The grave of Alesha Kimi Pramudita, a 22-month-old who died after being infected with the coronavirus in Yogyakarta, Indonesia, in July. Photo / Ulet Ifansasti, The New York Times
The disease kills far more children in developing countries than in rich ones, and some factors make them especially vulnerable in Indonesia.
When Debiyantoro, a hotel repairman, first lost his sense of taste, he wondered briefly if it might be Covid-19, but he quickly dismissed the idea. Having the disease would mean not being able to make a living.
Now he blames his reluctance to get tested for the death of his 22-month-old daughter, Alesha Kimi Pramudita. All 10 members of their crowded household suffered Covid-19-like symptoms, but none were tested until Kimi went for an unrelated checkup. Hospitalised immediately, she died a day later.
"Although I thought it might have been Covid, I was afraid I wouldn't be allowed to work, which means I couldn't have supported my family," Debiyantoro, who like many Indonesians uses one name, said as he tried to hold back tears. "But now I am filled with remorse that I lost my daughter."
Across Indonesia, children have fallen victim to Covid-19 in alarming numbers, with a striking increase since June, when the delta variant began taking hold. The pandemic has killed at least 1,245 Indonesian children and the biggest recent jump has been among those younger than 1, said Dr. Aman Bhakti Pulungan, head of the Indonesian Paediatric Society.
Researchers point to many reasons children would be more likely to die in developing countries, but many of those factors boil down to a single one: poverty.
Wealthy countries have gotten used to the idea that children are extremely rare pandemic victims. In the United States and Europe, people younger than 18 have accounted for about 1 of every 1,500 reported Covid-19 deaths.
But the toll in less developed countries tells a different story. The Paediatric society's figures suggest that in Indonesia, about 1 of every 88 officially counted deaths has been that of a child.
The true rate is impossible to discern, because testing is limited and many Covid-19 deaths in Indonesia have gone uncounted, but it is clearly much higher than in the West.
The undercounting may have worsened in the past two months, as the delta variant of the coronavirus drove a huge wave of cases and deaths in Indonesia, where only one-fifth of the population is even partly vaccinated. Delta is much more contagious than earlier forms of the virus, although there is no proof so far that it is deadlier.
Child Covid-19 deaths have exceeded 2,000 in Brazil and 1,500 in India — more than in Indonesia — but those countries have had several times as many deaths overall.
Detailed analyses have pointed to a slew of contributors to child deaths: Underlying health problems that can worsen Covid-19, severe air pollution, multigenerational families living in cramped quarters, poor nutrition, cultural factors and lack of access to information, diagnosis and treatment.
"The first thing to know is that socioeconomic inequality is a very important factor for mortality," said Dr. Marisa Dolhnikoff, a pathologist at the Sao Paulo University Medical School in Brazil.
Children living in poverty tend to have more underlying conditions like obesity, diabetes, heart disease and malnutrition that can multiply the risks of Covid-19. Respiratory ailments like tuberculosis and asthma that are more prevalent in poorer regions, and the corrosive effect of air pollution can make it more difficult for children to survive Covid-19, which can attack the lungs.
In Indonesia, nearly 6 per cent of reported child deaths from Covid-19 have been of children suffering from tuberculosis. Southeast Asia, including Indonesia, has the world's heaviest TB burden, accounting for 44 per cent of new cases globally in 2019, according to the World Health Organization.
Southeast Asia also has some of the world's highest rates of thalassemia, a genetic disorder that hampers the blood's ability to transport oxygen, and has contributed to some child deaths.
Raesa Maharani, 17, fought thalassemia for much of her life, receiving blood transfusions to treat it, but after she was hospitalised last month with Covid-19, she seemed to give up.
"Enough, it's been enough," she told her parents.
She pulled the oxygen mask from her face and needles from her arm, prompting nurses to tie her in bed so she could continue receiving treatment. Even so, she died July 19.
Even when children are visibly ill, parents and doctors may mistake the symptoms — body aches, fever, diarrhoea or coughing — for other conditions, particularly because of the widespread misperception that children cannot get Covid-19. By the time it is clear that the symptoms have a more serious cause, it is often too late.
In densely populated countries like Indonesia — the fourth-most populous in the world, with 270 million people — with limited access to vaccines, hospitals are overcrowded and understaffed, and many do not have Paediatric intensive care units or specialists in treating children.
