Public Health Responses to Climate Change Health Impacts in Indonesia.
Asia-Pacific Journal of Public Health
http://aph.sagepub.com
Public Health Responses to Climate Change Health Impacts in Indonesia
Made Ady Wirawan
Asia Pac J Public Health 2010; 22; 25
DOI: 10.1177/1010539509350912
The online version of this article can be found at:
http://aph.sagepub.com/cgi/content/abstract/22/1/25
Published by:
http://www.sagepublications.com
On behalf of:
Asia-Pacific Academic Consortium for Public Health
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Public Health Responses
to Climate Change Health
Impacts in Indonesia
Asia-Pacific Journal of
Public Health
Volume 22 Number 1
January 2010 25-31
© 2010 APJPH
10.1177/1010539509350912
http://aph.sagepub.com
hosted at
http://online.sagepub.com
I Made Ady Wirawan, MD, MPH
Although climate change is a global concern, there are particular considerations for Indonesia as
an archipelagic nation. These include the vulnerability of people living in small islands and
coastal areas to rising sea levels; the expansion of the important mosquito-borne diseases, particularly malaria and dengue, into areas that lack of immunity; and the increase in water-borne
diseases and malnutrition. This article proposes a set of public health responses to climate change
health impacts in Indonesia. Some important principles and practices in public health are highlighted, to develop effective public health approaches to climate change in Indonesia.
Keywords: climate change; Indonesia; public health practices; public health principles
C
limate change is a current global concern. Its impacts on the ecosystem and human
health were highlighted on World Health Day 2008 with the theme “protecting
health from climate change.” It is stated that a changing climate is likely to affect
the conditions that determine public health, including vector-borne diseases, safe drinking
water, secure shelter, food supply, and social relations.1 It is projected that the temperature
will increase from 0.2°C to 0.3°C per decade in Indonesia. This will result in changing in
water availability, rising sea level, and have other impacts on ecosystem.2
Being an archipelago, Indonesia is exceptionally susceptible to rising sea levels.
Approximately 100 of Indonesia’s more than 17 000 islands are considered as small and
generally flat.3 These small islands are mainly located in remote areas of Indonesia.
Additionally, Indonesia has 81 000 kilometers of coast of which 50% to 70% is inhabited.4
Communities living on the small islands and along the coastal lines are at higher risk of
flooding, which may necessitate coastal population evacuation. This could have a considerable impact on the population’s health, especially on the health of the refugees. Most displaced people are housed in camps and shanties, which are vulnerable to increased social
problems, violence, and communicable diseases.5
Rising temperatures and variable precipitation encourage the expansion of mosquitoborne diseases such as dengue, hemorrhagic fever, and malaria. Global warming could
potentially lengthen the transmission seasons of these important vector-borne diseases.6 An
increase in rainfall could expand Indonesia’s dengue transmission zone and considerably
increase the population at risk from the disease. This is of particular concern in regions that
From the School of Public Health, Udayana University, Bali, Indonesia.
Address correspondence to: I Made Ady Wirawan, School of Public Health, Udayana University, Gedung PSIKM Unud,
Jalan PB Sudirman Denpasar, Bali 80232, Indonesia; e-mail: [email protected].
25
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
26 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
lack immunity within the population as it results in more severe and fatal cases.7 Similarly,
malaria, which has caused high mortality and morbidity in eastern Indonesia, particularly in
Papua, Maluku, and the East Nusa Tenggara islands, could further expand into other parts
of this country. According to the Indonesian Ministry of Health,8-10 the incidence of malaria
in Java and Bali increased significantly from 18 per 100 000 people in 1998 to 48 per
100 000 in 2000, and showed a steady increase until 2007. It is also reported that malaria
has spread to almost a half of nearly 400 districts in 30 provinces.
Water-borne diseases such as cholera and diarrheal conditions could also become more
common in all areas. Food and water stored without proper refrigeration in warmer temperatures contain a higher concentration of pathogens.11 Water scarcity and problems of
freshwater supply can also been linked to climate change. Those who live in village areas
will be most affected by the increase in water-borne diseases.
Decline in agriculture productivity and aquaculture because of droughts in some areas,
rising sea levels, and extreme events would diminish food security.2 This situation contributed to starvation and malnutrition in the eastern parts of Indonesia in recent years.
There are also some direct impacts of climate change. Extreme temperatures could
cause other health problems, such as heart dysfunction, heat exhaustion, certain respiratory
problems, and lung tissue damage.12 Considerable forest fires caused by climate change–
driven droughts in the Indonesian island of Sumatera have resulted in the increase of respiratory illness and allergy symptoms.13
It is estimated that a significant increase in atmospheric greenhouse gas concentration
is likely in the next 5 decades. Combined with ongoing population growth, poverty, and other
environmental changes, projected climate change is expected to place a serious stress on
Indonesia and its population. This article aims to discuss a set of public health responses to
climate change health impacts in Indonesia. It addresses some important principles in public
health and its practices to find an effective public health approaches to climate change in
Indonesia.
