As Indonesian authorities look to ease coronavirus restrictions, doctors are warning that children seem particularly vulnerable to COVID-19 in South-East Asia’s most populous country.
- A peak paediatrician body found 160 children with suspected COVID-19 had died
- Poor nutrition can lead to stunting in children, making them 10 times more vulnerable to sickness
- Indonesia’s low rate of testing means the true number of cases could be much higher
According to Australia’s Department of Health, emerging epidemiologic reports on COVID-19 in children show that while they are less likely than adults to be infected and have severe illness, they are still vulnerable.
Nevertheless, nobody under the age of 18 has died in Malaysia, Vietnam and Singapore. The youngest person to die from COVID-19 in Australia was a 42-year-old Filipino man.
But in Indonesia, senior doctors have warned that more than 100 children may have died from the coronavirus.
And as Indonesia transitions to what the Government calls a “new normal”, the country’s curve continues to steepen.
So why have so many Indonesian children died from COVID-19 and is Government policy to blame?
How many Indonesian children have had COVID-19?
As of Wednesday, Indonesia has more than 40,000 confirmed cases of COVID-19 and about 2,200 deaths, according to Johns Hopkins University data.
The virus has reached every single one of the archipelagic country’s 34 provinces.
But Indonesia has one of the lowest testing rates in the world and it is widely believed the true number of cases and deaths is much higher.
As of Monday, Indonesia’s total number of tests per 1,000 people was just 1.2 — compared with 20 in Malaysia, 49 in Singapore and 72 in Australia, according to the Oxford University website Our World in Data.
Some 715 Indonesian children were confirmed to have COVID-19 as of May 22, and more than 17,000 were under observation or suspected to have the disease, according to data released by the Indonesian Child Protection Commission.
Of those confirmed cases in children, official figures show 28 children have died.
“Cases of children being exposed to COVID-19 have mostly been infected by family members who are positive patients or caregivers,” Commissioner Susianah Affandy said in a statement, calling for greater attention to be paid to the health of particularly vulnerable children, such as those with disabilities.
But the Indonesian Paediatrician Association (IDAI) independently calculated COVID-19 data for children, finding that at least 160 children suspected to have been infected with COVID-19 had died as of June 1.
IDAI chairman Dr Aman B Pulungan told the ABC their findings indicated the number of sick children and child deaths due to COVID-19 in Indonesia was high.
Is Government policy to blame?
President Joko Widodo said on Monday the coronavirus pandemic “requires a government response that is fast and precise”.
“We must control COVID so that it does not spread more widely [and so] the healthy do not get infected and the sick we take care of [are] healed,” he said.
Elina Ciptadi is the co-founder of KawalCovid19, a website that has independently collated reliable data and information about Indonesia’s COVID-19 epidemic.
“The Government’s narrative from the beginning has been one that denied the science and denied the need for early action,” Ms Ciptadi told an event organised by the International Institute for Strategic Studies this week.
Some observers have claimed that public health messaging has been inadequate, meaning many Indonesians still do not understand the risks posed by the coronavirus.
Pandu Riono, an epidemiologist from the University of Indonesia, told the ABC last month that “many people don’t understand why we should stay home, why we should limit our activities and not go out.”
The relatively lax lockdown arrangements, known locally as large-scale social restrictions, have now begun to be wound back — seeing the gradual reopening of shopping centres, offices, public transport and places of worship.
Under what Mr Widodo’s Government calls “new normal” measures, authorities have said Indonesians would have to learn to “co-exist” with the virus. People will be required to wear masks and observe physical distancing.
But Dr Hermawan Saputra of the Association of Indonesian Public Health Experts told the ABC it was likely many parents did not fully understand the risks coronavirus posed to children.
“[High rates of coronavirus deaths among children] may be because parents do not understand that children also have to wear masks, or it may be that there are no masks available for children, or that yes, parents are taking this issue lightly,” Dr Saputra said.
What is the role of childhood stunting?
Achmad Yurianto, a senior health ministry official, told Reuters that Indonesian children were caught in a “devil’s circle” — a cycle of malnutrition and anaemia that increased their vulnerability to the coronavirus.
He compared their bodies to weak structures that “crumble after an earthquake”.
Many Indonesian children are also affected by stunting, which the World Health Organization says is the “impaired growth and development that children experience from poor nutrition, repeated infection and inadequate psychosocial stimulation.”
Despite Indonesia’s middle income status, around one third of all children under the age of five nationwide have stunted growth — a rate comparable to much poorer countries in sub-Saharan Africa.
“Indonesia has more than 9 million stunted kids,” said Zack Peterson, co-founder of the 1,000 Days Fund, an NGO which works to reduce stunting in remote and marginalised communities in Indonesia.
“One part of being stunted is that you have a weakened immune system. Their immune system never develops the way that it should.
In the impoverished province of Nusa Tenggara Timur, where Mr Peterson has spent much of the COVID-19 crisis, more than half of children are stunted.
Meanwhile, some 20 per cent of primary school-aged children in Indonesia are overweight or obese, meaning the country has what UNICEF calls the “double burden” where under- and over-nutrition coexist.
What other factors might be at play?
Indonesia also has a relatively weak healthcare system.
The country has only four doctors and 12 hospital beds for every 10,000 people, and only three intensive care beds per 100,000 people.
Indonesia also has one of the highest male smoking rates in the world. Some 60 per cent of the male population are smokers.
According to a 2018 study, second-hand smoke exposure occurs in more than 70 per cent of Indonesian households.
While evidence remains scarce, some scientists believe that tobacco smoking could be a risk factor in contracting or dying from COVID-19.
An article in leading medical journal The Lancet recently noted that “robust evidence suggests that several mechanisms might increase the risk of respiratory tract infections in smokers.”
“The battle against tobacco use should continue, by assisting smokers to successfully and permanently quit,” the researchers concluded.
What are the challenges going forward?
In the short-term, Indonesia’s coronavirus epidemic seems unlikely to improve.
Pratiwi Sudharmono, a microbiologist, recently told the ABC that “the potential is still high for a second wave of COVID-19 because the awareness for people is still low, and there are no clear rules.”
While Mr Widodo has pledged to prevent 2 million children from suffering from childhood stunting by 2021, experts say the the COVID-19 crisis is likely to stall progress.
Mr Peterson said many community health posts, known as Posyandu, have had reduced operations or have shut completely during the epidemic.
Dr Pulungan said Posyandu workers “may also be afraid, not have the expertise to distinguish between sick and healthy children at this time — not to mention an absence of personal protection equipment.”
“Women and, particularly, children in rural and remote areas will bear the brunt of the effects of COVID-19-associated health system disruptions,” Mr Peterson said.
“There are more than 300,000 village-level health posts throughout Indonesia and COVID-19 has disrupted routine Posyandu, which will result in a spike in diphtheria, measles and polio cases and unwind years of progress made against stunting.”