VZCZCXYZ0000
RR RUEHWEB

DE RUEHJA #2253/01 2780953
ZNR UUUUU ZZH
R 050953Z OCT 06
FM AMEMBASSY JAKARTA
TO RUEHC/SECSTATE WASHDC 0930
RUEHPH/CDC ATLANTA GA
INFO RUEAUSA/DEPT OF HHS WASHINGTON DC
RUEHRC/USDA FAS WASHDC
RHEHNSC/NSC WASHDC
RHMFIUU/BUMED WASHINGTON DC
RUEHBK/AMEMBASSY BANGKOK 7365
RUEHBY/AMEMBASSY CANBERRA 9973
RUEHRO/AMEMBASSY ROME 1942

UNCLAS JAKARTA 012253 
 
SIPDIS 
 
SENSITIVE 
SIPDIS 
 
DEPT FOR EAP/MLS, EAP/IET, MED/DASHO/EMR AND MED 
DEPT FOR G/AIAG AND OES 
DEPT PASS TO USDA/FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG 
DEPT ALSO PASS TO USDA/FAS/FAA/DYOUNG AND USDA/APHIS/ANNELLI 
DEPT ALSO PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL 
DEPT ALSO PASS TO HHS/WSTEIGER/ABHAT/MSTLOUIS AND HHS/NIH 
PARIS FOR FAS/AG MINISTER COUNSELOR 
BANGKOK FOR APHIS/CARDENAS, RMO, CDC, USAID/RDM/A 
CANBERRA FOR APHIS/EDWARDS 
ROME FOR FAO 
NSC FOR JMELINE 
 
E.O. 12958: N/A 
TAGS: TBIO AMED CASC EAGR AMGT PGOV ID KFLU
SUBJECT: AN ENHANCED U.S. ROLE IN COMBATING AVIAN INFLUENZA (AI) 
IN INDONESIA -- MONEY AND PEOPLE 
 
REF: A) Jakarta 11582    B) Jakarta 11344 
 
¶1. (U) This is an action request.  Please see paragraph 3. 
 
¶2. (SBU) Summary. After a slow start that led to the unchecked 
spread of AI across much of Indonesia, the Government of 
Indonesia (GOI) has developed a simplified AI strategy with re- 
aligned priorities under a functioning National Committee for AI 
Control and Pandemic Prevention.  These developments represent an 
important organizational advancement over the past year, and 
offer donors a stronger foundation on which to base their AI 
assistance efforts in the future.  However, the GOI budget 
including international donor assistance cannot meet the 
requirements for its revised AI program, and the National 
Committee has no committed funding beyond 2007. 
 
¶3. (SBU) The moment is right for the USG to step up with a 
significantly expanded AI assistance package to help the National 
Committee implement its priorities--we estimate that a USG 
contribution of $20 million a year in each of the next two years 
would give Indonesia a real chance at permanently reducing the 
level of AI in Indonesia's poultry population.  Taking advantage 
of an upcoming VVIP visit in late November to announce such an 
assistance package would offer a superb opportunity to leverage 
USG assistance into a stronger GOI public commitment to combating 
AI.  We also recommend promptly placing permanent staff from the 
Centers for Disease Prevention and Control (CDC) and Animal and 
Plant Health Inspection Service (APHIS) in Jakarta and 
intensifying consultations with other donors so that GOI hears 
concerted and coordinated guidance on managing AI.  There may 
also be an opportunity for the UN or other international 
organizations to establish a data center to coordinate shared 
resources for countries facing the onset of AI. End Summary. 
 
¶4. (SBU) The USG has been a leader in the response to AI since 
before Indonesia reported its first human outbreaks in June 2005. 
Early on we developed a strategy that emphasized improving 
surveillance, enhancing animal sector AI control, and stepping up 
behavior change communications - the portions of Indonesia's 
national strategy that the GOI has recently made its top three 
priorities. 
 
