Letter from Indonesia

As an archipelago country, Indonesia consists of over 17,000 islands that lie mostly from east to west around the equator. The largest islands are Sumatra, Java, Kalimantan, Sulawesi and Papua. The population of Indonesia is over 280 million, making it the fourth most populous country, with Java as the most populated island. As a result, Indonesia has many local languages and a multicultural society. Altogether, the geography, demographics, multiethnic population and socioeconomics influence the distribution pattern of diseases in the country. Not only have respiratory infection diseases become major issues that must be taken seriously, but so have noncommunicable diseases (NCDs). In the last three decades, there has been a shift of the disease burden from infectious diseases to NCDs. Changes in environment, technology and lifestyle contribute to the pattern of disease in Indonesia, which is dominated by NCDs. Tuberculosis (TB) remains a major issue throughout Indonesia. According to the National Basic Health Research Report 2018,1 most NCDs are trending upwards compared to a previous report from 2013. Respiratory NCDs include COPD, asthma, interstitial lung diseases (ILDs), lung cancer and post-TB sequelae. As NCDs are chronic, often asymptomatic and progressive, patients usually do not realize that they have the disease until they experience signs and symptoms of complications. This indicates that there is a need for early screenings, early treatments and periodic monitoring in high-risk populations. According to the National Basic Health Research Report 2013,2 the prevalence of asthma, COPD and cancer were 4.5%, 3.7% and 1.4%, respectively. Occurrences of asthma and cancer were found to be higher in the female population, but occurrences of COPD were higher in the male population. Data on the prevalence of ILDs in the country is not yet available. However, ILD cases are starting to be encountered more frequently. Another study of COPD, conducted in Indonesia in collaboration with Vietnam in 2013, researched the impact of COPD in non-smokers aged 40 years and older, whose exposure to biomass was high. Approximately 25%–45% of COPD patients have never smoked, but their condition may have been caused by exposure to indoor and outdoor air pollutants, exposure to dust and fumes in the workplace, repeated lower respiratory tract infections during childhood, a history of pulmonary TB, chronic asthma or poor socioeconomic status. Globally, it is estimated that 50% of households and 90% of rural households use biomass fuel as their main source of energy, and approximately 700,000 of the 2.7 million global deaths from COPD can be attributed to indoor air pollution from biomass fuels, particularly in females. This study was conducted by visiting participants' homes. The data were obtained through spirometry with a portable spirometer and standardized questionnaires. The survey team chose the first household arbitrarily from within a small community (rukun warga/RW), then approached every household until nine participants were successfully enrolled. A total of six females and three males from each RW enrolled. The challenging part of this study was finding a participant who had never smoked. Almost every candidate who was approached was an active smoker. Besides participants in the province of Jakarta (urban area), participants in the provinces West Java and Banten (rural areas) were also sought. Sometimes more effort was required to reach mountainous areas, and it was even more difficult to find male participants who had never smoked in these regions. This study found that the prevalence of COPD in Indonesia was 6.3% (rural 7.2% and urban 5.4%), and exposure to biomass pollutants from cooking and heating in rural areas was higher than that in urban areas.3 According to the Global Adult Tobacco Survey 2021,4 34.5% of the Indonesian population (65.5% of men and 3.3% of women) consumed tobacco. This high rate of smoking has become a major issue that needs urgent countermeasures not only from the government but also from the community. The National Committee on Tobacco Control, which was established in 1998 and includes 23 non-governmental organizations, aims to protect the community from tobacco-smoking addiction and to create a cigarette smoke-free population. Smoking behaviour among Indonesian people remains a serious challenge amidst efforts to maintain and prevent tobacco-related diseases. Even though conventional cigarette smokers, such as kretek smokers, are still high among Indonesian people, electronic cigarettes, also known as vapes, have become popular in recent years, especially among young people, creating a new trend in smoking behaviour. Some smokers consider electronic cigarettes to be safer than conventional cigarettes and use them to quit smoking, while others turn to electronic cigarettes for pleasure or because of their curiosity and temptation to try. Therefore, there is an urgency to increase prevention efforts, education and strict regulations related to tobacco use. Other issues that must be addressed are air pollution caused by traffic congestion in large cities, forest fires in plantation areas, and air pollution from factory smoke, which often occurs near residential areas. Stolz et al.5 proposed classifying COPD according to risk factors, one category of which is infection-related COPD. Historically, TB has a strong association with the development of COPDs. Despite completed TB treatment, impaired lung function often persists. In a study in the Persahabatan Hospital Jakarta, 65 post-TB patients who were still sensitive to TB drugs (data not yet published) underwent spirometry and diffusion lung capacity for carbon monoxide (DLCO). Spirometry resulted in 42% lung function impairment (mostly with mixed obstruction and restriction), and more than 76% patients had low diffusion capacity. Given the evolving landscape of health in Indonesia, it is imperative to implement comprehensive public health strategies that address both communicable and NCDs (Figure 1). Prioritizing early detection, preventive measures, and targeted interventions can mitigate the burden of chronic respiratory conditions. Collaborative efforts among government, healthcare providers, and communities are essential to improving health outcomes and ensuring a healthier future for all Indonesians. The authors thank Vira Weldimira, MD and Fabiola AK Fau, MD (Pulmonology residents, Universitas Indonesia, Jakarta) for the pictures of this project. None declared.