Daniel Marzzaman was a healthy 4-year-old when his mother, Marlyan, was diagnosed in July with Covid-19 on the Indonesian island of Batam. Her doctor advised her to isolate at home. Within a few days, Daniel developed a fever. When it soared above 105, his parents took him to nearby BP Batam Hospital, where he waited until the next day for a bed in a Covid-19 ward.
The hospital, at full capacity with Covid-19 patients, was plagued by oxygen shortages and 60 staff members had been sidelined by Covid-19 infections.
"We have been overwhelmed, especially when our health workers also get Covid," said the hospital director, Dr. Afdhalun Hakim.
On the fifth day, Daniel's doctor wanted to put him in the intensive care unit, but the hospital had no ICU for children and the adult unit was full. He ordered oxygen but, despite the mother's pleas that Daniel was struggling to breathe, it did not arrive for 12 hours. He died soon after, in the early morning of July 23.
"I am very, very disappointed," she said later. "When I asked for help there was no response. They really don't value life."
A lack of information about Covid-19 also contributes to the high number of deaths.
"Most of the spread is within families now," and nearly all of it is avoidable with proper precautions, said Aman.
In Jakarta, the teeming Indonesian capital, Beverly Alezha Marlein was born in early June into an extended family of 16 residing in three nearby houses. Relatives came over frequently to admire and hold the newborn, just as family members would want to anywhere in the world, but the message to maintain social distance, so ingrained in some countries, has not taken root as deeply in Indonesia.
"When Bev was born, it was natural that everybody was happy and wanted to see and visit the baby," said her mother, Tirsa Manitik, 32.
Sometimes, the relatives wore masks or kept their distance, she said. But that was not always the case.
Some family members got Covid-19 soon after Beverly was born, including her father and aunt, the first two to test positive. Before long, all 17 family members were infected, including the 11 children. Beverly's grandfather died at home July 1.
When Beverly had trouble breathing, her doctor ordered her hospitalised but finding space was difficult. Tirsa drove her to 10 hospitals and all were full, with lines of patients waiting outside, before the 11th accepted her. Beverly, who was born healthy, survived for eight days in the hospital, dying July 7. She was 29 days old.
"I am not blaming anybody, but I want to alert people," Tirsa said. "Let's take more care to protect our babies. There is no need for a physical visit. Let's just do video calls."
In some parts of Indonesia, religious tradition also plays a role in infecting children.
In Central Java, one of the areas hit hardest by the virus, Muslim families commonly hold an Aqiqah, a traditional celebration usually involving an animal sacrifice to welcome a newborn. Such gatherings have led to a sharp rise in infant cases since late May, said Dr. Agustinawati Ulfah, a paediatrician in the town of Purwodadi.
"With this kind of ceremony, the neighbours and relatives share their joy for the newborn by carrying the baby and kissing the baby," she said. "Maybe during the gathering they wear a mask, but when they carry the baby and kiss the baby, they take it off."
The government has recruited clerics and midwives to educate the public, but long-standing customs have been difficult to overcome.
"Since it is tradition, people don't seem to be aware that health protocols need to be followed even though the government has been repeating the message over and over," said Dr. Novianne Chasny, the Central Java program manager for the nonprofit group Project Hope.
In the death of baby Kimi at 22 months, poverty, lack of knowledge and fear combined to create a tragedy.
The 10 family members from three generations shared a three-bedroom house in the farming village of Bulus Wetan about 10 miles south of the city of Yogyakarta. Kimi's father, Debiyantoro, earned the equivalent of about $190 a month at his hotel job and would have gone unpaid had he taken sick leave.
Kimi had two benign growths on her neck called hemangiomas, which by themselves would not have made her susceptible to Covid-19. But the treatment she received for them might have left her more vulnerable to the disease.
Her parents didn't realize she was suffering from Covid-19 until her hemangioma treatment, when the doctor recognised her symptoms.
"I am strong but I didn't think about Kimi, who was still a baby and had an illness," her father said sadly. "I only realized this after she was hospitalised."
When it came time to bury Kimi, other villagers were so fearful of the disease that they blocked the entrance to the cemetery with bamboo poles so she could not be interred there. Upset and angry, her parents buried her on adjacent land owned by a relative.
"I hope it was only the body being rejected and that her soul is resting in peace," Debiyantoro said after praying over her grave. "She has a final resting place even though she's all by herself. We didn't abandon her."
This article originally appeared in The New York Times.
Written by: Dera Menra Sijabat, Richard C. Paddock and Muktita Suhartono
Photographs by: Ulet Ifansasti
© 2021 THE NEW YORK TIMES
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