ROOTS OF GOI FAILURE FOR EARLY AI CONTROL 
----------------------------------------- 
 
¶5. (SBU) Indonesia was unprepared for the quick spread of AI 
among its poultry population.  Identified first in 2003, AI in 
poultry has now spread to 29 of the country's 33 provinces. 
Human infections have followed as a result of frequency of 
contact, limited understanding of AI, social customs, and poor 
poultry handling techniques.  Numerous factors contributed to 
creating an environment where the virus could pass quickly and 
quietly to become epizoonotic within the avian populations. 
 
--UNPREPARED, DECENTRALIZED GOVERNMENT.  The GOI was slow to 
grasp the enormity of its AI problem in 2004 and 2005. 
Indonesia's highly decentralized government created overlapping 
and unclear authority lines between central and district 
governments that in turn resulted in non-standard operating 
procedures and responses to outbreaks; inadequate surveillance 
and failure to report outbreaks; inadequate culling and 
vaccination procedures; and a lack of capacity to make proper 
funding and policy decisions at the local level.  The MOH and MOA 
have not coordinated well.  Nonetheless, community level programs 
have produced strong results in surveillance, outbreak response, 
and district level coordination between health and agriculture 
officials.  Community-based programs have also revealed a pool of 
knowledge and concern about AI among villagers that can be 
harnessed to create real change. 
 
--INDONESIAN VILLAGE CULTURE. Indonesian village life is 
 
conducive to creating disease conditions among poultry 
populations. Indonesian families live in close proximity to their 
uncaged poultry, raise chickens and ducks as a protein source, 
and also keep pet birds.  Children play with birds freely and 
people sometimes sleep with birds in the house. Sensitive to 
higher costs, residents ignore local regulations about bird 
import and smuggle in birds from other markets when locally 
supplied birds are too expensive. 
 
--LACK OF TRUST BETWEEN MOA AND POULTRY PRODUCERS:  A lack of 
trust between larger poultry producers (Sectors 1 and 2) and the 
MOA also severely inhibits efforts to combat AI.  Outbreaks in 
the Sectors 1 and 2 often go unreported, and MOA officials have 
no authority to enter poultry production sites for animal health 
reasons.  Obtaining the buy in of large poultry producers will be 
crucial for effectively controlling AI. 
 
MORE RAPID PROGRESS IN 2006 
--------------------------- 
 
¶6. (U) The GOI's national human health and animal health response 
began to take shape in early 2006. In February, the GOI created 
the National Committee for AI control and Pandemic Prevention 
(National Committee) under Bayu Krisnamurthi.  When a high 
profile cluster of human cases occurred in North Sumatra in May 
2006, key international partners (NAMRU-2, WHO, CDC, FAO) 
proceeded to the site, resulting in rapid case confirmation, 
epidemiologic assessment and subsequent genetic sequencing of 
virus samples.  In June, the GOI and WHO convened a panel of 
international influenza and animal health experts on AI 
management that made a set of important recommendations. 
International experts complimented the GOI for convening the 
meeting, but the MOH ultimately rejected the resulting report 
because it was unwilling to admit that limited non-sustained 
human-to-human transmission occurred during the outbreak. 
 
¶7. (SBU) With USAID funding, FAO piloted an effective 
Participatory Disease Surveillance and Participatory Disease 
Response (PDS/PDR) program in 12 districts in the first quarter 
of 2006. The program provided the first reliable reporting on 
outbreaks in the backyard and informal poultry sector.  An 
International Expert panel identified the program as a model 
program for district governments that offers the best hope yet to 
reduce AI infection in Indonesia's poultry population.  USAID, 
AusAID and Japan provided funds to expand the program to 159 
districts by June 2007. 
 
¶8. (U) In August, the GOI launched the National Committee.  Bayu 
announced a refocused National strategy and animal control 
program and also launched GOI's first national awareness 
communication campaign.  During the month, the National Committee 
convened two donor meetings to map resources, identify funding 
gaps and discuss animal control measures. The National Committee 
announced a refocusing of Indonesia's AI strategy to focus on 
three top priorities: 1) risk communication, information and 
public awareness, 2) epidemiological surveillance on animals and 
humans, and 3) AI control in animals.  The GOI also made progress 
in August and September implementing the Tangerang Trilateral 
Project, but has a lot of bureaucratic hurdles to overcome, such 
as working out a reimbursement mechanism.  Since the August donor 
meeting, international donors are expressing more confidence that 
the GOI is on the right track and that Indonesia has turned the 
corner on its struggle to control AI. 
 
