They Don’t Want to Listen to Me
Pandu Riono, Epidemiologist, Faculty of Public Health, University of Indonesia:
PANDU Riono found himself a target of a cyber-attack following his criticism towards the government for the latter’s handling of the Covid-19 pandemic. The Twitter account belonging to the epidemiologist with the faculty of public health, University of Indonesia, was hacked last Wednesday, August 19. Pandu views the attack as an attempt to divert attention away from the real issue at hand—the unsuccessful management of the pandemic—to him who is seen as ‘lecturing’. “We should always remember that our enemy is Covid-19, not the government or others,” Pandu, 64, said during a video interview with Tempo on Wednesday, August 19.
Pandu is one of a few scientists who are critical of the government’s Covid-19 response policies. Most recently, he criticized the joint venture between a research team of Airlangga University (Unair), Surabaya, East Java, and the State Intelligence Agency (BIN) and the Army in search of the Covid-19 cure. Unair claimed that a cocktail of drugs such as lopinavir-ritonavir, azithromycin, and hydroxychloroquine had the potential to become the first Covid-19 cure. Meanwhile, Pandu said the process and the clinical trial of the combined drugs lacked transparency and, reportedly, did not meet the international standards.
This is not the first time Pandu calling out the government for various irregularities in the Covid-19 policies. He, for instance, vigorously called for the discontinuation of rapid tests, urging the government to enhance testing and contact-tracing. He also pointed out that the Covid-19 taskforce’s performance had not been optimal. “Actually, the task force was unnecessary because we already have the health ministry,” he said. From the outset, Pandu felt that the Covid-19 management command should be under the direct control the President.
Pandu talked to Tempo reporters Sapto Yunus, Mahardika Satria Hadi, Nur Alfiyah, Dody Hidayat, and Abdul Manan. Former member of the National Bird Flu Control Commission who calls himself a pandemic expert talked about the importance of procedures in clinical trials of drugs, effective measures to combat the pandemic, and his critical stance towards the government. The interview was supplemented with WhatsApp chats on August 20.
You’ve said that you would challenge Unair’s Covid-19 drug if it passes the clinical trial and later gets registered at the Drug and Food Monitoring Agency (BPOM). What are your considerations?
A reporter asked me about it and I just heard that time that the Unair research team reported to the Army chief of staff. I questioned why they should report to the Indonesian Military (TNI), even more so when I learned that it was the Army chief of staff himself who took it to the BPOM for expedited distribution permit. I found it odd. It’s a pity for the BPOM if they went there for the permit straight away. It’s as if the whole thing is fait accompli.
Which part of the Unair’s research do you disagree with?
I disagree with the process although I don’t know yet the result. From what I understand from the power point presentation submitted to the TNI which can be downloaded at the TNI’s website, the clinical trial rules do not meet the standards. Perhaps there are procedures that were not followed. That casts doubt on the process. Moreover, I didn’t find the protocol (in the presentation).
What should the protocol look like?
Usually there is a protocol to follow in the international drug registration process, how the clinical trial process is done. Both the WHO (World Health Organization) and United States have clinical trial registries to document clinical research and trials. Many researchers in Indonesia who are doing vaccine or convalescent plasma research, for example, register their trials there so everything is transparent. I looked for Unair’s research there but it wasn’t there. There must be unusual procedures involved. I raised questions about the procedures from the start when they discovered that drug cocktail. After all, it was a cellular level research but it had been used directly for humans. The drugs used for the combination are already in use. The trial is for drug repurposing.
So, it’s not something new?
Several global clinical trials, including one in which Indonesia is involved called Solidarity Clinical Trial, are testing the use of existing drugs including hydroxychloroquine, remdesivir, and some HIV (human immunodeficiency virus) drugs for Covid-19 treatments on humans.
Can the Unair’s drug be called a preparation?
No, it’s a combination. Our Unair colleagues used the term preparation (racikan) as they mixed several drugs into one. In Indonesia, it’s known as ‘making powder’. Drug components are crushed and compounded in a capsule. That seems to be the method. So, they called it a preparation.
What procedures are involved in a clinical trial according to the international standards?
If I say ginger can cure Covid-19, I have to prove it in a scientific procedure. I have to do a proper clinical trial. Otherwise, my claim is not credible. Every claim must be based on a research method. The best method to study cause-and-effect relationships is the randomized double-blinded controlled trial method. It compares (the efficacy of) drugs in randomly selected groups of people. Like other vaccine trials, some get the drug, some placebo. As it is a double-blinded trial, no one—be it the researcher or volunteers—know who gets what.
