'God's SELECTION. God is choosing. Who continues to live and who is considered enough'. This is the last post of Bambang Purwoko, a lecturer at the Faculty of Social and Political Sciences and the Head of the UGM Papua Task Force on his Facebook page, Sunday (4/7/2021), who was all at that time. Ten days later, Mr. Bambang died. Hopefully he had died with blessing (husnul khatimah). Previously, the deceased had posted his worries. 'Anomaly? The epidemic is getting worse, but the streets and public places are getting livelier.” That is the reflection of Mr. Purwoko before he died, which is very appropriate in describing the conditions in mid-2021.
The posts aptly reflected this mid-2021 crisis. The second wave of Covid-19 that has plagued our country had to be controlled. President Jokowi had imposed an emergency community activity restriction (PPKM) on July 3-20 2021 and extended it until July 25, 2021, and had been extended again until August 2, 2021. When the emergency PPKM began, the daily additional rate was 27,913 people. The President's target was that the cases would fall below 10 thousand people per day. However, 10 days after the implementation of PPKM, the number of daily positive additions actually rose sharply to 54 thousand cases. The death rate had tripled. As of July 24, 2021, there were still 49,071 new cases and a record of 1,556 deaths. The PPKM led by General (Purn) Luhut B Pandjaitan turned out to be difficult to tame the deadly wave.
Previously, Jokowi ordered the free vaccination program for all people to be accelerated in order to immediately achieve herd immunity. The order is that the target is a million vaccines a day until the end of July and increased to 2 million a day from August. However, apparently this program is running slowly, not as expected. The President was angry because he found that the stock of vaccines was still piling up a lot. According to the Ministry of Health, on July 17, 2021, there were 18 million doses. Ironically, the Ministry of Health even announced a paid mutual cooperation vaccine program. Finally, the President ordered the paid vaccination program to be canceled and again ensured that all citizens received free vaccinations.
Based on data from the Covid-19 Handling Committee and National Economic Recovery (Komite Penanganan Covid-19 dan Pemulihan Ekonomi Nasional/KPC-PEN), as of July 18, 2021, the number of recipients of the first phase vaccination was around 41 million people and around 16 million people had received the second vaccine. In the last three weeks, an average of between 800,000 and 1.1 million people were vaccinated per day. With an average rate of 1 million vaccinations per day, it was still a very long time to achieve herd immunity, with 70%-80% of the population already receiving the first and second doses of vaccination. Until the end of 2021, herd immunity had not been achieved.
Regardless of the quality of each vaccine that had been circulating, vaccination was still the best choice at this time. Based on data from the Ministry of Health that was quoted by the Minister of State-Owned Enterprises Erick Thohir, around 90% of Covid-19 patients who died were those who had not been vaccinated. Meanwhile, the Head of Central Java Health Office in mid-July 2021 said of all Covid-19 patients who died in Central Java, 87% had not been vaccinated and 2.3% had been vaccinated but died. This figure was similar to the findings of the Center for Disease Control and Prevention in the United States that the spike in the number of patients admitted to hospitals in the US in July 2021 was 97% of people who had not been vaccinated.
Daily positive cases, which had reached 56,757 people on July 15, 2021, a day later began to decline to 54 thousand, then 51,592 on July 17, and 44,721 on July 18. Unfortunately, we could not be relieved because this positive decrease was accompanied by a decrease in the number of specimen testing. On Sunday 18 July 2021, 192,918 specimens were examined from 138,046 individuals. Whereas, Saturday, July 17, 251,392 specimens were examined, 258,532 specimens were examined on July 16, 129,059 specimens on July 15, and 240,724 specimens were examined on Wednesday, July 14, 2021.
This means that there were aspects that should have been reconfirmed. This decrease in daily positive cases could not be concluded as a result of successful treatment, but because the number of tests and examinations was reduced. If the number of examinations was reduced even more or if the examinations were closed for one week, certainly there would be no additional positive cases. In other words, this positive decline of the case numbers was data that might fool public perception.
