The government cannot fulfil its second phase target for immunisation against measles-rubella. The Indonesian Pediatricians Association has noted 699 cases of measles and rubella up to September this year. The Indonesian Ulama Council accused the Ministry of Health for being lax in requesting a change of their fatwa (edict) that declared vaccination was haram (illegal in Islam). Now preachers Abdul Somad and Mamah Dedeh have been roped in.
Mustaqowini, 35, did not bat an eyelash when an officer from her children’s school at the end of August handed her a letter to sign stating permission to conduct measles-rubella immunization. Instead of signing, she slid the unmarked letter back to the officer. “I knew the vaccine’s serum contains pork,” she said on Wednesday a week ago.
The woman from Kampar, Riau, was adamant in not allowing her two offspring be vaccinated, despite the government and the Indonesian Ulama Council (MUI) in Riau allowing for measles-rubella (MR) immunization to be conducted, after a prior edict postponing approval, because the vaccine did not yet carry the halal (allowable) label. As of June, the local health office had detected 50 cases of measles in the regency.
In fact, Mustaqowini understood full well that measles can be prevented with an MR immunization. But she chose to accuse the government for not clarifying the halal status of the MR vaccine.
Even stronger defiance occurred in several regions. Deputy II for Study and Management of Presidential Priority Programs of the Presidential Staff Office, Yanuar Nugroho, obtained a report that six health officers in the Popayato Induk community health center (Puskesmas), in Pohuwato regency, Gorontalo, received threats when they tried to carry out vaccination. “Parents had brought machetes, locked the door, and threatened to cut up the health officers doing the immunization,” said Yanuar.
Immunization officers in the South Selalak integrated health post (Posyandu) in Banjarmasin experienced similar intimidation. Yanuar related how a man brandishing a sharp weapon came to the Posyandu and said the MR vaccine was haram for containing pork enzymes. The unknown man also forced the health officers to throw away all their vaccine stock, which made the officers run for their lives.
Such high levels of opposition against the MR vaccine has resulted in failure of the Health Ministry to achieve its second phase MR immunization target carried out in 28 provinces outside the island of Java. The first phase was carried out last year in six provinces in Java. Yanuar said MR vaccination up to September had only covered 42.98 percent of 32 million children. The government target is 95 percent. “An extraordinary measles situation could very well reoccur,” said Yanuar.
The level of coverage was revealed by Yanuar in a meeting with the Health Ministry two weeks ago. Vaccination in Aceh, as an example, only managed to reach 4.94 percent of the children, in Riau less than 20 percent, and in other areas less than 30 percent. In fact, even if the government managed to immunize 85 percent of the child population, measles cases that occur can overwhelm 82,000 children with a tally of 1,000 deaths. “The ministry was quite taken aback because their data differed to ours,” said Yanuar.
The Indonesian Pediatricians Association recorded 699 cases of measles and rubella, popularly known as German measles, in Indonesia up to September this year. When affecting children, measles can cause death. Rubella has a slightly lighter effect on patients compared to measles, but turns up very similar symptoms in the form of a red rash. But, if rubella is caught by an expectant mother, the baby when born could be permanently disabled.
Several regional administrations have declared a status of extraordinary state of measles and rubella in their areas. One of them is South Kalimantan. Chief of the Southern Kalimantan Health Office Muhammad Muslim recorded 275 cases of measles and rubella since the beginning of 2018. The Health Office discovered that most patients were in Banjarbaru, some 30 kilometers southeast of Banjarmasin, with 71 cases.
A high number of cases occurred in pesantren (Islamic boarding schools), including the Darul Ilmi Pesantren and Al-Falah Pesantren. For that, Banjarbaru was declared an area with an extraordinary occurrence of measles. “MR vaccination in South Kalimantan had only reached 36 percent of the population,” said Muslim on Thursday last week.
Contagion of measles and rubella in South Kalimantan spread to neighboring province Central Kalimantan. Chief of the Central Kalimantan Health Office Yayu Indriarty said her region had already declared an extraordinary level of measles in Kapuas regency, which shares a border with South Kalimantan. To date, 68 cases of measles have occurred there.
Said Yayu, many Central Kalimantan people worked fields and did trading in South Kalimantan. Those who contracted the measles were probably exposed to the virus when they travelled to the neighboring area. “A number of patients have family ties or had recently made a trip to South Kalimantan,” she said.