Are there any other more streamlined approaches?
Randomized double-blinded trials are the gold standard for clinical trials in declaring that X drug can generally cure given diseases. The prescribed procedures must not be skipped even in times of emergency. There are examples everywhere that use the same procedures for (making) vaccines or drugs. Phase III trial is one of the procedures where the randomized double-blinded method is used. We simply can’t hand out the drug to everyone after observing a strong immune response in Phase II. We want to see, first of all, if there are effects and if it is relatively safe to be used for general population.
Pandu Riono at the Prince Mahidol Award Conference universal health insurance forum in Bangkok, Thailand, last February. Private Doc
Whatever discrepancies did you find in the Unair-BIN-Army research?
What made me doubtful is the use of 1,000 Covid-19 cluster in Secapa (the Army’s military cadet school) in Bandung in the trial. Initially, they were conducting the research in hospitals. But as soon as they saw this opportunity, they changed the protocol. They should have consulted with the university’s research ethic committee or the health research and development agency for such a protocol change. A national research usually needs review from that agency.
To protect the researchers as well as to ensure that they have done the research in line with the standard and that the drug does not cause adverse effects on humans. So, there will be no allegations of human rights violations later on as the treatment can harm or even cause death. This is very important.
Is the recruitment of Secapa students as research subjects wrong?
The fact that some of the students are people without symptoms raises the question. They don’t need medication actually. A lot of them recovered, of course (chuckles).
The samples are not reliable enough?
They don’t fit the initial criteria that the drug should be given to people with mild, moderate and severe symptoms. What many doctors and medical professionals are waiting for is a medicine for patients in severe conditions. A friend of mine said we needed a medicine for patients who are already in intensive care and using ventilator so that the ventilators can be taken off and patients can come out of ICU (intensive care unit) alive. That’s what we urgently need.
How about the research procedures?
Even reporting no longer meets the clinical trial reporting standard. Reports should represent ideas, processes, and other facts pertaining to the research. That’s very important. As such, we can see the weaknesses.
Since the government implemented the transition phase for social restrictions, the number of Covid-19 cases continues to rise and the first wave is not even over yet. What policies should the government enforce?
We certainly don’t want a surge in cases, but how do we slow down the virus’ reproductive number which is around three up to four to one? We did prepare a mathematical model and found that there are two initiatives that can suppress the spread as effectively as the stay-at-home initiative. The first is people’s strict compliance with the health protocol and second, active surveillance. In an active surveillance, there are three components: testing, tracing, and isolate those who are tested positive. That’s the way to break the chain of infection.
How about prevention?
Follow the three fundamental rules. Wear the right masks, keep a distance from others and wash hands frequently. If 80 percent of the population complies with these rules and with a good surveillance, we will be able to curb the spread while allowing social-economic activities to run.
Isn’t tracing still limited so far?
The test-trace-isolate ratio should be above 30 per one positive case. We want to identify and isolate virus carriers. The current ratio even in Jakarta is only five to 10. It’s still small. This needs special attention and also money to pay personnel called contact tracers.
How many contact tracers are needed to ensure optimal surveillance?
It depends on the number of cases found. For each case, one person may need to talk to people the whole day for a couple days. If there are 5,000 cases in Jakarta, for instance, we need at least 5,000 personnel. One tracer can handle two to five patients.
Can the model from the Faculty of Public Health of the University of Indonesia (FKM UI) predict when the pandemic will peak in Indonesia?
Yes. We gave a presentation to the presidential staff office. The team also discussed and debated to answer the question as to when the second wave will come and how to prevent it. It turned out we found ways to relax restrictions while at the same time limiting the spread. We don’t want to be seen as only giving solutions that kill the economy, but if the surveillance is not optimal, the test-tract-isolation ratio is still low, and the people’s compliance with the health protocols is still low, the curve will continue to point upward.
Besides presenting the model to the presidential staff office, to what other institutions did you and the FKM UI research team give input?
We often assist the National Development Planning Agency (Bappenas), particularly at the onset of the pandemic. We also helped several regional heads, among others, Pak Anies Baswedan (Jakarta governor) and Pak Ridwan Kamil (West Java governor). We also worked with the Tangerang and Bali city administrations with sero survey using antibody tests to measure people’s antibody levels as well as infection level among the communities. We utilized available rapid test kits.
