Offline: Indonesia—unravelling the mystery of a nation

Abstract

Size isn't everything. But population does make some contribution to a nation's presence, even its influence, in the world. China is the most populous country on our planet today, with 1·36 billion people (according to World Bank figures) making an increasingly telling impression on our lives. India is second (1·29 billion people). The USA is third (318·9 million). Which country comes next in this demographic league table? You might guess Brazil (population 206·1 million). Or Pakistan (185·0 million). Or maybe Nigeria (177·5 million). But you would be wrong. It's Indonesia (population, 254 ·5 million). Which is perplexing. Most of the countries mentioned occupy part of our imaginative reconstruction of the world (and of world power). But who knows anything about Indonesia? As one companion in Jakarta said last week, “People I meet always talk about going to Bali, never to Indonesia. It's a pity. There's so much more to my country than Bali.” Indeed. Recent excavations on the island of Sulawesi (Indonesia is composed of 17 000 islands, around 6000 of which are inhabited), have found the earliest evidence so far of hominins—teeth, bone fragments, and tools. This discovery dates Indonesia's ancient civilisation from around 118 000 years ago. Yet it is one of the least known, or discussed, today. Indonesia remains a mystery. This lamentation extends to medical science. The first published Lancet research paper with Indonesia in its title was in 1957—on homozygous haemoglobin-E disease, by Lie-Injo Luan Eng and Oey Hoey Giok at the University of Indonesia. But the footprint of Indonesia in the journal is, overall, weak. If you search for the word “India” in the title of Lancet publications, you will find 2098 entries. The US: 1287. China: 841. Indonesia? 33. On the positive side, the number of articles focusing on Indonesia is increasing: one in the 1950s, 22 after 2000. But the pattern of coverage does not reflect the country's burden of disease. Most papers we have published deal with infectious diseases—typhoid, malaria, and dengue, for example. There is almost nothing on non-communicable disease (only liver cancer and mental health after HbE). But the major causes of mortality and morbidity in the country are stroke, ischaemic heart disease, and TB. On health risks, the most influential are high blood pressure, smoking, obesity, malnutrition, and air pollution. Add to these dangers diabetes, road injuries, cirrhosis, and chronic lung disease, and one can see that, at least from this journal's perspective, we have given a wholly incomplete picture of current health predicaments in the fourth most populated country in the world. But these omissions are not ours alone. Why is the Indonesian voice so badly under-represented in the global conversation about health and medical science? Indonesians recognise the problem, and give several reasons. The country has more of an oral than a written culture. Its research community is less familiar with the dominant scientific language of English. The country has tended to look inwards rather than outwards, diminishing the importance of publishing in international journals. Yet Indonesia can be proud of several excellent research institutions. One is the Eijkman Institute, which is making a rapidly growing contribution to global medical science. A decade ago, its publication output was small. But in 2015, Eijkman could boast 50 publications in respected international journals—from strategies to manage hepatitis C to prospects for malaria elimination. Only last month, Eijkman scientists reported that Zika virus was circulating in Indonesia, alerting government authorities to a new public health danger. Indonesia has much to tell (and teach) the world about its experiences. Its struggle to achieve universal health coverage. The challenge of dealing with a double burden of disease. The gift of astonishing biodiversity. The Indonesian voice in medicine and science is too quiet. It's time that voice was heard. Indonesia's chief attribute, indeed its national motto, is Bhinneka Tunggal Ika—Unity in Diversity. The phrase sums up Indonesia's extraordinary cultural and linguistic variation. But, more importantly, it emphasises the nation's solidarity. There can be few phrases that best illustrate the global challenges that nations face today. The world is diverse, with many disagreements creating troubling prospects for our common future. But Indonesia's message is that unity must always overcome the diversity that threatens to tear us apart. Indonesia's values, its predicaments, and its attempted solutions have enormous global bearing.