Indonesia, bird flu viruses and the moral high ground

US Secretary of Health and Human Services, Michael Leavitt, is in Indonesia to discuss matters of mutual interest with the Indonesian government. Topic number one was the Indonesian government's opt out of the international influenza surveillance system which has been in place for almost 60 years and provides vital information on what flu strains to include in the next year's seasonal flu shots. But the system is not limited to seasonal influenza and is an important part of the global surveillance of all influenza viruses that might be of human health concern, chiefly among the non-seasonal subtypes, the avian influenza virus H5N1 (bird flu). The Indonesians in the person of Health Minister Siti Fadilah Supari refused to provide clinical specimens from humans and poultry, beginning at the end of January 2007. This meant that the biological and genetic character of viruses from the world's hot spot for bird flu disappeared from the view of the world scientific community. We have discussed this numerous times here (see posts under the "vaccines" category).

In our view Siti Supari has acted irrationally and badly but the uncomfortable truth is that there is merit to her concerns. Everyone acknowledges that, although the way forward is less clear:

U.S. Health and Human Services Secretary Mike Leavitt, making a two-day stopover that included meetings with Indonesia's president and health minister, acknowledged Monday that improvements to the global body's virus-sharing system could be made.

"But linking it to the sharing of viruses is not something we can support," he said, adding that once "people begin to trade viruses for value ... there will be no end" to it. (AP)

I agree with Leavitt, but unfortunately he has less moral standing to be correct about it than many of us might wish. The US has done little to aid the cause of equity in the provision of pharmaceuticals to a developing world that can't afford it. On the contrary, the US has consistently sided with the intellectual property mafia in Big Pharma that won't countenance a single tablet being made outside their precious licenses. Trading pharmaceuticals for value is the way the US does business but Leavitt now objects when Indonesia does it with viruses. This doesn't excuse the Indonesians, who are behaving disgracefully. But it doesn't give the US much moral leverage.

Moreover for Leavitt to sing the praises of international cooperation, as he did on his two day visit, also rings a bit hollow. He represents an administration who has made it clear to the entire world the US will act unilaterally when it thinks this is in its interest. That's what Indonesia is doing with the bird flu virus, to the detriment of the entire world, including its own citizens. That's what the US is doing in Iraq, to the detriment of its own and other's citizens as well.

Indonesia has taken a terribly wrong course here. But no member of the Bush administration has the right to lecture them on it. Maybe Leavitt should rephrase his question in this way: "Once a country decides to act unilaterally just because it thinks it serves its own interests, where will it all end?"

Guantanamo maybe?

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We are all in this together. Until economies get this, we'll catch each other's flu and other diseases. We also need more than vaccines as a solution.

By phytosleuth (not verified) on 15 Apr 2008 #permalink

Yeah Revere you are right. Sometimes a country has to act unilaterally and in this case we should just do nothing. I dont see any other countries holding back except Indonesia and Supari is just flat nuts. We act and have acted unitlaterally and you consider this to the a linking to a war or thats the insinuation.

There is a big difference in a war that has territorial boundaries always, H5N1 does not. Supari is also asserting some stuff that will license a virus for the first time. The virus has no use except to sicken and kill. A war has either economic or political goals.

Supari gets to play her cards right up until the first 50 cases show up all together and then acting unilaterally either the US, UK, France, Germany or China will take the samples plain and simple. They also might act under the UN Charter and take them as well. Too little too late and of course the Indons could resist militarily and they would be flyswattered into the ground. That same UN Charter would allow by resolution the invasion of that country and there are one hell of a lot of ethnic Chinese in there. This is the same premise that Hitler used in annexing the Sudetenland, ethnic Germans.

Okay so the spinner on the board has been turned once again. Supari and the US are still at odds and we still have a monster killer out there waiting to feed in the bush. I still wwant my money back that we sent in there to stop bird flu. You can ask for your money back for Iraq too. I think we will both still be waiting when the flu arrives though.

