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About two weeks ago, I wrote an open letter to Indonesian President Susilo Bambang Yudhoyono (or "SBY," as I understand he is called.  That reference comes from the always-welcome Blogsite of HHS Secretary Mike Leavitt).

The topic of my open letter was, of course, Indonesia's reluctance to participate in the community of nations.  The responses I received (not from SBY, but from faithful readers of this Blogsite)  were both welcome and interesting.  But they all had a common thread, which was:  Why spend good money after bad?  Why continue to accept Indonesia's pussy-footing on this important issue?  Haven't we done enough already?

Allow me to bring in a parallel:  Our Global War on Terrorism.  We have made it the stated policy of this nation that we will not wait for a terrorist attack to take place on American soil.  We will go after the terrorists wherever they are, whoever they are, and we will drive them into the ground.  We will gladly introduce them to whatever vestal virgins they may wish to visit  --  but on our terms, not theirs.

Let me say again: The global war on terrorism.  Now I want you to do a mental exercise:  Every time you read or hear the words "global war on terrorism," insert "fight against pandemic influenza." Or when you hear "the terrorists," think "pandemic flu."  Since homeland security experts (and the British government) have declared a pandemic to be as much of a risk as terrorism, we can substitute these expressions freely. 

Here we go:

We will take our Global War on Terrorism to all corners of the globe.  Anyone who is not helping us in this fight against The Terrorists is with the enemy.  We will defeat the terrorists because our fight is righteous and correct.  And woe betide anyone, or any nation, suspected of harboring the terrorists as a matter of national policy, or obstructing the Global War on Terrorism.  They will be dealt with.

We see the war in Afghanistan, the attempts to win the peace and build a new nation after winning the war in Iraq, and the efforts to wipe out individual al Qaida operatives via Predators, snipers, smart bombs (and occasionally some regrettably ill-placed bombs), and domestic arrests as evidence of the ongoing war against terrorism.

What we don't see are the deals, the secret agreements with nations such as Pakistan, and the flow of billions of dollars in aid (and other things) that allows us to continue to try and eliminate Islamic fascism's capacity to harm us.  That is both understandable and necessary; I am not sure I want to know how sausage and diplomacy are made, to paraphrase Mark Twain. 

You get the point.  If we are to remain consistent, we must engage bird flu as we also engage terrorism.  That means taking the fight to the enemy, no matter where it is.  It also confers a responsibility to other governments to be with us or against us.  "Us," in this case, is the WHO.  It is the UN.  It is 192 WHO member nation signees.  It is, quite simply, the rest of the planet.  In an ironic twist, it even includes some nations suspected of harboring terrorists!

We are dealing with an enemy -- the rise of pandemic influenza -- that is potentially a more indiscriminate killer of people than all the terrorist acts on the wish list of al Qaida combined.  It is amazing to me that various nations around the world are able to work cooperatively to ensure that the flow of information takes place to eliminate the spread of avian flu, despite their long-standing political and cultural differences.

As I mentioned in the open letter, we have nations such as Israel and the Palestinian Authority speaking regularly -- sometimes daily -- to corral H5N1.  India and Bangladesh are also working to try and contain bird flu, although things get mighty testy sometimes.

We even see transparency in the most unexpected of places.  Myanmar (Burma), arguably one of the most repressive regimes on Earth, is reporting its H5N1 problems.  China, which still "runs home to Momma" and reverts to secrecy at the worst times when it really needs openness and transparency, has improved its reporting of H5N1.  And Pakistan, which has almost as many geopolitical and geological problems as Indonesia, has the ability to welcome the WHO with open arms and securely move WHO lab workers into areas that are still crawling with al Qaida fighters.  We welcome these examples of transparency, even if we are not completely happy with the speed with which they occur.

In contrast, the nation of Indonesia has consciously decided to move into the opposite direction.  In fact, Indonesia has decided to become the bird flu equivalent of North Korea, becoming less and less transparent and trying to close off any attempt to determine its current status (NAMRU-2, WHO).

My goal -- and I am certain, the goal of HHS Secretary Mike Leavitt and his recent, unplanned and urgent trip to Jakarta -- was to try and get Indonesia to understand it has a global obligation in the fight against H5N1.  My open letter was certainly not intended to usurp or undermine Secretary Leavitt's diplomatic efforts, and I don't think anything I write could ever pack that much weight.  It was intended to show Indonesia that Americans care about what is going on in that nation, and that we all realize that this impasse could kill Indonesian and American children alike.  It was intended to show that Indonesia does not have to go it alone.  I also wanted to give some flexibility and options to both parties, and to show that some creative way might be found to end this impasse.

Part of the agreement signed between 192 nations and the WHO, as I understand it, makes viral strains the intellectual property of each nation.  That means Chinese H5N1 is the intellectual property of China.  But it also means that each signee nation must provide those samples in a timely manner to the WHO.  The WHO may or may not be allowed to release public sequences (which arouses the continual ire of Dr. Henry Niman and others), but at least someone gets to sequence those samples and look for mutations. 

Indonesia is a signee to that agreement.  Regrettably, Indonesia seems to have decided not to honor that treaty, and instead to continue to bicker and trivialize the situation.  By demanding some sort of vaccine guarantee in exchange for viral samples is the equivalent of cutting off one's nose to spite one's face.  No one knows if a Clade 2.1 mutation will spark the Next Pandemic.  No one knows if any currently-existing clade will trigger H5N1 H2H in humans.  And it is arrogant beyond words for Indonesia to think it should be guaranteed some sort of vaccine even when no one knows if it is their strain that will "go pandemic."

We already are shipping Tamiflu in prodigious quantities to Indonesia.  We are spending millions of American taxpayer dollars on preparedness in Tangerang province.  And only God and the OMB know how much in American taxpayer aid has already gone toward stomping out an Indonesian flu pandemic before it starts there.  In short, we are doing enough to help Indonesia.

By resolving to keep its H5N1 samples internal to Indonesia, and no matter how well-qualified its scientists are, it is playing Russian Roulette with the world's health.  This fact was underscored by the excellent recent editorial in the Wall Street Journal.  The Journal editorial also presented a political factoid; namely, that Health Minister Siti Fadilah Supari is courting Islamic factions in some bid for political office, and it always plays well in Jakarta and elsewhere to give the U.S. a hotfoot whenever possible.  this is confirmed by Secretary Leavitt's blog entry:

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.

Except that this hotfoot will potentially burn everyone -- especially Indonesians.  Medical realities disclose that vaccine is an endgame strategy.  Vaccine will not be available until the second wave of a flu pandemic at best.  Maybe we won't see vaccine until the third wave.  No one knows.  But basing a global strategy on the basis of vaccine guarantees ignores the reality that most of Indonesia's population will be impacted well before a vaccine becomes available. 

The problem is, like the war on terrorism, we still have to work with recalcitrant nations.  We just cannot "write off" Indonesia.  We must convince this nation to cooperate with the United States.  This, too, was at the top of my list and the forefront of my consciousness when I wrote the open letter.

However, patience is a virtue that is not inexhaustible.  Secretary Leavitt underscored that thought when it gave Indonesia a time certain for a return to its treaty obligations.  Secretary Leavitt said in his blog:

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. 

Well said, Mr. Secretary.  We need to accept this worldview.  Indonesia needs to live up to its obligations. If not, move NAMRU-2 to a nation that would welcome it.  We'll get the Indonesian flu samples some other way.

And may God help us all if Supari wins any election for anything important.