Yanuar Nugroho of the Presidential Staff Office said the polemic surrounding the MR vaccine was triggered by MUI Fatwa No. 4/2016 on immunization. One of the articles of the fatwa states that use of a vaccine made from impure substances are declared haram. The MR vaccine used in Indonesia makes use of enzymes taken from the pancreas of pigs—which in Islam are haram—despite that in production, the end vaccine has gone through a purification process.
The MUI fatwa was used by regional administrations to postpone the immunization drive. Aceh Governor ad interim, Nova Iriansyah, and Balikpapan (East Kalimantan) Mayor Rizal Effendi even forbade immunization to be carried out in their areas. “Let’s not yet allow immunization until there’s a halal declaration from the Ulama Council,” said Nova.
Chair ot the Riau MUI Muhammad Nazir said his organization had declared MR immunization haram in accordance with the fatwa from the central MUI. The reason, said Nazir, was because the Health Ministry had not reported the composition of the vaccine which was produced in India. “We could not tell the people the vaccine was halal because in truth there is that pork element in it,” he said.
In the regions, the MUI also noted that health officials could not openly declare whether their vaccines were halal or not during dissemination of the intended vaccination drive. MUI Deputy Secretary-General Salahuddin Al-Ayyubi said his colleagues several times came across government officials who said the MR vaccine had already been stamped with the halal label. “Our colleagues in the regions were very confused. There had never been a halal vaccine label, yet the health office declared it already halal,” said Salahuddin.
An effort to prevent the news that the MR vaccine was halal escalated. MUI wrote the Health Ministry on July 25. According to Salahuddin, the letter reiterated that there was no MR vaccine bearing the halal label because the Health Ministry and the producer had not yet submitted a request for certification. “If there was a declaration of halal-ness, then that was duplicity to the public,” he said.
The ministry responded to the MUI letter three days after. According to Salahuddin, Health Minister Nila Moeloek requested a meeting. The meeting only came about on August 3. MUI Chair Ma’ruf Amin himself received the Health Ministry group at the MUI office in Jakarta.
In the meeting, Nila and Ma’ruf discussed the fate of the MR vaccine program already declared haram. According to Salahuddin, MUI had prior suggested the government contact the MR vaccine producers in India to immediately submit the its composition to the MUI Institute for the Study of Foods, Drugs, and Cosmetics. While that was in the process, the MUI and the ministry agreed to get on with immunization, particularly for the portion of the community not impeded by Sharia (Islamic) law. “The MUI in fact was quite helpful,” said Salahuddin.
The ministry only sent a letter to the Serum Institute of India, the producers of the MR vaccine, on August 6. On the same date, Minister Nila also sent a circular to the heads of regional administrations on implementation of the second stage of MR vaccination. Said Salahuddin, also on that date, the ministry sent a letter of request to the MUI. “They requested a fatwa and certification for the product stating it was allowable and halal.”
MUI Chair Ma’ruf Amin stated the ministry was laggard in requesting a mubah (permissible) fatwa for the MR vaccine. With a fatwa stating it was allowable, the vaccine initially declared haram was allowable in a condition of emergency and with the consideration there was yet no alternative. According to Ma’ruf, the ministry had left the status of the MR unclear for two years since the MUI announced the fatwa on Immunization in 2016. “In the end, the community had no trust (in the product),” said Ma’ruf.
Despite accusing the ministry for being laggard, the MUI processed the request for a mubah fatwa. The Fatwa Commission held a session on August 17. Secretary of the MUI’s Fatwa Commission Asrorun Ni’am led the meeting attended by at least 40 ulama members of the commission and representatives of the Health Ministry, the Food and Drugs Supervision Body, and Bio Farma—the importer of the MR vaccine in Indonesia. “The ulama indeed wanted to help find a solution, but first we had to know the composition of the substances,” said Hasanuddin A.F., chair of the MUI’s Fatwa Commission.
According to Hasanuddin, the commission finally allowed the vaccine to be used by announcing the allowable fatwa on August 20. Still, the MUI cannot publish a halal certification as requested by the Ministry because the MR vaccine makes use of an element considered haram in its production process.