By M. Randolph Kruger (not verified) on 15 Apr 2008 #permalink

Indonesia is mostly Muslim. Just as the Presidents hands are tied regarding Somalia, we dare not do anything to further anger Muslims in any other country at this time. There is no way we are going to do anything precipitous unless it is too late to do otherwise, i.e. the pandemic is already under way. It would be ill advised at this time anyway.

Food is getting scarce in Indonesia, as well as in many other parts of the world. Today Indonesia forbid the sale of rice to foreign buyers. And, Supari has the backing of the President of Indonesia. We may think she is half a bubble off plumb but evidently her President agrees with her. So, you have disease, poverty, ignorance, paranoia, hunger, rising energy costs and, only have one pawn that may help you-a deadly virus with which to blackmail the world. Desperate times requiring desperate measures.

Levitt really doesn't have anything else in his pockets to offer that Indonesia wants and thinks it can get. Given our history with emerging nations would you trust us? We nearly always back the big business interests who step in and rob and dupe the locals. Indonesia cannot afford the vaccine for which they will provide the key ingredient. Those in power see it as an opportunity provided by Allah to help protect their people. We see it as reprehensible. How could they doom the entire (paying) world to increased morbidity and mortality. Funny how we demand more from the Indonesians than we do from ourselves. We don't care if it costs money we can afford the cost. But, if we were in their place, how would we feel about the fairness of the deal?

They know exactly what that wee small pawn is worth to the world. They also know that they have us over a barrel. We either pony up what they want or, they withhold the newest samples. What do they have to lose? Our choice remains, pay up or try to steal the specimens. Even more interesting this time is which alternative really does follow the moral high ground? The real solution would be for the world to finance a vaccine making it available to everyone, not just those with enough money to buy the cure. But, that would mean big pharma won't make a killing on the profits.

When there is utter chaos in Indonesia over H2H2H then someone will be able to waltz into the country and gather samples. Then rush the samples to whatever country can develop the vaccine the fastest.
Until then I'd like it if "we" would just give up on them.

With gaining attention on big pharma etc . . . , there will be a point in time when people basically revolt. Why it hasn't happened yet amazes me.

Bill Gates is scheduled to go to Indonesia next month on a software trip. There has been speculation on different blogs that he may also offer a solution to the stand off we are in with Indonesia. If his foundation could guarantee vaccine funding, perhaps sample sharing will begin again.
It would offer a solution for Leavitt's concern that once "people begin to trade viruses for value ... there will be no end" to it. I don't know if this will really happen or not, but it does offer food for thought. Read Scott McPherson's blog for more.

By Science Teacher (not verified) on 15 Apr 2008 #permalink

How about this? Bill Gates can go and become an Indonesian. this is the guy that ripped us off for so many years with software that didnt work, was infected with viruses or left holes in it that exploited the software that then allowed infection.

How fitting he should go. But to answer the question he shouldnt be negotiating with terrorists.

Here is my read on it if he does and gets them....The situation is far more grave than we are being led to believe.

MTA's for viruses. He isnt the government of the US or any other for that matter. It once again puts that snake Supari back onto the world stage.

There will be no end to it.

By M. Randolph Kruger (not verified) on 15 Apr 2008 #permalink

"Here is my read on it if he does and gets them....The situation is far more grave than we are being led to believe"
I agree with this. It would be a last ditch effort to get Gates involved. I don't know if we are there yet. Time will tell, I guess.

I do think that Leavitt is a very talented negotiator and a master of diplomacy. What he said to the President's ear may be a far cry from anything Supari got from him.