The community has finally responded to the complexity of the management of this pandemic. The LSI survey involving 1,200 respondents in 34 provinces released on July 18, 2021 showed a decline in public confidence in the government in dealing with the pandemic. The level of public confidence in the President in dealing with the pandemic continued to decline. In September 2020, public trust in Jokowi in handling the pandemic reached 60.6%. However, in February 2021, the confidence level fell from 56.5% and in June it fell to 43%. This was the lowest figure during the pandemic. For the first time, public confidence in the President was below 50%.
Doctors and medical personnel died. Until July 9, 2021, the Coalition of Citizens to Report Covid-19 (Koaliasi Warga Lapor Covid-19) recorded that 1,141 health workers had died during the 16 months of the pandemic. They were doctors (general practitioners, specialist, dentist), nurses, midwives, ambulance officers, pharmacists, and medical laboratory assistants. Those who were still alive, many of whom were already exhausted were approaching the limits of their endurance. The public was also increasingly tired after entering the second year of facing the onslaught of a pandemic with deteriorating economic conditions.
Meanwhile, on the other hand, the corona virus was increasingly spreading and continued to stubbornly adapted to its new environment. The corona virus will continue to mutate and face natural selection. Weak variants will die and will be destroyed by antibodies and strong variants will continue to survive and strengthen themselves. Darwin's theory of evolution says that organisms with genes that are able to adapt (fittable) to the environment will survive and pass on the next generation. Survival of the fittest.
Humans also seem to be competing in this Darwinian situation. At the beginning of the spread of the Sars-Cov-2 virus that caused Covid-19, there was no cure or vaccine, so the exposed people who only relied on the immune response (natural immunity) to fight the infection. Those who are completely healthy and have an adequate immune response are able to survive. However, for the weak, including vulnerable groups, such as the elderly and those who have comorbidities, it is often very fatal.
Strengthen immunity phase 1-2
The more troublesome thing is, the more people infected with corona virus, the more likely it is that the virus will mutate. The single-stranded RNA of this corona virus is very susceptible to new mutations and can mutate up to a million times faster than others. What is worrying is if these mutations produce new, more virulent variants.
The second wave we experienced was the delta variant effect. As if it wasn't bad enough, this delta variant had already given rise to delta plus (AY1 and AY2). There had been no official report whether the delta plus variant had entered Indonesia. Data compiled from various sources, such as Public Health England, Al Jazeera, Indian Express, and Katadata, stated that until June 22, 2021, the AY1 genome had spread to at least 10 countries, including the US, Portugal, Switzerland, Japan, Poland, India, Nepal, Canada, Russia and Turkey. The CDC said that delta and delta plus attacks were then dominant in the US, whose numbers were also increasing. As of June 20, 2021, there were 8,137 daily cases and 143 deaths. However, by July 24, 2021, it had skyrocketed to 67,460 new infections and 425 deaths. As of July 24, the superpower had become the country that had suffered the most with 35.28 million infected and 626,657 deaths.
Of course it had been a serious concern because this delta plus character was more dangerous than the usual delta. It was more infectious, attached more to lung cell receptors, and had the potential to decrease antibody responses. The delta variant alone had spread so quickly, which in a short time made the island of Java a red zone and led Indonesia to become the epicenter of Covid-19 in Asia, and even the world. The more contagious delta plus variant was certainly more dangerous.
On the other hand, humans have an effective immune response against viruses. When exposed to Covid-19, people who have a balanced immune response will be able to clear the primary infection without being exposed to excessive inflammation so that they can survive and recover. However, people whose immune response is weak and unbalanced will not be able to clear the infection and will eventually lose out against the corona virus.
Currently the corona virus is still unstable and continues to mutate to strengthen itself. So are humans. In this life and death competition, humans are still trying to build an immune system to deal with the onslaught of corona. Corona virus and humans are still battling on the battlefield, both struggling to survive.
