The Fatal Strain (58 page)

294 despite some projections:
Hitoshi Oshitani, Taro Kamigaki, and Akira Suzuki, “Major Issues and Challenges of Influenza Pandemic Preparedness in Developing Countries,”
Emerging Infectious Diseases
14, no.6 (June 2008): 875-80.

295 “He just knows everybody”:
Interview with Dr. Megge Miller.

296 The health workers at the two local clinics:
Interviews with Ly Lai and Dr. Ou Sary, Kampot province.

297 it went a long way:
Interviews with current and former WHO officials in Cambodia, including Drs. Michael O’Leary, Isabel Bergeri, and Megge Miller. See Richard Stone, “Combating the Bird Flu Menace, Down on the Farm,”
Science
311, no. 5763 (Feb. 17, 2006): 944-46.

298 a surprising item:
William Prochnau and Laura Parker, “The Waiting Plague,”
Vanity Fair,
Nov. 2005.

298 had pledged $2.3 billion:
UN System Influenza Coordinator (SIC) and World Bank, “Responses to Avian Influenza and State of Pandemic Readiness, Third Global Progress Report,” Dec. 2007 (1st printing, released Nov. 29, 2007). The total figure increased modestly to $2.7 billion in 2008. See UN SIC and World Bank, “Responses to Avian Influenza and State of Pandemic Readiness, Fourth Global Progress Report,” Oct. 2008.

299 ninety-one-page progress report:
UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (1st printing).

299 a new version of the report:
UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (2nd printing, released Dec. 18, 2007), 8-9.

299 would decline even further in 2008:
UN SIC and World Bank, “Responses . . . Fourth Global Progress Report,” Oct. 2008. The report warned, “There is a risk that this decline in resources pledged, especially for countries with the greatest remaining needs, could undermine the sustainability of the investments made to date.”

299 warned of growing “flu fatigue”:
Paula Dobriansky, undersecretary of state for democracy and global affairs, “Remarks at the International Partnership on Avian and Pandemic Influenza Ministerial, Sharm El Sheikh, Egypt,” Federal News Service, Oct. 25, 2008.

299 the World Bank had helped estimate:
World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework,” Nov. 30, 2006. The original estimates were in World Bank, “Avian and Human Influenza: Financing Needs and Gaps,” Jan. 12, 2006.

299 sector after sector:
UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (1st printing).

300 “Adequate financial support”:
Ibid.

301 Yet the obstacles are many:
An excellent examination of the challenges facing
the development of a pandemic vaccine is the seven-part series “The Pandemic Vaccine Puzzle,” written by Maryn McKenna for the Center for Infectious Disease Research and Policy and posted online beginning October 25, 2007. The articles are available at
www.cidrap.umn.edu
. Another fine overview is Joost H. C. M. Kreijtz, Albert D. M. E. Osterhaus, and Guus F. Rimmelzwaan, “Vaccination Strategies and Vaccine Formulations for Epidemic and Pandemic Influenza Control,”
Human Vaccines
5 (Mar. 2009): 3. See also WHO, “Global Pandemic Influenza Action Plan to Increase Vaccine Supply,” Oct. 23, 2006; and National Institute of Allergy and Infectious Diseases, “Report of the Blue Ribbon Panel on Influenza Research,” Sept. 11-12, 2006.

301 research into any kind of flu vaccine:
See, for example, a pair of studies by the Institute of Medicine. Kathleen R. Stratton, Jane S. Durch, and Robert S. Lawrence, eds.,
Vaccines for the 21st Century: A Tool for Decisionmaking
(Washington; National Academies Press, 2000); and Institute of Medicine staff,
New Vaccine Development: Establishing Priorities
(Washington: National Academies Press, 1985).

301 An analysis in 2007:
Aeby Thomas, Niels Guldager, and Klaus Hermansen, “Pandemic Flu Preparedness: A Manufacturing Perspective,”
BioPharm International,
Aug. 2, 2007. For further discussion of the delays inherent in developing a pandemic vaccine, see Jesse L. Goodman, “How Fast Can a New Vaccine for an Emerging Respiratory Virus Be Developed and Available for Use?” Presentation at the International Conference on Emerging Infectious Diseases, Atlanta, GA, Mar. 22, 2006.

301 confound efforts to develop a single vaccine:
See, for example, WHO, Report of WHO Working Group, “Influenza Research at the Human and Animal Interface,” Sept. 21-22, 2006; Steven Riley, Joseph T. Wu, and Gabriel M. Leung, “Optimizing the Dose of Pre-Pandemic Influenza Vaccines to Reduce the Infection Rate,”
PLoS Medicine
4, no. 6 (June 2007): e218; and G. J. D. Smith et al., “Emergence and Predominance of an H5N1 Influenza Variant in China,”
PNAS
103, no. 45 (Nov. 7, 2006): 16936-41.

