Covid-19 Transmission in Indonesia: Possible Risk for Counselling Physician
Indonesia is one of the countries struggling against Covid-19 with limited resources, unclear guideline, and poor support from the community. On the other hand, due to these limitations, Indonesia might be able to provide a better picture about how transmission happened and which area is vulnerable. However, limited data and records make it difficult to draw any meaningful conclusion. Even with those opportunities and limitations, certain data suggest a concerning development, which is the fact that among medical specialism, psychiatry is the one with the most number of deaths caused by Covid-19 in Indonesia. It could be a coincidence, as the number of cases are limited, but there is a pressing need to investigate further.
On August 4, 2020, according to Ikatan Dokter Indonesia (Indonesian Medical Association/ IDI) there has been 74 doctors who died as confirmed case of covid-19 or highly probable case ("Pasien dalam Pengawasan" /PDP). Since then, there is at least 2 more cases of doctor death in Indonesia, as there has been 1 death in Natuna and 1 in Medan. The data of positive cases are available, but probably less reliable than the data of deaths, as only a small fraction of doctors are tested using PCR, resulting in only around 300 doctors being considered positive.
Among these 76 doctors, there are 43 general physician (GP) and 33 specialist: 5 psychiatrists, 3 ENT specialists, 3 general surgeons, 3 pulmonologists (The one who deals with respiratory diseases), 3 Obstetrics and Gynecology specialists, 3 internists, 2 neurologists, 2 radiology specialists, 2 anesthesiologists, 1 neurosurgeon, 1 orthopedic specialist, 1 occupational health physician, 1 forensic specialist, 1 pediatrician, 1 urologist, and 1 physical medicine and rehabilitation specialist. Among the GPs, 2 of them are internal medicine resident and pediatric medicine resident.
Although a doctor catching covid-19 during everyday life is possible, the risk of a doctor dying by covid-19 is more than 20 times the general population, so it's quite likely that a significant proportion of those deaths are related to the medical profession. Some might be getting the disease from operating room (surgeons, neurosurgeons, anesthesiologists, urologists, orthopedists), some might be infected directly from isolation chambers (internist and pulmonologists), some might be from the burial protocol (forensic specialist) and some might be infected during the X-ray session (radiology specialist).
Deaths among ENT specialists might mean that ENT examination allows transmission even from patients less likely to be considered Covid-19 patients. Child patients and pregnant women, although often considered less likely to have severe Covid-19, might have played significant role on transmission to the ob-gyn and pediatrician communities.
However, the concerning oddity in the data is that there has been five psychiatrists who died as confirmed case or PDP of Covid-19. The oldest of the deceased is 80 year-old, the second oldest is 69 year-old, while the other three are not yet reaching geriatric age, being 62 year old, 57 year old, and 57 year-old. The number might not seem enough to raise alarm, except for the fact that Indonesian psychiatrist association (Persatuan Dokter Spesialis Kedokteran Jiwa Indonesia/PDSKJI) claimed that there are only around 1,000 psychiatrists in Indonesia. The odd ratio of psychiatrists dying from Covid-19 is around 220 times general population, while the odd ratio of any doctors dying from Covid-19 is around 20 times general population (Table 1).
The data might seem strange to some people. Why is it that among 168000 of Indonesian doctors, only 1000 people are psychiatrists? First of all, Indonesian doctors do not always have specialism. Every Indonesian doctor would start as GP, and then choose whether or not to continue further education as specialist. So, GP is not a specialism. Although there has been attempt to create family medicine specialist, the specialism remains unpopular and many choose to be unspecialized GP.
To further proceed to residency, sufficient economic capacity is necessary. Residency in Indonesia is university-based, and residents need to pay for around 4 years instead of getting paid. During the process of residency, most doctors can not practice outside the education system. It brings the condition of 4 years of negative income, with many residents having family to feed. This is one of the main reason that, although at the end of 2019 there is around 168000 doctors, less than 40000 are specialists.
Less popular specialisms suffered the most from lack of workforce. Even among the 40000 specialists in more than 10 specialisms, psychiatrists only amount to around 1000. It brings us back to the previous question: Why is it that among 1000 psychiatrists, there are already five deaths?
As previously mentioned, as there have been five cases so far, so it is highly possible that it was a coincidence, with the deaths being unrelated to the field of psychiatry; the five cases were actually outliers that doesn’t represent the population of psychiatrists; or there may be confounding variables that are many times higher in psychiatrists compared to general population. Nevertheless, prevention is better than reparation, as there might be a chance that the data might point to previously unknown risk factors which may be controllable.
Psychiatrists or psychiatry residents in Indonesia have not been directly assigned to manage Covid-19 patients, and thus, are generally not considered front-liners in the battle against Covid-19. Although in many countries, the role of doctors in any specialism can be interchangeable during the pandemic, such practice is not common in Indonesia. Psychiatrists will only see Covid-19 patient when there is concerning mental health problems, such as agitation or severe anxiety, but in most cases of Covid-19, mental health professional is not required.
One of the possible missing link in these cases is the prolonged session of psychotherapy. Psychiatrists can see a patient five times longer than doctors of many other specialism, and the psychiatry clinics are often not considered infectious area during the pandemic. It would be very likely to label the psychiatry clinic as “green zone” and put less priority on the clinic’s ventilation and sterilization. There is growing evidences that prolonged speech in enclosed space by asymptomatic individual can lead to transmission, and we can easily see that a session of psychotherapy is the perfect example of such situation.
Although it’s only an assumption, it is supported by another data: 1 death of occupational health physician, and 1 death of medical rehabilitation specialist. The two specialisms have even less doctors than psychiatry, and there is one similarity: Prolonged session of counselling or prolonged session of therapy. Although the data are at best a circumstantial evidence, there might be a need to prevent further transmission in offline direct meeting.
I believe that any session that require prolonged therapy or discussion should be done in a clinic with standardized ventilation, and if it’s not possible, for example in developing countries, could probably be done in open area with proper sound-proofed partitions. If you were considering psychotherapy or in need of prolonged counselling, it would be best to consider telemedicine first. Deaths among counsellors, might not just reflect tremendous loss in the field of medicine, but might also reflect transmission risk to the patients.
Although the pandemic is far from over, do not lose hope, wear your masks, and avoid prolonged discussion in indoor area.
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