Malaria remains a major health policy challenge in Indonesia

David Mitchell

Malaria is always high on the political agenda. It is a major cause of death in childhood and stops affected adults from working. Indonesia has sometimes achieved the tightly organised system needed to bring malaria under control, but in times of political turmoil, malaria breaks out again. The political and economic crises of the late 1990s were accompanied by breakdowns in the health system and outbreaks of disease. In the year 2000 it was estimated that 30,000 Indonesians died and 15 million Indonesians contracted malaria each year.

Malaria control is sensitive to changes in the political situation because its prevention involves environmental controls like spraying which need to be done regularly. Even in the colonial period the Dutch saw their public health programs as a key pillar in establishing the legitimacy of their rule. The Dutch mass-produced quinine, drained coastal swamps and worked to eliminate mosquitoes from the rice paddies in an attempt to control malaria.

After independence, the World Health Organisation sponsored a malaria eradication program in Indonesia using DDT and chloroquine. DDT was sprayed inside people’s houses on the surfaces where the mosquito rested before approaching its victims. Chloroquine made it easier to treat patients with malaria. It was cheap and free of the ringing in the ears that came with quinine. This double-barrelled approach was very effective. The choloroquine cleared the malaria parasite from the bodies of infected patients, while the DDT reduced new infections.

Malaria rates dropped dramatically all over the densely populated heartlands of Indonesia. For a time it looked as if eradication of malaria could be achieved. Malaria transmission had in fact ceased over most of Java, Bali and Madura. In the outer islands, where the population was more scattered, progress was much slower. Yet in spite of subsequent ups and downs, 50 per cent of the population of Indonesia had been effectively protected from malaria by the mid sixties.

From eradication to control

After 15 years of impressive success the weaknesses of the eradication strategy became apparent. Mosquitoes first developed resistance to DDT and then to the dieldrin that was introduced to replace it. Then resistance to chloroquine appeared. Malaria casQs rose dramatically during the 1970s, and new approaches needed to be devised.

After the failure of the Sukarno government and the bloody suppression of the PKI in 1965, the government was impoverished and dysfunctional and unable to respond to the mounting malaria problem. Once the New Order consolidated its administration, its capacity to take action improved. The goal of the malaria program was redefined as control rather than eradication, and there was a return to the emphasis on environmental management initiatives used in colonial times.

Between 1984 and 1987 malaria incidence was reduced once again in the densely populated heartland areas. The program was then extended to the outer islands, where irrigated agricultural areas and plantations were targeted. Some new industries also helped control mosquitoes. In prawn and fish farming ponds along the coast the brackish water which enabled mosquitoes to breed was replaced by salt water. Mosquito breeding in rice paddies was drastically reduced by synchronising the rice production cycle so that large blocks of contiguous paddy fields could be flooded then dried out at the same time.

At the same time the new network of Health Centres (Puskesmas) in every sub-district and small local Health Care Posts (Posyandu) improved the level of health care available to villages. Each Health Centre ran active public health programs as well as a polyclinic.

By the mid-1990s perhaps 75 per cent of the Indonesian population was substantially protected from malaria. Malaria remained endemic in the three eastern provinces of Irian Jaya, Maluku and Nusa Tenggara Timur, where it was a major cause of death. Elsewhere malaria was localised and confined to specific ecological situations. However, the malaria story was still far from over.

Resurgence of malaria

As the New Order itself began to fail, the incidence of malaria again began to rise in many places. From 1998 onwards the graphs that had been proudly displayed on the walls of the Health Centre started heading upwards again.

This increase in malaria incidence was in some ways part of a wider problem. Malaria was increasing throughout the tropical world. Mosquitoes were rapidly becoming resistant to insecticides and malaria organisms were developing a similar resistance to existing medicines. Indonesia had its own specific problems. Declining funding for established programs and changes in the physical environment were responsible for new outbreaks where malaria had once been well controlled.

As always with malaria, local changes in the environment and local changes in human behaviour determine where each particular outbreak occurs. An outbreak on Pulau Seribu just north of Jakarta was found to be caused by people processing seaweed by soaking it in fresh-water wells. In Banjarnegara in Central Java the development of salak plantations, which require an environment where surface water collects, allowed forest mosquitoes to reach the local population. In Lampung neglect of shrimp ponds allowed mosquitoes to re-establish themselves.

Elsewhere illegal mangrove logging and sand digging and other environmental disturbances have encouraged the spread of malaria. The longer period of rainfall in La Ninya years also extended the period of malaria transmission. Conflict has also played a role. As people flee violence, non-immune people move into malarious areas and infected refugees may sometimes reintroduce the parasite into non-malarious areas.

Roll back malaria

Once again the health systems have responded both internationally and in Indonesia. In 1998, the World Health Organisation launched a new program called ‘Roll Back Malaria’. The program was launched in Indonesia in April 2000. This time DDT was replaced by a biodegradable insecticide from the pyrethrum flower. The simple technology of the mosquito net impregnated with biodegradable insecticides was also introduced.

Parasite resistance to antimalarial medication remains a big problem because the new antimalarial agents are expensive. Even simple cases cost 80 cents instead of 20 cents to treat. In complicated cases multi-drug treatments are replacing monotherapy. This often means that these drugs are not available in local health centres, even when drug companies make their products available on an at-cost basis.

The long campaign against malaria is far from over.

David Mitchell is a medical academic at Monash University. He can be contacted at david.mitchell@med.monash.edu.au