301 unusually resistant to experimental vaccines:
See, for example, Karl G. Nich olson et al., “Safety and Antigenicity of Non-adjuvanted and MF59-adjuvanted Influenza A/Duck/Singapore/97 (H5N3) Vaccine: A Randomized Trial of Two Potential Vaccines Against H5N1 Influenza,”
Lancet
357, no. 9272 (June 16, 2001): 1937-43; Jean-Louis Bresson et al., “Safety and Immunogenicity of an Inactivated Split-Virion Influenza A/Vietnam/1194/2004 (H5N1) Vaccine: Phase I Randomised Trial,”
Lancet
367, no. 9253 (May 20, 2006): 1657-64; Isabel Leroux-Roels et al., “Antigen Sparing and Cross-Reactive Immunity with an Adjuvanted rH5N1 Prototype Pandemic Influenza Vaccine: A Randomised Controlled Trial,”
Lancet
370, no. 9587 (Aug. 18, 2007): 580-89; and Nega Ali Gogi et al., “Immune Responses of Healthy Subjects to a Single Dose of Intramuscular Inactivated Influenza A/ Vietnam/1203/2004 (H5N1) Vaccine After Priming with an Antigenic Variant,” paper presented at Third WHO Meeting on Evaluation of Pandemic Influenza Prototype Vaccines in Clinical Trials, Geneva, Feb. 15-16, 2007.

302 This could cut the production time:
Peter F. Wright, “Vaccine Preparedness—Are We Ready for the Next Influenza Pandemic?”
NEJM
358, no. 24 (June 12, 2008): 2540-43.

302 Initial clinical trials:
Hartmut J. Ehrlich et al., “A Clinical Trial of a Whole-Virus H5N1 Vaccine Derived from Cell Culture,”
NEJM
358, no. 24 (June 12, 2008): 2573-84.

302 than even seasonal flu shots:
David Brown, “Bird Flu Vaccine Shows
Promise,”
Washington Post,
July 27, 2006; Leroux-Roels, “Antigen Sparing”; and Suryaprakash Sambhara and Gregory A. Poland, “Breaking the Immunogenicity Barrier of Bird Flu Vaccines,”
Lancet
370, no. 9587 (Aug. 18, 2007): 544.

302 could radically increase:
WHO, “Projected Supply of Pandemic Influenza Vaccine Increases Sharply,” press release, Oct. 23, 2007.

302 “can’t provide vaccines to the world free”:
Wayne Pisano, quoted in a Council on Foreign Relations letter from Laurie Garrett, senior fellow for global health, June 20, 2007.

302 a local vaccine against hepatitis B:
Tini Tran, “Vietnam Struggles to Rein In Hepatitis B,” Associated Press, July 17, 2000.

302 a new generation of vaccines:
“Health: Vietnam Successfully Produces Second Generation Hepatitis Vaccines,”
Vietnam News Briefs,
Apr. 11, 2002.

303 “future availability to Vietnam is doubtful”:
“Report of WHO Mission to Support Influenza A/H5N1 Vaccine Development in Vietnam,” 2005.

303 “serious ethical reservations”:
Ibid.

304 “the volunteer ‘spirit’ may not be universally shared”:
Internal WHO document, 2005.

304 monkey kidney cells:
“Vietnam-made Bird Flu Vaccine Proves Effective,” Vietnamese News Agency, Aug. 22, 2008.

304 on researchers at the institute:
“Volunteers for H5N1 Vaccines Get Second Injection,” Vietnamese News Agency, May 17, 2008.

304 student volunteers:
Ibid.

304 “Good results”:
Tranh Dinh Lam, “Vietnam: Bird Flu Vaccine for Humans May Be Available by 2009,” Interpress Service, June 4, 2008.

304 mass production by late 2009:
“Vietnam-made Bird Flu Vaccine Proves Effective,” Vietnamese News Agency, Aug. 22, 2008.

304 30,000 Vietnamese dong:
Ibid.

304 Siti Fadilah Supari was far less patient:
The accounts of Supari’s political rise, her battle over the sharing of viruses, and the wider international dispute over samples and benefits are drawn from interviews with Supari, current and former officials of the Indonesian health ministry, and other Indonesian public health officials and political figures. It also draws on interviews with WHO officials and public health and diplomatic officials from the United States, Australia, and other countries, as well as documents from the Indonesian health ministry, WHO, and the U.S. Department of Health and Human Services.

305 Her scheduled flight:
Details of Supari’s trip to Geneva are drawn from Siti Fadilah Supari,
It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza
(Jakarta: Sulaksana Watinsa Indonesia, 2008), 112ff.

