Effect Measure

Nature’s senior correspondent, Declan Butler, was one of the first to raise the profile of a pandemic threat in the scientific community and has had done some superb reporting since, including several stories on sharing gene sequences. The problematic actors in his earlier stories were respected scientists and the business-as-usual way they were approaching release of genetic sequences even as the world worried that the virus they were studying, influenza A, was inexorably searching for the right recipe to enhance its own raison d’etre, to make still more copies of itself, potentially with the help of the 6 billion bioreactors called human beings. That was then. Now the problematic character is Indonesia’s health minister, Siti Fadilah Supari, an erratic, obstreperous, often ignorant sounding one person obstacle to access to viral isolates of great interest to the global public health community, the ones isolated from humans and birds in Indonesia, the world’s hot spot for bird flu.

Declan is an excellent reporter and understands the issues. I knew he was going to interview Supari and was curious about what he would learn. The answer: not very much. She repeated the same arguments she has been using for over a year, with little variation:

Indonesia is open to international collaboration but this must be fair, transparent and equitable. The WHO’s Global Influenza Surveillance Network system is obviously unfair and opaque. Samples shared become the property of the WHO collaborating centres in rich countries, where they are used to generate research papers, patents and to commercialize vaccines. But the developing countries that supply the samples do not share in these benefits. In the event of a pandemic, we also risk having no access to vaccines, or having to buy them at prices we cannot afford, despite the fact that the vaccines were developed using our samples.

The above mechanisms can lead to a vicious cycle, in which poor countries become poorer because they have diseases, and industrialized countries become richer at the expense of poor countries. As a consequence, there will be some people who will create diseases and take advantage of the situation. This is a form of neo-colonialism and neo-capitalism. (Declan Butler, Nature)

This is vintage Supari. Some of it makes sense and some of it is orbiting slightly past Pluto. WHO reference labs don’t “own” Indonesia’s or anyone else’s viral isolates. The idea that someone should have property rights to a naturally occurring pathogen is outlandish and Supari is accusing WHO of what in fact she is advocating. On the other hand, she is signaling an important, unsolved problem, the problem of access for poor countries, a problem that won’t be solved by “selling” their pathogenic property to the highest bidder. But of course that’s what Big Pharma intends to do with the vaccine they make from the pathogen and they have a full arsenal of intellectual property laws and the best lawyers money can buy to obliterate anyone who doesn’t like it.

But the idea that neo-colonialists (who do exist) and neo-capitalist (who do, too) are creating diseases so they can sell vaccines to countries that can’t afford them is bizarre and stupid. Supari also responded to the question of why Indonesia does a much worse job at controlling bird flu than other countries with this defense:

Vietnam, as a centralized socialist country, can get high compliance on national policies and so has succeeded, for example, in implementing rapid culling of birds. Thailand’s monarchy is well respected, resulting again in good compliance. In contrast, Indonesia is in transition towards a decentralized democracy after three decades of authoritarian national rule. We are still on a learning curve, and compliance of the relatively independent regional authorities with national policies is often poor. Indonesia is made up of more than 17,000 islands, which again complicates compliance.

The cultures are also different. Birds play an important role in Indonesian culture — pet singing birds are considered signs of respectable households, for example. In rural communities, backyard farming is a major income source, and has been a key element in improving nutrition.

But bear in mind that Indonesia has a population of more than 200 million, so one needs to keep in perspective the total of 113 cases of H5N1 — I’d argue that we’ve been fairly successful in controlling the disease.

Again, a mixture of truth and implausible deniability. Indonesia’s government is extremely decentralized and the central government has little ability to issue decrees and hope to see them implemented. But it is also corrupt, incompetent, ineffective and elitist from top to bottom, according to many with intimate knowledge of the country. We have written before (more than once) that the special place birds play in Indonesian culture is critically important and unlike what we are used to in Europe and North America. Birds are companion animals more like cats and dogs here. And the country is huge, with many parts geographically distant or difficult to access. But the problems of decentralization, corruption and an even huger population describes China. China has reported only 27 cases to Indonesia’s 115. Does anyone believe either number? And does anyone believe either has been “fairly successful in controlling the disease”?