An effective way to induce an immune response to produce antibodies is by vaccination. In this way, humans are prepared to have a strong immune response in phase 1, when the immune system clears the Covid-19 infection and blocks its spread in the lungs. On the other hand, the immune response in phase 2 is also amplified when the immune system must be able to prevent excessive inflammation (preventing a cytokine storm). Therefore, it is becoming increasingly clear that why the speed with which research finds vaccines and administers vaccinations competes with the speed at which the virus spreads and mutates, as well as with the rate at which vaccinations are injected to a large part of the population.
We must remember that, apart from the undisciplined factor of some people, the delay in vaccination achievement coupled with the emergence of the more contagious delta plus variant, plus inconsistent government policies will lead us to the condition of accidental herd immunity, namely the achievement of group immunity due to 'accidents' due to lack of the effectiveness of various government measures since the beginning of the pandemic, including the lack of comprehensive vaccinations and because many people are less enthusiastic about following health protocols.
This condition will lead to Darwin's survival of the fittest. A condition where everyone competes in the selection pandemic will occur. Who can adapt, he is the one who can survive and who is weak will lose. This is like going back to the beginning of the pandemic when there was no vaccine, when there was a choice about natural herd immunity, i.e. when 70% of the population was exposed, herd immunity would be formed. Of course, this is a brutal condition because those who cannot survive exposure to COVID-19 will die. The number can be above 10 million people. Horror!
This condition occurs when the government and society raise ‘white flag', unable to withstand the onslaught of the pandemic. The indications are that all policy options are not optimal and are widely opposed. Even more so if a new variant, we don't know what else, that is more vicious is rampant. Now there are signs that a dead end is happening. Therefore, accidental herd immunity will occur. This immunity will arise in the largest number of the population because they managed to survive after suffering from exposure to Covid-19.
This indication was happening in Jakarta. As of March 31, 2021, 44.5% of the total population of Jakarta had been infected with Covid-19. This figure was obtained from a serological survey conducted by the Faculty of Public Health, University of Indonesia, together with the Jakarta Health Service, the Eijkman Institute, and the Indonesian CDC. With a total population of 10.6 million, there were 4,717,000 people who have been infected in Jakarta. Meanwhile, the number of Covid-19 cases detected until March 31, based on data from the Jakarta Health Service, was only 382,055. This means, 92% were undetected. This survey can be an indicator that the possibility of similar condition happening in other areas, at least in densely populated areas. It could be said that the silent majority affected by Covid-19 struggled alone to recover (or lost) without being recorded by the government.
In this Darwinian condition, of course we humans have to be smarter than viruses. The accidental aspect of the herd immunity process must be reduced by endeavor and trust. The trick, of course, is to strengthen the immune shield. Therefore, the universal vaccination program for the people of Indonesia must be accelerated as soon as possible. If possible, this can be completed in 2021. If the speed of this vaccination exceeds the speed of transmission of Covid-19, humans will be superior in this Darwinian competition. Vice versa. If vaccinations are still slow, complicated, bureaucratic, questioning administrative details, Covid-19 and its variants will control us. May God protect us from it.
In addition to vaccination, of course humans can win against viruses if they continue to change their behavior, which is getting smarter to adapt to this pandemic situation. The current vaccination enthusiasm shows a change in behavior after witnessing the current second wave of horror. This can be an entry point for awareness to strengthen health protocols so as not to be careless and remain disciplined. This is an opportunity for the government to win the hearts of the people through reliable, flexible, precise communicators who can embrace and provide understanding. This communicator can take over the roles of officials who are often confused.
Policy communication will be effective if government policies reflect the attitude of divinity (always trusting in endeavors), humanity (always humanist), unity (gluing together, not dividing people), deliberation (not allergic to criticism), and justice (no favoritism between the strong and the weak). The point is, be Pancasilais.
Professor, Faculty of Medicine, Universitas Airlangga
Chairman of Health Department, Indonesian Council of Ulama, East Java
Translated from Indonesian:
"Setop Accidental Herd Immunity" by Djoko Santoso
Media Indonesia, 26 July 2021