Indonesia: hope for the best but expect the worst

As you read this a meeting of more than three dozen avian flu experts should be convening in Jakarta to discuss the disastrous state of public health in that country. Many poor countries have disastrous public health systems, but Indonesia has something else: a huge population of people living in close contact with a huge population of poultry infected with an influenza A subtype (the H5N1 subtype) that has crossed the bird/human species line. Influenza A is a major killer of human beings worldwide, but the global population has substantial (at least partial) immunity to the circulating subtypes. H5N1 is new to the human population (hence no residual immunity) and unusually virulent. The recorded case fatality is over 50%, although no one knows the real proportion of infected cases that die because we don't have a good way to count the infected cases. We suspect many or most of them have gone undiagnosed and unrecorded. More worrying, cases are appearing in small clusters, often in areas where no sick poultry can be found, or at least where no contact can be determined. About a third of the cases are in urban areas, although many city dwellers also keep birds. the latest large cluster exhibited all the marks of spread from person to person within the unfortunate extended family decimated by the virus.

Indonesia is now number two worldwide in officially counted human H5N1 cases and deaths. The official count as of today according to the WHO's conservative tally is 50 cases with 38 deaths (76% case fatality). Indonesia is a public health basket case, with an ineffectual and often incompetent central government who has ceded both authority and control to local authorities in a sprawling nation of island archipelagos that is fourth most populous on earth. They have been beset not only with bird flu but an erupting volcano and a serious earthquake within the last month. Earthquake survivors were dying in scores of tetanus, a completely preventable disease. Tetanus toxoid can be administered after the injury and doesn't require prior immunization. It is not a new treatment. But it wasn't being done. This gives some indication about how unprepared the Indonesians are for disaster.

As flu experts gather, it is hard to think how they will be able to make much of a difference in a setting like this, although there were the obligatory expressions of optimism :

Observers say the expert consultation, taking place at the request of the Indonesian government, is a welcome sign of that country's concern about the threat H5N1 poses both for its citizens and the global community.

"I think calling this meeting is a step towards recognizing that they have got a problem and they do have a responsibility to the rest of the world in terms of trying to deal with it," says Lance Jennings, a virologist and epidemiologist at Christchurch Hospital in New Zealand.

"I think it's a positive move and will lead to improved understanding," adds Jennings, who last year participated in a similar World Health Organization-led assessment of the H5N1 problem in Vietnam. (Helen Branswell, Canadian Press)

Doubtful. Very, very doubtful.