When it was pointed out that many scientists still don’t think Indonesia is doing enough, here was her response:

It is the international scientific community that delays the acquisition of critical knowledge. If they wish to have rapid results, why don’t they come to Indonesia and work with our scientists here? We have the necessary facilities, such as biosafety level-3 secure labs and good Indonesian scientists. That would also put an end to disputes over virus sharing.

This doesn’t make sense from many points of view, but there is an important point here she doesn’t make. There are still too many scientists — good ones, decent people — who have isolates, sequences and databases they have yet to be shared in a timely way because they are profiting off it, not monetarily, but professionally. Supari can’t make this point because she wants Indonesia to be as bad as they are. Neither can see that this attitude is ethically unacceptable if we are on the threshold of a pandemic.

Supari is neither rational nor responsible. Some very reputable scientists are rational but also irresponsible. There is more than a grain of truth to the fact that Indonesia and other developing countries have a problem which the developed countries aren’t solving. The scientists can’t see it because they are merely conducting themselves in the same ways as always. No one has ever said it was wrong or unethical. But this is a special situation.

I’m saying it, now. We can’t keep pointing fingers at Indonesia when we refuse to put our own house in order.

Comments

  1. #1 RobT
    December 20, 2007

    What an excellent, important post, Revere. Thank you for highlighting the issues so clearly re Indonesia, once again. We are all in the cross hairs of the pandemic, even Minister Supari and the scientists who exploit the viral sequence data for their own credentials and advantage. If ever there was a time for our species to work together to tackle a common microbial enemy, this would be it. But sometimes our species is very slow on the uptake of solutions eg. pandemic and global warming, so once again education is key to exposing the issues.
    You do it well.

  2. #2 M. Randolph Kruger
    December 20, 2007

    Short of a nuclear launch, the fastest way to start a war is to insinuate that the West is creating bugs and planting them in underdeveloped countries just to watch them grow. What is that idiot thinking? Does she really thing that is going to keep her in power? Pretty ingratiating statement. I wonder if she really believes her own press? The West isnt going to take this one sitting down. The West in this respect includes the Chinese with SinoVac. All are actively pursuing a vaccine for something that hasnt been created yet.

    Supari and her 200 million will be down to about 40 million if the current CFR is maintained and it comes. I dont disagree that there shouldnt be some sort of deal made for pro rata vaccines for them. But I certainly disagree that we should go in and build them facilities to compete with us. But this should be a WHO thing. We pony money up for the support of the WHO, they can do with it what they will and have. All those new houses in Thailand… I mean we just are going to have to make a few corner cuts and only use mahogany instead of teak on those stairs. Shit, call the WHO and tell them we got a new MTA we want to run by them.

    Supari has zero credibility with me for one. Auntie Margaret has some but not much and she should have come out swinging in the Geneva conference and called both sides of the argument. Supari’s demand wasnt so much for cheap vaccine but more so for the free facilities to make it.

    I for one dont want to get soaked as the “standard” for pricing of a vaccine. E.g. It costs a US purchaser $150 per dose, just so some guy in Indonesia can get it for $20 that they aint going to pay anyway. I am confused. Where does it say we are responsible for the health of Indonesia? The WHO is supposed to handle world situations and that also means tin gods. Supari needs to be very, very careful here. Its not just the bug… Its the power of money and politics she needs to fear and like Revere says, she is either delusional, dumb or both.

    There are those that are very hard in their attitudes towards Indon right now. I am one of them, but I am not the hardest. The Chinese might be the hardest and their newspapers are less than cordial about the situation as I read an editorial last week that called Supari, “incompetent as is her country to handle a bird flu outbreak.”

    Them’s fighting words. The Chinese have 30,000 laborers in country and they could go in and snatch their bug bearing people anytime they wanted. Indon might be dumb enough to try to stop them, but with the removal of those people it would ensure the demise of the argument for samples both politically and maybe physically. The bug would be out and plenty of samples. One thing is sure in that respect, by the time a vaccine was produced and the CFR was maintained by even half, they would cease to be an Indonesia. It would be a cake walk for the Chinese, the Aussies or the Vietnamese to take the place. How about Dutch rule again?

