Indonesia, as usual, presents us with a dilemma. It is one of the least effective nations in dealing with their bird flu problem, exhibiting massive incompetence spiced by corruption. This has helped make them the bird flu epicenter of the world, with more deaths (by a long way) than any other nation and fast approaching Vietnam for most number of recorded cases. At the same time they have raised a legitimate issue: developing nations like Indonesia provide essential information to WHO on how to make effective vaccines against circulating influenza virus strains. WHO in turn shares the information with pharmaceutical companies who make the vaccines. The resulting product is too expensive for the Indonesians and others in the developing world and they can’t compete with rich countries for purchase of the scarce supply. Current estimates of the world’s productive capacity for influenza vaccine is about 500,000 doses a year, while the world’s population is 6 billion. Indonesia’s population alone (240,000) would take up about a third to half the total yearly product and in a pandemic the demand would be concentrated in a few months. So Indonesia and other countries where the disease is endemic in poultry with sporadic human cases is in the unhappy position of providing a vital resource from which they themselves will unlikely receive much benefit.
Unfortunately the Indonesian response — to withhold viral isolates from WHO — does no one any good, nor is the Indonesian demand – to be guaranteed vaccine in exchange for resuming participation in a system that has been operating for fifty years – likely to solve things. There are two major problems. One is a system that relies on the market and power to gain access to an influenza vaccine properly matched to the circulating virus. The other is a grossly inadequate global capacity to make the vaccine. The WHO proposal — to require vaccine makers to set aside a certain percentage of their output for Indonesia and other developing nations — sounds good until you realize that by the time a percentage of an inadequate supply is split up to supply Indonesia and possibly other nations, the amount of vaccine will be so small it will be overwhelmed by the spread of the disease. And a small vaccine supply in a country like Indonesia is not likely to make its way to its poorest inhabitants. Or maybe I’m too cynical.
There is no short-term solution to the problem. WHO and vaccine makers can give in to Indonesia’s demands for a guarantee, but it will be a pyrrhic victory since Indonesia will obtain little vaccine in this way. Even a sizable percentage of too little, remains too little. WHO is talking about “technology transfer” to Indonesia to enable them to produce their own vaccine, but the Indonesian central government is so incompetent this doesn’t sound like much of a solution. The longer term solution to both fundamental problems seems clearer: a crash program to ramp up vaccine capacity, regionally distributed and operated outside the market system. WHO should make a bold initiative to propose urgent construction of internationally supported, regional vaccine institutes where the product is made at cost and used in the region. The capital costs will have to be shared and subsidized by wealthy nations, but the result will be a global good that benefits everyone.
Meanwhile Indonesia continues to withhold their viral isolates from the scientific community. My dilemma is this. I want to have sympathy for them. But they make it so hard.