Viet Nam – Blog IV

Today, I’ll finish the ten observations about Viet Nam I promised.

Observation Seven: The Viet Nam government appears to have taken the threat of Avian Influenza seriously. They seem to be doing what they can. Inherent in that observation is the acknowledgement that they don’t have the capacity to do much. However, I have now been in two small village areas in Viet Nam during different visits. The first was where a family of five contracted the virus. The second visit was in an area where H5N1 was in the poultry population. In both cases, I was impressed by the response.

On this trip I met Mr. Chien, who I’m guessing by the fact that he started in the chicken raising business 18 years ago, is in his late thirties. He appears to be a natural entrepreneur. He started with 200 chickens in 1991 and now has over 11,000.

We walked through his operation while he showed me how he vaccinates his chickens. He told me about the morning he found 100 out of 200 breeder hens dead. He didn’t know what it was, but he called a vet from the Province who determined it was avian influenza.

Vaccinating a chicken

We went back to his house where a group of his friends from the area had gathered to talk. I asked about how the village reacted when they understood what they were dealing with. Mr. Chein said, “Our children were afraid, and we were afraid for them.”

There is no question if the H5N1 virus begins to spread efficiently, person to person, all of southeast Asia is highly vulnerable including Viet Nam. However, we have a much better chance of catching it quickly there, than in other countries in the region.

Observation eight: There are promising signs that Viet Nam may have acted fast enough to avert a major spike in HIV/AIDS cases. Viet Nam is one of the 15 countries in the President’s Emergency Plan for Aids Relief. I’m told the decision was made to invest aggressively in Viet Nam because it looked like HIV/AIDS was just about ready to spike dramatically. Over the past four years, our investment has increased from $17 million to $88 million a year.

I was pleased to learn we are spending much of that amount on building infrastructure and people. The reports I received were quite positive.

I visited a clinic in a section of Ho Chi Min City where they are starting a program to focus on intravenous drug users. A high percentage of the HIV/AIDs in Viet Nam comes from the use of dirty needles. The approach is to help people stop drug use, hence having fewer risks generally. They use a system of peer educators; kids that have had a drug problem but overcame it. I spent about an hour talking with them. I saw the use of this technique in Africa. They have teams of people who are HIV positive trying to convince others to “know their status and get tested.” It seems very effective.

When I met with the Health Minister, we discussed the fact that rapid response HIV/AIDs tests are not being used in Viet Nam. I hope we made some progress in persuading them.

Observation Nine: The rapid increase in the price of food is becoming a big problem in Viet Nam. I mentioned in my blog entry on Indonesia what a problem the rising price of food has become. I simply hadn’t focused on this as an issue until this trip. Rice is now more than $700 a ton, more than three times the rate of five years ago.

Apparently there are many contributing reasons for the price going up. There is a growing problem with various pests and viruses that adversely affects the crops. Also, there has been a series of weather-related matters, which have been part of the problem too. This could become a major issue worldwide if it continues to develop.

Observation Ten: Viet Nam is a young country and I saw a disproportionate number of women emerging in leadership roles within the bureaucracy. I don’t know if that is true within the Communist party however.

More than 60 percent of the population is under 30 years old. As one moves around Viet Nam, it is highly evident. If they can find a way to educate this group and provide an economic system where they can succeed, the youth of their population is a huge asset because they are hungry to succeed.

I gave a lecture and answered questions at the Hanoi School for Public Health. It was a delightful hour. The students were more than willing to engage. Apparently attendance at the school is highly competitive with many applications for each slot. Again, it interested me that the group I spoke to was nearly three quarters female.

Viet Nam – Blog III

Following on yesterday’s blog, here are some additional observations about my recent trip to Viet Nam.

Observation two: While they maintain a communist structure of government, Viet Nam is obviously devoted to being part of the global market economy. As people vote with their dollars, markets are highly democratic. It seems clear they have found a way to reconcile the ideology. They have attained status in the World Trade Organization and seem highly motivated to come into conformance on global economic standards.

When I visited with a group of shrimp farmers, we discussed market conditions, world prices and the demands of entrepreneurship. Clearly, the government plays a different role in their business than it does in a democracy. These were small businessmen, looking to find niches in a market where they could optimize their opportunity.