306 “We do not really know”:
Statement by the Minister of Health of the Republic of Indonesia H. E. Dr. Siti Fadilah Supari at the Inter-Governmental Meeting for Pandemic Influenza Preparedness, Geneva, Nov. 20, 2007.

307 her cell phone rang:
Yanto Soegiarto, “Diving into the Deep End,”
Globe Asia,
Oct. 2007.

309 a running dispute with foreign scientists:
The account of the NAMRU dispute is based on interviews with Andrew Jeremijenko, other NAMRU staff, and Indonesian health ministry officials.

309 “difficult to get the damn virus”:
Interview with Jeremijenko.

310 cease all activities:
“Circular Regarding the Status of NAMRU-2,” Oct. 25, 2005, signed by Secretary Titie Kabul Adimidjaja, acting head of Badan Litbangkes.

312 “I never gave permission”:
Wahya Dhyatmika and Pramono, “WHO’s Virus?”
Tempo,
Feb. 20, 2007.

312 unless they met Supari’s demands:
The Indonesian position is best detailed in Endang R. Sedyaningsih et al., “Toward Mutual Trust, Transparency and Equity in Virus Sharing Mechanism: The Avian Influenza Case of Indonesia,”
Annals of the Academy of Medicine
(Singapore) 37, no. 6 (June 2008): 482-88. Supari was one of the authors on this paper written by Indonesian health ministry officials. The position prevailing in many developing countries, in particular the United States, is well articulated in Richard Holbrooke and Laurie Garrett, “‘Sovereignty’ That Risks Global Health,”
Washington Post,
Aug. 10, 2008. An Indonesian response to the column by Holbrooke and Garrett is Makarim Wibisono, “The Responsible Virus and Sharing Benefits,”
Jakarta Post,
Aug. 27, 2008. Wibisono was the Indonesian ambassador to the United Nations in New York and in Geneva.

313 Her attack was unprecedented:
For a discussion of the global health issues raised by Indonesia’s decision to withhold virus samples, see Chan Chee Khoon and Gilles de Wildt, “Developing Countries, Donor Leverage, and Access to Bird Flu Vaccines,” DESA Working Paper no. 41, UN Department of Economic and Social Affairs, June 2007.

313 viruses were biological resources:
On two rival interpretations of international law governing virus samples, see David P. Fidler, “Influenza Virus Samples, International Law, and Global Health Diplomacy,”
Emerging Infectious Diseases
14, no. 1 (Jan. 2008): 88-94.

313 “WHO has become a target”:
Personal notes of conversation.

314 “Indonesia’s leadership alerted”:
“RI ‘Will Not Share’ Flu Samples,”
Jakarta Post,
Feb. 7, 2007. The joint statement issued after the meetings between Supari and Heymann is “Sharing of Avian Influenza Viruses and Pandemic Vaccine Production,” Joint Statement from the Ministry of Health of Indonesia and the World Health Organization, Feb. 16, 2007.

314 “the answer is still no, no, no”:
Wahya Dhyatmika and Pramono, “WHO’s Virus?”
Tempo,
Feb. 20, 2007.

314 The Indonesian leader stressed:
“RI Stresses Need for Production of Affordable Bird Flu Vaccines,” Antara news agency, Apr. 4, 2007.

314 “We will resume the sending of virus samples”:
“Indonesia Confirms Readiness to Send Bird Flu Virus to WHO,” Xinhua, April 4, 2007.

314 “I believe the developing countries are right”:
Margaret Chan, Opening remarks at the Meeting on Options for Increasing the Access of Developing Countries to H5N1 and other Potential Pandemic Vaccines, Geneva, April 25, 2007.

315 “I will fail you”:
Laura MacInnis, “WHO’s Chan Pledges Fair Access to Bird Flu Vaccines,” Reuters, May 17, 2007.

315 suggested the UN Security Council:
Laurie Garrett and David P. Fidler, “Sharing H5N1 Viruses to Stop a Global Influenza Pandemic,”
PLoS Medicine
4, no. 11 (Nov. 2007): e330, 1712-14.

315 “I was exhausted”:
Siti Fadilah Supari,
It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza
(Jakarta: Sulaksana Watinsa Indonesia, 2008), 129.

315 their private encounter:
Accounts of the meeting were provided by several Indonesian and WHO officials. Supari’s comments are drawn from Supari,
It’s Time for the World to Change,
129-31.

317 weapons of mass destruction:
Supari,
It’s Time for the World to Change,
19.

317 “the nuttiest idea I ever heard”:
“Remarks by Defense Secretary Robert Gates
to the Indonesian Council on World Affairs, Jakarta, Indonesia,” Federal News Service, Feb. 25, 2008.

317 a rapturous reception:
See, for example, “Alarm as Indonesia Thumbs Nose at West over Bird Flu,” Agence France Presse, Sept. 7, 2008.