Staying home is considered key in suppressing COVID-19 transmission, but many Indonesians confirmed or suspected of having the disease cannot afford to self-isolate because of lack of space.
Ambulance driver Bambang Siswoyo, 46, was suspected of having COVID-19 in July when he developed asthma so bad that his wife had to help him get up in the mornings. A chest X-ray showed white spots on his lungs. He was swab-tested, but the results never came back to him as "they were lost", he said quoting health authorities.
Siswoyo, who since 2004 has been working for a community health center (Puskesmas) in Sidoarjo, East Java, one of Indonesia's epicenters of the outbreak, spent over two weeks, until August, isolating himself in his kost (rooming house).
He lives in a 4 meter by 4 m room, which he rents for about Rp 250,000 (US$16.81) per month. It has one small bed that he shares with his wife and son — who refused to take refuge at their relatives' houses while Siswanto was in isolation.
"We couldn't keep a distance from each other and we slept on the same bed [...] I took up the space at the foot [of the bed]," Siswanto said, adding that he worried about infecting his family members.
Before going into self-isolation, Siswoyo had been transporting confirmed or suspected COVID-19 patients to hospitals. He said he had to shower up to five times a day to make sure he did not transmit the virus to his family.
"It was suggested that I isolate in a hospital, but I've heard from other people that I would have to pay [the medical bills]. I was afraid because I don’t have any savings, so I rejected the suggestion,” he said. “I was afraid that if something came up, I would have to pay for photocopies [of administrative documents] because I didn't have money at all at the time. I had to borrow money even for food.”
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Jakarta is seeing a similar problem. When the novel coronavirus infected dozens in Muara Baru, North Jakarta, in May, some coming from the same families and households, residents and some advocacy groups did all they could to find a government-run quarantine facility.
Self-imposed quarantine would not work because houses in the neighborhood are small and shared by many family members and are adjacent to one another, said resident Herdayati, who actively takes part in the Jakarta Urban Poor Network (JRMK).
Letting confirmed patients stay at home could pose further transmission risks to other family members or residents in the neighborhood, she said. At the time, the local Puskesmas was still looking for a place to isolate them, but within two or three days after civil society groups stepped in, the infected residents were eventually taken to a government-run facility.
"They're informal workers, so they couldn't go to work and earn money at all. It's a very unfortunate situation. We provided them with meals.”
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In a country with cities that have house price-to-income ratios that are higher than those in New York in the United States, Singapore and Tokyo, according to a 2019 World Bank report, one-fifth of its urban dwellers — or some 29 million Indonesians — lived in slums in 2015.
Their living conditions prevent them from accessing proper health services.
Even by paying more, more living space is not necessarily guaranteed, the World Bank report said, with more than half of poor and vulnerable households residing in metro cores being overcrowded, defined as less than 8 square meters of floor area per person.
Overcrowding is especially severe in Jakarta's core, with the share of households experiencing it rising from 28 percent to 35 percent in 2016, the report said.
Meanwhile, to be eligible for self-quarantine at home, the Health Ministry's COVID-19 protocols require that houses have good air ventilation with restricted mobility of people and with shared rooms being kept to a minimum.
Even if people in the households have to share rooms, they have to keep a 1 m distance from each other and sleep on different beds. Patients must wear masks around their family members and have separate cutlery that is washed with dish soap and warm water after use, according to the protocols. The surfaces of toilets must be routinely cleaned.
Patients' clothes, bed sheets, towels and masks must be cleaned using hand gloves and dipped in 60-90 degrees Celsius water, with other family members required to avoid contact with these contaminated goods.
Amid concerns that not everyone can follow these protocols and also over emerging household clusters, Jakarta Governor Anies Baswedan announced on Sunday that all confirmed cases with mild to no symptoms must be isolated at government facilities instead of at home starting on Monday.
The central government is now partnering with up to 15 two- and three-star hotels that can accommodate up to 3,000 guests each to provide self-quarantine facilities for Jakarta’s confirmed COVID-19 cases, on top of preparing two apartment towers of former Kemayoran Athletes Village to house nearly 5,000 mild to asymptomatic patients for isolation.
The hotel groups have also agreed to provide similar facilities outside the capital, the government said, with the Health Ministry planning to transform its training centers in Cianjur in West Java, Batam in Riau Islands, Semarang in Central Java and Makassar in South Sulawesi into self-isolation facilities.
But experts said that facilitating only confirmed cases was not enough, and instead, similar facilities must be provided for suspected cases and close contacts of confirmed cases in order to effectively break the chains of transmission.
Masdalina Pane of the Indonesian Epidemiologists Association (PAEI) said monitoring for suspected cases and close contacts remained very weak, adding that the government must also provide better assistance for those quarantined to fulfill their basic needs.
Experts have also urged for the revision of the Health Ministry's protocols so that all close contacts must be tested right away instead of simply being suggested to self-isolate for 14 days.
Isnani Dzuhrina, a lecturer in Malang, East Java, completed her self-isolation at home last week safely, but she recalled how she constantly feared about infecting her children while living in self-isolation with them.
She said health authorities, who ordered her to go into self-isolation after she came into close contact with a confirmed case, should have tested her right away for clarity.
“The local Puskesmas didn’t check on me daily, but I was asked to report if I developed symptoms because they said they had many cases to monitor.”