Dinner with Shrimp Farmers

Observation Three: The Vietnamese government seems to understand the importance of protecting the made in Viet Nam brand. They are proud of the fact that it is beginning to show up more places. We discussed openly how quickly a brand that is not known well can be damaged by adverse quality events. We agreed during our talks to develop a working group to develop MOUs, similar to what we have done with China, which will allow our regulatory agencies to work interoperability, even though we have different systems of government.

Viet Nam is drafting new framework laws for food and drug safety so this is an opportune time to work with them. We agreed to move on aggressive time frames.

Observation Four: The business environment has a frontier quality to it. There appears to be opportunity everywhere, but you would have to have a high tolerance for the type of bureaucratic and political uniqueness that accompanies a country in transition. I had lunch with members of the American Chamber of Commerce. I sat next to Tony Foster, a Chicago based businessman who is building several businesses in Viet Nam. He is actually married to a Vietnamese physician who now lives in Chicago.

One of his businesses is a company providing international telephone services, and from his short description, he appears to have taken advantage of a need Viet Nam had for telephone capacity. As part of his willingness to invest in telephone infrastructure, his company was granted status that, for a time, gave him a comparative advantage in the market.

At the Port of Saigon, the Port executive told me they had contracted with a Seattle company to build a new Port. I know little about it, but presumably the company will invest money and bring expertise, earning a return from Port fees and securing an early position in a growing enterprise. I observed a similar arrangement in southern India.

As we boarded the plane to Ho Chi Min City, our Ambassador, Michael Michalak, introduced me to a private equity fund manager specializing in Viet Nam investments who was also boarding. There are obviously unique challenges investing right now, but with a populations growing rapidly in number and prosperity, Viet Nam is an intriguing marketplace.

Viet Nam still has state control of most of the key industry groups, and they have been slow to give up control. State owned enterprises make up 37% of their GDP. The government owns and controls industries like banking, energy, air travel, and health care.

Observation Five: Reduction of poverty is a primary social goal of the government and they seem to be succeeding to some extent. In 1993 58 percent of the nation’s population was in poverty. Today it is only 15 percent.

They will have to do substantially better in basic areas like education, health care system, etc. However, they seem to know where the problems are.

The Vietnamese government has a goal to be a country with middle income. They also aspire to be considered an industrialized country by 2020. It feels like, to me, that the Vietnamese and Chinese have similar approaches to planning. They also have the ability to compel things done that democracies require more time to finesse.

Observation six: Personal freedom is still mixed. Freedom of religion has dramatically improved the past few years and the churches are full.

However, freedom of speech is not as good. The embassy told me there are many situations in recent years where people have been imprisoned for speaking out against the government.

Viet Nam - Blog II

This is a continuation of my discussion on Viet Nam. I just returned from a trip there. Today, I’m going to list the first of several observations about Viet Nam coming from my trip.

Observation One: The Vietnamese government and people have put war behind them, and we need to as well.

I was a teenager during the war in Viet Nam. To eliminate the uncertainty of the draft, I joined the National Guard and went through basic training and advanced artillery training side by side those regular Army soldiers, most of who anticipated the skills we were learning would be used in Viet Nam. Many people I knew fought there. I lived through the political, social and cultural turmoil that accompanied the war during the late 1960s and early 1970s. The war in Viet Nam was a big part of all our lives.

The first time I flew into Viet Nam, I had a hard time not linking everything I looked at to my war time perceptions of what the country was like. I did not feel animosity, but my curiosity of what things were like then was not easy to suppress. My perceptions came from news reports and pictures of places and situations 40 years ago, but they are stored in that part of the brain teenagers put things that shape them.

In October of 2005 when I was there, I asked several Vietnamese people about how they felt toward Americans. After several questions, one of them said to me: “We have put the war behind us.”

I saw evidence that there are still remnants of the war in Vietnamese society, but they seem to be biases which faintly endure between North and South Viet Nam. However, those seem to have been worn down over time as well. In fact, everything I have experienced in Viet Nam leads me to conclude Americans are well liked generally. And, speaking as one American, I really like Vietnamese people.

