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.

Comments

Thank you for the summary, Mr. Secretary. Thank you for again
pressing this issue with Indonesia.

Indonesia has dug in its heels on this one. If a pandemic happens, I bet they will be one of the first ones to knock on our door for help just as they had their hands out to receive the Tamiflu we gave them.

I do understand their worry over being unable to access vaccines for their population. They have chosen the wrong path to address this issue. Blackmail is a very poor choice on their part.

It would be nice to see some other WHO countries address this stand-off with them, as you have, by meeting in person. It must have been a frustrating experience for you.

Perhaps NAMRU-2 could provide resources to a different country?
Surely other 'incentives' could be used as well.
Just a thought.

Sixty days left to walk softly and carry a very large stick.

Posted by: Science Teacher | April 17, 2008 at 04:24 PM

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David Haley

Posted by: David Haley | April 17, 2008 at 08:58 PM

What the Indonesian government is doing should be considered a crime against humanity.

Posted by: Goju | April 18, 2008 at 04:53 AM

Kudos to you, Mr. Secretary! I, personally, was cheering when I read your blog!

I am relieved to hear that Indonesia's leaders have been unsucessful in extorting payment for viral samples that may be of vast importance to the world. I hope the U.S. will indeed quickly move on to securing samples elsewhere to begin work on pre-pandemic vaccines that, even if only partially effective, are better than nothing.

I am particularly glad you have directly addressed the issue of Dr. Supari's book, in which she apparently claims the U.S. is deliberately using disease and the high cost of vaccines against them to keep third world nations in some sort of impoverished neo-colonial state. As you mentioned in your blog, she has even gone as far to insinuate the U.S. is, or would, use avian flu to this end. This is exactly the kind of inflammatory rhetoric that engenders fury against the U.S., something we surely don't need in areas that are becoming more and more Islamist. Thank you for mentioning this conflict directly; I hope you will continue this conversation with Dr. Margaret Chan of the U.N. from whom Dr. Supari says she's derived her information.

Thank you once again for providing your thoughtful and well-spoken window to the international affairs that affect all Americans. I appreciate this blog!

Posted by: Katherine in Michigan | April 18, 2008 at 10:16 AM

Secertary Mike Leavitt, I recently read comments attributed to you about import drug safety in an Associated Press interview by Kevin Freking. I was disappointed to hear you comment that market expediancy needs to be balanced with regulations (inspections)regarding a drug's fittness for use when bringing it into this country. Specifically the heparin issue. Heparin has been manufactured in the U.S for years and now that someone wants to bring an imported version into the country (at a much lower cost to produce but sold at the same price), we need not look at it in the same light as the U.S. version was looked at????? Please....don't put our health at risk for corporate profits!!!!!!!!!! If we are going to business with drug makers from overseas then see to it that what comes here is fit for use. It is not in our best interests to rely on the foreign governments to do our inspections for us.

Posted by: Dwight Gentz | April 23, 2008 at 12:08 PM

Secretary,
Please read my blog on your blog. Your words are always welcomed.
Scott

Posted by: Scott McPherson | April 24, 2008 at 05:38 PM

Thank you for your informative blog, Mr. Secretary. I agree with your statement, "World health should not be the subject of barter." but how is that different from having vaccines available only to countries that can pay for them?

In the case of an influenza pandemic in the U.S., and assuming a vaccine is available, it would be poor public health practice to vaccinate only those who can afford to pay for the vaccine...doesn't the same hold true on the international scale?

Posted by: Graybeard | April 29, 2008 at 11:26 AM

You say that the benefits from Indonesia sharing samples are minimal in comparison to the potential detriment of agreeing to their demands. As Indonesia has the highest incidence of death by Avian Influenza in humans, do they have much to lose by not participating in the sharing scheme? What exactly would happen if the Health minister's demands were met? Has there been any progress since your meeting?

Posted by: Jenny de Montalk | May 04, 2008 at 07:59 PM