Explaining social mixing and COVID-19 mortality trends for

improved responses to future waves of coronavirus in Indonesia

Perigrinus H. Sebong

Department of Public Health,

Email: falconperin_consultan@yahoo.com.
 Explaining social mixing and COVID-19 mortality trends for
improved responses to future waves of coronavirus in Indonesia

Abstract

Most countries are facing an unprecedented, highly dynamic situation due to the
COVID-19 pandemic and need essential information to guide their responses.
Accordingly, it is necessary to gather current and accurate evidence which can
specifically explain the prevailing social structures and determine the contact
patterns within and between different target populations. The Indonesian
intervention policy should reflect the intersection between social determinants of
health, populations with higher risk for infectious disease outbreaks, and potential
chronic conditions such as obesity, diabetes and hypertension. The pandemic
responses should consider the emerging psycho-social scientific evidence related
to chronic diseases and the strong influence of local social constructs concerning
health and public stigma. Risk communication should include emergency
preparedness and disaster mitigation protocols involving self-protection, self-
resilience, identification of potential risk factors for coronavirus complications,
and stigma reducing efforts within each community.

Keywords: COVID-19; social mixing; emergency evidence; pandemic response;

risk communication; social stigma; emergency preparedness and disaster

mitigation; case reproductive value (R0)

Subject classification codes: Global Health, Public Health

1. Introduction

Covid-19 has created a worldwide crisis that attacks the global population

indiscriminately. According to recent estimates, over 6 million people have become

infected, with more than 366,891 deaths and 2,661,163 recovered patients

(Worldometer, 2020). As of 30 May 2020, approximately 25,216 cases of COVID-19

disease have been confirmed in Indonesia, with more than 1,520 deaths reported among

those infected, 17,204 patients still under treatment, and 6,492 recovered (Indonesian

Ministry of Health, 2020).

Most countries are facing an unprecedented, highly dynamic situation due to Covid-19

and need essential information to guide their responses (Losa et al., 2020; Alqahtani et

al., 2020). Findings from several countries have proven that the mortality risk due to

COVID-19 is higher for elderly people and for those who already have chronic diseases

(Banerjee et al., 2020; Verity et al., 2020). While Indonesia has a growing burden of

people with chronic diseases and an increasing number of elderlies, the mortality trend

due to COVID-19 among people with chronic diseases has been slightly different

compared to worldwide fatalities. In 2019, the Ministry of Health report indicated that

70% of Indonesia's population over 40 years old are at risk for hypertension and heart

disease (Indonesian Ministry of Health, 2020). Out of a total of 33 million people over

40 years old with hypertension, only 2.5 million of them control blood pressure

regularly and more than 12 million do not know their hypertension status (Maharani et

al., 2019). This chronic disease condition means that if they are not vigilant concerning

the health dangers, most of population within the productive age are at increased risk of

dying due to COVID-19 infection.

Similar to other countries affected by COVID-19, Indonesia also has implemented a

nationwide physical restriction policy aimed to reduce social mixing. This approach is

considered the most effective strategy to reduce new infections, prevent overloads in

health facilities and limit the R0 value or any potential local transmission (Chowdhury

et al., 2020). However, the ‘stay-at-home’ program in Indonesia, which includes

physical ‘lock-down’ restrictions and large-scale travel and social gathering restrictions

(Pembatasan Sosial Berskala Besar/PSBB) continues to face various obstacles such as

wide-spread social stigma and resistance, lack of epidemiological data or evidence

about potential risk factors for COVID-19 complications, and failures of risk

communication strategies that have not directly reduced the prevalent stigma in some
 communities (Jakarta Post, 2020; Kompas, 2020). One recent study highlighted that the

COVID-19 pandemic in Indonesia is predicted to continue to affect the population

significantly over an extended period of time, possibly for years (Djalante et al., 2020).

It means the government should develop and implement strategic interventions based on

the most current evidence to protect all of the communities, both rural and urban. The

variations of social mixing and mortality trends require more accurate and effective

strategies to improve the responses to the potential for future waves of coronavirus

(Berger et al., 2020; Chowdhury et al., 2020). This paper aimed to inform policy makers

concerning possible improvements which are needed in responding to the present health

crisis based on recent COVID-19 responses.

2. Transmissions and mortality trends due to COVID-19

Since March 2020, data from 99 countries have shown that obesity is the biggest risk

factor for death due to COVID-19 among people under 50 years besides age and sex

(Morrison, 2020; Betron et al., 2020). While the mortality rate in Indonesia among

young people is higher than the elderly, new confirmed cases continue to fluctuate in

many provinces and districts (Jakarta Post, 2020a). In addition, hypertension has also

been proven to accelerate the death rate among COVID-19 patients with an increase of

8% in each age group under 70 years old. However, the distribution of age groups

within the Indonesian population that suffer from chronic diseases differs from most

other countries. Globally, patients with underlying chronic diseases have severe and

often fatal COVID-19 complications when they are more than 70 years old (Banerjee et

al., 2020). Meanwhile, the most recent Basic Health Research report in Indonesia shows

the prevalence of diabetes mellitus in adults (> 15 years) reaches 10.9%, prevalence of

coronary heart disease is 1.5% of the total population, and high blood pressure occurs in

34% of the 18 years old population (Indonesian Ministry of Health, 2019).