ROLE OF DONOR COMMUNITY 
------------------------ 
 
¶9. (U) The U.S., Australia, Japan and World Bank are the major AI 
donors in Indonesia. Australia is providing approximately $12 
million to support WHO/MOH rapid response teams, stockpile 
Tamiflu, and support the FAO's PDS/PDR program.  In addition, 
 
Australia is designing a new program covering detection, 
prevention and management of AI in humans and animals.  The 
program will be part of an approximately $75 million Australian 
commitment for emerging infectious diseases in the Asia Pacific 
Region (the final amount that will go to Indonesia is unclear). 
Japan provides the majority of its assistance through UNICEF for 
communications, WHO for human health, and FAO/OIE for animal 
health.  The World Bank is finalizing a proposed $15 million, 2- 
year program for animal surveillance and containment.  This 
program will include support for the PDS/PDR program, 
compensation for culled birds, outbreak response vaccination, and 
preventive vaccination.  Other donor support includes $1.3 
million from the Netherlands for animal vaccine trials and $6 
million from Canada for human health, including purchase of 
hospital equipment. 
 
GAPS REMAIN 
----------- 
 
¶10. (SBU) The GOI is now on the right path to managing AI, but 
Indonesia's enormous size makes tackling AI a huge task. Key gaps 
include the following: 
 
--MOH CAPACITY: The MOH needs a range of assistance to improve 
its diagnostic capacity and response to human outbreaks.  By 
their own admission, the MOH lacks trained research technicians 
and scientists who understand the scientific process or can 
conduct assays.  Only a long-term commitment to develop and 
support the training of a cadre of scientists will alleviate this 
problem.  Moreover, rank and file health care workers have 
critical training needs for patient diagnosis, case management, 
and infection prevention. 
 
--PUBLIC AWARENESS: Indonesia badly needs a more robust and 
sustained AI public awareness campaign. The National Committee's 
communications strategy is designed to increase public awareness 
about AI so people can identify AI outbreaks in animals and AI 
symptoms in people.  In addition, the National Committee hopes to 
change behavior to reduce the risk of and increase appropriate 
responses to animal outbreaks and human infection.  In August, 
the GOI launched a national mass media campaign to reduce the 
risk of human infection from animal outbreaks.  Financial support 
from UNICEF and the Government of Japan is sufficient to air 
public service announcements (PSAs) through December 2006. USAID 
is working with UNICEF to analyze results from the national 
campaign and fine-tune messages. USAID is also supporting a 
community level interpersonal communications effort to complement 
the mass media campaign.  USAID funding is sufficient to support 
public awareness campaigns to cover 100 districts through July 
¶2007.  Additional funding is needed to purchase airtime for new 
mass media messages to air in 2007 and 2008 ($6 million) and to 
continue community level behavior change communications through 
2007 ($2 million). 
 
--SURVEILLANCE FOR ANIMALS AND HUMANS: The GOI needs increased 
epidemiological surveillance of animals and humans including 
active community-based surveillance for animal and human cases; 
hospital based passive surveillance, and laboratory diagnostic 
capacity.  Capacity and skills within the GOI are severely 
limited for surveillance.  The USG is at the forefront of 
surveillance efforts for both human and animals in Indonesia. 
NAMRU-2, with financial support from CDC and DOD-GEIS, has 
operated a hospital-based human influenza study in Indonesia 
since 1999.  In September 2005, USAID provided financial support 
to NAMRU-2 to expand its study to include key AI risk areas.  The 
NAMRU-2 study has provided vital support to Indonesia in case 
confirmation and to global AI research.  NAMRU-2 has requested 
authority to expand its human surveillance program to include 
additional referral hospitals.  Toward this end, almost a dozen 
hospitals and/or health care centers have requested enrollment 
into the surveillance network.  However, officials at National 
 
Institute of Health Research and Development (NIHRD) have not 
approved this expansion. 
 
