This post is part of a feature on “Urban Struggles,” moderated and edited by Raúl Acosta (LMU Munich), Flávio Eiró (Radboud University Nijmegen), Insa Koch (LSE) and Martijn Koster (Radboud University Nijmegen).
On 1st March 2018, a group of protestors blocked a dual-carriageway in front of Acevedo Metro (and Metro cable line) Station in the North of Medellín, Colombia. Those who have read something about Medellín’s internationally acclaimed urban transformation in recent years will have almost definitely found their gaze drawn to the image of a cable car suspended above a tapestry of terracotta roofs that cascades down Medellín’s Aburra Valley. This image has become emblematic of a wondrous turning-point in Medellín’s contemporary urban trajectory. Once a hotbed of urban violence, state abandonment and spatial disconnection, these underprivileged peripheral neighbourhoods received state investment in bold infrastructural projects, and via the introduction of participatory governance mechanisms, now enjoy an empowering degree of protagonism in shaping Medellín’s urban future. Welcome to the ‘pro-poor’ city of Medellín.
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.
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.
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 Tijajacompleted 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/