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 hospitalized 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.
As in many other nations, Indonesian politicians have been accused of not recognizing the seriousness of the situation early enough, and some eventually admitted to misinforming the public. Sophia Hornbacher (2020) only recently highlighted the populist rhetoric and neo-liberal policy of the Indonesian government, which once more illustrates the country’s problems of social injustice and welfare. 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 corporate theft with government backing. 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 (Weydmann 2019: 60).
Recent history offers some good reasons for why medical professionals, patients 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 regulation 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” (Mack, Choffnes & Relman 2010: 27). 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 have already criticized 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, as the medical context is critical for understanding the government’s response..
Jamu will do?
During the initial phase of the pandemic, some Indonesian policy makers claimed publicly that COVID-19 infections could heal without intervention, as long as a person’s body had a strong resistance to disease. For this reason, they reminded the public to maintain or boost levels of body immunity. President Joko Widodo supported this assessment and recommended that citizens drink traditional herbal jamu remedies to prevent infections.
In order to understand the political play on the role of jamu during the pandemic, it is important to know that the consumption of herbal plants as medicine has been part of Indonesian culture for thousands of years (Beers 2001), mainly based on oral traditions and without systematic canonization. Jamu isoften produced by households of jamu gendong sellers, who carry bottled remedies in baskets or via bicycles or motorbikes to customers.
Today, however, jamu is no longer the medicine of the poor but an economic sector with large international companies such as Air Mancur, Djamu Djago or Nyonya Meneer producing a variety of jamu remedies sold as instant powders, tablets or capsules. Street vendors compete with big drugstores over jamu sales and the Indonesian government campaign for jamu as a remedy against Covid-19 supported an important “economic pillar for the nation” (Prabawani 2017: 81) that generated IDR 21.5 trillion (US$1.38 billion) in 2019; up 13.1 percent from Rp 19 trillion in 2018.
Image 1: Jamu Gendong with trademark label on her Caping Gunung (traditional hat) (Erny Mardhani, 2020)
As early as mid-March, the Singapore-based newspaper The Straits Times reported that 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 claimed he was convinced “that a herb concoction can ward against being infected with the coronavirus”. His statements on the use of jamu medicine contributed to a rapid price increase so that prices of red ginger, turmeric and curcuma multiplied.
Like Jokowi, other politicians have pointed to the benefits of traditional medicine in the current crisis. The district health office 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 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 early suggestions of Indonesian politicians to use herbal Jamu remedies as well as their general assessment of COVID-19 as a harmless virus, has been 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 assessing the current pandemic, Indonesia’s politicians and many citizens are turning to 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 contextualize their calls within Indonesia’s corporate health care market as much as within the nation’s medical pluralism and the concept 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 (“Pusat Kesehatan Masyarakat”, acronym: 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 center 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 centers 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 any other nation in the world, 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 (Ferzacca 2001; Woodward 2011, among others). 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 not only in the supermarket shelves stacked with the jamu-style soft drinks promoted by the government, but also in a 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 (Lyon 2005: 14).
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 summarized several reports from marketing and consumer research agencies, e.g. McKinsey, and emphasized 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”. (However, no data on current market shares of small-traders and corporations in the sector is available.)
Yet, from a medical anthropology perspective, jamu consumption and prescriptions 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 characterized 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 are essential to withstand outside influences such as viruses, evil spirits or social discrepancies (Weydmann 2019: 213ff.).
It is a long way to go for anyone to provide academic evidence that jamu medicine helps against Covid-19. And yet, some scientists now claim that the more-established traditional Chinese medicine (TCM), both traditional and modern remedies, strengthens the body’s immune system in ways that reduce viral pathogenic factors (Zhou et al., 2020). As has been demonstrated by Hartanti et al. (2020), jamu remedies promoted as Covid-19 prevention in Indonesia are adaptations of the TCM formula which has been officiated in the Chinese National Clinical Guideline as a means to prevent Covid-19 or treatment during severe and recovery stages.
While such trials and debates continue, one thing is certain. The current crisis of Covid-19 seems to be a big chance for the jamu industries. Recently, the head of the Indonesian National Agency of Drug and Food Control BPOM (Badan Pengawas Obat dan Makanan) declared that from January to July 2020 new permits have been distributed for 178 traditional medical remedies, 3 phytopharmaca, and 149 local health supplements with properties to help strengthen the immune system. BPOM also supports research on eight herbal products to combat symptoms of Covid-19. And, as the Jakarta Post recently wrote that there will be “a bright, post-pandemic future for Indonesian ‘jamu’” (Susanty 2020), it comes as no surprise that the Indonesian herbal products manufacturer Sido Muncul is expanding into the Saudi Arabian market as “an opportunity amid the COVID-19 pandemic”.
However, besides the economic opportunities, we also need to consider that the pandemic negatively impacts the poorest sectors of the population. Even though the Indonesian Supreme Court on the one hand annulled the increase of premiums for the National Health Insurance System (BPJS Kesehatan), Indonesian politicians are now asking the poor to spend money for jamu medications or ingredients in order to cope with Covid-19.
Against this background, the current pandemic and emerging practices of healthcare are an economic question. In short, the Covid-19 crisis “turned out to be a capitalist thing” in Indonesia as much as elsewhere (see earlier blog contribution by Don Kalb). Herbal medicine offers economic opportunities in times of crisis and even though we may dream of a system that enables health seekers to freely decide on their healthcare – independent of their economical background – we realize the many obstacles that need to be overcome before such a system can become reality for everyone.
Nicole Weydmann is postdoctoral researcher at the chair of Comparative Development and Cultural Studies with a focus on Southeast Asia at the University of Passau, Germany and works on the use of traditional and alternative medicine in Southeast Asia and Europe.
Kristina Großmann is professor at the anthropology of southeast Asia at the University of Bonn, 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.
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Cite as: Weydmann, Nicole, Kristina Großmann, Maribeth Erb, Novia Tirta Rahayu Tijaja. 2020. “Healing in context: Traditional medicine has an important role to play in Indonesia’s fight against the coronavirus.” FocaalBlog, 8 September. http://www.focaalblog.com/2020/09/08/nicole-weydmann-kristina-grosmann-maribeth-erb-novia-tirta-rahayu-tijaja-healing-in-context-traditional-medicine-has-an-important-role-to-play-in-indonesias-fight-against-the-coronaviru/