From 24 infection cases initially reported on June 13, the number exploded to 877 within just seven days. As of July 9, or after three weeks, 1,102 people had been infected across Pacitan. Apart from in Sudimoro, three-digit incidence rates have also been seen in Arjosari, Ngadirojo, Tulakan and Tegalombo subdistricts.

This massive spread has exposed significant weak spots and gaps in our public health system, particularly its surveillance, monitoring and prevention of HAV, despite the fact that this disease is not a new kid on the block.

Hepatitis A is specifically related to food intake and generally poor water, sanitation and hygiene conditions.

It becomes a disease after a person consumes food or water contaminated by feces from a person infected with HAV.

In fact, several years ago, an alarm rang loudly. Back in 2013, based on a report prepared by the Health Ministry’s Center for Data and Information, there was an HAV outbreak in six provinces and 11 regencies, including Pacitan, with a total of 448 cases. The following year, there was another outbreak, but with a smaller coverage. It only occurred in three provinces and four regencies with a total of 460 cases.

Between 2014 and 2018, no outbreak was reported, thanks in part to the hepatitis immunization program.

However, the outbreak in Pacitan shows us an inconvenient truth. The success of food sufficiency and hepatitis immunization failed to tame the ticking time bomb of HAV there. The outbreak in 2013 appeared to be just the tip of the iceberg. The plan A for Hepatitis A did not seem to work.

The way the health authorities have handled the disease could be the culprit. During a seminar on hepatitis held by the Health Ministry in 2016, many experts agreed that hepatitis had never been a government priority in the last 15 years.

For years, HAV has been overlooked, compared with other types of hepatitis virus, perhaps because it is easier to cure. We forget that HAV is the hepatitis type that can spread rapidly and cause an outbreak.

Our attention to HAV has been lacking for several reasons. First, HAV is still viewed as a mild disease that can be self-cured and therefore nobody needs to worry about it. Second, the campaign for the prevention of HAV is only limited to normative healthy lifestyle of individuals, rather than community and the wider environment.

Third, both the government and the public deem HAV to only be related to indoor sanitation. Worse, health facilities at the subdistrict level (puskesmas) are not well prepared and designed to handle an outbreak on a massive scale. As a result, most patients do not receive proper treatment.

The current HAV outbreak in Pacitan is different from the previous one. The local environment agency found the outbreak was related to contaminated water provided in a refilling depot, which is operating because the dry season has drained the river. Environmental issues play a crucial role here.

The case reminds us of John Snow’s finding a century ago in London. He found the cholera outbreak in the city stemmed from contaminated tap water. History repeats itself, but we fail to connect the dots.

Coincidently, in July last year the Pacitan Disaster Mitigation Agency reported that drought had affected seven subdistricts, two of them were Arjosari and Ngadirojo, both of which are now experiencing HAV outbreaks.

Pacitan is sending a clear message that combating communicable disease like HAV is not as simple as connecting patients-disease-hospital. The health authorities need to think beyond the conventional pattern. The routine vaccination and health promotions should be revisited.

As the current HAV outbreak is related to water supply and even climate change, collaboration among wider stakeholders is a must. The health authorities need to emphasize multifaceted prevention that involves other parties.

First is the Meteorology, Climatology and Geophysics Agency (BMKG) in order to get the big picture of incoming climate behavior and anomalies as they can affect people’s health directly or indirectly. Second are public works and environmental agencies to map, assess and sanitize clean water sources during the dry season.

Pakistan is perhaps a good model for Indonesia in this case. A document entitled Drought Mitigation in Pakistan outlines systematical and comprehensive handling of drought-related diseases.

District governments there incorporate the departments of agriculture, livestock, public health and even revenue in monitoring public health and drought.

What happened in Pacitan can happen elsewhere, as draught is affecting many parts of the country. The media have reported the drought has spread from Yogyakarta to Bekasi. People must realize that climate change is real and it may affect our health. The connections are becoming apparent every day.

In combating communicable diseases like HAV, Plan A is no longer effective. It is time to execute Plan B, which requires health authorities to directly go beyond the hospital wall, play a more active role in developing robust coordination and mitigation actions.

_____________________

The writer is a lecturer in the School of Public Health at the University of Indonesia (UI). The views expressed are his own.

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