USAID provided seed money to FAO's PDS/PDR program, which has 
provided the first reliable reports of AI animal outbreaks and 
improved rapid response and control measures.  USAID is the 
primary donor for this program, providing 2/3 of the funding, but 
the success of the program has drawn support from other donors, 
including AusAID, the Government of Japan, and the World Bank. 
Additional funding is needed to support program operations in 
currently covered districts over the next 2 years ($10 million 
for 159 districts) and to expand the program to train and operate 
the program in the remaining AI 150 endemic districts ($13 
million). 
 
--VACCINATION, CULLING AND COMPENSATION PROGRAMS: The GOI lacks 
resources to fully implement the FAO guidance for animal control, 
including focal culling with compensation and ring vaccination. 
Over the next six months, USAID and the World Bank will pilot a 
control plan for animal outbreaks.  Experts will then use lessons 
learned to further improve animal containment across Indonesia. 
The USG strategy does not at this time fund compensation which, 
under current endemic conditions, would cost about $150,000 per 
district per year. Support for vaccination would help to free GOI 
budget to more consistently pay compensation for culled birds. 
Under current endemic conditions, an adequately resourced 
targeted vaccination campaign would cost $50,000 per district per 
year.  The World Bank plans to support full vaccination coverage 
of 12 districts over two years.  Additional funding would be 
necessary to cover the remaining 147 districts for one year ($7.3 
million) and 288 districts for the second year ($14.4 million). 
 
--MINISTRY OF AGRICULTURE LEADERSHIP AND INFRASTRUCTURE: Lack of 
leadership and infrastructure within the Ministry of Agriculture 
remains a critical gap in Indonesia's AI management. The MOA has 
not consistently implemented standard operating procedures, 
elevated AI as a priority for central and local agriculture 
authorities, encouraged restructuring of the poultry industry, 
and ensured adequate funding for AI surveillance and control. 
Despite the fact that Indonesia is struggling with other animal 
diseases, the MOA has not developed a cadre of animal health 
extension officers. (Note: The strength of the FAO program is 
that it is managed at the provincial level and implemented at the 
district level.) 
 
¶11. (SBU) The GOI also faces an across the board fiscal 
sustainability problem that affects all of its anti-AI program. 
The GOI's AI budget including international donor assistance 
faces significant shortfalls in 2007, and the National Committee 
has no committed funding beyond 2007. 
 
THE PATH FORWARD 
---------------- 
 
¶12. (SBU) With the National Committee up and running, and a 
refocused AI strategy, and the piloting of a successful animal 
surveillance and response program, the time is right for the USG 
to step up with a significantly expanded AI assistance package. 
We recommend Washington provide an additional $40 million in AI 
funding ($20 million per year over a two-year period) to assist 
the National Committee in implementing its priorities.  Fully 
funding the FAO PDS/PDR program in Indonesia's remaining AI- 
endemic districts to manage the disease at the source is our top 
priority.  We would also use any new USG funds to support public 
awareness programs and address other shortfalls that are 
hindering the achievement of the National AI Committee's three 
priorities.  These programs offer the best hope yet to, over the 
medium term, drive the "viral load" down in Indonesia's poultry 
population, protect human health, and limit opportunity for the 
virus to shift. 
 
¶13. (SBU) In addition to sharply expanding USG assistance to the 
National Committee, we also need more USG boots on the ground in 
Indonesia.  We are grateful for the continuing TDY assistance 
from both CDC and APHIS.  However, we need permanent animal and 
human health experts assigned here quickly to build relationships 
with key GOI staff and implement programs.  If this is not 
possible, we recommend CDC and APHIS develop rotations among a 
small cadre of experts who have previously assisted in Indonesia. 
The learning curve here is steep.  Key GOI contacts work best 
where relationships and trust are already developed.  When APHIS 
and CDC are fully operational in Jakarta, we expect that they 
could draw on increased USG funding to expand their programs. 
For example, APHIS could enlarge and fully fund planned 
epidemiological training, laboratory training for sector 1 labs, 
and pilot intensive area vaccination programs. 
 