I had two experiences on this trip worth relating along these lines. The first happened before we left. I had a conversation with Ashleigh, a young woman HHS colleague of mine, assigned to do advance work on the Hanoi portion of our trip. She related the reaction of joy her Father had to learn of her assignment. He had fought in Viet Nam. She said, he told her how it thrilled him that things had changed in a generation so his daughter was able to return in peace to a place he had fought in war.

Secretary Leavitt and Ashleigh

The second experience took place at a remarkable dinner we had in Hanoi put on by my new friend and colleague, the Minister of Health from Viet Nam. His name is Nguyen Quoc Trieu. Minister Trieu was a soldier, fighting for the North. He was wounded during intense fighting. Also at the dinner was a doctor who works with our U.S. Centers for Disease Control and Prevention and is assigned in Viet Nam. Over dinner they concluded they had fought during the same period in roughly the same region. They toasted, hugged and celebrated their friendship of our nations.

Viet Nam - Blog I

An Overview

The final three days of my trip to Southeast Asia were spent in Viet Nam. This was a follow up trip to my October 2005 visit. I focused on three issue areas: HIV/AIDS, Avian Influenza and the safety of imports. Meeting the new health minister was a priority as well.

As a general overview, I arrived in Hanoi on Tuesday night, the 15th of April. I spent Wednesday the 16th of April there working. On Thursday, I flew to Ho Chi Min City, where I spent the day working, and then on Friday, I was able to go out into the countryside, which always turns out to be a highlight.

In Hanoi, I visited the Ministries of Health and Agriculture; spoke to the American Chamber of Commerce; spent an hour interacting with students and faculty at the Hanoi School of Public health; and then met with Prime Minister Nguyen Tan Dung. In the evening, my new friend, Nguyen Quoc Trieu, the Minister of Health, held a banquet that none of our delegation will ever forget. This was not your routine diplomatic gathering. It was a party, full of personalities, music and bonding.

On Thursday I did media interviews, traveled to Ho Chi Min City, and toured the seaport in the same way I have many American ports; working to understand their role in the safety of imported products. I then visited a clinic our HIV/AIDS money supports, which is setting up the nation’s first methadone clinic as a way of assisting in the prevention of HIV/AIDS, and then met with the party leaders of the city.

Friday morning early, we drove into the countryside about three hours. Seafood is one of the biggest trade items between the U.S. and Viet Nam. I wanted to get a sense of the processes and sophistication levels in that industry, in a similar way as I was able to in India. The three hour drive by itself was worth the effort of going. I saw many different kinds of communities along our route in varying degrees of change.

I visited a large seafood processor and had a two hour discussion over lunch with a group of shrimp growers, a regulator and fellow who appears to have a job similar to an extension agent. I then went to meet with a group of chicken growers in a rural residential area along with public health people. We talked avian influenza.

At fish farm in Viet Nam

In the evening, we had a reception at our hotel and picked up the midnight flight for a connection in Tokyo for D.C. These trips are non-stop events. By the time I get to the end of the week, I’m usually feeling exhausted, but greatly enriched. This was a successful mission, but I’m ready to get back into a normal routine. With the time zone changes, different beds most nights, and fifteen hour days, the last seven days feels like one continuous day.

I was able to keep better control of my diet and exercise routines this trip. Both usually take a hit on these forced marches. I think I got exercise all but two mornings and with only one major banquet, didn’t do any serious caloric damage. It’s a small victory in my long fight to stay healthy.

Having provided this overview of the trip, over the next few days I’ll post a series of observations I have as a result of the trip.

Singapore: More Observations

I mentioned yesterday my short visit to Singapore. I thought I’d add some additional observations.

Singapore spends only 4% of its gross domestic product on health care(Singaporean Health Minister’s estimate). Just a reminder, in the United States we spend 16% of ours — nearly four times as much. What are we getting for that? The life expectancy of a male in Singapore is 79.29 and 84.68 years for a female. Again, just a reminder, in the United States the life expectancy of a male is 75.29 years; a female can expect to live to 81.13 years.¹ Hmmm.

