by Alan Sipress
Supari, Indonesia’s health minister, was scheduled to give her speech in half an hour, and she was still on the plane. “Dear God, help me!” she thought. As she descended a stairway from the jetliner and headed finally for the VIP lounge, she was welcomed by a delegation of fellow Indonesians, including her country’s ambassador at the UN mission in Geneva. They exchanged pleasantries. Then her colleagues handed the minister a draft of the address she would give at the meeting. When Supari read what they had written, she felt wounded. “I was thoroughly shocked,” she recalled. “They had no idea of the core of the problem.”
By that time, in November 2007, Indonesia had long since become the epicenter of the bird flu outbreak. More people were dying of the virus there than anywhere else on Earth, and many flu specialists feared Indonesia would ultimately be the source of a pandemic. Yet for more than a year, Indonesia had refused to provide virus samples from the overwhelming majority of its cases to WHO-affiliated labs, leaving the world blind to the evolution of the virus. The danger was grave. If the pathogen was mutating into a pandemic strain, no one might know. This could preclude the world from launching an effort at rapid containment before the virus spread or making emergency preparations in case it did. Without current samples, scientists would be hampered in developing vaccines against the pandemic strain, monitoring the effectiveness of antiviral drugs, or producing updated diagnostic tests to identify the virus elsewhere.
WHO had convened a special meeting of representatives from more than a hundred countries to address complaints raised specifically by Supari over how the developing world shared virus samples and what health benefits it received in return. The speech penned by her colleagues explained that Indonesia’s objective was to safeguard the lives of those in poor countries by winning them better access to pandemic vaccines. But Supari’s fight had gone beyond that by now. It was no longer a technical dispute over the distribution of vaccines. It was a wider struggle over fundamental inequities in the global health system embodied by WHO. In short, she told her colleagues, she was taking aim at the “oppression between nations.” Supari chided them, informing them she had her own draft and that was the one she would deliver.
Supari stopped at her hotel only long enough to change clothes. Then she dashed for the Palais des Nations. Initially erected as the headquarters of the League of Nations in 1919, the monumental building now served as the European seat of the United Nations. The meeting itself was running late, and Supari was allowed to proceed with her speech.
For ten minutes she skewered the long-standing system under which countries like Indonesia freely provided virus specimens to WHO labs and they in turn supplied them to commercial drug makers. The countries of origin were rarely told what purpose their samples were put to. “We do not really know whether they are used for research and publication or they are shared with vaccine manufacturers for vaccine production. Or maybe they are utilized for the development of biological weapons,” Supari told the audience. Her hyperbole was startling for those accustomed to the diplomatic palaver of Geneva. She pressed on, lambasting the arrangement in which developing countries were forced to pay market prices for vaccines, even if these countries were the original source of the vaccine strain. “If these oppression practices continue, poor countries will become poorer and rich countries will become richer,” she warned. “This is more dangerous than an avian influenza pandemic itself—and even a nuclear explosion.”
The gap between rich and poor that had provoked resentment elsewhere was here begetting full rebellion. Nor was this resistance at the margins of global efforts to stem a pandemic. Now it struck at the heart.
Barely three years earlier, few even in Indonesian public health circles had heard of Supari. She had been an obscure cardiologist and medical researcher at a Jakarta hospital. Then, one evening in October 2004, her cell phone rang. She never did find out who the caller was. But he told her that Indonesia’s incoming president, retired general Susilo Bambang Yudhoyono, urgently had to meet her. He wanted her to be his health minister. She would be sworn in the following day. “Why me?” she asked. “I am just a woman. The president needs someone who is tough. Am I that?”
What she had were the right credentials. One day before his inauguration, Yudhoyono was still struggling to assemble his cabinet. He’d won a decisive electoral victory, but his own political party was tiny. His government would be stillborn unless he could line up backing from larger political forces. Supari’s family had long been active in Muhammadiyah, a Muslim civic organization that claimed about 30 million members nationwide, and its support would be a boon to any politician. So when the group’s chairman suggested Supari, Yudhoyono agreed. Besides, she was indeed a woman. The cabinet was short on those.