    As for the bug. We are getting into this world socialism thing again and its disgusting. What are these people going to do when the great USA doesnt have the money any longer as we swallow it up in our own socialist programs? We did it in the 70’s with all the giveaway socialist programs…then the economy tanked for almost 3 years until the election. What are they going to do? They are going to be screwed and big if it happens. Simply wont be any money for it. The West will surely hold onto their toys more closely in a UHC environment because it will be their ONLY cash cow.

    Those EU countries that depend on the US for defense will see that melt away and then, they are going to have to pony more of their money to make sure that a hungry Russian bear doesnt come for a dinner. Revere will get his confederation of regions or states idea confirmed very quickly.

    In many ways a pandemic bug would be a good thing. Not if you got it, not if you cant stand to watch people suffer. But as far as the drain on the resources of the planet it would be a massively good thing. Is that what is really the end game for this? Are they deliberately coming up with an answer for the planet? Its sure beginning to look like it.

    Indon wont be on the list of survivors….

  3. #3 revere
    December 20, 2007

    Randy: :. Where does it say we are responsible for the health of Indonesia? The WHO is supposed to handle world situations and that also means tin gods”

    It says it in the same place that it says Indon has a responsibility to us, to provide the isolates to protect the rest of the world. You seem to want the responsibility to go one way. As for WHO, the Repub right wing has done all it can to cripple it and especially to make sure nothing it does encroaches on the prerogatives of any member state. So the Repub and right wing made our bed and now the rest of us have to lie in it. Thanks.

  4. #4 herman
    December 20, 2007

    This is an excellent summary of how economics and other factors can destroy any attempt to deal with a possible bird flu pandemic.
    Another example of how information regarding bird flu can be concealed is the fact WHO and the government of Pakistan have not given the onset dates in regard the human clusters there. This information is critical in order to determine if all the victims were infected by a common source or if there was possible human to human contagion. If it is a common source, they should have all become sick within 2 to 4 days. But in Pakistan, the index case was infected around November 26th. And people in the cluster continued to become infected with bird flu for most of December. This would indicate human to human contagion. But if the dates of onset are concealed, it is impossible to determine this.
    In the past, there were times when WHO released this information in regard to human clusters. Why are they concealing it now? Especially because one of the clusters in Pakistan is probably the longest human cluster of H2H ever observed, meaning H2H2H2H. And please note the most recent person infected in this cluster is a health care worker.
    Human clusters are very common between family members, and usually include 2 people, although at times the chain of infection has been longer.
    Dr. Yoskihiro Kawaoka, a virologist who lead the team that identified a single change in a viral protein of H5N1 that facilitates the virus’ ability to infect cells in the upper respiratory system of mammals, stated the virus is now capable of infecting a wider range of cell types, and is more easily spread through coughing.
    Dr. Kawaoka is an internationally recognized authority on influenza, and he is convinced it is only a matter of time before H5N1 evolves into a virus capable of causing a pandemic. Are we seeing that happen right now in Pakistan and Indonesia?
    And please note he specified the upper respiratory system of mammals. He did not limit it to just birds. H5N1 has infected tigers, cats, birds, and humans. Therefore the exclusive concentration on birds as a vector is dangerous, because, if there are other mammals that are infected, it may be possible the pandemic will develop through a vector such as cats.
    And Randy has specified that when you see a country stop culling birds, it may be because the government officials there know it is already too late to stop it, since it has gone human to human, with efficient transmission.
    There is every reason to now justify raising the alert level to 4, meaning evidence of increased human to human transmission. To fail to do this is like the captain of the Titanic drinking whiskey in the ballroom as the ship approaches the iceberg.

  5. #5 anon
    December 20, 2007

    Supari, give us the vaccine-irrelevant segments,
    3rd bases in codons, please.

  6. #6 Ron
    December 20, 2007

    Maybe I have a jaundiced view since I work in a marginalized area (Chiapas, Mexico) similar to many parts of Indonesia in terms of health conditions and services. But it is perfectly clear to me what she means. Bird flu, MRSA and other potential pandemics have been fostered on us all by the expansion of capitalist farming systems such as CAFOs. These units for the mass production of cheap chicken and pork are arguably the origin of these highly pathogenic, antibiotic resistant forms of these diseases. In that sense, the capitalists are making the bugs, as well as the patent-protected medicines to cure them. Negocio redondo, as we say in Mexico.

