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Asia/South Asia
Incubating a crisis: Why the fight against bird flu could be won-or lost- in Indonesia
Andrew Jack from Jakarta

          As Mt Merapi, Indonesia's most active volcano, spews out smoke and lava, a disaster is incubating in the farms and villages of Central Java with potentially far greater consequences for human health.
In the nearby Ambarawa livestock market, Joko, a local farmer, laughs at the risk of bird flu as he runs his hand lovingly over the rear of his prize black chicken. Ducks and other birds for sale mill nearby, feathers drift in the air and their dung cakes the ground. When one of his birds gets sick, he says, he sucks the mucus from its beak with his mouth.
Joko, who trained as an agriculture teacher and raises birds in his backyard, helps distribute free government vaccine to protect against bird flu but says many farmers do not use it. "No-one is concerned about the flu here," he says. "I sleep with my chickens. In any case, the illness comes from God."
Such insoucience is fuelling fears that the current H5N1 bird flu virus will mutate into a human pandemic, with the potential to kill millions of people, hospitalise far larger numbers and cause billions of dollars global economic disruption.
More people have died from the strain in Indonesia than anywhere else in the world. Epidemiologists are on constant alert for the first sign of human-to-human transmission. Yet the country has failed to get to grips with the danger -- and that could fatally undermine the preparations other nations are making to combat the disease within their own borders.
"There has been a pandemic of international flu meetings of experts from around the world gathering in different venues, but it's not really helping us," says one western expert based in Jakarta, the capital. "We're sitting on a powder keg here and we've not got enough money."
In contrast, many of the world's richer nations, and some of the poorer ones, have drawn up detailed contingency plans to help limit the impact on their own populations. Seventy five have ordered anti viral drugs and a smaller number have invested in research into new vaccines that could limit the impact of a pandemic.
There have also been more modest gestures of support towards those who are less well prepared. At a donors' conference in Beijing in January, $1.9bn was pledged in a combination of loans and grants via multilateral agencies such as the World Health Organisation, and directly to countries in need.
Much, however, was simply reallocations of existing commitments and the imbalance between rich and poorer nations remains startling. While the US has committed $7.0bn, for example, the vast majority is for domestic use. Just $20m has been earmarked for Indonesia.
How serious is the situation? The outlook is plagued with frustrating uncertainties for decision makers and forecasters alike. The final pre-condition for a pandemic - that the virus already proving lethal in birds mutates into a form that is easily transmitted between humans - has yet to be met. So far, there have been just 208 confirmed human cases and 115 deaths.
As Martin Meltzer, an economist at the US Centres for Disease Control, puts it: "The crystal ball is not just foggy. it's completely pitch black."
Yet at a gathering of some of the world's top researchers, organised in Singapore by the Lancet this month, Robert Webster from St Jude Children's Research Hospital in Memphis, a leading flu virologist, said: "I have been working with flu all my life, and [H5N1] is the worst I have ever seen. If it spreads to humans, God help us."
What emerged was how many scientific questions remain unanswered: whether wild or farmed birds have been most responsible for the spread of the virus, if, and in what form, it will mutate to spread easily among humans, and how to prevent and treat it most effectively if it does so.
As Zsuzsanna Jakab, head of the European Centre for Disease Control, told EU representatives in Uppsala recently: "The bad news is that there are still gaps in our knowledge about influenza and in our preparedness against a pandemic."
If a lot remains to be done in Europe, the challenge elsewhere is even greater -- and nowhere more so than in Indonesia.
H5N1 is endemic in animals in Java and much of the rest of the country, where it has killed at least 11m birds since 2003 and last year depressed sales 20 per cent below poultry raisers' forecasts. With 1.3bn chickens hatched each year living in close proximity to 220m people, there is every chance for the infection to spread to humans.
Since it officially declared its first human H5N1 case in July last year, outbreaks in Indonesia have risen quickly. Of 33 confirmed infections to date, 25 have since died. Meanwhile authorities say that of eight suspected cases reported until the middle of this month, at least five are H5N1.
Indonesia is planning its own foreign donors' meeting later this month in an effort substantially to boost assistance levels.
The first challenge is to bring the virus closer to the centre of the national radar screen. Beyond occasional scares in the local press, there has been no concerted attempt to make Indonesians aware of the importance of basic hygiene when handling birds or identifying signs of illness.
Doctors working in the overstretched health system focus on alleviating the suffering they meet every day, rather than on an illness that rarely materialises. "We have had one confirmed case of flu in the past three months and many meetings," says Dr Hussein Gasem from Kariadi hospital in the city of Semarang. "But we have had many cases of Dengue, malaria and tuberculosis. These are real problems.
For those who fall sick, the costs and long waits involved in seeking medical help mean that many hold back until it is too late. With treatment of H5N1 most successful if started within 48 hours of symptoms appearing, the delays may be one reason why Indonesia's fatality rate from the virus is even higher than in other countries."
The authorities have responded with a 2006 budget that doubles spending on avian influenza to about $50m. "We are reading while running," says Bayu Krishnamurti, who runs the government pandemic coordinating committee set up by the president. "I don't want to say that what we have already done is satisfactory, but it is quite reasonable."
However, the allocation of resources still raises concerns. Controlling the infection in animals will be the key to limiting its potential to spread to humans. But two-thirds of the avian influenza budget is being channelled instead into human health measures, and 38 per cent alone into the purchase of large, expensive stockpiles of the antiviral drug Tamiflu.
The ministers of health and agriculture have different approaches and priorities and -- as in many countries -- there is also poor coordination between the two departments. Politics have played a role in the response -- the agriculture minister, who is from an orthdox Islamic party, has publicly argued that H5NI could be a western plot.
The result is insufficient effort to control animal infection. Both culling of diseased poultry and vaccination to protect healthy birds takes place in Indonesia, but funding levels that will allow for 3.0m birds to be culled and 30m vaccinated this year will be insufficient. Reliable diagnostic tests are scarce and surveillance systems poor.
Infection seems to have been largely brought under control in the large industrial poultry farms. Far more difficult is improving the situation in backyard farms. An estimated 30m Indonesian families keep chickens, many the result of a programme that seemed successful twenty years ago to boost the nation's intake of protein.
In Indonesia, the situation is further complicated by corruption and the decentralisation of recent years. That may have helped foster greater democracy, but it has also created new obstacles to the allocation of funds and weakened the healthcare infrastructure for humans and animals alike.
A final concern is with the foreign donors themselves. Multiple missions to the country have resulted in repetition, duplication and a lack of coordination. "The Japanese, the US and the Australians are all doing their own thing," says one western diplomat. "It's as much political as it is technical."
Most seriously, many grants from abroad are being made for a single year with no guarantee that they will be renewed. Yet there is no time limit on the fight against avian influenza.
Mr Krishnamurti, who opposes taking out loans and wants to see a greater contribution from foreign governments to flu control, says: "Avian influenza is not only a problem for Indonesia. If we succeed, it will be a significant contribution to success for the world. If we fail, all the world will probably face the problem."
Some countries in the region have already made significant progress: Vietnam, as well as Thailand and Hong Kong, appear to have mastered outbreaks. Others - Cambodia, Burma and parts of Africa, for example, which have far fewer resources than Indonesia - face similar challenges over surveillance, education and control.
But unless richer nations use their cash to attack the problem at source, the pandemic the world dreads may confound the best efforts to avert it.
under syndication arrangement with FE


  More Headline
Incubating a crisis: Why the fight against bird flu could be won-or lost- in Indonesia
Japan waits in limbo for policy move
Feast of a moveable workforce

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