This article focuses on what we can learn about good public health delivery through the experiences of indigenous peoples and local officials in Borneo’s borderland throughout the COVID-19 pandemic.
The government of Indonesia says it has committed to improving the healthcare system to safeguard vulnerable populations from the pandemic’s destructive impacts. However, the results of our research in Borneo frontier communities in North Kalimantan Province near the Malaysian border reveal that there is a discrepancy between the priorities and policies of the government and the responses of community and local officials.
We are undertaking a four-year collaborative research project (2021-2024) led by the Asia Institute, University of Melbourne and the Asia Research Centre Universitas Indonesia on the response by Asian governments and civil society organisations to the COVID-19 pandemic, funded by PRIME-LPDP (Partnership in Research Indonesia and Melbourne—Lembaga Pengelola Dana Pendidikan (Indonesia Endowment fund for education)).
The participants in this study were selected from two separate field research periods: one conducted from May to June 2022, and the other from July to August 2023. The research was carried out among various indigenous communities, including the Kenyah communities residing in three villages in Apokayan (Kayan plateau) along the Boh and Kayan rivers and the village of Pujungan in the Pujungan River, and Teras Nawang in Bulungan Regency, the Lundayeh communities situated around the town of Malinau and Pulau Sapi, and the Punan communities residing in two villages in Upper South Malinau and the village of Paking. Additionally, the study involved the participation of Adat leaders and healthcare professionals, such as doctors and nurses working at community health centres and the regional hospital. The interviews were conducted verbally and supplemented with on-site observations.
Long Nawang village and lam adat (village hall), 22 July 2023. Credit: Indrawan Prasetyo.
In the absence of state care infrastructure, indigenous communities in Borneo have relied on their local cultural elite (Adat leaders), local institutions such as kinship care, traditional medicine and practices, and stories of past plagues to respond to the pandemic. The success of their caring practices has varied and some have been more effective than others. It is important to learn from and institutionalise these community-level initiatives while also addressing the limitations and resource gaps.
After the World Health Organisation declared COVID-19 a Public Health Emergency of International Concern on 30th January 2020, the Indonesian government decided to evacuate Indonesians in China, particularly students who were in the city of Wuhan where COVID-19 originated. The first wave of approximately 200 COVID-19 evacuees from Wuhan arrived in February 2020 at the designated quarantine camp on the Island of Natuna, Indonesia’s most remote location. They were then further isolated for almost three weeks before being flown to Jakarta and then their hometowns. A group of 20 evacuees from Wuhan arrived at Tarakan, the nearest large town in North Kalimantan where two of them were taken to the smaller town of Malinau, where district healthcare officials met them wearing personal protection equipment.
At the time, our findings indicate that many officials and village leaders were not very concerned about the spread of disease. The Kenyah communities (in Sarawak, Malaysia, East Kalimantan, and North Kalimantan Provinces in Indonesia) had experienced the arrival of new diseases before and the symptoms of COVID-19 were often compared to Krapit/ Kelapit, a local name for the smallpox epidemic that ravaged Central Borneo in the first half of the 20th century. Oral histories about more severe pandemics in the past and responses to them helped soothe the villagers. For example, one of the last remaining elders in Apokayan village of Metulang was confident that traditional medicines could help treat COVID-19.
In Pulau Sapi, a COVID-19 spread in Malinau began with a large church congregation in Loreh made up of people from various villages and sub-districts. A second spreading event was a wedding ceremony held in the Apokayan region, attended by families from the coastal towns of Samarinda, Tanjung Selor, and Tarakan—591 people were confirmed positive with the virus in Long Nawang and Long Ampung. This was a huge number in a region with a population of 4,331 or only 2,632 if only including those in Long Nawang, Nawang Baru, Metulang, and Long Ampung.
According to official statistics, there were 46,319 confirmed cases of COVID-19 in North Kalimantan up until May 2023 out of a total population of 696,000. There have been approximately 883 deaths, according to official records, but this is likely lower than the reality on the ground due to obstacles relating to recording cases in remote areas.
The response of local officials and indigenous leaders
Our research suggests that the Indonesian government’s response to the pandemic in Borneo was weak, uncoordinated, and mostly dependent on local community institutions and actors.
In an interview with us, a district healthcare official estimated that only half of the healthcare officials in Malinau believed in the central government’s COVID-19 warnings about the pandemic. This disbelief among medical personnel was partly fuelled by the expectation of ‘nothing more serious than flu-like symptoms’. Only later, when the more severe symptoms of the Delta variant among the Apokayan people and a rising death toll in 2021 became apparent was there serious concern about the situation.
We found that sometimes the local response was totally inadequate, especially when front-line healthcare workers didn’t have the information and equipment necessary to keep themselves safe. A resident of Long Nawang, for example, recounted that during the early days of the super-spreading event there ‘the staff at the health centre ran away. They did have the oxygen, but they abandoned it and told us to use it on our own. What do we know (on how to use it)?’ She added that after the pandemic, the health centre was short of staff and now many of her kin depend on either generic medication or traditional medicine. In a nearby health centre, there was only one nurse on standby, supported by two midwives, a nutritionist, two public health staff members, and no doctors for the village of 1,008 people and the subdistrict of 2,441 people. The staff said that a doctor is expected to arrive, while a nurse is on leave for nursing school sponsored by the regional government.