Though the mubah fatwa got the gavel, the rate for immunisation still went haltingly. Health Ministry data shows, since the publication of the MUI Fatwa No. 33/2018 on the use of the MR vaccine SII product for immunization, vaccination has only managed to gain traction by a mere one percent a day.
Presidential Staff Office Yanuar Nugroho said the MR immunization rate was slow because among other things, the knell of the MUI’s mubah fatwa did not ring as loudly as their haram fatwa. “In the end we had to go through informal channels in order for the mubah fatwa to sink in properly,” said Yanuar.
Yanuar met Muhammad Dian Nafi, the leader of the Al-Muayyad Pesantren in Surakarta, Central Java. Dian suggested the government work closely with the MUI to disseminate the mubah fatwa in the regions. “The Health Ministry and ulama communications drive had to work in better synergy,” said Dian, who claims to also slip in messages on the dangers of the measles and rubella in his more recent sermons.
Abdul Ghofarrozin, member of the presidential special staff on pesantren matters, was also contacted by Yanuar. Ghofarrozin suggested the Fatwa Commission go more aggressively into the heart of the areas that refused the MR vaccine. “I’m also suggesting the government make approaches to preachers and proselytizers who have huge followers,” he said.
A government official said several people have been dispatched to lobby celebrant preachers such as Abdul Somad Batubara and Dedeh Rosidah alias Mamah Dedeh, to mention the MR vaccine and the MUI’s mubah fatwa in their sermons. Abdul Somad confirmed the news he had assisted in disseminating MR immunization. “I carried it out with the Riau Province Health Office three months ago,” he said in a text message sent through a friend’s cell phone.
Somad is of the opinion, despite the MUI not giving out a halal fatwa, because we are facing an emergency, people may use the product. In one of his sermons on video, Somad says something similar. “Choose pigs or death?” he asks his congregation. The clip was taken from one of his appearances three months ago.
Somad gives an analogy. If a person finds themselves in a jungle, and there is no halal food to be found, only a pig, then one may eat the pork rather than die of starvation. “To this day, there is no halal vaccine. Thus, if you’re scared of dying, use the vaccine,” he said.
The same government official also claims to have communicated with Mamah Dedeh. The female preacher was asked to convey the immunisation proposition in an emergency situation. “I once explained it at an off air sermon once because someone in the congregation asked. If the ruling is mubah, then immunization is allowed,” said Mamah Dedeh when asked for confirmation.
Health Minister Nila Moeloek said the government has worked hard to disseminate and implement the second stage of MR immunization. The ministry has no wish for Indonesia to become one of the countries with the most cases of measles in the world as in 2015. “The target is for Indonesia to have completely eliminated measles and rubella by 2020,” she said.
Nila admits that there many areas still with very low immunization reach. She hopes the ministry and the MUI can work shoulder to shoulder in making MR immunization successful. “I think the ministry and the MUI can go together to the regions and inform people about the latest fatwa,” she said.
RAYMUNDUS RIKANG, DEVY ERNIS (JAKARTA), KARANA W.W. (PALANGKARAYA), ADI WARISIDI (ACEH), RIYAN NOFITRA (PEKANBARU)
Health Minister Nila Moeloek:
Immunization Until We Hit the Target
THE Health Ministry has failed to achieve its second stage measles-rubella immunization target. Health Minister Nila Djuwita Moeloek said there have been several obstacles that resulted in the low vaccination achievement rate. Nila’s following explanations were compiled from several question-and- answer occasions.
Why is the reach of the second stage MR immunization drive below target?
We need to vaccinate 70 million children en masse. Last year, half of that number was carried out on the island of Java. This year it’s outside of Java, where conditions are not easy and our officers have to face extraordinary geographical challenges. We have worked very hard. In Papua, our officers had to take many initiatives.
Is one of the factors for public refusal the MUI’s haram fatwa?
Maybe. I do not want to say whether that was or was not the factor, nor that refutation in the community was because of that factor.
What’s the solution?
If we can, the period should be extended. The success rates of several areas are quite high, such as in Papua and Bali. Particularly for areas where acceptance was low, the ministry and the MUI (Indonesian Ulama Council) need to go together to provide understanding in the community. We will continue immunization until we reach the target, which is for people to understand why immunization is so important.
What if still many people refuse the vaccine?
Please understand the emergency situation is not for them alone, but also for their community. Please remember the measles epidemic in Asmat. The disease is easily contagious and can kill.