  7. #7 Ron
    December 20, 2007

    PS for Randy, your money is going down the rat hole of Iraq. Social programs, especially public health programs are being cut willy nilly.

  8. #8 Jon Herington
    December 20, 2007

    An excellent breakdown of the probles in Indonesia but I think you dismiss the effect that decentralisation has had too swiftly. In particular, one of the major reasons that the Indonesian bureaucracy is so corrupt IS because of decentralisation.

    In particular, the Agriculture Ministry – which has most of the responsibility for control of H5N1 because it has its finger on the cull button – is riddled with senior bureaucrats who are in the pockets of the poultry industry. One of the best examples is the sacking of the rather rational and committed Chief Veterinary Officer in 2005 for exposing the initial cover-up (which swapped AI for Newcastle). Not at the behest of the Health dept and Supari, but Anton at the Ag Ministry.

    In fact, I’d contend that Supari, in the face of obstruction from the AG department and the provinces, is seeking the only kind of leverage she has left – and that is using the time honoured tactic of brinksmanship on the international stage. Borne more of frustration with domestic impotence than irrationality or malevolance.

    Supari may not be a saint, but her actions are symptomatic of much larger problems within the Indonesian governance structure. Picking on her seems mightily unfair when there are much bigger snakes, like the Ag dept, holding up the control efforts in Indonesia.

  9. #9 paiwan
    December 21, 2007

    Jon: Very good in balancing the criticism on Supari.

    In fact, not only Indonesia but globally, the H5N1 flu solution shall come out from the collaboration between Health and Ag departments. The first step in this collaboration and the thrust perhaps should start from WHO and FAO.

    Inborn ego-centricity is a genetic disease harder than viral infections, what our medical doctors shall say?

    Randy, Bar: We had some thought of posible ice-breaking discussions about Pharma’s stakeholding approach before. I know that among Muslim countries, Indonesia is one of most democratic ones and dynamic in global economy, would you enlighten more, I mean constructively.

  10. #10 herman
    December 21, 2007

    There is a reported cluster of 7 suspect H5N1 patients in Serang Indonesia. Five members of one family are an infectious disease hospital in Jakarta. There are two other patients from the same area of Serang that are not hospitalized.
    The obvious lack of transparency of the governments of Indonesia and Pakistan will assist in the death and illness of more and more H5N1 patients as the virus gradually adapts to humans. WHO is controlled by these governments, and will not release information without governmental permission. Therefore WHO is impotent in this situation. Vital information, such as the dates of onset of disease, is being withheld in Pakistan.
    The spanish flu epidemic of 1918 killed up to 100 million by some estimates. That is more than 3 times the number of those killed in World War 1. And the mortality rate was between 2 and 3%. If bird flu maintains a mortality rate of 60% as it expands, how many will die?
    I honestly do not know if the alert level should be moved to stage 4 or not; but if WHO waits until entire villages are full of human infections, it will be too late. And how will we know when this happens if governments refuse to release the information due to negative economic factors? That means the pandemic may arrive suddenly and massively in the first wave, killing perhaps 60% of those infected. Our health care system will then collapse.

  11. #11 revere
    December 21, 2007

    Jon: I didn’t mean to minimize the decentralization. It is a major part of the problem. They essentially dismantled central authority. But the style of leadership Supari is using is not effective any more than George Bush’s is effective. Ed Hammond’s account of the Geneva summit indicated several other countries were much more effective. Supari doesn’thave credibility. All she has is control of the isolates and no authority other than that. Of course, that’s all that counts in this case but she could be doing so much better.

  12. #12 Jon Herington
    December 21, 2007

    I haven’t read Ed Hammond’s account (Sunshine Project?), but I hope to do so over the Christmas period.

    I think my point is that it’s unfair, and potentially unproductive (in the sense it distracts from wider problems), to expect Supari to do the politically improbable. She is, after all, the only part of the Indonesian response that has actually had to face the international community; and IMO is a force for good within the government.

