Alan Sipress - The Fatal Strain

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.