Public Health Approaches to Climate Change in Indonesia
It is clear that the indirect impacts of climate change in Indonesia would be wider than the
direct impacts. The strategic response to address the indirect health outcomes will require
the principles and practices of public health.
Public health practices concern on three levels of prevention, that is, primary, secondary, and tertiary prevention.14 With regard to climate change, primary prevention deals with
how to reduce greenhouse gas emissions to slow and stem global warming, which is known
as mitigation. Secondary and tertiary prevention related to adaptation, that is, how to deal
with the risks and threats posed by climate change to diminish the related health burden.15,16
Public Health Role in Mitigation
Department for International Development (DFID) and the World Bank17 stated that
Indonesia has become one of the 3 largest emitters of greenhouse gases in the world. In
mitigation attempts to reduce greenhouse gas emissions, the involvement of other sectors is
imperative, although the role of health sector cannot be denied.15 Although the mitigation
to reduce greenhouse gas emissions is not the main area of public health, health input is
still significantly needed. Health professionals and scientists could provide explanation on
the health justification for climate change mitigation and present evidence on the health
impacts of a variety of approaches to climate change mitigation.18 In Indonesia however, this
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
Climate Change Health Impacts in Indonesia / Wirawan
27
role could be appropriately performed by health professionals and scientists, if they are supported by sufficient resources, facilities, and supplies to conduct high-quality research. This
means that universities, the government, nongovernmental organizations, and international
bodies should work closely to increase capacity to perform interdisciplinary research. In
addition, one of the public health principles, intersectoral collaboration, is needed. There
are some current governmental departments in Indonesia, including Department of
Environment, Department of Transportation, Department of Energy and Natural Resources,
Department of Forestry, and Department of Health that could collaborate with one another.
Indonesian efforts have been shown by strong commitment from the government to
address this issue. It was indicated by signing the Kyoto Protocol in 1998 and ratifying it
through Law No. 17 of 2004.19 However, Indonesian efforts on emissions reduction have not
yet been optimal.17 It seems that the degree to which these efforts will have an effect will
depend on the leadership in every sector to deal with these serious concerns in Indonesia.
Public Health Role in Adaptation
Health promotion. It is important to provide communication, information, and education
about health issues arising because of climate change. Some people might believe that the
climate change health effects are threatening. However, it is shown that only 20% of
Americans understand climate change very well.15 In developing countries such as Indonesia,
the percentage of people who understand the issue might be lower.
The messages about climate change health effects could be integrated into some existing health promotion programs. This is feasible although that practice has not been optimally applied.20 The integration of such efforts would be effective if it is performed in
primary health care (PHC).21 PHC in Indonesia, which is commonly known as community
health center, is available in every subdistrict. This practice would increase the accessibility
of 240 million or more people, almost a half of whom live in remote Indonesia. The PHC
approaches are also suitable to address specific groups, considering differences in the levels
of understanding, culture, ethnicity, and susceptibility to the climate change health effects.
Relocating populations. There are some particular concerns related to climate change impacts
on small islands. People living in the small islands and coastal areas are particularly vulnerable
to tropical cyclones, flooding, drought, and tsunami. It is stated that adaptation strategies
to sea level rise are classified into 3 categories, namely, “retreat, accommodate, and protect.”13
Retreat means leaving the land to minimize the risk of loss of infrastructures. Accommodation
indicates altering land use because of rise in water levels, such as “raising buildings, or
changing to more salt-tolerant crops.” Protection means the use of constructed barriers to
protect coastlines from the sea.13
In Indonesia’s small islands, this could mean moving people from some low-level areas
to higher grounds, if possible on the same island. However, this will face strong ethical and
human rights issues. It is unethical to encourage people to abandon their land when there
is uncertainty about the outcomes. Accommodation and protection could face difficulties
related to the availability of resources. The challenge here is to shift this responsibility to
local government because the decentralization process at regency level is currently improving, with guidance from central government and experts.
Although most disasters cannot be prevented, their effects could be anticipated.22 It is
therefore important to create early warning systems to be able to address potential health
impacts more effectively. The development of public health infrastructure in small islands
and coastal areas should be strengthened. Furthermore, disaster preparedness plans should
be developed. Public health sectors would much contribute in addressing population’s health
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28 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
related to displaced population. Most displaced people are generally housed in camps and
slums, which are vulnerable to increased social problems, violence, and the spread of communicable diseases.5 However, these approaches are difficult to follow because of the lack
of awareness from the community, government, and other related sectors about this issue.
This is mainly because of the uncertainty related to the climate change outcomes especially
those related to population displacement.16,23 It is a challenge to convince all sectors that
there should always be preparedness to deal with the worst scenario. The precautionary
principle suggests that precautionary measures should be taken when there is threat of
harm to human health, although the scientific associations are not fully established.24 This
principle can be used to increase the awareness of related sectors to collaborate in ensuring
community safety.