Indonesia has the highest COVID-19 mortality rate in Asia, which is between 8-9%.

These conditions are related to poor public health management during the infectious

disease outbreak, poor health system capacity to maintain resilience, and regional

disparities in health care services and social infrastructure (Jakarta Post, 2020b).

Tragically, the ‘front-line’ healthcare workers who are dying due to COVID-19

exposure and infection are mostly the primary care physicians and attending nurses.

Table 1 provides more details about the mortality trends of COVID-19 in Indonesia and

worldwide.

Table 1. Patterns of COVID-19 deaths in Indonesia and worldwide

Worldwide Indonesia (updated May 2020)
Most common Male Male
victims
Most common age > 65, 70 years old > 50 years old, some at 40 years
of death old
Underlying disease Hypertension, diabetes mellitus, Hypertension, diabetes mellitus,
Chronic Heart Disease Chronic Heart disease
Health Workers Physicians, nurses, counselors, Physicians, nurses
ambulance officers, porters,
homecare nurses, janitors

Minorities/Marginal/ Black Not available

Vulnerable group

Source: Worldometer, 2020; Indonesia COVID-19 Task Force, 2020; Guzman et al., 2020.

In general, both globally and in Indonesia, the pandemic patterns show similar mortality

trends due to COVID-19. More men have died than women from COVID-19 infection

and the increased risk of death among COVID-19 patients with underlying diseases is

mostly due to hypertension, diabetes mellitus and chronic heart disease. However, the

mortality trend of COVID-19 patients by age is slightly different in Indonesia compared

to worldwide. Instead of fatalities predominantly in patients over 70 years old, the

numbers of deaths by age are highest among those over 50 years old (Indonesia

COVID-19 Task Force, 2020).

3. More social mixing analysis needed on COVID-19 responses in Indonesia
The COVID-19 pandemic has shocked and stunned most of the world community

causing health systems to breakdown from overloaded facilities and exhausted resources

which can be particularly seen in the worst conditions involving large-scale

ineffectiveness and unpreparedness in the medical care systems to deal with the rapidly

rising spikes in cases in many countries, as well as severely limited capacity of intensive

care facilities and the small numbers of available health workers, and a dangerous

scarcity of personal protective equipment (Guria, 2020). While these challenges appear

to be almost universal, each country has different response strategies as described in

Table 2.

Table 2. Comparison of COVID-19 responses in Indonesia, China, South Korea

and the Philippines

Country Strengths Weaknesses

China The government is moving quickly The response was delayed due to slow
to prevent the spread of disease, by news coverage from the beginning that
quarantines, case tracking in the involved the world community tending
population, coupled with lock to underestimate the potential of the
down. pandemic Covid-19.
South Using a combination of extensive Non-compliance with social
Korea testing, tracking locations of restrictions protocols in religious
transmission, and contact tracing activities
after a case surge, the South
Korean response is exemplary for
other countries affected by
COVID-19.
Philippines It is imposing several restrictions, There was rejection and intimidation of
including banning the entry of residents.
foreigners, canceling military
exercises as well as announcing
economic stimulus packages and
social protection programs.

Indonesia The government is imposing Initially underestimating the rapid

several territorial restrictions,
including banning travel to and
from red zone countries and
closing some land borders in
addition to large-scale social
restrictions.
Source: DRI, 2020
spread of COVID-19, the response was
late; the government failed to take
firmer actions, including preventing
some citizens abroad from returning
home; ill-equipped health systems are
characterized by large number of
medical personnel deaths and lack of
proper personal-protection equipment.
Based on the previous explanations, the author concluded that the greatest effort to stop

the transmission of COVID-19 is by controlling social mixing through social and

physical contact restrictions in the general population. Epidemiological research has

emphasized that systematically assessing the characteristics of social mixing can

increase the readiness of local governments to deal with a contagious disease outbreak.

Social mixing assessment helps to identify the risk of transmission within a community

(Strömgren et al., 2017). To verify the effect of social mixing on the disease

transmission process, the current cases are divided into clusters, location of contacts and

the extent of physical contact among community members in order to develop

appropriate prevention strategies through case tracking and transmission tracing. Table

3 presents a typology of social mixing used to track the transmission of a contagious

disease in the community.