¶14. (SBU) Our strategy going forward should have a diplomatic 
component as well.  The recent European Union letter to the GOI 
noting serious concerns with Indonesia's handling of AI 
underscores the need to develop a coordinated diplomatic message 
with other donor countries.  This would ensure that senior GOI 
officials are hearing concerted and coordinated guidance on 
managing AI.  This could benefit us directly.  For example, the 
GOI is resisting the idea of expanding NAMRU-2's hospital 
surveillance program.  A coordinated message from the donor 
community about the need for additional human surveillance could 
be very effective in persuading the GOI to allow NAMRU-2 to move 
forward.  A concerted diplomatic message, delivered both in 
Jakarta and at major AI conferences, could also be helpful in 
endorsing the success and importance of the National Committee, 
securing additional GOI budgeted resources for AI, and convincing 
the GOI to more openly share AI samples. 
 
INDICATORS OF SUCCESS 
--------------------- 
 
¶15. (SBU) Over the long term, we would be able to judge the 
effectiveness of increased USG assistance by the number of human 
infections and animal outbreaks.  However, in the short-term, 
improving the surveillance system would likely result in 
increased reports of human cases and animal outbreaks.  This was 
the case when we expanded NAMRU-2's surveillance network and 
piloted the FAO PDS/PDR program.  Other factors, such as weather 
conditions and cultural practices can also impact on the number 
of reported outbreaks at any given time.  The National AI 
Committee, in collaboration with donors, is developing country 
level indicators for Indonesia, and several USAID-funded programs 
are jointly developing program specific performance indicators, 
including intermediate indicators that can help inform program 
impact.  Examples include the level of active surveillance as 
indicated by the number of health facilities engaged in 
surveillance and reporting cases to MOH, the number of PDS/PDR 
teams searching for AI outbreaks, the number of interviews 
conducted by PDS/PDR teams, etc.  Additional indicators could 
include the level of outbreak/case response (e.g. the percentage 
of reported suspect human cases or animal outbreaks investigated 
within 24 hours). 
 
LEARNING FROM INDONESIA 
----------------------- 
 
¶16. (SBU) The scale and complexity of Indonesia's struggle 
against AI, and the size of the donor response, suggests that 
Indonesia's experience may contain lessons for other AI-afflicted 
countries.  Indonesia could also surely benefit from real-time 
knowledge of AI control efforts in other countries. Although 
averting a pandemic is a scientific and medical challenge, 
combating AI is also a long term management problem involving 
coordination, logistics planning, organization and resources.  We 
recommend Washington consult closely with the UN, World Bank and 
others to see what opportunities may exist to leverage technology 
 
and institutional knowledge to develop tools for global 
coordination.  Such tools might have been very helpful to 
Indonesia in its early efforts to contain AI.  The UN or WHO 
would likely be best positioned to lead the development of such 
coordination tools, which might include some of the following: 
 
--An international donor data base could provide an excellent 
reference tool to not only monitor and record current donor 
levels and functions but also to provide users with ideas for 
additional programs.  A government user in a country facing AI 
for the first time might research other countries for ideas of 
donor programs.  An in-country user might pull off the latest 
statistics in preparation of meetings.  A Washington user could 
sort donor efforts by country, by AI strategy, by year or any 
other data element. The WHO might be a possible host for an 
expansion of tools. 
 
--A central website could also feature a range of useful 
reference materials by country such as maps tracking bird and 
human AI outbreaks, a who's who of key AI players for each 
country, national strategic plans and a list of reference 
materials. 
 
--A central website could also feature useful templates and 
descriptions of AI management best practices so that less time 
and resources are spent in recreating the wheel in every country. 
 
HEFFERN