Another issue that is well established in public health is health inequity. The threat of
climate change impacts on small islands and coastal areas, especially in the eastern parts of
Indonesia is one of the contributors to this health inequity. This excessively threatens some
populations, especially poor people in isolated community, ethnic and minority groups.25
Vulnerability assessments should be performed in such areas to be able to make public health
actions that address the most vulnerable populations and focus on eliminating the health
inequity.
Surveillance. The role of surveillance in determining disease trends, identifying vulnerable
groups and areas as well as in planning, implementation, and evaluation of public health
programs is without doubt an important one.14 Good surveillance systems will provide
guidance to design effective public health programs. There are some data that should be
systematically collected in developing responses to climate change, including data on
environmental risks, vulnerability, and diseases. Data of environmental risks comprises
meteorological data such as temperature trends. These data also cover ecological data such
as mosquito density. The vulnerability of each area should be assessed, including physical
factors such as altitude, infrastructure, and facilities, as well as social factors such as
remoteness and poverty.26,27 The collection of the environmental risk and ecological data
could be integrated to a public health approach specifically developed for the small islands
and coastal areas that is mentioned in the previous section.
Diseases data are usually collected in the current public health programs. The communicable diseases programs currently collect these data routinely. This is related to climate
variability and should be strengthened to be able to monitor food-borne and water-borne
diseases.28 Surveillance of vector-borne diseases could be closely linked to the environmental
risk surveillance, especially mosquito density data in prevention of malaria and dengue hemorrhagic fever. Additionally, current integrated service centers in every village that are run by
PHC could be used to collect data related to malnutrition, particularly in areas that face
decrease in agriculture or aquaculture productivity.
Surveillance on environmental risk, vulnerability, and disease is currently performed
separately through different methods. It is imperative to integrate all these data to make an
effective surveillance system to address adverse health impacts caused by climate change.
This system should be also expanded to reach all community levels.15 This can be achieved
through vertical coordination from central government to subdistrict level with clear mechanism of reporting.
Prevention and preparation for communicable disease control. The opportunity here is to
develop an effective early warning system and preparedness to counter disease outbreaks.
Early warning systems are usually developed by combining the data collected in the surveillance programs, including environmental data (weather and climate forecast), ecological
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
Climate Change Health Impacts in Indonesia / Wirawan
29
data (vector density), and epidemiological data (water-borne and vector-borne diseases
rates).29 This system will give warnings when increased risk could be expected. Although
Indonesia has not yet developed a national early warning system for disease outbreaks, the
Indonesian Ministry of Health has instructed all provincial governments to prepare for
potential dengue outbreaks before the rainy season (August to September).13 The preparation includes health campaigns, cleaning up mosquito breeding sites, and data collection
of dengue incidence in every local district hospital. Policy makers, local governments, and
community must be regularly informed about the importance of these measures. Meanwhile, the central government should start multisectoral collaboration to create an effective
early warning system.
The instruction could be also expanded to the prevention of water-borne diseases and
malnutrition. In this light, the instruction is for local governments to prepare for possible
outbreaks of diarrheal diseases because of the lack of safe water supplies before the dry
season (April to May). The preparation might include health education about the importance of sanitation and adequate supply of drinking water to prevent diarrheal diseases. In
addition, every health center and hospital should ensure the availability of supplies, essential drugs, and so on in anticipation of the increased number of cases.
As suggested in the previous section about health promotion, the role of PHCs is a
very important one. The basis of this program has been developed since the introduction
of PHC during the declaration of Alma-Ata.30 This really needs strong commitment from
all sectors; and community involvement to support this idea is pivotal. Community involvement could be in the form of the provisions of community health workers (CHWs) or
volunteers and the participation of the community per se to the success of the early warning system.31 CHWs are available as part of the health system in Indonesia. The provisions
of imparting appropriate training to them and what simple steps can do for their involvement would be beneficial and can create a bridge between the community and the health
sectors. This is particularly important for addressing the concerns of people who live in
remote and vulnerable communities.
In Indonesia, particular consideration should be given to the spread of vector-borne disease to the areas that lack immunity.23,32,33 Areas such as Jakarta, Bali, East Java, and East
Kalimantan have a high incidence of dengue and so the population have better immunity than
Sumba for instance, which has a low incidence of dengue but the highest rate of malaria.9
Poorly developed infrastructure and high levels of poverty here mean that a dengue infection
could worsen the situation. Indeed, the spread of dengue in areas where there is lack of immunity is one of the reasons why the fatality rate for dengue has been so difficult to control. The
application of the surveillance system to monitor the cases is important and should be combined with the preparedness of health care to provide adequate case management.
Health workforce training. The integration of preventive and curative approach is also needed.