Table 3. Typology of social mixing transmission of disease in the community

Clusters Location of Contact Physical

Contact (%)
Family Home 73.3
School and Workplace Workplace 55.8
Formal School 71.1
Pre-school 73.3
Sport place 53.8
Transportation Cars 25.8
Public transportation 8.3
Market Public areas 28.3
Shops 8.3
Mall 18.0
Restaurant 30.8
Social Relation Friendship/Intimate 80.1
Source:

In social mixing, there are several conditions such as close contact including duration of

contact, frequency of contact and skin-to-skin contact which can affect disease

transmission (Strömgren et al., 2017). Contacts with longer and more intimate duration

tend to carry a greater risk of transmission. Physical contact at home is greater than

physical contact at public transportation hubs and retail shops. Community transmission
is certainly a result of different social mixing patterns in these locations. The application

of this typology shows that the density of clusters increases the risk of infection in a

variety of social mixing locations.

A precise description of contact variations in social mixing settings is important for

prevention and assessment of disease transmission during an outbreak. Specifically, the

distribution pattern is obtained by calculating the interaction of contacts with index

cases in the community and estimating the level of transmission in social mixing. It

should be noted that the distribution of cases does not depend entirely on the basic

reproductive value (R0) or local source of transmission but is also driven by the types of

contacts that are relevant for transmission which include socio-demographic structure

and social determinants of health (Abrams & Szefler, 2020; Viceconte & Petrosillo,

2020). To evaluate the effect of specific physical distance based on location, we not

only measure the R0 value but also consider the homogeneity and heterogeneity in

social contact (Strömgren et al., 2017). Therefore, it is necessary to collect current and

accurate evidence which can specifically explain the prevailing social structure and

determine the pattern of contact within and between different target populations.

4. Future control strategies for better responses to Indonesia’s disease

outbreak

5.1 Tightening healthy living practices during the pandemic response

Extended periods of physical distancing during the COVID-19 pandemic can

negatively impact on a population’s health through lack of physical activities which can

exacerbate chronic conditions (Pinto et al., 2020). To improve the present strategies that

are currently in place to safeguard the public health, the COVID-19 pandemic responses

should not only focus on who becomes infected but also on those most often “killed” by
COVID-19 infection. In Indonesia, most of the fatalities have occurred in patients with

chronic diseases such as hypertension, diabetes and coronary heart disease, who are in

their productive ages. Chronic conditions besides being triggered by metabolic factors,

are also due to unhealthy lifestyle behavior (Abbas et al., 2020). Consuming an

unhealthy diet such as fatty food consumption and excessive smoking and drinking;

diets containing excessive amounts of sodium, sugar and sodium and; and low intake of

fruits and vegetables can increase the risks of hypertension, diabetes mellitus and heart

disease (Schulze, 2018). Additionally, the lack of physical movement due to staying at

home for long periods can cause obesity (Abbas et al., 2020). In order to prevent these

chronic conditions, people need to be encouraged to maintain a healthy lifestyle,

especially during a pandemic situation. To prevent health conditions from decreasing

because of the strict enforcement of physical distancing during the present pandemic,

the Indonesian intervention policy should reflect the intersection between social

determinants of health, populations with higher risk for infectious disease outbreaks,

and potential chronic conditions such as obesity, diabetes and hypertension.

4.2 Increased health system resilience for future waves of coronavirus

4.2.1 Planning and preparedness in the pandemic response

Resilience is a key feature of high-quality health systems and should be optimized

through disaster planning and emergency preparedness for future disease outbreaks or

health crises by responding to changing population needs (Kruk et al., 2018). Proactive

governments must detect and assess potential outbreaks more closely to reduce the

catastrophic health, social and economic impacts. These efforts should also be

supported by increasing community preparedness in facing public health emergencies.

Accordingly, periodic disaster management simulations can be conducted at the

community level. For the Indonesian context, particular attention must be directed

toward the social mixing characteristics of the various communities. The pandemic

responses should consider the emerging psycho-social scientific evidence related to

chronic diseases and the strong influence of local social constructs concerning health

and public stigma.

4.2.2 Ensuring civil trust through risk communication before, during and after
an outbreak
In panic and emergency situations, health emergency communications such as

warnings, risk messages, evacuation notifications, messages about self-efficacy,

information about symptoms and availability of medical care are very important.

However, the main purpose of these communications in a crisis situation becomes

ineffective when the community does not have an awareness of the dangers and respond

appropriately with cooperation (Lundgred, 1994). Therefore, the government must be

more serious in giving these public health warnings and health promotion messages

whether part of a series of risk communications or an eminent crisis communication. If

the government intends to persuade the public about the real dangers of COVID-19,

then risk communication can be highlighted more than crisis control messages.

Meanwhile, if the government plans to provide current epidemiological information

such as COVID-19 case updates, then crisis communication is more critical for

increasing public cooperation (Covello, 1992). Risk communication should include

emergency preparedness and disaster mitigation protocols involving self-protection,

self-resilience, identification of potential risk factors for coronavirus complications, and

stigma reducing efforts within each community.

Disclosure statement

No potential conflicts of interest are reported by the author.

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