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.

Comments

Mr Secretary,

If Health Minister Supari and SBY wish to be compensated for "their" virus, then perhaps they should be reminded that they then will be held accountable and responsible for whatever damages "their" virus may do to mankind. If they "own" it, then they own it all, the good, the bad, and the ugly.

I wonder what the World Court would say at the Crimes Against Humanity trial....

Please try harder to educate the public to prepare.

Thanks.

Posted by: NawtyBits | April 18, 2008 at 02:49 PM

Thank you, Mr. Secretary, for your blog. I suspect there are many people, like me, that rarely comment or post, but pay much attention.

Please keep it up.

Posted by: Dean B | April 18, 2008 at 09:34 PM

You have written a good lesson in perspective, Mr. Secretary. It is easy to judge the culture of another country by ones own.

The perspective of the individual leaders will also influence the public healthcare path that is taken.
Good preventative health campaigns focusing on H5N1 in Indonesia will save lives. Many Indonesians have not even heard of a pandemic threat so no motivation exists to change high risk behaviors of ordinary citizens. He can include this information in speeches, radio and TV communications.

I hope President Yudhoyono will agree to share samples. Ultimately the knowledge acquired by this action may benefit his country as well.

Posted by: | April 20, 2008 at 10:58 AM

Secretary Leavitt,

Regarding your "strong, philosophic objection to linking virus-sharing with compensation":

The United States' position in this debate might be enhanced if it acknowledges that "compensation for samples" isn't just some bizarre outrageous notion of a poor Third World country.

The U.S. National Park Service has also tried to get compensation -- for microbes found in Yellowstone Park.

In a November 2007 article entitled "The Gold in Yellowstone's Microbes", Time magazine reported:

"... hoping to cash in on its natural resources, the National Park Service signed a secretive research-sharing agreement with Diversa Corporation in 1998. Non-profit groups quickly cried "bio-piracy!" when they found out and sued the Service over the arrangement. While a federal court dismissed the case, it ordered the Park Service to address the issue — throughout all its parks — by assembling a full-blown environmental impact statement that allowed for public comment. A 340-page draft was completed last year. But the Park Service is still trying to come up with an acceptable, benefits-sharing agreement that might allow bio-prospecting of microbes and disclosure of findings, with a fair return to the Park from any commercial success."
(available on line)

And WHO's position in this debate might be enhanced by empathically acknowledging that if a pandemic started tomorrow, Third World countries would probably be last in line for the eventual pandemic vaccine.

WHO's May 2005 draft internal contingency plan for a pandemic (first publicly revealed by Nature reporter Declan Butler, August 17, 2005) included these lines:

"If a new pandemic virus strain emerges it will be critical to identify the first cases, using the virus to rapidly develop an effective vaccine. It would be a number of months before a vaccine would be available."

[a cached version of the WHO draft is online at http://tinyurl.com/4rg854]

Virus to develop a vaccine -- virus from whom? Presumably from the poor souls dying at the epicenter of a pandemic.

Availability -- for whom? Unless unprecedented arrangements are made, "availability" will be mostly for the First World, where most vaccine production capacity lives.

Outrage and frustration at Minister Supari's accusations and demands could be tempered by remembering and acknowledging examples like the two above.

Such acknowledgments would deflate the overly-righteous posturing of some western officials, and allow negotiations to proceed on a more "I - Thou" basis.

With gratitude and admiration for your continued blogging --

Jody Lanard

Posted by: Jody Lanard M.D. | April 21, 2008 at 02:09 AM

Mike,

As one of the Boards of Trustees of Medicare, you have reported in March of this year to Congress that Medicare will be broke in 11 years. What solutions are you working on? Are you just putting in your time until you are out of office? You never took me up on my offer to privately fund a two year CMS demonstration project which has the potential of saving Medicare $386 billion over the next 20 years. Why are you not interested in looking seriously at this offer? What do you fear? CMS has nothing to lose and everything to gain. You can look like a hero. I will pay the bill. Check out my web site.

David Haley

Posted by: David Haley | April 22, 2008 at 11:10 PM

Let us review:
YOU are Secretay of the U.S. Department of H&H Services, yet you travel to Indonesia and other parts of the world, rather than to Appalchian Mountains, bayous of Louisiana, ghettos of major cities, shelters for homeless under bridges, Veteran Hospitals, free clinics for the non-insured?
I don't understand your disregard of the people right here in our country! This is where many undocumented diseases are taking hold of OUR CITIZENS! Yet another disgrace of our government!
Could be you are wanting to pad your resume for the future?

Posted by: Micke Jinks | April 23, 2008 at 01:21 PM

Dr. Leavitt,

Thanks for posting. Virus samples should not go the highest bidder as Japan and South Korea are already developing vaccines.

I hope Indonesia does share their samples. I hope the WHO or some other group supplies Indonesia and else where with help to get vaccines.

With so many people working on the virus a solution could be found. If their version of H5N1 gets out, they may still be held responsible in world court.

A virus should never be a political footbal or barganing chip.

As a side effect, H5N1 has raised the price of food where chickens have been culled.

Like others I do not post often but your efforts are appreciated and the April 30th webcast is looked forward to.

Regards
Kobie
Thought for the day: "You can not tell which way the train goes just by looking at the track, nor when it will arrive. Just that we have an oncomming train."

Posted by: Kobie | April 23, 2008 at 02:31 PM

Is it true that Indonesia is the only country that does not cull all its infected domestic birds once infected?. If so are not they then the direct culprits of future strains and quite possibly then the fathers of the inevitable pandemic strain?. Perhaps international funds could be made available to them for this purpose and then the collection of the new strains could be accommodated?.

Posted by: | April 24, 2008 at 03:38 AM