The capacity of health centers in disease management should be enhanced. This could be
achieved by providing regular health workforce training.15,29
It is stated that a qualified and competent health worker is essential to the success of
the health system. An intensive effort will be required at the district, provincial, and central
levels, in preparing the health workforce for the possible impacts of climate change and for
other challenges over the next decades. Medical and public health practitioners should
be trained to identify and manage emerging health threats that may be related to climate
change. This should ensure an essential set of competencies throughout the health system and
building capacity for scientists with multidisciplinary and specialized skills.15 The involvement of universities, especially medical and health education providers to include this issue
in current curriculum could be beneficial for the long term.
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30 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
Conclusion
There are particular conditions that should be considered for Indonesia as an archipelago in
dealing with climate change. These include the vulnerability of people living in small islands
and coastal areas to rising sea levels, the expansion of the important mosquito-borne diseases
(dengue and malaria) into areas that lack of immunity, and the increase in water-borne diseases and malnutrition.
Public health approaches to those issues are mainly placed into mitigation and adaptation measures. Public health plays more important role in the adaptation, which can be
categories into some practices, including health promotion, relocating populations, surveillance, prevention, and preparation for communicable disease control and health workforce
training. It is clearly shown that all of those practices are interdependent on each other.
Interdependence is also shown between preventive and curative approaches.
There are some public health principles that should be highlighted to develop an effective approach. Intersectoral collaboration is imperative in all practices both in mitigation
and adaptation. This would involve all sectors and departments, governmental and nongovernmental organizations, universities, community elements as well as international bodies.
Some ethical, human rights, and inequity issues could, however, arise especially in addressing more remote, vulnerable, and small island communities.
The capacity of existing PHC centers should be improved, as PHC approaches could
reduce health inequity and bring health services closer to the community. The role of community health workers is undoubtedly important and would provide a bridge between community and health centers especially in addressing people living in more remote areas.
The highly complex effects of climate change will vary significantly by region and population group. The degree to which the approach will give maximum beneficial effects will be
determined by the quality of governance and leadership that addresses this serious issue of
uncertainty of the impacts.
References
1. World Health Organization. Protecting health from climate change—World Health Day 2008.
http://www.who.int/world-health-day/toolkit/report_web.pdf. Accessed May 29, 2008.
2. Naylor RL, Battisti DS, Vimont DJ, Falcon WP, Burke MB. Assessing risks of climate variability and
climate change for Indonesian rice agriculture. Proc Natl Acad Sci U S A. 2007;104:7752-7757.
3. Indonesian Government. Presidential Regulation No. 78 of 2005 on Management of the Outer
Small Islands [in Indonesian]: http://www.indonesia.go.id/id/index.php?option=com_content&tas
k=view&id=705&Itemid=696. Accessed May 27, 2008.
4. Indonesian Ministry of Health. Indonesia Country Profile 2006. Accessed May 12, 2008. http://
www.depkes.go.id/downloads/publikasi/Indonesia Country Profile 2006.pdf
5. Watson RT, Patz J, Gubler DJ, Parson EA, Vincent JH. Environmental health implications of
global climate change. J Environ Monit. 2005;7:834-843.
6. Case M, Ardiansyah F, Spector E. Climate change in Indonesia: Implications for humans and
nature. http://www.worldwildlife.org/climate/Publications/WWFBinaryitem7664.pdf. Accessed
October 14, 2009.
7. Patz JA, Reisen WK. Immunology, climate change and vector-borne diseases. Trends Immunol.
2001;22:171-172.
8. Indonesian Ministry of Health. Indonesia health profile 2004. Accessed May 12, 2008. http://
www.depkes.go.id/downloads/publikasi/Indonesia Health Profile 2004.pdf
9. Indonesian Ministry of Health. Indonesia health profile 2005. Accessed May 12, 2008. http://
www.depkes.go.id/downloads/publikasi/Indonesia Health Profile 2005.pdf
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31
10. Indonesian Ministry of Health. Protecting health from climate change effects. Accessed May 12,
2008. http://www.depkes.go.id/en/0704pr.htm
11. Fleury M, Charron DF, Holt JD, Allen OB, Maarouf AR. A time series analysis of the relationship
of ambient temperature and common bacterial enteric infections in two Canadian provinces. Int
J Biometeorol. 2006;50:385-391.
12. Haines A, Patz JA. Health effects of climate change. JAMA. 2004;291:99-103.
13. Ebi KL, Lewis ND, Corvalan C. Climate variability and change and their potential health effects
in small island states: information for adaptation planning in the health sector. Environ Health
Perspect. 2006;114:1957-1963.
14. Lin V, Smith J, Fawkes S. Public Health Practice in Australia: The Organised Effort. Crows Nest,
New South Wales, Australia: Allen & Unwin; 2007.
15. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health
response. Am J Public Health. 2008;98:435-445.
16. Menne B, Bertollini R. Health and climate change: a call for action. BMJ. 2005;331:1283-1284.
17. Department for International Development, World Bank. Executive Summary: Indonesia and
Climate Change: Working Paper on Current Status and Policies. 2007.