By Science Teacher (not verified) on 15 Apr 2008 #permalink

The United States has no basis for citicizing Indonesia. The US is a failed state economically, and is imploding. The banks will soon collapse as the credit default swap market disintigrates. Does the US protect human life, either in the US or internationally? The answer is no. Just ask those who have had heart attacks and called for an ambulance, only to have the ambulance turned away from the nearest emergency ward, and diverted to another hospital, while their life dangles on a thread, losing precious time.
The world will soon be blindsided by a combination of influenza and drug resistant tuberculosis. Extensive drug resistant TB is now an epidemic in South Africa. In Asia drug resistant TB is out of control. Bird flu attaches to the bird flu bacteria, and in that way enters the lungs of the victim, where it replicates.
The doctors in Indonesia test for H5N1 and conclude the victim died of bird flu. What they do not realize, is that a virulent drug resistant strain of TB may have actually killed the victim. Of course they do not test for TB. Even if they do, the sputum tests are not very accurate.
Did you know avian tuberculosis can infect humans and even kill them? Did you know H5N1 can attach to a TB bacteria, and be airborne, to infect the lungs of another human? And as it does, the H5N1 attached to the millions of TB bacteria, infecting the human lungs, begin to replicate, often killing the patient. Did you know many infected with Spanish Flu in 1918, were also infected with TB?
Even if the doctor determines the patient is infected by both H5N1 and drug resistant TB, what does he do? Antiobiotics are almost useless. So he or she watches helplessly as the patient dies a horrible death, just as the doctors did in 1918.

The bird flu virus attaches to the drug resistant TB bacteria, and in that way enters the human lungs.
Sorry for the error.

Lea wrote above:
"When there is utter chaos in Indonesia over H2H2H then someone will be able to waltz into the country and gather samples."

Indonesia is hosting a "pandemic epicenter" simulation in two weeks, to practice drilling the WHO rapid response plan to contain or delay the spread of a fictional outbreak that will look like WHO-Phase-4-going-on-6 pan flu.

It will be interesting to learn how quickly -- in the simulation -- samples get to where they can be used to make vaccine.

By Path Forward (not verified) on 15 Apr 2008 #permalink

Why bother. Supari will want someone to guarantee they wont leave the country and if they do, they'll have to agree to license the bug and deliver the first entire batch of it to Indonesia.

Ever heard the words, "Let them eat cake"? Know what happened just a few weeks after that? Indonesia would be invaded so fast it would make their hair stand on end. Aussies, US, UK,Russia and Chinese all are maintaining a sizeable military presence down there right now and just outside in international waters.

They are playing with fire and they are sitting on a can of gasoline. there is no limit to what these countries could agree to do to stop it from getting out of there. I was lambasted for suggesting the use of neutron or chemical weapons to neutralize the country... You can bet under the current regimes in every country save maybe Oz and the UK, its been discussed.

By M. Randolph Kruger (not verified) on 15 Apr 2008 #permalink

Earlier, whilst running around doing a few domestic chores and attempting to process the tick tock tick tock seriousness of this post, I thought 'bout the political simplicity of the sentence, "Let's work together, instead of against each other." Yes, this cool diplomacy is the way forward according to Scott McPherson's, "An open letter to Indonesian President Susilo Bambang Yudhoyono" (dated April 14th, '08 and posted on his blog).

Yes, many of you would suggest a Disney-esque naivety in McPherson's words, especially given recent bizarre epidemiological examples of Indonesia's "off-course" global positioning. But, with Japan set to shortly begin prepandemic vaccination -- based on older H5N1 strains from China, Indonesia and Vietnam -- of up to ten million citizens involved in maintaining crucial social infrastructure, the proverbial "pandemic ball game" has moved to a defacto higher level (in spite of WHO's current phase 3)...

Of course, we have yet to dicover what degrees of H2H H5N1 immunity will eventuate from Japan's prepandmic vaccination. But, this nation is behaving very much like a responsible adult and investing in reality -- now, will the Bush and Yudhoyono administrations throw away "delusional fiction" and follow suit!?!

