Effect Measure

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.

Comments

  1. #1 Michael Pezzulli
    March 27, 2007

    Revere:
    Not that I am any good with numbers, but I think Indonesia’s current population is 207.4 Million people (not 240,000), it being the fourth most populous country in the world.

  2. #2 revere
    March 27, 2007

    Michael: I’ve seen 230, 242 (est. for 2005) and now your number. For the purposes of the post it didn’t matter much so I didn’t bother trying to be precise. I think the conclusions are the same with any of these numbers (which is why I threw in a fudge factor of “a third to a half”).

  3. #3 crfullmoon
    March 27, 2007

    They said they’d share samples again; will they all be made globally public once the WHO gets ‘em?

  4. #4 Tom DVM
    March 27, 2007

    The lazy and the greedy need a fall guy…I guess Indonesia is it.

  5. #5 Benjamin Franz
    March 27, 2007

    It isn’t the ‘fudge factor’ of a third or half: It’s the missing three zeros. ;)

  6. #6 Michael Pezzulli
    March 27, 2007

    Revere:
    Sorry, I must have misread your post. I thought you said 240 Thousand not 240 Million.

  7. #7 M. Randolph Kruger
    March 27, 2007

    Revere follow along with me here. 1. Indonesia has little or no capability to make vaccine itself. 2. The US and EU do. 3. As I understand it and unless something DRAMATICALLY changes, both will need a whole new process to make vaccine. E.g. Webster has a vaccine that is so powerful even after reengineering on a molecular level it so hot that it could kill you itself. That process is YEARS? away. 4. Once the antigenic pattern fixes for the finally human HPAI, it would take facilities costing I hear at least 250 billion dollars to make vaccine to cover just the US. 5. Production would not be underway until six months after the said newly improved virus is already wading into the population of the world for at least four months. Said wave would be a large wave with multiple micro-waves imbedded in it. 6. At the current very mathematically wrong number of at least 67% (WHO) to the more realistic 83%(rolling average for the last year), we find ourselves a good 62% and/or 79% above what every government on this planet is forecasting when it comes. 7. One way to preclude this that the affected nations come clean and produce all data to the scientific world.

    Okay, so at the 1/2 way mark in item 4 and its even 40% of the initial 1/3rd of the planet that will get it that will die, its 2 BILLION PEOPLE give or take a country or two that will die in that single wave. Their numbers dont compute against the reality of 5% to the real number of 67-83%. So what are the Indons complaining about? A t 207 million by the time the first vaccine comes available by my calculations there will be about 66 million gone and maybe another 33 milion by the time it finishes the wave. Then it could mutate into less of a killer, but another 20 million or so in the following season. Who is going to be around at at those kinds of numbers to take the vaccine even if it is available? What the Indons are doing is called extortion in most countries. To go along with this is insanity and we shouldnt even be talking to them. Back off and let them come to us. The WHO/UN is going to use this as an excuse to in turn extort money from the rest of the world that will IMO, produce no vaccine and goat rope us into yet another “deal” that hoses us all.

    Your thoughts?

  8. #8 bar
    March 27, 2007

    CIA world factbook: 245,452,739 (July 2006 est.)

    https://www.cia.gov/cia/publications/factbook/geos/id.html#People

  9. #9 davidp
    March 27, 2007

    I feel the intellectual property argument is weak – If Indonesia says it’s their bird flu strain, will they compensate the rest of the world if we get infected by it? Of course not.

  10. #10 Patch
    March 27, 2007

    Well said davidp! Excellent!

  11. #11 davidp
    March 27, 2007

    http://www.abc.net.au/news/newsitems/200703/s1883539.htm

    Indonesia has agreed to resume sending samples of bird flu virus to the World Health Organisation (WHO) after talks in Jakarta.

    Under the new mechanism, the WHO will have to seek consent from individual countries before their virus samples are used to create commercial vaccines.

  12. #12 Greg
    March 28, 2007

    Influenza will kill people differently in Indonesia than in Indiana.

    In Indiana, whatever percentage will be killed by the virus and its immediate effects. The survivors will perish for lack of food, water, and heat.

    In Indonesia, whatever percentage will be killed by the virus and its immediate effects. The survivors, many of them, will live off the forests and rivers which we haven’t yet gotten around to destroying.

    In both Indonesia and Indiana, armed governments will meddle in ways which are highly significant to individuals but mostly irrelevant to the overall disaster.

    You will note, we have already two (veiled) proposals to steal what we want by force. Indonesians, among others, are rather used to this treatment. Used also to promises repudiated or reinterpretted at the whim of those with bigger guns.

    Doubtless we have thugs on the ground and bankers in the backrooms. We must be careful, however. If we eliminate the people who demand fair exchange, we eliminate the people who care for the sick and collect the samples.

    Soros reports that the World Bank is perfectly capable of assuring that any loan / extortion be spent exactly where they want. Leftist agitators the worldover report the same, at least regarding the arms to suppress public protest. WB, if it wishes, simply ignores bills from Sachs Fifth Avenue, and pays qualified contractors only after WB’s own inspectors certify the existence and quality of the physical plant and of the workers to work it.