What are the differences? I obviously haven’t had enough time to explore that question fully, but I’m going to now. There are a couple of obvious ones. In their system, everybody pays part of the cost. If you are poor, the percentage is very low, and if you simply can’t pay, the debt is written off, but there is a personal responsibility and it undoubtedly causes patients to engage.

Our system has an ailment I refer to as the “Chronic More Disorder.” Most patients in our country have very little reason to care what the cost is. Doctors have an adverse incentive to do more procedures, make more money. In a market, there have to be countervailing incentives to keep things in check. It doesn’t happen in our country. (An old theme for me, right?)

So, what about the quality you say? Aside from the statistics on life expectancy already cited, let me suggest we think about this. The Government of Singapore estimates that, in 2008, over 600,000 people, including many Americans, will engage in medical tourism. They will fly to Singapore to get their care at a fraction of the price. The Singaporean Government believes by 2012 the number will exceed a 1,000,000 people a year. In order to attract these people, they are transparent with both cost and quality outcomes. Patients have more information about care in Singapore than about care they would get from their local hospital. Hmmmm.

Here’s another thing I learned. When the government was formed in the 1950s, the British had set up a system of Central Provident Fund (CPF) which requires the Sing people to set aside 35% of their earnings. They allow the savings to be tax free. Does that sound like Social Security? Well, there is an important difference. Each citizen’s account is segregated. They cannot use it until it is time for retirement, but they do have influence on how it is invested. It is not like our Social Security System where each generation of workers pays for the retirement of their parents.

If you were simply looking at these two different systems as an investment opportunity and doing steely-eyed analysis on the likelihood of their prosperity in the future, which would you invest in?

• Investment 1: Spending 4% of their total receipts on health care with no future liability.
• Investment 2: Spending 16% of their receipts on healthcare with a $24 trillion legal and moral liability in the future.
• We should also toss in that number 2 above will have half as many workers per retiree in 20 years and that both get similar big picture results.

The global market is now weighing this question. I will have much more to say about this soon.

¹ Singapore statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/sn.html 

US statistics: The CIA factbook accessed on 4/21/2008 at https://www.cia.gov/library/publications/the-world-factbook/geos/us.html

Some Lessons in Singapore

I stopped in Singapore while transitioning between Indonesia and Viet Nam. There were a couple of HHS investments I needed to see.

First of all, Singapore took me by surprise. It is beautiful. You would think you were in southern California—climate, quality of infrastructure, construction, etc. It is well run and on a roll of success. I’ve heard this for years, but seeing was believing, for me.

A conversation I had with the Health Minister Khaw Boon Wan had several interesting aspects to it. In some ways Minister Khaw is typical of the policies that have made Singapore a success. He grew up in Malaysia but accepted a grant from the Singaporean Government to study in Australia. The grant had what he described as an 8 year bond. It was an obligation to work in Singapore for that period after they paid for his education. Singapore became his home.

Health Minister Khaw Boon Wan of Singapore

Because the country is so small and has few natural resources, they have mined talent internationally. The Minister is an example of their investments paying off.

I want to mention three topics we discussed that I will be thinking more about. The first is the importance of a population continuing to grow.

The Singaporean Government identified many years ago that their population growth rates were beginning to fall. Intuitively they understand that if a nation’s population growth falls below replacement, it will, under normal circumstances, create serious problems in the future. They have been working to increase their birth rate now for nearly 20 years, with little success.

I asked the Minister what Singapore had learned from the millions they have spent researching and trying different policies. He said they had done mountains of demographic research and tried many different incentives including direct tax subsidies amounting to as much as $20,000 for couples producing a child. They have produced disappointing results. Direct financial subsidies he said are, “like pushing a string.”

Interestingly enough, many other nations provide the subsidies but the results seem to have far more to do with other factors. Australia pays $2,500 (his estimate) and has seen a resurgence in birth rate. He thinks there is simply a different attitude among nations with lots of space. He pointed to super cities like Hong Kong and Tokyo and that they have low birth rates.