By Jonathon Singleton (not verified) on 15 Apr 2008 #permalink

Revere, I agree with much of the rest of your post, but must disagree with your sweeping statement about the U.S. and the provision of pharmaceuticals to developing nations. Just one example: the U.S. provides huge amounts of AIDS medications at no cost to many, many people in Africa--and this since President Bush came into office. When reporters have spoken to AIDS patients in Africa, many have cited the president as a hero for this program. Huge additional funds are spent for AIDS prevention, which has been shown to be incredibly effective in Uganda, for example, which is turning itself around in its HIV infection rates. (Yeah, I know you really, really don't like him. But don't throw the baby out with the bathwater.) In other examples, there are many programs--both government-sponsored and privately supported--which provide various meds to the poor all over the world, and both in and out of our borders. AnnieRN

Annie: This isn't about "foreign aid." It is about US policy that almost indiscriminately supports the intellectual "property" rights of Big Pharma even when those "rights" are based on a very distorted IP system devised and designed by the same Big Pharma solely to its advantage.

revere, thank you for being the voice of conscience.

Whilst I believe that sharing of information including virus samples is vital for the good of everyone on this planet, the reality is until Indonesia raised this ruckus a year ago, NO ONE in the West (at least not those in power) was interested in discussing how we can help developing countries if and when a pandemic happens. Suggestions from David Fedson and others to investigate the use of statins and fibrates, and to fast track technology for production of massive quantities of pandemic vaccines for the world, have been mostly met with "that's a great idea, but that's not our field".

Everyone appears to think it is not their problem, that come a pandemic, much of the world will perish with no hope of any intervention. Are we surprised that the poor will use desperate means?

I don't pretend to know what the Indonesians' intentions are, beyond trying to get some affordable pharmaceuticals; I daresay there must be others. But the case for making essential medicines available to the world's poor is not just a moral one, but also a public health one. Are we so short-sighted as to believe that having massive fatalities and/or systemic breakdowns in a significant number of countries is not important for our own wellbeing?

As Fedson said when this first started, when everyone was expressing shock and outrage at the Indonesians' behavior "we should have seen this coming."

He has written a commentary just published on Lancet Infectious Diseases Confronting an influenza pandemic with inexpensive generic agents: can it be done?

Avian influenza A H5N1 presents a serious and possibly imminent pandemic threat. In such an event, adequate supplies of affordable vaccines and antiviral agents will be unavailable to most people in the world. In view of the overwhelming need for effective alternatives, generic agents that target the host immune response or the pandemic virus should be considered. Many scientists doubt the effectiveness of these agents. Nonetheless, several studies suggest that statins improve outcomes in patients with bacteraemia and pneumonia and might be similarly effective against influenza.

Statins, fibrates, and chloroquine are produced as generic medications in developing countries. They are inexpensive, could be stockpiled, and would be available on the first pandemic day. With a lack of realistic alternatives for confronting the next pandemic, research is urgently needed to determine whether these and other generic agents could mitigate the effects of what might otherwise become an unprecedented global public-health crisis.

It's been close to 5 years since the call to find inexpensive alternatives for developing countries was first made. It is a reasonable case, and well within our means in research terms. Once the work is done, any stockpiling of such drugs can be left to the countries themselves, as the drugs are affordable.

Is anyone heeding the call? All I hear is deafening silence.

All I can think of is the word 'Shame'.


Bill Gates is scheduled to go to Indonesia next month on a software trip. There has been speculation on different blogs that he may also offer a solution to the stand off we are in with Indonesia. If his foundation could guarantee vaccine funding, perhaps sample sharing will begin again.

It isn't so much the funding as the technology that is problematic. As I wrote here more than a year ago, no matter how you cut it, the gap is so big with existing technology that there's no way that production capacity can meet the needs of even the vaccine producing countries, let alone those of the Third World. What needs to happen is an entirely revolutionary approach not just to technology (which are already available) but to overcome the legal and intellectual property issues, in order to fast-track some promising methods. It's a vastly complex problem but not impossible to solve. As I said in this comment at the time

no single company can handle something of this size, they will have to be part of a consortium. The regulatory, financial, IP issues involved are huge but not insurmountable. The WHO and the US need to bring in expertise from not just the science sector, but finance, legal, regulatory, security, venture capitalists, etc. Many of the global leaders who attend Davos would have expertise to bring this about.