    USAID can be even more exacting. They don’t ship the product until the loan is signed and sealed at the World Bank and until the domestic adjustments have been adjusted.

    The real problem is not so simple. No matter how venal and incompetent the Indonesian government, WHO, UN, our governments, and we are; even were sufficient cash to magically appear in the (metaphorical) WB vault in the morning; even were suitable factories to pop up scattered across the third world, like mushrooms overnight; there would still lack the trained workers and the growth medium to grow the essential vaccine ingredient.

    We never considered that Indonesians should have vaccines. Certainly never thought Indonesians would find a way to make us consider it, however, fleetingly.

    Some Indonesians will console themselves with the thought that given the shambles of our health care system and the absense of a public health system, we never considered that we should have vaccines either.

  13. #13 v
    March 28, 2007

    I’ve said it before and I’ll say it again this is all about money. Corruption at the highest level. This is all about money and who is going to control the distribution of said vaccine. Nothing else. Who are the vested interests in this debate? The vaccine, if and when it is produced, will not get to the people that need it.

  14. #14 M. Randolph Kruger
    March 28, 2007

    And so we come full circle as the only way so far to make vaccine is to reengineer it and take the hairy part out put it into eggs and and then stick it back in for the response…. Websters process for the better part. If it takes 3 months IAW Revere’s estimates it wont matter. We wont be able to build crap due to the lack of supplies to do it. This will have to be molecular level vaccine for it to become effective at producing a vaccine. The Indons should just shut up, share and then take what they get if there is any get. This is a tempest in a teacup because the ones that know and I mean really know understand that this isnt going to just go away. Indonesia is very aware that they have a devil running up and down the streets and they are as naked as it gets. Vaccine? Shit…. show me some that works and I’ll get a lot more excited about what the Indonesians think. Strains mean send me a check. Great, how would you like that in worthless currencies when it starts. I have seen some briefing stuff that indicates that the dollar would fall in value to about 1/3rd of its current world standing and only because we can grow food. It gets worse in year 2-3 after the pandemic pass because oil might not be worth much either. Food would become the currency of exchange. We send you food for oil. If the oil doesnt show we cant grow food because we cant make fertilizers out of it.

    Maybe it isnt such a bad idea to be in Iraq after all. We certainly at least initially could send people in to get and keep the pumps going. It would be a cobbled up deal but NATO nations would be applauding us for it. Takeover? Yeah for al lintents and purposes I guess. Thats a different discussion though.

  15. #15 Greg
    March 29, 2007

    You lack imagination, Kruger. There is enough petroleum in the Americas to supply the military. They’ll sequester the corn crop, too, if they wish. Nuclear reactors will be built in Alberta to sweat fuel out of the oilsands.

    Iraq and Iran shows are the current manifestation of our old old policy to deny oil to China and Japan.

    Where we cannot destroy agriculture economy by flooding with subsidized grain, we will provide improved high-maintainance frankenseed (with terminator genes when we can get away with it) until native varieties become scarce. Then, when their bellies are sufficiently dependent on our grain and our seed, we will cut them off.

    We won’t send food. We will send arms to the underdogs wherever peace threatens to break out.

  16. #16 M. Randolph Kruger
    March 29, 2007

    I lack imagination Greg? Yesterday it was fear? I can tell you for a fact that my imagination is running wild with the possibilities of this stuff. Frankenseed? Is that another name for ganja?

  17. #17 SusanC
    March 31, 2007

    The critical issue, IMHO, is not institution, not money, not corruption, its technology. Unless and until we move rapidly away from the egg-based system and towards systems capable of producing in massive quantities, every discussion is moot.

    The fastest shortest route to that goal, IMHO, is the recombinant HA protein vaccine produced in cell cultures. Because it is a protein vaccine, ie you are not injecting genetic material into people, the issues around cell culture that are currently slowing down the route to licensing can be circumvented. Because you are only making a protein antigen, you do not need to use BSL3 labs, as was needed for the Baxter whole virus vaccine. Nor do you need to do RG engineering to remove/modify the cleavage site, which cuts down the production process by about 8-10 weeks, I believe.

    And, the beauty of that is, you don’t even need a virus sample, all you need is the sequence of the HA protein. Which makes the possibility of making a vaccine in the absence of sample sharing a lot more likely, as long as we have access to SOME information on the evolving HA antigen.

    I have come to this view over the last few months after giving this much thought, and, since all vaccines are at present commercial ventures, it is not possible to discuss the merits of individual vaccines without encountering the question of potential conflicts of interest. So I’m going to say here that I have no connection with the company involved, or any other vaccine companies. Neither I nor any member of my family have any investment or interests in any form associated with the recombinant protein vaccine or any other pandemic or prepandemic vaccines.

  18. #18 SusanC
    March 31, 2007

    Forgot to add this: because you can make massive quantities of the vaccine in a short space of time, there is no need for any dose-sparing strategy. The seasonal flu version of the rHA vaccine uses 45ug each of the trivalent antigens ie a total of 135ug. We can certainly do the same with any pandemic vaccine.