18. Epstein PR. Climate change: healthy solutions. Environ Health Perspect. 2007;115:A180-A181.
19. Indonesian State Secretary. Statement of the President of the Republic of Indonesia at the
Informal Ministerial Meeting on the Preparation of COP 13 and CMP 3. 24 October 2007.
20. Kates RW, Wilbanks TJ. Making the global local: responding to climate change concerns from the
ground up. Environment. 2003;45:12.
21. Keleher H. Why primary health care offers a more comprehensive approach to tackling health
inequities than primary care. Aust J Primary Health. 2001;7:57-61.
22. O’Brien G, O’Keefe P, Rose J, Wisner B. Climate change and disaster management. Disasters.
2006;30:64-80.
23. Patz JA, Campbell-Lendrum D, Holloway T, Foley JA. Impact of regional climate change on
human health. Nature. 2005;438:310-317.
24. Wingspread Conference on the Precautionary Principle. http://www.sehn.org/wing.html. Accessed
June 1, 2008.
25. Campbell-Lendrum D, Corvalan C. Climate change and developing-country cities: implications
for environmental health and equity. J Urban Health. 2007;84(3 suppl):i109-i117.
26. Ying Z, Peng B, Hiller JE. Climate change and the transmission of vector-borne diseases: a review.
Asia Pac J Public Health. 2008;20:64-76.
27. Sullivan C, Meigh J. Targeting attention on local vulnerabilities using an integrated index
approach: the example of the climate vulnerability index. Water Sci Technol. 2005;51(5):69-78.
28. Charron D, Thomas M, Waltner-Toews D, et al. Vulnerability of waterborne diseases to climate
change in Canada: a review. J Toxicol Environ Health A. 2004;67:1667-1677.
29. Blashki G, McMichael T, Karoly DJ. Climate change and primary health care. Aust Fam Physician.
2007;36:986-989.
30. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR,
September 6-12, 1978.
31. Maeseneer D, Willems S, Sutter AD, Geuchte Vd, Billings M. Primary health care as a strategy
for achieving equitable care: a literature review commissioned by the Health Systems Knowledge
Network. http://www.who.int/social_determinants/resources/csdh_media/primary_health_care_2007
_en.pdf. Accessed May 27, 2008.
32. Ataka Y, Ohtsuka R, Inaoka T, et al. Variation in malaria endemicity in relation to microenvironmental conditions in the Admiralty Islands, Papua New Guinea. Asia Pac J Public Health.
2001;13:85-90.
33. Reiter P. Climate change and mosquito-borne disease. Environ Health Perspect. 2001;109
(suppl 1):141-161.
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
http://aph.sagepub.com
Public Health Responses to Climate Change Health Impacts in Indonesia
Made Ady Wirawan
Asia Pac J Public Health 2010; 22; 25
DOI: 10.1177/1010539509350912
The online version of this article can be found at:
http://aph.sagepub.com/cgi/content/abstract/22/1/25
Published by:
http://www.sagepublications.com
On behalf of:
Asia-Pacific Academic Consortium for Public Health
Additional services and information for Asia-Pacific Journal of Public Health can be found at:
Email Alerts: http://aph.sagepub.com/cgi/alerts
Subscriptions: http://aph.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Citations http://aph.sagepub.com/cgi/content/refs/22/1/25
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
Public Health Responses
to Climate Change Health
Impacts in Indonesia
Asia-Pacific Journal of
Public Health
Volume 22 Number 1
January 2010 25-31
© 2010 APJPH
10.1177/1010539509350912
http://aph.sagepub.com
hosted at
http://online.sagepub.com
I Made Ady Wirawan, MD, MPH
Although climate change is a global concern, there are particular considerations for Indonesia as
an archipelagic nation. These include the vulnerability of people living in small islands and
coastal areas to rising sea levels; the expansion of the important mosquito-borne diseases, particularly malaria and dengue, into areas that lack of immunity; and the increase in water-borne
diseases and malnutrition. This article proposes a set of public health responses to climate change
health impacts in Indonesia. Some important principles and practices in public health are highlighted, to develop effective public health approaches to climate change in Indonesia.
Keywords: climate change; Indonesia; public health practices; public health principles
C
limate change is a current global concern. Its impacts on the ecosystem and human
health were highlighted on World Health Day 2008 with the theme “protecting
health from climate change.” It is stated that a changing climate is likely to affect
the conditions that determine public health, including vector-borne diseases, safe drinking
water, secure shelter, food supply, and social relations.1 It is projected that the temperature
will increase from 0.2°C to 0.3°C per decade in Indonesia. This will result in changing in
water availability, rising sea level, and have other impacts on ecosystem.2
Being an archipelago, Indonesia is exceptionally susceptible to rising sea levels.
Approximately 100 of Indonesia’s more than 17 000 islands are considered as small and
generally flat.3 These small islands are mainly located in remote areas of Indonesia.