Supari had graduated with a medical degree from Indonesia’s elite Gajah Mada University but, unlike many in the cabinet, had never studied abroad. She was a stout woman with large, round, rimless eyeglasses. She had jet-black hair and, though a devout Muslim, often appeared in public without concealing her bouffant beneath a traditional headscarf. She favored batik dresses and suit jackets, acces sorizing generously with gold and pearls. At first she had difficulty being taken seriously as a minister. Jakarta’s chattering classes dismissed her as giggly and prone to public gaffes. But she proved shrewd. She honed her public relations, even launching her own Sunday evening television talk show. She also tapped into Indonesia’s profound sense of national grievance.
Every way Indonesians looked, life seemed to be getting harder. That was particularly true for their health. The public health system Supari inherited as minister was sorely underfunded and had eroded sharply since the 1997 Asian financial crisis. In one typical clinic in southeastern Sumatra, the director explained to me that he could no longer offer routine immunization against childhood diseases. “For us, it’s hard to answer the parents when they ask why the vaccines have run out,” he complained. Apologizing for the rat droppings that littered the clinic floor, he shuffled into his tiny, tiled office and opened the rusty clasps on the fifteen-year-old freezer once stocked with vaccines. It was almost empty. He told me that health workers were forced to scavenge for unused syringes in other medical offices or scrape together money to buy their own. The refrigerator used for making ice to transport vaccines into the field was broken. “Money is our unending problem,” he said. Already unable to provide basic care across much of the archipelago, Indonesia’s health system then suffered a series of staggering calamities within months of Supari taking office: the tsunami that killed at least 150,000 in Sumatra, earthquakes, and a resurgence of polio. Finally, bird flu struck.
Indonesia was fortunate that it started with an isolated outbreak. At the premier hospital in Jakarta for treating infectious diseases, there were enough doses of Tamiflu on hand to treat no more than eight people. “When we have an epidemic, we cry for help,” said Santoso Soeroso, a physician at Sulianti Saroso Infectious Disease Hospital, as he gave me a tour of his facility’s spartan isolation wing. He acknowledged that he worried there was not enough of the drugs for preventive use by doctors and nurses who would care for flu patients. The balance of the national supply had already been divvied up among thirty-three other hospitals, with each receiving enough for just two patients. Soeroso said he had no budget for any more.
WHO eventually shipped over more supplies of Tamiflu. But these were just limited emergency stockpiles. Indonesia had no money to follow the lead of wealthier nations that were already ordering sufficient quantities of the drug to treat as much as half their population should the disease spread beyond Asia. Supari learned that Indonesia would have to wait months to buy more Tamiflu if it wanted any, and even then would have to pay up to forty dollars per treatment. She was flabbergasted.
In November 2006, David Heymann and Keiji Fukuda came calling in Jakarta. Heymann, who had helped stand up WHO’s global strike force, was the agency’s new assistant director general for communicable diseases. Fukuda, who had helped
quarterback the world’s response to the Hong Kong bird flu outbreak in 1997 and the Vietnam outbreak just over six years later, had been tapped to become WHO’s new influenza chief. The agency was planning to spell out in an official resolution what had long been the informal process for sharing virus samples with WHO, and the pair wanted to run it by Supari.
What she told them in response brought them up short. Indonesia would no longer share, not at all.
Behind the scenes, Indonesia had already been locked in a running dispute with foreign scientists over access to flu virus samples. For a year, researchers from the U.S. Navy lab in Jakarta had been engaged in what an Indonesian health officer called a “cat-and-mouse game,” trying to collect specimens in hospitals and stricken villages despite government efforts to stop this. “It was so difficult to get the damn virus out of Indonesia and analyzed,” recalled the navy lab’s influenza chief at the time. “You had to go around the system.” Neither side ever publicly disclosed this subterranean contest, but the competing claims to local virus samples silently poisoned relations between Indonesian and foreign scientists.