    PS: I rarely comment here, but I read EM regularly and find it to be the best source of global health news on the web. Hope the New Year treats the Revere(s) well.

  13. #13 M. Randolph Kruger
    December 21, 2007

    And if we pull out of Iraq you effectively give control of Iraq to Syria and Iran Ron. Going into Iraq was a good idea, the post war stuff was poorly thought out. If I were going to stay I would have put my puppet into power, and left. Thats the difference here from all the other nation building projects. We are actually giving them the right to domestic rule. No Shah’s or Castro’s from two ends of the spectrum.

    And since we had 9000 add ons to the funding for Iraq, I would say your social problem programs are alive and well Ron. I particularly liked the pork barrel for how goats mate…… Lots of science in that one but it keeps the Ag university funded.

    Hey Revere, it aint just the Republicans. The California Dem delegation apparently were contacted by Pharma and their displeasure with what was coming in Geneva was expressed. Basically they told them what side their bread was buttered. But thats a common thing with the Dems, say one thing, do another. Its pretty hard to be in charge sometimes but it gets down to national interests. Its in the interests of the US, EU, Russia and China NOT to cave to Supari’s wants list. Hell they could have made a lot of inroads on building their own if they hadnt stolen all the money that went in there for the last 5 years. For what they spent on their dumbass airplane projects under Habibi they could have built 50 vaccine plants. But thats not the rub now is it? The real rub is that they are quantum leaps behind us on being able to make vaccines. Not that they are stupid, they just dont have the magnet to gravitate towards to get the brain trust to move in.

    The ideas suggested about regional facilities is based upon the one thought that someone thinks it should happen. Been my experience that once we build something with all those assurances that suddenly one day we are shown the door and we get to leave behind millions if not billions of dollars of investments. They did it to the USNAVY with NAMRU 2.

    Its also kind of like those pirated microchips in China…. They do work in our computers you know. Even Reagan imposed 100% tariffs on the Japanese for flooding our markets with chips that we taught them to make. National interests again….. hmm?

    Its not as simple as you would posit Revere. There are yet more US jobs at stake here and if you are a socialist then thats fine I can live with it, but not a communist ideal that creates an all level playing field worldwide. It would by logical conclusion result in revolution. Not everyone is a little lemming from “Brazil” and I dont intend for my kids to grow up with a lesser life style because someone thinks that they will make too much money, or that they pay too little taxes or that someone on the other side of the planet isnt getting what someone else thinks is a fair shake in their eyes. In the last 50 years we have seen it over and over again. The de-evolution of our business base either by poor decisions or by taxation.

    Thats the reason capitalism is here and here to stay. Its alive and well in even the communist countries. Suppress of our steel business put it off shore, suppression of our pharma by litigation put it off shore, suppression of our movie industry forces it to operate in other countries because of the costs involved. I never, ever see anyone in all of these developing countries doing anything for their people, only themselves and demanding that we do something for them because they are developing. We send money in, it gets stolen.

    Its a capitalistic payoff. We want samples? We could roar in there and offer them say 100 mill and they would give them to us, plain and simple. But we are smarter than that. We simply wait for it to leave in a human, a duck, or like the Chinese we send someone in unsuspecting and then repatriate. All the samples in the world after that.

    Like I said, its not as simple as postured. The difference this time is that there are ramifications for all in a direct and massive way.

  14. #14 M. Randolph Kruger
    December 21, 2007

    And if we pull out of Iraq you effectively give control of Iraq to Syria and Iran Ron. Going into Iraq was a good idea, the post war stuff was poorly thought out. If I were going to stay I would have put my puppet into power, and left. Thats the difference here from all the other nation building projects. We are actually giving them the right to domestic rule. No Shah’s or Castro’s from two ends of the spectrum.

    And since we had 9000 add ons to the funding for Iraq, I would say your social problem programs are alive and well Ron. I particularly liked the pork barrel for how goats mate…… Lots of science in that one but it keeps the Ag university funded.