What might work is if the WHO sets up, either independently or as part of the Pandemic Task Force, a Global Pandemic Vaccine Task Force, to do a case study with a tight deadline to come up with a model with feasibility analysis, identification of stakeholders and production capacity, funding, expertise required, specific legal and regulatory challenges that need to be urgently addressed etc.

Another, less ambitious and easier, way of doing this would be for the US to unilaterally change their regulatory approach for the US pandemic vaccine market to facilitate and incentivize the evolution of the US project to a global one.

It may be entirely wishful thinking on my part, but I sure hope that the Gates visit is a sign that they are using the first option that I suggested, since it sure looks like neither WHO nor the USG will take the lead on this issue!

Susan-With all due respect the US and the EU are NOT going to pony up vaccines and things that Indon needs as we have already done that by way of the money that was flat stolen down there. Fool me once.....

I love the bleedin' heart liberals who think that what we really need to do is just socialize the entire world and everything will be just fine. In reality we would have a have a severe drop in lifestyles if we do. A full blown shrink in the US makes what, 350 an hour? Under the UHC in the Netherlands its left up to the local health committees what you make. Shit.

Then there is the usual assertion that WE are doing something wrong by having boards of directors who vote compensation that someone ELSE thinks is exhorbitant or that it needs to be regulated. So now government is going to tell you what you can make now too? The supposition is that they by way of accession CEO's and others are doing something wrong. Hey, how about them goddamn football players? They make too much, and urps, they charge too much for a ticket and gasoline is too high and oil companines make too much money. Windfall taxes is what we need... All they ever do then is raise the price of gas again. Some people are just too dumb to understand it. If the pharma people spend hundreds of millions to field a drug or treatment, you always have the right NOT to buy it. But the answer is to that well, I'll die if I dont get it. Yup, and then the market determines the price. Cant sell it to dead people.

There are really two systems and those are communism and capitalism. We know one doesnt work. If they screw the little guy then welcome to capitalism folks and the insinuation is that its wrong just falls on deaf ears. Thats the silence you are talking about. Its not shameful either. I would bring you up on current events a bit.... We are all or a bunch of us are going to be dead from BF if it comes. Beefing up the healthcare system creates an artificial barrier against what would or will be inevitable for many people. It might create a few better outcomes. But who is going to be around to pay for it if does? .

The US and EU just aint kissing Supari's ass to get the samples because the outcome will simply still be the same. No vaccine for the poor here, or the poor in Indon or anywhere else for that matter. You assert that we could get onto these other treatments. Prove that please. UT is on Revere's statin thing but only on a minimal grant. But its all about the money. Pharma has to fund most of this out of pocket. But those same little socialists and communists would like to take the money from your pocket for all of their little programs which are not in the Constitution of the US and then try to throw up how we got into Iraq and how we are still there. Show me Kosovo which was done without resolution. Thats the reason that Bush had Congress sign on to it via resolution. To hell with that. Next time just declare war. Kick their asses and just leave with all of the damage in place... Maybe they'll think twice?

"Its a reasonable case and well within our means in research terms." Yeah, if you want your company to go broke. Shame? Shame is if you are doing something immoral. Prove that one. They are operating within their corporately taxed guidelines just like I am and respectfully, I dont want another dollar worth of anything going out the door to Indonesia, period. Indonesia got the bulk of a billion dollars and they stole it Susan. What they didnt steal they didnt use for bird flu prevention either. They put it into their TOTALLY failed UHC system. It was fine for two years and now its broke again and they are looking for a handout in the middle of a huge world financial crisis.