The Singaporeans have concluded a series of sociologic changes have clearly contributed to their dilemma. Woman desiring careers, couples deferring the age of marriage, and a de-emphasis on marriage were other points he raised. Our conversation came on a day I had just received a brief on a CDC report indicating that in 2006, 38.5% of all births in the United States were to unmarried mothers. The Minister’s main point was that married couples have more children and foster them more successfully than unmarried parents.

Singapore is pursuing policies that work to develop three things: supportive employers, supporting families, and Government policies that are family-friendly. I took that to mean encouraging marriage. They are also working to increase the percentage of births from successful in vitro fertilization. They have found some European countries, such as Denmark, have as many as 6-7% of births from this method. Singapore has only 1% of their births from successful in vitro fertilization. Even science can play a role, he pointed out.

When I was Governor, I started a Marriage Commission to encourage the practice of marriage and to strengthen existing marriages. It was the first in the country and it was criticized by some. Others have since followed and it has become more common for governments to recognize what a hugely important issue this is.

I have spent time looking at the long-term problems faced by cultures that have limited family size. Japan is deeply worried about its population trend. China has also begun to deal with the impact of their “one child” policy.

In the United States, our population figures are just slightly over replacement. Frankly, if it weren’t for the increase of immigrants, we would be in the same spot as many European countries, facing negative growth.

If you think that sounds like a positive thing, I would recommend two things. First read Will and Arial Durant’s book, The Lessons of History. After studying every major civilization in a 5000 year period they concluded societies that fail to grow, fail to survive. The second thing I would recommend is looking at the Medicare program to which our nation is obligated. Today there are four workers to pay the health care benefits of each senior. In 20 years, because of lower birth rates, there will be two workers for every person on Medicare. Add social security to that mix and a declining birthrate becomes a rather serious problem.

Demographics are destiny.

Indonesia II

Written April 15, 2008

Following the meetings I wrote about yesterday, I met with President Susilo Bambang Yudhoyono (or "SBY," as everyone calls him) at his office in Jakarta. We met previously in October of 2005, on my last trip to Jakarta.

President Yudhoyono is a former soldier. He did a significant part of his training in the United States, including an MBA from Webster University, in Missouri. He is tall, with a strong military bearing. Generally speaking, he struck me as a gracious man, with a good grasp of the complicated problems of governing a nation like Indonesia, and a good understanding of regional and global problems.

Coordinating Minister Bakrie and I opened the meeting by recapping the nature of our meetings earlier in the day. The Foreign Minister, Health Minister and the President's Foreign-Policy Advisor were also there.

The President stated clearly Indonesia wants to be a cooperative part of the world health community, and stressed a desire to get both the NAMRU issue and virus-sharing problems behind us. Minister Bakrie reported his two-month timeframe. I re-stated our strong, philosophic objection to linking virus-sharing with compensation.

What I wanted to write about today, however, is an interesting conversation we had about the challenge of governing a developing nation. This was a continuation of a set of themes that interested me from my conversation with the Indonesian Foreign Minister earlier in the day.

The President reminded me that Indonesia has only been a democracy for 10 years. He made the point that for democracy to succeed, it must prove to people it can deliver them a better life. In essence, he said, it’s likely the vote of a person who lives on a remote island in Indonesia who earns $1.60 a day will decide if democracy is working, less by ideology and more by the cost of what fills his rice bowl.

I spent time earlier in the day discussing the economics of rice with Indonesian Minister of Agriculture, Anton Apriyantono. Rice is the most significant dietary staple for Indonesians. At times, the Indonesian Government goes into the world market to supplement its domestically grown supply. For a variety of reasons, the price of food, specifically rice, has increased sharply over the past year. Ambassador Hume had told me earlier in the day that a ten-percent increase in the price of rice in Indonesia pushes two million people into poverty. So, the price of food has serious political and sociological ramifications.

Energy also fits into the category of priorities for President SBY for the same reasons as food. The Indonesian Government heavily subsidizes fuel. It occurred to me, as bio-fuels become more prominent, and more grain goes for that purpose, it could bring two of the most important needs of the world's poor into conflict with each other.