One regional health official believed that many deaths were due to malnutrition rather than COVID-19. One resident from the upper reaches of the river Pujungan recounted how some patients were not given much food because health centre staff were afraid to have contact with them. *Liang, (a pseudonym) a member of subdistrict community watch who we interviewed. told us that he cared for his wife while she had COVID-19, including providing nutritious food for her. She recovered and he concluded that many deaths were due to malnutrition. It is worth noting that as the pandemic progressed, more adequate pandemic care packages were prepared by the regional government. However, these packages were only able to be given regularly to those living around the city of Malinau because of the lack of connective infrastructure and the cost of providing the packages was almost prohibitive.
After the first news of local transmissions in Malinau, which reached even the innermost sub-district, people began taking refuge, enacting the tradition of isolating from the plague. For most of the Kenyah, Lundayeh, and Punan (formerly a nomadic ethnic group in North Kalimantan) population, this meant going to the fields and forests. For Punan communities this meant they were at less risk of contracting the virus, and in the village of Metut, they were safe for most of the early pandemic until the head of their community health centre contracted the Delta variant. For district officials and coastal-urban dwellers, local transmissions raised fears of an economic downturn due to social distancing measures and shop closures.
There were examples of successful healthcare in Borneo during the pandemic. In the village of Long Pujungan, a Kenyah village on the confluence of Pujungan and Bahau Rivers, the district health centre head nurse secured primary medical resources such as oxygen cans for a critically ill COVID-19 patient. The head nurse had worked in the area for a decade and had developed close networks with locals through participation in hunting parties and customary (adat) meetings regarding COVID-19. When a Punan family from upper Bahau visited the health centre without the required documents, he assisted them to process their paperwork—work which exceeded his duty as medical staff. Difficulty with paperwork is a common problem among indigenous communities in terms of accessing healthcare.
Two participants in our research, *Lebong and *We Bangen (pseudonyms), who are residents of two different villages in Pujungan and Long Nawang, insisted on caring for their kin despite advice from nurses who were concerned about them contracting and spreading the virus. In spite of this, neither contracted COVID-19–or were asymptomatic–and their kin recovered.
Another example of successful pandemic response was the way some regional chiefs (in Apokayan, Malinau Selatan Hulu) devised rules to regulate how people and commodities moved into and out of the area. As a result, the economy suffered a decline, but the health outcomes were improved. Across Northern Borneo, such isolation practices were common, although in the middle of the COVID-19 pandemic, they were hit by African swine fever which obliterated wild pig in the area. Most of the villages in innermost central Borneo could still rely on fish, deer, and as a last resort, various wild game, but the situation raised the issue of food security, particularly for other indigenous communities that inhabit the interior of Jambi in the Island of Sumatera such as Orang Rimba who were surrounded by palm oil concessions and national park, which limited their opportunities for hunting.
The weak response by local state officials was due to many reasons. One significant problem was the varying quality of training of medical professionals. In Malinau, a group of nurses sent there had not been properly accredited. In addition many local nurses refused to be placed in the interior, because of the working and living conditions such as difficulty accessing basic services such as running water and electricity.
A lack of training and equipment meant that medical staff in frontier areas often describe their first encounter with COVID-19 cases as hambur, meaning that they felt scattered and frightened. Despite the emphasis on the fearlessness and often heroic work of medical professionals, on-the-ground personnel in North Kalimantan often had to grapple with doubt, confusion, and paralysis.
During the peak of COVID-19 cases in Apokayan, a team of seasoned doctors and nurses from the regional hospital who already had experience with the pandemic was sent to train and assist the medical staff there, who were very much afraid of the COVID-19 patients.
Some of the general challenges to the provision of good healthcare include a lack of fiscal power and an ineffective bureaucracy. The lack of all-weather transport infrastructure, communications connectivity, and the generally sparse demography renders the area, especially in the Indonesian Kalimantan provinces, challenging in terms of the adequate provision and monitoring of social and health services.
A muddy road to Long Top, a Punan village along the Boh River, 19 July 2023: Credit: Indrawan Prasetyo.
Adat leaders, personal medical staff initiatives, and kin network approaches may have played a significant role in shaping a more effective response to the pandemic care. While some scholars argue that local and grassroots initiatives often obscure the state’s slow response, we believe that it is crucial to acknowledge and institutionalise various inclusive forms of caring that are emerging on the community level; to learn from their mistakes, breakthroughs, and deployment of networks. These efforts must be expanded and institutionalised, rather than idealised or dismissed.
The future of care during crises
As we move further away from the critical phase of the pandemic, it is important that we learn to better deal with future possible challenges, such as other zoonotic diseases, food insecurity, and climate-related issues such as heatwaves, droughts, and floods. If not, we risk once again putting an unequal burden on those who have always been deemed disposable.
In the past, the solution to a lack of health and other infrastructure in Indonesian Central Borneo was seen to be resettlement programs that brought upriver villages nearer to larger towns on the coast. However, in recent years, some of these coastal communities’ arable lands have been displaced due to coal mines flooding and massive deforestation. As a result, some communities have considered moving back to their upriver villages. In Malinau, on 22 September, 2023, the largest flood in 20 years occurred. In the context of a climate crisis, this too, is an increasingly pressing matter to settle.
Main image: The port of Malinau, one of the main gateways for people in and out of Malinau. (15 May, 2022) Credit: Indrawan Prasetyo.