Additionally, Indonesia has 81 000 kilometers of coast of which 50% to 70% is inhabited.4
Communities living on the small islands and along the coastal lines are at higher risk of
flooding, which may necessitate coastal population evacuation. This could have a considerable impact on the population’s health, especially on the health of the refugees. Most displaced people are housed in camps and shanties, which are vulnerable to increased social
problems, violence, and communicable diseases.5
Rising temperatures and variable precipitation encourage the expansion of mosquitoborne diseases such as dengue, hemorrhagic fever, and malaria. Global warming could
potentially lengthen the transmission seasons of these important vector-borne diseases.6 An
increase in rainfall could expand Indonesia’s dengue transmission zone and considerably
increase the population at risk from the disease. This is of particular concern in regions that
From the School of Public Health, Udayana University, Bali, Indonesia.
Address correspondence to: I Made Ady Wirawan, School of Public Health, Udayana University, Gedung PSIKM Unud,
Jalan PB Sudirman Denpasar, Bali 80232, Indonesia; e-mail: [email protected].
25
Downloaded from http://aph.sagepub.com at Monash University on January 5, 2010
26 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
lack immunity within the population as it results in more severe and fatal cases.7 Similarly,
malaria, which has caused high mortality and morbidity in eastern Indonesia, particularly in
Papua, Maluku, and the East Nusa Tenggara islands, could further expand into other parts
of this country. According to the Indonesian Ministry of Health,8-10 the incidence of malaria
in Java and Bali increased significantly from 18 per 100 000 people in 1998 to 48 per
100 000 in 2000, and showed a steady increase until 2007. It is also reported that malaria
has spread to almost a half of nearly 400 districts in 30 provinces.
Water-borne diseases such as cholera and diarrheal conditions could also become more
common in all areas. Food and water stored without proper refrigeration in warmer temperatures contain a higher concentration of pathogens.11 Water scarcity and problems of
freshwater supply can also been linked to climate change. Those who live in village areas
will be most affected by the increase in water-borne diseases.
Decline in agriculture productivity and aquaculture because of droughts in some areas,
rising sea levels, and extreme events would diminish food security.2 This situation contributed to starvation and malnutrition in the eastern parts of Indonesia in recent years.
There are also some direct impacts of climate change. Extreme temperatures could
cause other health problems, such as heart dysfunction, heat exhaustion, certain respiratory
problems, and lung tissue damage.12 Considerable forest fires caused by climate change–
driven droughts in the Indonesian island of Sumatera have resulted in the increase of respiratory illness and allergy symptoms.13
It is estimated that a significant increase in atmospheric greenhouse gas concentration
is likely in the next 5 decades. Combined with ongoing population growth, poverty, and other
environmental changes, projected climate change is expected to place a serious stress on
Indonesia and its population. This article aims to discuss a set of public health responses to
climate change health impacts in Indonesia. It addresses some important principles in public
health and its practices to find an effective public health approaches to climate change in
Indonesia.
Public Health Approaches to Climate Change in Indonesia
It is clear that the indirect impacts of climate change in Indonesia would be wider than the
direct impacts. The strategic response to address the indirect health outcomes will require
the principles and practices of public health.
Public health practices concern on three levels of prevention, that is, primary, secondary, and tertiary prevention.14 With regard to climate change, primary prevention deals with
how to reduce greenhouse gas emissions to slow and stem global warming, which is known
as mitigation. Secondary and tertiary prevention related to adaptation, that is, how to deal
with the risks and threats posed by climate change to diminish the related health burden.15,16
Public Health Role in Mitigation
Department for International Development (DFID) and the World Bank17 stated that
Indonesia has become one of the 3 largest emitters of greenhouse gases in the world. In
mitigation attempts to reduce greenhouse gas emissions, the involvement of other sectors is
imperative, although the role of health sector cannot be denied.15 Although the mitigation
to reduce greenhouse gas emissions is not the main area of public health, health input is
still significantly needed. Health professionals and scientists could provide explanation on
the health justification for climate change mitigation and present evidence on the health
impacts of a variety of approaches to climate change mitigation.18 In Indonesia however, this
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Climate Change Health Impacts in Indonesia / Wirawan
27
role could be appropriately performed by health professionals and scientists, if they are supported by sufficient resources, facilities, and supplies to conduct high-quality research. This
means that universities, the government, nongovernmental organizations, and international
bodies should work closely to increase capacity to perform interdisciplinary research. In
addition, one of the public health principles, intersectoral collaboration, is needed. There
are some current governmental departments in Indonesia, including Department of
Environment, Department of Transportation, Department of Energy and Natural Resources,
Department of Forestry, and Department of Health that could collaborate with one another.
Indonesian efforts have been shown by strong commitment from the government to
address this issue. It was indicated by signing the Kyoto Protocol in 1998 and ratifying it
through Law No. 17 of 2004.19 However, Indonesian efforts on emissions reduction have not
yet been optimal.17 It seems that the degree to which these efforts will have an effect will
depend on the leadership in every sector to deal with these serious concerns in Indonesia.