Haven’t you been calling for rapid tests to be discontinued?
Yes, except to measure antibody levels (sero survey). For example, in New York, after the outbreaks subsided, people’s antibody levels are surveyed via rapid test. Some were sick and some were not. From there, they found how many residents already had antibodies against Covid-19.
What are the benefits of a sero survey?
It is useful in determining infection levels in communities or how many percentage of the population of a given area has been infected, etc. If the data are reliable, they can be used in formulating policies.
Why didn’t you favor rapid test in managing the outbreaks?
We should refrain from using rapid tests because they can make us become lax in our war against the disease. Antibody rapid test can only detect accurately if someone already has antibodies. A non-reactive or a negative result does not necessarily mean the person doesn’t carry the virus. He/she just doesn’t have the antibodies yet. A virus carrier, albeit already infected, may not show symptoms and can be tested non-reactive via a rapid test. But if person is tested a week later as antibodies are formed seven to 10 days after the infection, he/she can be positive. A swab test is needed to determine if someone has the virus.
Has the Covid-19 mitigation committee ever asked you for input?
Of course not. It’s impossible for them to ask for our advice. More often than not, whatever I voice is what they don’t want to hear. They only listen to what they want to hear.
Why do you feel that President needs to lead the Covid-19 response measures?
He indeed needs to lead it with the assistance of the ministries. A task force was unnecessary. Its presence caused the health ministry to be left out. I urged that the health ministry be involved regardless of whoever the minister is. The ministry is a system consisting of many experts. Sulianti Saroso was once the director-general for prevention and eradication of infectious disease and she successfully eradicated smallpox. The disease control and prevention directorate-general currently led by Pak Achmad Yurianto and his staff are ready to tackle the disease.
Hasn’t the health ministry already joined under the task force?
A task force or a national task force is for handling disasters. Disasters usually end but this disaster continues. They don’t really understand how to tackle the problems although they have expert teams.
You’ve been known to be critical of the government. Has your faculty ever raised an objection against your harsh criticisms towards the government?
Some have asked the dean to prohibiting me from using the FKMUI’s name. If I’m interviewed, I always say I speak on my own behalf because some things I say may disgrace my faculty. Attacks come from everywhere particularly when I, for instance, asked Pak Jokowi to directly lead the Covid-19 response measures. I’ve said it since March when the government was assembling the national task force. I protested it because it would not work optimally. Perhaps there will be a lot of threats and attempts to smear my reputation. I’m not a perfect person, you see.
Are you also being terrorized?
Subtle threats have always been there for some time and are increasing including circulating photos to smear me. But I always ignored them. Hopefully I’ll survive.
You fell victim to hacking and doxing and a photo of you and a woman was spread online.
My (Twitter) account was hacked and it was normal I was given warning. But I will continue to voice as to what should be done by the state to respond to the Covid-19 pandemic strategically so as to stem the spread or control the outbreaks. Indonesia must be safe first so that it can achieve social-economic recovery quickly.
Why was the photo used as a weapon to attack you?
It was a distraction, an attempt to divert the attention from the real issue of the unsuccessful management of the pandemic to me who is seen as ‘lecturing’. We should always remember that our enemy is Covid-19, not the government or others.
PANDU RIONO | Place and date of birth: Jakarta, April 22, 1956 | Education: Bachelor of Medicine, University of Indonesia (1982); Master in Biostatistics, University of Pittsburgh, US (1989); PhD in Epidemiology, University of California, US (2001) | Career: Lecturer, Faculty of Public Health, University of Indonesia (since 1985); Specialist, Advocacy and Oversight, FHI-Jakarta (2002-2009); Consultant, World Bank, Jakarta (2007); Consultant, HIV/AIDS Data Hub for Asia Pacific, UNICEF Bangkok (2008); Consultant, Estimation of Population Vulnerable to HIV Infection, Health Ministry (2009); Guest Researcher, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney (2010); Senior Consultant, National Tuberculosis Program, Health Ministry (2012-2018) | Organization: Member, Indonesian Medical Association (since 1982), Member, Indonesian Public Health Association (since 1989), Member, Indonesian Statistics Association (since 1992), Member, International Epidemiological Association (since 1993), Chairman, Communicable Diseases Division, Indonesian Medical Association, (2003-2009)