    Hey Revere, it aint just the Republicans. The California Dem delegation apparently were contacted by Pharma and their displeasure with what was coming in Geneva was expressed. Basically they told them what side their bread was buttered. But thats a common thing with the Dems, say one thing, do another. Its pretty hard to be in charge sometimes but it gets down to national interests. Its in the interests of the US, EU, Russia and China NOT to cave to Supari’s wants list. Hell they could have made a lot of inroads on building their own if they hadnt stolen all the money that went in there for the last 5 years. For what they spent on their dumbass airplane projects under Habibi they could have built 50 vaccine plants. But thats not the rub now is it? The real rub is that they are quantum leaps behind us on being able to make vaccines. Not that they are stupid, they just dont have the magnet to gravitate towards to get the brain trust to move in.

    The ideas suggested about regional facilities is based upon the one thought that someone thinks it should happen. Been my experience that once we build something with all those assurances that suddenly one day we are shown the door and we get to leave behind millions if not billions of dollars of investments. They did it to the USNAVY with NAMRU 2.

    Its also kind of like those pirated microchips in China…. They do work in our computers you know. Even Reagan imposed 100% tariffs on the Japanese for flooding our markets with chips that we taught them to make. National interests again….. hmm?

    Its not as simple as you would posit Revere. There are yet more US jobs at stake here and if you are a socialist then thats fine I can live with it, but not a communist ideal that creates an all level playing field worldwide. It would by logical conclusion result in revolution. Not everyone is a little lemming from “Brazil” and I dont intend for my kids to grow up with a lesser life style because someone thinks that they will make too much money, or that they pay too little taxes or that someone on the other side of the planet isnt getting what someone else thinks is a fair shake in their eyes. In the last 50 years we have seen it over and over again. The de-evolution of our business base either by poor decisions or by taxation.

    Thats the reason capitalism is here and here to stay. Its alive and well in even the communist countries. Suppress of our steel business put it off shore, suppression of our pharma by litigation put it off shore, suppression of our movie industry forces it to operate in other countries because of the costs involved. I never, ever see anyone in all of these developing countries doing anything for their people, only themselves and demanding that we do something for them because they are developing. We send money in, it gets stolen.

    Its a capitalistic payoff. We want samples? We could roar in there and offer them say 100 mill and they would give them to us, plain and simple. But we are smarter than that. We simply wait for it to leave in a human, a duck, or like the Chinese we send someone in unsuspecting and then repatriate. All the samples in the world after that.

    Like I said, its not as simple as postured. The difference this time is that there are ramifications for all in a direct and massive way.

  15. #15 Grace RN
    December 21, 2007

    Herman,

    Our health system is collapsing now. It may well be DOA prior to the arrival of the next flu pandemic.

  16. #16 M. Randolph Kruger
    December 21, 2007

    I doubt it Grace…. The insurance companies are in the biz to make money. Just as the trial lawyers are. Ballooned payments for malpractice are what really got us here. We have every test known to God done to ensure that they have covered every base for a common case of measles now. It got to be too expensive for the businesses and we are now seeing the end of a cycle. Its uninsured people not people who cant get healthcare. It may not be the greatest but its available and free to those who cant pay for it.

    A study was done recently and brought to light on Rush Limbaughs show. It said that with the exception of only 4%, that people who didnt have healthcare had cable or satellite receivers…. Thats between 50 and 75 bucks a month. More than enough to enroll in the state programs if you are poor. Guess we need that on the questionaires…Do you have cable or satellite?

  17. #17 Hank Roberts
    December 23, 2007

    > the fastest way to start a war is to insinuate that the
    > West is creating bugs and planting them in underdeveloped
    > countries just to watch them grow.

    Especially if you believe your country has to do it because other countries are already doing it.

    Especially if people like this claim they already did it:

    Britan using biological warfare in the Falklands?
    http://www.guardian.co.uk/environment/2007/may/06/observerreview.climatechange

    “Monckton won the Falklands conflict from his armchair after suggesting, he claims, to the Prime Minister that the best way to undermine the Argies was to have the SAS introduce a mild bacillus into the water supply in Port Stanley. ‘I can tell you from experience there is nothing more demoralising than having the trots in a trench!’ He believes, laughing a little wildly, she took him up on this idea and the rest is history.”

    Yes, it’s madness. But are there people who believe it?

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