Public Health Role in Adaptation
Health promotion. It is important to provide communication, information, and education
about health issues arising because of climate change. Some people might believe that the
climate change health effects are threatening. However, it is shown that only 20% of
Americans understand climate change very well.15 In developing countries such as Indonesia,
the percentage of people who understand the issue might be lower.
The messages about climate change health effects could be integrated into some existing health promotion programs. This is feasible although that practice has not been optimally applied.20 The integration of such efforts would be effective if it is performed in
primary health care (PHC).21 PHC in Indonesia, which is commonly known as community
health center, is available in every subdistrict. This practice would increase the accessibility
of 240 million or more people, almost a half of whom live in remote Indonesia. The PHC
approaches are also suitable to address specific groups, considering differences in the levels
of understanding, culture, ethnicity, and susceptibility to the climate change health effects.
Relocating populations. There are some particular concerns related to climate change impacts
on small islands. People living in the small islands and coastal areas are particularly vulnerable
to tropical cyclones, flooding, drought, and tsunami. It is stated that adaptation strategies
to sea level rise are classified into 3 categories, namely, “retreat, accommodate, and protect.”13
Retreat means leaving the land to minimize the risk of loss of infrastructures. Accommodation
indicates altering land use because of rise in water levels, such as “raising buildings, or
changing to more salt-tolerant crops.” Protection means the use of constructed barriers to
protect coastlines from the sea.13
In Indonesia’s small islands, this could mean moving people from some low-level areas
to higher grounds, if possible on the same island. However, this will face strong ethical and
human rights issues. It is unethical to encourage people to abandon their land when there
is uncertainty about the outcomes. Accommodation and protection could face difficulties
related to the availability of resources. The challenge here is to shift this responsibility to
local government because the decentralization process at regency level is currently improving, with guidance from central government and experts.
Although most disasters cannot be prevented, their effects could be anticipated.22 It is
therefore important to create early warning systems to be able to address potential health
impacts more effectively. The development of public health infrastructure in small islands
and coastal areas should be strengthened. Furthermore, disaster preparedness plans should
be developed. Public health sectors would much contribute in addressing population’s health
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28 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
related to displaced population. Most displaced people are generally housed in camps and
slums, which are vulnerable to increased social problems, violence, and the spread of communicable diseases.5 However, these approaches are difficult to follow because of the lack
of awareness from the community, government, and other related sectors about this issue.
This is mainly because of the uncertainty related to the climate change outcomes especially
those related to population displacement.16,23 It is a challenge to convince all sectors that
there should always be preparedness to deal with the worst scenario. The precautionary
principle suggests that precautionary measures should be taken when there is threat of
harm to human health, although the scientific associations are not fully established.24 This
principle can be used to increase the awareness of related sectors to collaborate in ensuring
community safety.
Another issue that is well established in public health is health inequity. The threat of
climate change impacts on small islands and coastal areas, especially in the eastern parts of
Indonesia is one of the contributors to this health inequity. This excessively threatens some
populations, especially poor people in isolated community, ethnic and minority groups.25
Vulnerability assessments should be performed in such areas to be able to make public health
actions that address the most vulnerable populations and focus on eliminating the health
inequity.
Surveillance. The role of surveillance in determining disease trends, identifying vulnerable
groups and areas as well as in planning, implementation, and evaluation of public health
programs is without doubt an important one.14 Good surveillance systems will provide
guidance to design effective public health programs. There are some data that should be
systematically collected in developing responses to climate change, including data on
environmental risks, vulnerability, and diseases. Data of environmental risks comprises
meteorological data such as temperature trends. These data also cover ecological data such
as mosquito density. The vulnerability of each area should be assessed, including physical
factors such as altitude, infrastructure, and facilities, as well as social factors such as
remoteness and poverty.26,27 The collection of the environmental risk and ecological data
could be integrated to a public health approach specifically developed for the small islands
and coastal areas that is mentioned in the previous section.
Diseases data are usually collected in the current public health programs. The communicable diseases programs currently collect these data routinely. This is related to climate
variability and should be strengthened to be able to monitor food-borne and water-borne
diseases.28 Surveillance of vector-borne diseases could be closely linked to the environmental
risk surveillance, especially mosquito density data in prevention of malaria and dengue hemorrhagic fever. Additionally, current integrated service centers in every village that are run by
PHC could be used to collect data related to malnutrition, particularly in areas that face
decrease in agriculture or aquaculture productivity.
Surveillance on environmental risk, vulnerability, and disease is currently performed
separately through different methods. It is imperative to integrate all these data to make an
effective surveillance system to address adverse health impacts caused by climate change.
This system should be also expanded to reach all community levels.15 This can be achieved
through vertical coordination from central government to subdistrict level with clear mechanism of reporting.
