those in the informal sector who could not afford to skip work.
“There were people who hung up as soon as they knew it was a contact tracer calling them. We tried to go to their house but the house was empty and the neighbours said they moved a long time ago,” he said.
Then there were people who believe in hoaxes, Widyartanto said, ranging from claims that hospitals would be given cash incentives from the government for every COVID-19 patient they treat or detect, to swab tests being more dangerous than COVID-19 itself.
There were even those who think COVID-19 does not exist at all, he shared.
Dr Yakub knows this too well.
“Patients were sometimes in denial. They felt fine and couldn't believe that they tested positive. Their family couldn’t believe it too and refused to have themselves tested or self-isolate. They accused us of manipulating the diagnosis. They accused us of getting paid to declare someone as positive,” he said.
“Before it happened to me, I thought such violent rejection and assault only happened in remote areas. I never thought it could happen in Jakarta. I never thought that there are people in Jakarta who would be so gullible to believe the hoaxes they read online.”
Windhu Purnomo, an epidemiologist from Airlangga University said everyone must work together to combat myths and hoaxes surrounding COVID-19.
“We need to tell people that it is better to have themselves tested so they can receive proper care immediately and stop the virus from spreading further. We need to communicate that going into isolation is for the benefit of our loved ones and people around us and that we shouldn’t ostracise former patients,” Dr Purnomo told CNA.
GOVERNMENT PLEDGES TO IMPROVE TESTING CAPACITY, CONTACT TRACING
On Aug 6, the government’s spokesman for COVID-19 Wiku Adisasmito admitted that "Indonesia’s contact tracing capability is still low at the moment” adding that there were efforts to improve the situation.
“Our testing capacity will continue to be improved … so (contact) tracing can be conducted more aggressively,” he said.
Prof Adisasmito also noted that Indonesia’s testing rate is still far below the standards set by the World Health Organization (WHO), due in part to the struggles faced by contact tracers on a daily basis.
Among the standards set by the WHO is to test one person for every 1,000 people every week. Indonesia, a country with a population of 267 million, is only able to test less than half the WHO standard as of Wednesday (Sep 2).
Pandu Riono, an epidemiologist from University of Indonesia said because testing is still low, it is hard to get an accurate picture of how the virus has spread.
“There are many more who have not been identified, let alone isolated. My estimate is that there could be five to 10 times more than the number of confirmed cases,” Dr Riono told CNA.
There are now more than 180,000 confirmed cases of COVID-19 in Indonesia.
“We need to recruit more (contact tracing) workers. Jakarta for example has 1,000 new cases every day, which means workers ideally need to contact 30,000 people who might have come into close contact with the patients. That requires a lot of manpower,” he said.
It is not known how many people are working as contact tracers, but the government said that there could be two to four people assigned as contact tracers for each of the 10,000 district level community health centres spread across Indonesia.
But Dr Yakub believes that recruiting more contact tracers would amount to nothing without a change in people’s attitude towards testing.
“If people are uncooperative, everyone will suffer. Isolation facilities are almost full, hospitals are already overwhelmed and that affects their abilities to treat other illnesses. If people keep being uncooperative the pandemic will never be over,” he said.