As with all things in this respect the poor are going to suffer but the affluents around the world will not escape bird flu if it comes in highly pathogenic form. Not this time around Susan. Nope, not a family out there that will not either be touched or take the near brush. I am interested. Who do you think is going to pay for Indonesia who is the fifth largest oil producer in the world. Hell, at 114 a barrel they could pull a France and offer us up oil at 39 a barrel. I would be more than happy to give them vaccines for say 50 a barrel. But thats just me. When does extortion for the world become a simple money transaction...When its contracted under an MTA, thats how.

You have to remind yourself that we have to operate within the law. Those pharma companies have stockholders to answer to and if they do something that the shareholders think is wrong, they can be personally sued. Unlike the US government for going to Iraq, that suit will be expensive, not contained in the constitution except under torts and those directors and managers will be liable. They call that breach of fiduciary and its not good common sense.

I hate to off on this but I plan to make as much money as I can, when I can and stick it to the little guys when I have them over a barrel as much as possible. It really gripes my butt when someone tells me that some problem in Indonesia is mine. Let them enjoy the effects of watching their people die in droves. Supari will get the blame and their government will topple. They have a really good scapegoat in her, but in this case the shoe more than fits.

By M. Randolph Kruger (not verified) on 16 Apr 2008 #permalink

Good points MRK. Was wondering when I'd agree with you again!

Lee, I'm with you. MRK has hit the nail on the head.

SusanC, Randy, Revere, Victoria, Bar and friends:

I remembered one time, Bar agreed with my analysis that Supari has obtained the authorization from her democratically elected Indonesian president. Victoria has mentioned that Suharto' group is still behind the system. Their analyses are pretty correct. In a word, Indonesia has painfully moved forwards with the struggle against the past system and the invisible power behind; back and forth.

What can international communities respond to the current situation in Indonesia especially in dealing with the development of vaccine manufacture for BF prevention?

I am still holding the idea of Parma syndication to commission this function and ultimately deliver the outcome.

Compassion and let go the past wound, restore the covenantal relationship with a newly democratic fledged country perhaps is our new stance.

So, Revere, we need you to give us an inspiration talk....

They have no moral high ground. They just have diseases, poverty and over population. If it is their virus' or diseases then they should keep them. We certainly don't want them. Do we not give them aid? What good does it do? More population. A cycle that just gets worse and now they are hungry. Who would have thought over population would do that? And when we feed them, they will continue to over populate even more and continue to blame the U.S. for their problems. An endless cycle which too many here subscribe to.

Right on Rob, wish I had said that.

Question for someone who "really" knows the answer: how long has the term "developing nations" been around, been used?

Let these countries develop on their own from now on.
But alas, that won't happen as long as the power mongering, globally minded elites have to break into new territory and increase their already ridiculous wealth.

Apologies! Rod, I meant Rod.

Right on Rod, wish I had said that.

Question for someone who "really" knows the answer: how long has the term "developing nations" been around, been used?

Let these countries develop on their own from now on.
But alas, that won't happen as long as the power mongering, globally minded elites have to break into new territory and increase their already ridiculous wealth.

Can not be so easily tired, Rod. The world belongs to you. And you have to be engaged.

As Revere's philosophy, every country has good and bad people. I had worked in Indonesia from 1992-4. So, I understood there a bit.

One of the biggest issues in Indonesia is ethnic friction between Chinese origin and Indonesian natives, lots of corruptions have been caused by insecurity. Most of big corp. all has big accounts in Singapore, nowadays partly transferred to PRC.

I personally believe that US leadership includes governmental level and private sectors are pretty positive in Indonesia. So, my advice is staying calm and positive. I am most concerned that Chinese -origin merchants have been dragging towards PCR too much.

I have observed several American friends and families have flourished well in Indonesia, children have grown up more competently due to cross cultures experiences.

Rod, travel to this part of the world and look for broad engagement, IMO.

A correction, PRC not PCR. LOL.