The U.S. Naval Medical Research Unit 2, or NAMRU-2, was established in Jakarta in 1970 to help U.S. military forces research diseases they might encounter in the tropics. Along the way, the lab worked on maladies that also afflicted the local population, including malaria and dengue fever, and eventually set up a system to monitor for seasonal flu viruses in collaboration with six Indonesian hospitals. NAMRU was the most sophisticated infectious-disease lab in Indonesia, the only one with safeguards required to fully analyze pathogens like bird flu, and its staff, largely Indonesian, was the most technically proficient in the country.
In 2000 the agreement between the United States and Indonesia authorizing the lab to operate ended. But for several years, the lab continued its activities with the approval of Indonesian officials and even expanded its flu surveillance network to cover twenty hospitals on most of the country’s main islands, stretching from Papua in the east to Sumatra in the west. In return for supplying virus samples from patients, Indonesian doctors were paid a monthly stipend by the lab. It also gave them money to come to training sessions, with daily allowances that often exceeded the actual expenses. The payments to each doctor could come to several hundred dollars a year, a generous sum in Indonesia. Plus, NAMRU helped the doctors pay for equipment, such as microscopes and refrigerators for storing specimens. As long as the navy lab was focused on seasonal flu, few Indonesian officials objected.
In July 2005 that relationship changed with the country’s first recorded case of bird flu. NAMRU had dispatched Andrew Jeremijenko, the leader of its influenza surveillance project, to investigate the outbreak along with Gina Samaan of WHO. Jeremijenko already had a relationship with the pathologist at the local suburban hospital through the flu network and was able to secure samples of this new, mysterious virus taken from the victims. It was NAMRU scientists who initially identified H5N1 in Indonesia. But Indonesian officials barred Jeremijenko and his colleagues from disclosing these results. Moreover, the government insisted bird flu was different from seasonal flu and thus not covered by the protocol allowing the lab to conduct research. To the navy lab, the distinction was preposterous.
“We were doing human influenza surveillance in the hospital and that’s all influenza. It doesn’t matter what sort of influenza it is. The problem with H5N1 is that it is a political disease,” recalled Jeremijenko, an Australian doctor who worked on contract at the lab between 2004 and 2006. “We were walking on eggshells. The whole time, I was afraid I was going to get thrown out of the country.”
Indonesian officials were determined to keep control over both the samples and any findings about the disease’s evolution, which were potentially staggering for the country’s economy. The government tried to block NAMRU staff from investigating subsequent outbreaks. Then, in late October 2005, a senior health ministry official informed health agencies and more than two dozen hospitals around the country that the navy lab would have to cease all activities at the end of the year. No longer was any agency or hospital permitted to collaborate with the lab.
But the lab persevered. It continued to offer payments to doctors in the hospital network, and they continued to send samples. The lab also continued to dispatch staff to various hospitals, where they collected even more virus specimens and related material such as copies of X-rays, often beating government health officials to the site. “We had to push these things,” Jeremijenko said. “We couldn’t do anything in Indonesia if we didn’t break the rules sometimes.” On several occasions he and his colleagues even eluded government restrictions to visit the scene of outbreaks, arriving under the radar in a private van. It was always on a Sunday, when Indonesian officials were scarce. “We weren’t officially anywhere,” he put it to me. “We didn’t have the right to go sample and investigate anything. We did it surreptitiously.”
Indonesian health officials weren’t completely in the dark. After one outbreak in Sumatra, a stricken man resisted giving mucus and blood samples to government disease investigators. “Some of you already took my blood,” the patient told them, one official recounted. “Why would I give two times?” NAMRU had already been there. And when a girl on the eastern island of Sulawesi fell sick, her family refused to give samples to government health investigators, another official recalled. NAMRU staff, accompanied by a team from the provincial hospital, had already been through the village gathering specimens.