Prevention and preparation for communicable disease control. The opportunity here is to
develop an effective early warning system and preparedness to counter disease outbreaks.
Early warning systems are usually developed by combining the data collected in the surveillance programs, including environmental data (weather and climate forecast), ecological
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Climate Change Health Impacts in Indonesia / Wirawan
29
data (vector density), and epidemiological data (water-borne and vector-borne diseases
rates).29 This system will give warnings when increased risk could be expected. Although
Indonesia has not yet developed a national early warning system for disease outbreaks, the
Indonesian Ministry of Health has instructed all provincial governments to prepare for
potential dengue outbreaks before the rainy season (August to September).13 The preparation includes health campaigns, cleaning up mosquito breeding sites, and data collection
of dengue incidence in every local district hospital. Policy makers, local governments, and
community must be regularly informed about the importance of these measures. Meanwhile, the central government should start multisectoral collaboration to create an effective
early warning system.
The instruction could be also expanded to the prevention of water-borne diseases and
malnutrition. In this light, the instruction is for local governments to prepare for possible
outbreaks of diarrheal diseases because of the lack of safe water supplies before the dry
season (April to May). The preparation might include health education about the importance of sanitation and adequate supply of drinking water to prevent diarrheal diseases. In
addition, every health center and hospital should ensure the availability of supplies, essential drugs, and so on in anticipation of the increased number of cases.
As suggested in the previous section about health promotion, the role of PHCs is a
very important one. The basis of this program has been developed since the introduction
of PHC during the declaration of Alma-Ata.30 This really needs strong commitment from
all sectors; and community involvement to support this idea is pivotal. Community involvement could be in the form of the provisions of community health workers (CHWs) or
volunteers and the participation of the community per se to the success of the early warning system.31 CHWs are available as part of the health system in Indonesia. The provisions
of imparting appropriate training to them and what simple steps can do for their involvement would be beneficial and can create a bridge between the community and the health
sectors. This is particularly important for addressing the concerns of people who live in
remote and vulnerable communities.
In Indonesia, particular consideration should be given to the spread of vector-borne disease to the areas that lack immunity.23,32,33 Areas such as Jakarta, Bali, East Java, and East
Kalimantan have a high incidence of dengue and so the population have better immunity than
Sumba for instance, which has a low incidence of dengue but the highest rate of malaria.9
Poorly developed infrastructure and high levels of poverty here mean that a dengue infection
could worsen the situation. Indeed, the spread of dengue in areas where there is lack of immunity is one of the reasons why the fatality rate for dengue has been so difficult to control. The
application of the surveillance system to monitor the cases is important and should be combined with the preparedness of health care to provide adequate case management.
Health workforce training. The integration of preventive and curative approach is also needed.
The capacity of health centers in disease management should be enhanced. This could be
achieved by providing regular health workforce training.15,29
It is stated that a qualified and competent health worker is essential to the success of
the health system. An intensive effort will be required at the district, provincial, and central
levels, in preparing the health workforce for the possible impacts of climate change and for
other challenges over the next decades. Medical and public health practitioners should
be trained to identify and manage emerging health threats that may be related to climate
change. This should ensure an essential set of competencies throughout the health system and
building capacity for scientists with multidisciplinary and specialized skills.15 The involvement of universities, especially medical and health education providers to include this issue
in current curriculum could be beneficial for the long term.
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30 Asia-Pacific Journal of Public Health / Vol. 22, No. 1, January 2010
Conclusion
There are particular conditions that should be considered for Indonesia as an archipelago in
dealing with climate change. These include the vulnerability of people living in small islands
and coastal areas to rising sea levels, the expansion of the important mosquito-borne diseases
(dengue and malaria) into areas that lack of immunity, and the increase in water-borne diseases and malnutrition.
Public health approaches to those issues are mainly placed into mitigation and adaptation measures. Public health plays more important role in the adaptation, which can be
categories into some practices, including health promotion, relocating populations, surveillance, prevention, and preparation for communicable disease control and health workforce
training. It is clearly shown that all of those practices are interdependent on each other.
Interdependence is also shown between preventive and curative approaches.
There are some public health principles that should be highlighted to develop an effective approach. Intersectoral collaboration is imperative in all practices both in mitigation
and adaptation. This would involve all sectors and departments, governmental and nongovernmental organizations, universities, community elements as well as international bodies.
Some ethical, human rights, and inequity issues could, however, arise especially in addressing more remote, vulnerable, and small island communities.
The capacity of existing PHC centers should be improved, as PHC approaches could
reduce health inequity and bring health services closer to the community. The role of community health workers is undoubtedly important and would provide a bridge between community and health centers especially in addressing people living in more remote areas.
The highly complex effects of climate change will vary significantly by region and population group. The degree to which the approach will give maximum beneficial effects will be
determined by the quality of governance and leadership that addresses this serious issue of
uncertainty of the impacts.
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