The President indicated health was obviously another priority, but confessed he was not able to budget what he aspires to provide. He remembered our discussion in 2005 about the dangers of the H5N1 strain of avian influenza, and made an interesting observation: Places like Indonesia have many unique health challenges, so a problem like influenza has trouble penetrating the public agenda. Coordinating Minister Bakrie told me tuberculosis kills 400 people a day in Indonesia. Put next to that statistic, the 107 people who have died in that country from infection with the H5N1 flu virus is such a small number that it is hard to get the Indonesian public or government too worked up.

Of course, it is the potential that the H5N1 strain of influenza could spark a worldwide human pandemic that demands a response. However, countries with limited resources are often more concerned with the snake biting at their ankle than to worry about the one hiding in the bush.

I remember the Health Minister of Cambodia telling me in 2005 that 12,000 people a year there die from rabies. Consequently, it is hard to get farmers worried about a few sick chickens. It put a lot of things in perspective for me.

Indonesia

Written April 14, 2008

I’m in the Jakarta Airport, having just finished a day of meetings with Indonesian Government officials. I met with President Susilo Bambang Yudhoyono, Coordinating Minister for Family Welfare Aburizal Bakrie, Foreign Minister Noer Hassan Wirajuda, Agriculture Minister Anton Apriyantono, and Health Minister Siti Fadilah Supari. The meetings involved discussions on a group of issues, among them the control of H5N1 avian influenza, the U.S. Naval Advanced Research Laboratory (NAMRU-2) in Jakarta, and Indonesia’s departure from international expectations on sharing samples of influenza viruses.

I was here in October 2005 as we were scaling up our own pandemic preparedness in the United States. Being here is an important reminder of how different the problem looks from different perspectives. Indonesia has 245 million people, who live in a space about the size of New York State. About 60 percent of the country's area is water, since the nation is really thousands of islands. It appears to me that most of those people must have highly localized lives, and developing a national strategy on anything would be difficult.

The next presidential election in Indonesia will take place in 2009. Just like in the United States, the upcoming election has begun to affect the formulation of policy. The night before I arrived, local elections took place in the largest Province, West Java, and, in what appears to have been a surprise, an Islamist party took power. It would be similar to having a populist movement win a statewide election in California. The election in West Java is an event that will clearly begin to factor into everyone’s political calculus in Indonesia.

I didn’t have any political discussions about this with Indonesian officials. These are observations I am picking up from reading the local papers, and from talking with people at the U.S. Embassy. I’ve always found it important to understand the political context in which foreign government officials are operating- it helps you understand the filter through which they are seeing the world.

My first meeting was with Foreign Minister Noer Hasson Wirajuda. He is a sophisticated and well-educated man who spent five years doing legal studies in the United States. We talked at length about a group of themes related to the challenges of governing an undeveloped country. Later in the afternoon, our discussion continued. I think rather than discuss those in this entry, I will do a separate piece tomorrow.

Next, I visited the office of the Coordinating Minister for People’s Welfare, Aburizal Bakrie. A Coordinating Minister oversees several Ministries or areas of the Indonesian Government, and has the responsibility to coordinate their work. The meeting included the Ministers of Agriculture and Health.

Minister Bakrie is a noted businessperson. His family holdings are extensive, and their reputation looms large within the region. He speaks excellent English, and deals confidently with people. His business background is evident in his willingness to engage directly on problems.

Minister of Agriculture Apriyontono was invited because of the animal-health connection in avian Influenza. I met him in 2005 as well. Likewise, I have met multiple times with Health Minister Supari. She has become a controversial figure within the health world, because she has stopped sharing with the World Health Organization (WHO) any samples of influenza viruses that are circulating in Indonesia. She asserts that if a nation provides a virus from which a manufacturer makes a vaccine, that country is entitled to monetary compensation of some form. This is a dangerous course that threatens to undermine a worldwide agreement honored by nations for nearly 60 years. I wrote previously about this subject.

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

NAMRU-2 is an important public-health asset in Indonesia. The lab is a WHO reference lab, which means the level of expertise there is high enough that the world accepts its work. If a communicable disease breaks out in South East Asia, any country can send samples of the virus there to have them identified. The laboratory has been in Indonesia for decades, and exists under a Memorandum of Understanding (MOU) between our Governments, which is up for renewal.

