The Jakarta Post
Indonesia’s coronavirus response has once again become clouded by confusion after the government attempted to rework the definition of COVID-19 deaths, evoking criticism that it was focusing on anything but the most essential efforts to contain the virus.
East Java Governor Khofifah Indah Parawansa has reportedly told the Health Ministry that deaths among patients with comorbidity factors should be categorized differently from the deaths of patients without preexisting conditions, which would affect the death toll.
Critics lashed out when an expert staffer on health economy, M. Subuh, one of the advisors to Health Minister Terawan Putranto, visited the province on behalf of the minister and appeared to back Khofifah’s request.
“[In order to get] a decline in the number of deaths, [we] must intervene by providing the correct operational definition; that is, death by COVID-19 or death from comorbidities,” Subuh said as quoted on the ministry's official website on Sep. 17.
“[This is done] in accordance with [World Health Organization] guidelines and supported by BPJS Kesehatan [Health Care and Social Security Agency] during the claims submission process for a patient who has died of COVID-19.”
East Java remains among the nine Indonesian provinces hardest hit by the COVID-19 pandemic that President Joko “Jokowi” Widodo has specifically assigned central government officials to oversee in a bid to suppress death rates and boost recoveries within two weeks.
National COVID-19 task force spokesman Wiku Adisasmito said during a press briefing on Tuesday, however, that the government would stick to the current WHO guidelines for tallying COVID-19 deaths.
“As of now, the government has no plans to make the change proposed by the East Java governor,” he said.
COVID-19 deaths are defined as all deaths of people with confirmed or probable cases of SARS-CoV-2 infection, with exceptions made for unrelated causes of deaths, such as traffic accidents.
Probable cases refer to people who did not receive their test results before their deaths but who suffered from upper respiratory tract infection (URTI) or acute respiratory distress syndrome (ARDS), which clinically suggest COVID-19 infection.
Indonesia, though yet to include probable deaths in its death toll, saw the tally cross 10,000 on Thursday.
East Java logs the highest number of COVID-19 fatalities in the country with 3,084 deaths as of Friday, with a case fatality rate of 7.2 percent, much higher than the national rate of 3.8 percent. The figure is almost double Jakarta's recorded fatalities, even though the latter has more cumulative confirmed cases.
Khofifah, on the receiving end of criticism, took to her Instagram account on Tuesday to clarify an article reporting on her request to redefine COVID-19 deaths, saying that her administration had never made such a suggestion.
"On the contrary, East Java encourages honesty and openness in the recording and reporting of all information related to COVID-19 in a manner that is more detailed than the WHO guidelines, so this pandemic can be brought to an end quickly,” the governor wrote.
Subuh said on Thursday that there was no plan to change the definition of COVID-19 deaths, but rather to add operational details on deaths related to COVID-19 by following the WHO International Guidelines for Certification and Classification (Coding) of COVID-19 as Cause of Death, published on April 16. The guidelines show doctors how to write down the cause of death on death certificates.
Subuh mentioned, for instance, that people who tested positive but died of an accident, cancer or heart attack should not be recorded as COVID-19 deaths. He said that any such categorization could only be determined in consultation with relevant doctors associations.
Masdalina Pane of the Indonesian Epidemiologists Association (PAEI) slammed the government's apparent emphasis on jargon in its COVID-19 response, calling instead for the focus to be shifted to systematic and comprehensive containment efforts. This means testing, tracing and isolating people right away.
"All the strategies are already in the guidelines, the Quarantine Law and the Health Ministry's regulation on large-scale social restrictions, but the problem is the task force had yet to seriously implement them from the get-go,” she said.
However, another expert staffer to the health minister, Mariya Mubarika, said ensuring doctors could separate "deaths from COVID-19" with "deaths with COVID-19" was important insofar that they are better able to deduce the particularities of the disease.
The latter definition refers to patients who tested positive for the virus but did not die of the disease it caused but rather of other identified reasons, such as trauma caused by accidents or severe diarrhea commonly found among children.
Mariya claimed that the current death toll announced by the government still included these deaths.
She said there could still be a possibility to revise the death toll, which would arguably result in a “significant” reduction in the number of deaths, but only with the explicit agreement of concerned doctors associations who have the final say in determining the cause of death.
But two doctors at different hospitals who were approached by The Jakarta Post and are members of doctors associations said people with COVID-19 who died of other reasons were not logged as COVID-19 deaths.
Even if there were such cases, the number would not be significant enough to guarantee a revised death toll, Erlina Burhan of the Indonesian Association of Pulmonologists (PDPI) said. She said doing so would be like "changing the school curriculum when only one student doesn't understand mathematics".
She expressed concerns that the death toll would otherwise not represent the true conditions.
Indonesian Forensic Doctors Association chairman Ade Firmansyah said doctors at his hospital had already provided further details on the COVID-19 death logs, such as comorbidity factors.
This would help them better study the effects of the disease and provide prompt services, he said.