From the country’s first encounter with H5N1, authorities have wondered whether it spread to humans only from birds, or whether it was being passed from human to human as well. “In some instances we have seen some very limited human-to-human transmission,” says infectious-diseases expert Keiji Fukuda, the WHO’s interim assistant director general for health security and environment and director of its global influenza program. “But these instances involve very intense contact, where a parent might be taking care of an infected child.”
Fukuda notes that avian flu has been just as severe and difficult to control in other affected countries, such as Egypt, where a spate of human cases this year has drawn international concern. But nearly half of all bird flu deaths in humans have occurred in Indonesia, the world’s fourth most populous nation. Birds are of supreme economic importance and national pride here, status symbols kept as pets for their beautiful feathers or their song. Culling them to stop the flu is no simple matter.
Indonesians have hidden their birds when government agents have come to kill sick chickens and domestic ducks, common conduits of H5N1 to humans. Fruits and vegetables are widely sold in open-air venues called wet markets, which are points of sale for infected poultry as well. Children and adults have contracted avian flu while shopping for groceries.
With the danger so clear, Indonesia has cooperated with international disease-control efforts—but only at times. In 2007, after negotiations with the WHO’s Intergovernmental Committee, Supari agreed to share samples. The release of specimens was intermittent at best. “That is not enough for a country that seems to be a natural bioreactor for influenza strains,” says Michael Greger, director of public health and animal agriculture at the Humane Society of the United States. “It is important to know what’s really going on there.”
Far more often, Indonesia has played the renegade, openly ignoring guidelines governing the WHO’s Global Influenza Surveillance Network, a 57-year-old system through which researchers gather and share samples from patients with flulike illnesses. About 128 laboratories in 99 countries, including Indonesia, are signatories; large national public-health laboratories in the United States, Great Britain, Australia, and Japan anchor the network.
Yet most Americans are barely aware of the political folderol that has been going on for years. Many view bird flu as a passé threat that rarely makes the news anymore and hope that swine flu will similarly fade from view. “When a pandemic didn’t happen the week after the bird flu stories broke, the stories were no longer interesting,” says Greger, who wrote the book Bird Flu: A Virus of Our Own Hatching. “For many people, bird flu is the story of the boy who cried wolf. And just like the story, not only is the wolf real, but it is still out there.”
Aria of the flu diva
Siti Supari is as adept at getting under the collective skin of the world’s superpowers as she is at playing on the fear of Western science that runs through Indonesia’s population, which is predominantly Muslim. She knows how to gin up the rhetoric and rev up the crowds. Her jingoism often inflames activists, who can be found protesting outside the American embassy in Jakarta, trying to shout the remaining Americans out of town. But she did not start her professional life with a vision of standing on the global stage or adopting the multiple, competing public personas she has assumed: agent provocateur, warrior-defender of Indonesia, trash-talking drama queen.
In various snapshot biographies used as introductions before her speeches, Supari is said to hail from central Java, where she was born in 1949. From a young age she set her sights on a career as a physician, a goal she achieved after earning a medical degree from Gadjah Mada University in Yogyakarta. Neither influenza nor global public health was a part of her work. Throughout the 1980s Supari treated heart patients; she then went back to graduate school to obtain a second doctorate, in cardiology. An academic career consumed her time until 2004, when the newly elected president, Susilo Bambang Yudhoyono, appointed her to head Indonesia’s Health Ministry. Diminutive and bespectacled, with a penchant for poufy, retro hairstyles, Supari has a soft, high-pitched voice that contrasts sharply with the incendiary tone she adopted in her new position.
Supari’s press representatives in Jakarta declined repeated requests for an interview. However, Triyogo Jatmiko of Indonesia’s Permanent Mission to the United Nations in New York City provided a transcript of a Supari speech delivered to global health officials in Geneva, which helps illuminate her dramatic approach. In it she casts her country as resource poor, seeking a level playing field alongside the rich nations that are home base to Big Pharma.
“As a citizen of a developing country, I must keep voicing the need to explore the development of transparent, fair, and equitable virus sharing and benefits sharing,” she said. The “benefits,” she explained, are the vaccines, diagnostics, and other technologies developed from flu viruses and their genes. These products, she said, elude resource-poor countries such as her own because costs can be crippling.
In press reports and speeches, Supari says Indonesia has shared freely for decades and received nothing for its cooperation. In a book entitled It’s Time for the World to Change, published last year, she charges the United States and the WHO with conspiring to use H5N1 as a biological weapon against Indonesia and other poor countries. In March she reportedly announced that she wanted to stop vaccinating children against meningitis, mumps, and other childhood diseases with Western-made vaccines. The Associated Press quoted her as saying she did not want global pharmaceutical companies exploiting Indonesians the way they have exploited Africans. Supari further accuses the West of harboring plans to profit from third world misery by selling frightened, flu-affected nations expensive vaccines. Her willingness to speak out loudly against Western companies and governments has upped the wattage of her star power in Indonesia.
“She’s a national heroine. They love her and treat her like a rock star,” says Sharon Sanders, editor in chief of FluTrackers, a nonprofit Web site headquartered in Winter Park, Florida. The site sponsors discussions about all forms of influenza, and Indonesia’s reluctance to abide by international agreements is a frequent topic of concern. Many bloggers are outraged that a manipulative, second-tier official from a developing nation can hold the rest of the world by the throat. “It is apparent that many Indonesians don’t trust the U.S. government,” Sanders says.
Scientists who have dealt with Supari see her as a crafty negotiator capable of bargaining successfully with the strongest nations on earth. The key tenet in her intellectual property argument—that viruses infecting Indonesians belong to Indonesia —extends beyond pathogens that cause the flu. She doesn’t want Western scientists to study blood samples from any Indonesian for any reason, at least not until she gets something valuable in return.
“Minister Supari is a smart lady because most of this is about leverage,” says Anthony Gaspari, chairman of dermatology at the University of Maryland in Baltimore. Gaspari has been studying an exceptionally rare disorder affecting a 37-year-old Indonesian man named Dede. “What she’s saying is ‘We have something that is very desirable, but we are not giving it to you unless we get a cut of the action.’?”
Supari and her Health Ministry have barred shipments of blood samples from Dede, who is known as Tree Man. His unusual response to the human papilloma virus—HPV—caused him to develop thick, barklike warts all over his body, giving him the appearance of a man in a tree suit, minus the leaves.