Friday, June 02, 2006

Behind the Indonesian curtain

The curtain is being pulled back on the Indonesian bird flu control program and it reveals there is nothing there. In the last few days several major stories have highlighted the open secret that Indonesia is a No-Man's-Land of bird flu, a free for all with no one in control. This comes at the end of May, a month which saw 15 bird flu deaths in Indonesia and reports of several small clusters and one alarmingly large one. WHO is saying there is so far no evidence of spread beyond the family, information consistent with what we have heard through independent sources. But the ability of WHO and the Indonesian authorities to perform thorough contact tracing is limited.

Exasperation with the Indonesians is clearly evident. Even WHO epidemiologist Steve Bjorge, by all accounts a diplomatic and generous person, seems to be running out of patience:
"The situation is that there is a leak in the roof, and the Ministry of Health is just mopping up the floor every day," epidemiologist Steve Bjorge said.

Indonesia has the world's second- highest number of confirmed human bird flu deaths after Vietnam with 36 - and the most deaths this year.

Bjorge said Indonesia had to start mass culls of infected birds and more intensive testing of fowl suspected of carrying the H5N1 virus if it wanted to stem the spreading of the virus, which he said was "pandemic in poultry."

In Papua's Manokwari district, he said, "they have had three outbreaks in the last nine months, and each time they've culled and they've stopped it. That to me means, even in Indonesia, it is possible to do it."

But the sprawling country's hugely decentralized government - spread over 17,000 islands - means that preventing the spread of the virus among birds is a very complicated task, Bjorge said, adding there is no central authority that can order culling "on a minute's notice." (Marianne Kearney, AFP via The Standard, Hong Kong)
This is not just one person in WHO expressing a personal opinion. Almost exactly the same language was used by WHO spokesperson Dick Thompson, not previously known for the boldness of his pronouncements:
"We're tying to fix this leak in the roof, and there's a storm," World Health Organization spokesman Dick Thompson said. "The storm is that the virus is in animals almost everywhere and the lack of effective attention that's being addressed to the problem."

Indonesia, an archipelago of 17,000 islands with a population of 220 million people, has a patchwork of local, regional and national bureaucracies that often send mixed messages. The impression, health officials said, is often that no one is truly at the helm.

"I don't think anyone can understand it unless you come here and see it for yourself," said Steven Bjorge, a WHO epidemiologist in Jakarta. "The amount of decentralization here is breathtaking."

He said Health Ministry officials often meet with outside experts to formulate plans to fight bird flu, but they are rarely implemented.

"Their power only extends to the walls of their office," Bjorge said, adding that the advice must reach nearly 450 districts, where local officials then decide whether to take action.


But public awareness and bio-security standards remain low in the densely populated countryside, home to hundreds of millions of backyard chickens.

"It's not quite so easy here, where you have to have the local authorities and provincial authorities and national all on board," said Jeff Mariner, an animal health expert from Tufts University working with the FAO in Jakarta.

"We find outbreaks every week scattered throughout Java. It's a diffusely endemic disease. In most districts, you can find it at any time," he said. "It's a staggering undertaking in a decentralized country." (AP)
Two things strike me about this. The Indonesian situation is probably mirrored in numerous countries in Africa. Who knows what's going on there? Second, WHO appears to be flexing its newly authorized muscles. We don't yet know if this is a sign of a sea change, and if it is, what its origin is. The agency is operating under the direction of an interim Director-General who may be taking advantage of international concern to do things differently, as WHO did during the SARS episode. Or maybe the newly revised International Health Regulations are starting to bite. Or maybe its a combination of factors.

Whatever it is, we can hope.