Traditional medicine has an important role to play in Indonesia’s fight against the coronavirus
Nicole Weydmann, Kristina Großmann, Novia Tirta Rahayu Tijaja, Maribeth Erb
The first two cases of COVID-19 in Indonesia were announced on 2 March 2020, quite late compared to other countries. The first patient was a 31-year-old woman who came into contact with a Japanese citizen – who later tested positive – at a dance event in South Jakarta. She then passed it on to her mother. Both women were hospitalised in North Jakarta, which later became one of the referral hospitals for COVID-19 cases in the city. By early May, the number of confirmed cases nationwide had reached 9800, including 800 deaths. While elsewhere around the world governments are easing lockdown restrictions, in Indonesia there is still minimal testing being undertaken and the COVID-19 pandemic is showing little sign of decline.
Indonesian politicians have been accused of not recognising the seriousness of the situation early enough, and some eventually admitted to misinforming the public. In a statement made in early March the health minister Terawan Agus Putranto said he was surprised by the commotion arising from the spread of COVID-19, as in his perspective ‘flu is more dangerous than the corona virus’.
In mid-April, 46 health workers at a hospital in Semarang were infected after patients had not revealed their travel history from areas with a high number of infections, or coronavirus red zones. Six weeks after the first case of COVID-19 was announced and in the face of what looked like becoming an uncontrollable pandemic in Indonesia, Lindsey and Mann summed up what many Indonesia watchers around the world and indeed Indonesians were feeling – that the government had been in denial of the health threat for too long and a clearly structured approach on how to handle infections and sources of these infections was still missing.
Crisis in healthcare
For some time there has been rising criticism of Indonesia’s public healthcare, including the closeness of pharmaceutical industries to medical practitioners and related ‘unhealthy practices’ of corruption. Now, the existing structural and personnel shortage in the public health system has become glaringly stark due to the pandemic. The latest World Health Organisation (WHO) data shows that Indonesia’s ratio of doctors per 10,000 people is 3.8, and it has 24 nurses and midwives per 10,000 people. This is well below Malaysia’s 15 doctors per 10,000 people and Thailand and Vietnam’s eight. Besides this, questions about pharmaceutical monopolies and cartel practices in the medical sector, and cases of malpractice and fraud at the expense of patients, are mounting. Underlying this mood is a latent mistrust not only of the pharmaceutical industries, the medical profession, and the medical structures of hospitals, but of the national elites in general and the civil servants of health-related authorities in particular.
Recent history offers some good reasons for why medical professionals and those watching Indonesia’s health sector are wary. In 2006, during the H5N1 pandemic crisis, or bird flu as it was commonly known, Indonesia claimed ‘viral sovereignty’ and refused to cooperate with the WHO, going against a 2005 international health regulations on responsibilities and rights of national governments when dealing with a public health emergency. The contentious issue was around samples of H5N1, which were collected within Indonesia’s borders. In their analysis of this debate, Relman, Choffnes and Mack observed that the government declared ‘it would not share them until the WHO and high-income countries established an equitable means of sharing the benefits (particularly, the vaccine) of the sample collection’. Against this background many have reservations about the level of cooperation that can be reached between the WHO and Indonesia’s government in handling the current pandemic.
Many parties in the weeks and months to come will critique the emergency strategy of the government and the national health care system. We want to shed light on another issue raised by the COVID-19 pandemic, that of medical pluralism in Indonesia and different approaches to illness and health.
Jamu will do?
During the initial phase of the pandemic, some Indonesian policy makers claimed publically that COVID-19 infections could heal without intervention, as long as a person's body has a strong resistance to disease – for which reason they reminded the public to maintain body immunity. President Joko Widodo supported this assessment and recommended that citizens drink traditional herbal jamu remedies to prevent infections.
In mid-March, the president posted a statement on a government website saying that he started drinking a mixture of red ginger, lemongrass and turmeric three times a day since the spread of the virus and was sharing it with his family and colleagues. He was convinced that a herbal concoction could ward off the coronavirus. The home affairs minister also encouraged people to eat more bean sprouts and broccoli.
Like Jokowi, other politicians have pointed to the benefits of traditional medicine in the current crisis. The district health officer of Situbondo in East Java invited members of his community to a public event to drink jamu medicine. He also involved hundreds of school students to further promote the benefits of the traditional medicine for strengthening of the immune system. The minister for health also handed over jamu remedies to the first three recovered COVID-19 patients.
The WHO has issued a list of recommendations for handling the current pandemic, including handwashing, following general hygiene and maintaining social distancing. The suggestions of Indonesian politicians to simply use traditional herbal remedies and specific diets as well as their general assessment of COVID-19 as a harmless virus, stands in clear contrast to the WHO assessment.
This approach has led to public criticism and questioning of whether politicians are intentionally withholding important information in order to avoid panic. In late March mixed messaging from the government triggered the formation of a coalition of civil society organisations, including Amnesty International Indonesia, Transparency International Indonesia and the Jakarta Legal Aid Institute. The group urged the House of Representatives ‘to perform its checks and balances function during the COVID-19 pandemic to ensure the government’s policies are on the right track’.
However, ‘healthcare’ is not a singular process but consists of a complexity of different medical traditions, external influences and dynamics. As such the ongoing COVID-19 challenge may call on different medical approaches, which are not exclusive from one another. So, whilst the WHO uses a biomedical understanding as the basis for the assessment of the current pandemic, Indonesia’s politicians and many citizens are calling on traditional Javanese medical paradigms. Rather than dismissing outright the calls from Jokowi and others to use traditional medicine during the pandemic, it is necessary to contextualise their calls within Indonesia’s medical pluralism and the conceptual ideas of traditional Javanese jamu medicine in particular.