“They manipulated our agreement,” a senior Indonesian health official later fumed. “They think they can just go to the field without proper procedure and violate the protocol.”
Three months after their initial visit with Supari, Heymann and Fukuda were back at Indonesia’s health ministry, a large, modern structure on a downtown boulevard lined with bank towers, embassies, and hotels. The meeting was off to a late start. That day in February 2007 was a Friday, the Muslim Sabbath, when everything in Jakarta runs even slower than usual. Supari and her staff had temporarily disappeared to make their midday prayers while the visitors kept their eyes on the clock. They were scheduled to fly out of Jakarta later that same day. When they were finally ushered into the minister’s spacious second-floor office, there were far more people gathered around the large wooden coffee table than three months before. The dispute over virus sharing had escalated.
Supari had been stunned weeks earlier to learn that an Australian drug maker, CSL Limited, had used an Indonesian virus strain provided by WHO to manufacture an experimental human bird flu vaccine. “I never gave permission to any Australian company to produce a vaccine based on the Indonesia strain of the virus,” she protested.
Even before that, she had opened talks with U.S. drug maker Baxter International over acquiring 2 million doses of bird flu vaccine for Indonesians. Baxter had offered to sell the vaccine, which was based on a separate H5N1 strain from Vietnam, but at the steep market price. That was when Supari gained her first glimpse of what she called the “neocolonialism” of WHO. “The situation is ironic,” Supari later told me. “The virus obtained by vaccine manufacturers came from dead Vietnamese people who had been grieved by their brothers and sisters and parents, and then it is commercialized by other nations without compensating Vietnam.” Supari had made Baxter a counter-offer. Indonesia would give permission to Baxter to develop a vaccine from the Indonesian subtype in return for 2 million vaccine doses and help in establishing a vaccine plant in Indonesia itself. Indonesia and Baxter signed a memorandum of agreement just days before Heymann and Fukuda returned to see the minister. The suggestion from Jakarta was that no one else would get access to the Indonesian strain, now the deadliest on Earth, unless they met Supari’s demands.
For half a century, countries had freely provided samples of circulating flu viruses to WHO’s collaborating labs under a system called the Global Influenza Surveillance Network. These routine viruses were analyzed by WHO each year to predict which would cause the next
round of seasonal flu. Then the seed viruses were turned over to drug companies to make annual flu vaccines. The developed world has been home to both the labs and the drug makers. But since most of those getting flu shots were in Temperate Zone industrialized countries anyhow, poorer nations had paid the process little mind. Now, facing a possible pandemic, Supari was challenging not only this traditional system but the integrity of WHO itself. Her attack was unprecedented in the agency’s history. Further, she was making the claim that viruses were biological resources owned by the countries where they circulate, not public health information that must be shared freely with the world. She insisted that WHO acknowledge Indonesia’s sovereignty over its viruses and sign a material transfer agreement, which would limit what could be done with Indonesia’s virus samples and potentially entitle it to compensation if they were used commercially.
But senior WHO officials feared that such conditions could wreck the global surveillance system. Flu specialists depended on unencumbered access to virus specimens to watch for menacing twists in viral mutation, keep the tests for the virus updated, and ensure that vaccine research remained current.
“WHO has become a target for Indonesia,” Fukuda later lamented. “That’s not us. We support Indonesia.”
There were already signs the Indonesian rebellion might spread. Thailand, for one, had recently signaled its sympathy in remarks at a WHO executive board meeting. Heymann and Fukuda aimed to keep the disagreement from escalating any further. They wanted to frame the debate around proposals for reform, like making the virus-sharing system more transparent and enhancing the access of poorer countries to vaccines and vaccine production technology. Heymann balked at Indonesia’s more radical demands. The meeting was deadlocked, and yet they kept talking and arguing for five hours, right until the last minute when the visitors had to leave for the airport.