The MOU that governs the status of NAMRU-2 expired two years ago, and both sides have been trying to renew it. When I was in Indonesia in 2005, the lab was a major topic of conversation in my discussions with various Ministers, and with the President. At that time, I received absolute assurances the Indonesian Government would approve the MOU shortly.

Minister Supari recently issued orders to prohibit Indonesian institutions from providing tissue samples to NAMRU-2, under the justification that such sharing is not legal in the absence of an active MOU and a Material-Transfer Agreement. Her action is obviously linked to her global initiative to seek specific benefits for sharing samples.

To add more drama to this picture, Minister Supari, recently published a book in which she asserts the U.S. military is using influenza samples to create biological weapons. Secretary of Defense Gates was asked about the Minister's accusation when he was in Indonesia this past February; he replied, “That’s the nuttiest thing I’ve ever heard.”

All this background created great media interest in my visit. The morning of my discussion with Minister Supari, an article appeared in the English-language Jakarta Post that said I might refuse to meet with her. The truth is, I came all the way to Jakarta quite specifically to see her. Anyway, all this added up to a minor drama.

We met privately in Coordinating Minister Bakrie’s office for a while, and then joined the rest of our delegation and Indonesian Government staff who had gathered. The conversation was refreshingly straight-forward, an outcome I attribute to the style of the Coordinating Minister. While we talked about a number of other issues, such as HIV/AIDS, most of our time focused on the NAMRU-2 and sample-sharing. After a time, the Agriculture and Coordinating Ministers left, but Health Minister Supari and I continued our conversation.

It is important to remember that, while the NAMRU-2 issue is between the United States and Indonesia, the influenza-sample issue is between Indonesia and the other 192 Member States of the World Health Organization. The United States has been part of a group that has been trying to resolve the problem for the past two years. They have held numerous meetings, and various other types of negotiations. These have yielded a short list of things the parties believe the WHO Secretariat could do to improve its influenza program. The Minister mentioned this several times as "progress."

However, I could see little real progress in the key question whether contributing countries should receive direct, monetary benefits as compensation for sharing samples. The Minister’s main point is that what she wants should not be considered "royalties" or "compensation." What she says she wants is for the contributing countries to be eligible for some share of the value commercial companies create out of the influenza samples they provide. Or, as she expressed it in a hand-delivered letter to me later in the afternoon, “Allow me to reiterate that when I raised the term ‘monetary benefits,' I was not referring to any type of royalty, nor any type of quid-pro-quo arrangement, but rather to a method that leads to the allocation of values derived by commercial interests into one commonly defined system, which will provide benefits to those that have made contributions.”

I told the Health Minister two things. First, I understand her desire to assure people in her country have access to medicines and vaccines. This is a problem in developing countries all over the world. It is a complicated issue, but we need to address it, while preserving the incentives for innovation. I pointed out that technology is improving and might well hold solutions we don’t currently have. I used as an example the billon-dollar investment our nation has made in cell-based vaccine technology. Once we are using cell-based methods of making vaccines, the capacity and cost of making vaccines will dramatically drop, which will change the entire equation. The world is working on solutions.

However, linking sample-sharing to payment in any form will immediately begin to erode our ability to make vaccines at all, because once the practice of free and open sharing of viruses stops, the slope is slippery, and there will be no end to the demands.

The issues of the availability of vaccines and the sharing of samples are both legitimate ones, and we must deal with them both, but we should not link. World health should not be the subject of barter.

The second thing I told her is that I find it impossible to distinguish a difference between what she is seeking and royalties. The bottom line in both is this: share samples, get paid.

I would summarize the conclusion of my meetings this way: We celebrated the small list of consensus recommendations that are emerging from the multi-lateral discussion at the WHO on this matter, and committed to keep looking for solutions. The Coordinating Minister suggested we could find a solution within two months. He later reported that to his President in our meeting with him.

I have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable.

We will work on this for the next 60 days. If we haven’t been successful in resolving the matter, I think it will be time for the world to just accept Indonesia’s unwillingness to participate in the WHO influenza system, and move on to other ways of making the world safer. Perhaps when circumstances change, Indonesia will rejoin the mainstream on this issue.