Alan Sipress - The Fatal Strain

Finally, in early 2008, clinical trials began. It was the same vaccine, developed in monkey kidney cells. And it was initially tested, as long planned, on researchers at the institute, ten in all. Then the vaccine was tested on what Vietnamese officials described as thirty student volunteers at the country’s Military Medical Institute, with larger trials planned. “Good results,” Van reported. Her institute planned to start mass production by late 2009. Each dose would cost 30,000 Vietnamese dong, or a mere $1.80.

If Van confronted global inequities with determination and forbearance, Indonesia’s Siti Fadilah Supari was far less patient. And on a crisp Geneva morning on a climactic day in 2007, Dr. Supari was already running late. Her scheduled flight on a British airliner had been grounded. But she had been lucky enough to find a later flight to Geneva, this one on Lufthansa. She had flown through the night and, once on the ground, had to wait again, this time for nearly everyone else on board to file out. There had only been room for her at the very back of the plane, even though she was a cabinet member from the world’s fourth-largest country.

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.