Traditional Javanese medicine and the pandemic
The public provision of healthcare in Indonesia is almost exclusively based on biomedical treatment approaches and corresponding ways of defining health and disease. Each sub-district in Indonesia is expected to facilitate one community health center (puskesmas) in order to focus on preventing diseases and promoting health. In the present COVID-19 outbreak, this has meant that puskesmas are key institutions for public health treatment and also surveillance. It is expected that each centre will trace and monitor infections locally. However, puskesmas are mostly small medical units with perhaps only one medical doctor on staff. In the current crisis, these small local centres are now required to split their limited teams in order to provide public education about the pandemic, contact tracing of infected persons, and treatment of COVID-19 patients in isolation from patients with other diseases.
Indonesia, like most Southeast Asian countries, consists of an ethnically diverse society and this social diversity is reflected in a pluralistic medical system. Large parts of Indonesian society rely on traditional medical approaches. The use of ‘traditional’ medicine or a combination of biomedical treatment and ‘traditional’ medicine, is a common phenomenon all over Indonesia. Relatively recently, more educated urban households have also been found likely to use ‘traditional’ rather than biomedical healthcare. This vivid diversity of medical traditions is represented in the large informal medical market, though not in the national primary health care system.
Despite the dominance of biomedical approaches in primary health care and the accompanying skepticism towards other health etiologies, over the past 30 years the market for traditional and complementary medicine in Indonesia has experienced a veritable boom. The use of a whole range of over-the-counter (that is, non-prescription) medications, pharmaceuticals, tonics and new forms of herbal or other mixtures has sprung up, with a wide spectrum of herbal products and stamina remedies.
As the COVID-19 crisis deepened a new market emerged offering ‘Corona Jamu’ that contains turmeric, ginger and other ingredients, in order to strengthen the body's immune system against viruses. An existing traditional remedy, Wedang Uwuh – a herbal specialty in the region of Yogyakarta – is also being promoted, as it is used to prevent colds, warm the body and boost immunity. The remedy is composed of secang wood, cinnamon, ginger, cloves, nutmeg leaves, lemon grass roots and cardamom. The Jakarta Post reported that a number of jamu producers have seen an increase in revenue of up to 50 per cent and predicted that the habit of drinking jamu will be ‘a new normal’, claiming jamu as ‘the new espresso’.
Recommendations of jamu are based on the principles of humoral medicine, which has a long and sophisticated tradition. It identifies bodies as having four important fluids which are characterised as hot/cold and wet/dry, and is based on the belief that a balance of these bodily fluids is fundamental to good health. According to this understanding, a balanced unity of body, mind and spirit is also necessary to withstand outside influences such as viruses, evil spirits or social discrepancies. Preventative self-care is a fundamental element within humoral medicine, and so a key component in the prevention of a coronavirus is use of a specific herbal formula and related diets in order to keep the body in balance.
Ultimately, the goal is to prevent infection. Besides general hygiene and sanitation, this approach recommends the use of specific herbal remedies to boost the immune system. Molecular biology expert Professor Chaerul Anwar Nidom from Airlangga University in Surabaya, who is also Chairperson of the Indonesian Covid-Vaccination Research Unit at the laboratories of the Professor Nidom Foundation, takes the recommendation of herbal remedies further. Nidom recommends the use of ‘curcumin’, which is found in turmeric, ginger and cinnamon, to ward off infectious diseases, including COVID-19. He encouraged the habit of regularly drinking specific jamu remedies and cooking with spices, pointing to research into the bird flu showing that curcumin has been effective in warding off previous coronaviruses.
Allowing for interpretations across more than one medical paradigm means allowing for more complexity in assessments, prevention and healing. If we assess the current health crisis from a perspective of medical pluralism, then policymakers’ recommendations to stick with herbal medicine may also be regarded as responsible advice.
The examples above highlight the co-existence and interaction of different medical approaches in Indonesia. At the hospital in North Jakarta where the first COVID-19 case was identified, alongside the biomedical treatment, COVID-19 patients were also given jamu herbal remedies. This shows that even though the biomedical paradigm is prevalent, navigating healing in Indonesia is characterised by improvisations with ‘whatever is at hand’. Weydmann’s study of healing in Yogyakarta traced common routines in combining and tinkering with healthcare practices – not only by health seekers, but also medical practitioners. In interviews and focus group discussions Javanese medical professionals from all sectors located their own medical tradition within a pluralistic medical system, and recognised that each school of thought presents both limitations and benefits. This willingness to be open to medical variety enables such exchanges within the current COVID-19 pandemic.
Globally the pandemic is being approached by a singular universal biomedical interpretation. At the same time, with the crisis particularly impacting the poorest sectors of the population, this global biomedical approach needs to confront local structural difficulties. Against this background, we argue in favour of overcoming any normalising of one medical approach over another, in order to enable health seekers to freely shape the structuring of their healthcare.
This would allow for a truly people-centered and context-sensitive structuring of healthcare in which health seekers are free to combine all tools, techniques and approaches available to address their particular needs and uncertainties. This could of course also entail legitimating hybrid approaches to health, illness and healing, even though approaches differ or sometimes even contradict each other.
Nicole Weydmann is postdoctoral researcher at Jacobs University in Bremen and works on traditional and alternative medicine in Southeast Asia and Europe. Kristina Großmann is an assistant professor at the chair of Comparative Development and Cultural Studies with a focus on Southeast Asia at the University of Passau, Germany. Maribeth Erb is an associate professor at the Department of Sociology at the National University of Singapore (NUS). Originally from the US, she has worked and lived in Singapore since 1989. Novia Tirta Rahayu Tijaja completed her MA degree in Southeast Asian Studies at the University of Passau and currently lives in her hometown, Jakarta.