Indonesia has been hardest by bird flu. The virus was first detected in poultry in 2003. The first human infection was found in July 2005, when three people in the same family — a man and his tow daughters — died on the outskirts of Jakarta. In February 2008 it recorded its ninety-ninth and hundredth bird flu — a nine-year-old boy and 20-year-old woman from near Jakarta. At that time Indonesia accounted for half of all deaths attributed to the disease worldwide. As of August 2012, The World Health Organization says Indonesia remains the hardest-hit country, accounting for 159 deaths of 359 victims worldwide.

Donald G. McNeil Jr. wrote in the New York Times, “The disease took Indonesia, the world's fourth-most populous country, by surprise, he said. It had no response plan or clear chain of command for veterinarians, and it has endemic Newcastle disease, which mimics flu in chickens. Large producers protected their own flocks quickly, he said, but the flu became entrenched in "kampong chickens," the millions of free-roaming household birds that roost in trees. Peter Roeder, a FAO veterinarian, told the New York Times,"The virus got away before the first cases were detected.”[Source: Donald G. McNeil Jr., New York Times, January 29, 2007]

In February 2006, the Jakarta Post reported: “ A total of 304 human bird flu cases have been reported since last July, when the first human case was reported. Twenty-six of these 304 people have tested positive for bird flu, with 18 fatalities. The deadly H5N1 strain of the bird flu virus has continued its insidious spread through the country, while the government seems to have adopted an attitude of "everything will be all right". When the first human bird flu case emerged last July, it took at least three months before another case was detected. Today we are seeing new cases almost every three days. [Source: Jakarta Post, February 21, 2006]

“Indonesia now has the highest human mortality rate from bird flu (69.56 percent), compared to Thailand and China (63.63 percent), Vietnam (45.16 percent) and Turkey (33.33 percent). A meeting between President Susilo Bambang Yudhoyono and the governors of the six provinces with the highest numbers of bird flu cases provides fresh hope the government is ready to get serious about dealing with the virus. There is reason to be optimistic the government is finally determined to take firm measures, including mass culls of poultry within a radius of up to 10 kilometers of an outbreak, which it has avoided in the past.

“Birds travel fast. It only takes six months for them to spread the virus from Sumatra to Java, Kalimantan, Sulawesi, Bali, West and East Nusa Tenggara. Closer to the capital, the virus has spread from Tangerang to Jakarta and now to Indramayu regency in West Java When the virus was first detected in poultry in 2003, the government was quick to deny it. It did the same when the first human infection was found in July 2005.

Backyard Chickens and Live Markets

Alan Sipress wrote in the Washington Post: Markets in several countries, including Vietnam and Cambodia, have long sold live chickens and ducks, but health experts now warn that the virus can be spread by sick birds to other poultry and to people who buy and sell them, especially if they do not wear protective gear. At Phnom Penh's cavernous Orussey Market, for instance, live chickens and ducks are hawked on muddy floors, where they are crammed together, legs bound. In the warren of aisles, peddlers with bare hands butcher, pluck and wash them. [Source:Alan Sipress, Washington Post, April 14, 2005]

“Millions of villagers across the region, meanwhile, raise chickens in their back yards and even inside their homes. When the birds fall sick, villagers are more likely to eat them than dispose of their bodies, U.N. agriculture officials say. Often, the home-raised birds are fighting cocks. In Thailand alone, estimates put their number in the millions.

Complacency About Bird Flu in Indonesia

Alan Sipress wrote in the Washington Post: “Indonesians have learned after two years to live with bird flu. Their now-sober response offers a lesson in levelheadedness to those abroad who are panicked or might soon be.The initial scare over the mysterious new ailment faded in Indonesia as deaths became routine -- an average of almost one a week now. The virus proved exceptionally hard to catch, even for those who work closely with birds. Restaurants and butchers reported a recovery in their sales, and voracious Jakartans continue to crowd into food stalls along the roadsides, sheltered from the sun and exhaust fumes by large tarps adorned with cartoon chickens cheerfully advertising the house specialty. [Source: Alan Sipress, Washington Post, October 20, 2005]

"The bird flu cases don't affect us," said Elitha Tambunan, 38, a customer at a restaurant that specializes in chicken. "We're assured the chicken here is of the highest quality. It's a matter of trust." "People here are coming to realize that most of us are not at great risk of getting the virus," said Steven Bjorge of the World Health Organization's office in Jakarta. "People are figuring out that on a day-to-day basis, this is not a real threat."

“The issue of bird flu has all but vanished from the front pages of the newspapers. Peddlers hawking spicy chicken soup with coconut milk from pushcarts boast of a brisk business. The U.S.-based restaurant chain KFC, which operates 242 outlets across the archipelago, recorded a slight decline in sales when bird flu was first reported two years ago, but they rebounded within a week, according to Adi S. Tjahjadi, customer relations manager.

“Indonesians have already surmised what researchers demonstrated in findings published last month: It's awfully tough to catch bird flu. "The media coverage of the first bird flu cases really blew them up big. Then it died down, so the people came back," said Yulianti, 30, with a broad smile, wiping her forehead with a rag as she peddled feet and livers off the tile countertop. "Indonesians have become resilient because the cases are such a regular thing." Around her, shoppers strolled the muddy tile floors of the indoor market, perusing odd bits and pieces of chicken in the twilight of a few naked bulbs dangling from the high ceiling.

"People don't really believe you eat chicken and then you die," said Nashirin, 50, a skinny butcher whose frequent smile revealed a set of crooked teeth. "They've been eating chicken forever, and they just keep doing what they've been doing."His words were interrupted by the defiant cackling of scores of chickens awaiting their fate in dirty cages fashioned from bamboo and wire mesh. Several butchers, some barefoot and wearing only shorts, were squatting among the pools of blood, hacking apart the carcasses and untangling their insides with bare hands. "There's no reason to worry about bird flu," said Mohamed Nur, 42, a burly man with a soiled green T-shirt and blood-splattered pants. "Not only don't we die, we don't even get sick. And we cut up chickens every day."

Bird Flu in Indonesia Gets Out of Control

Donald G. McNeil Jr. wrote in the New York Times, The flu is ubiquitous in thousands of backyard flocks, and it appears to be killing more birds every month, increasing the likelihood of human cases. Forty-two people have in Indonesia died since the first human case was confirmed a year ago. “It’s like trying to fix the roof while there’s a storm going on,” said Dick Thompson, a spokesman for the World Health Organization. “Until the animal situation gets under control, there’s going to be this steady drip, drip, drip of human cases, and that’s a problem.” [Source: Donald G. McNeil Jr., July 21, 2006]

“Although the A(H5N1) flu arrived relatively late in Indonesia, it soon spiraled out of control, and deaths have mounted quickly. Mathur Riady, chief of livestock for Indonesia’s Health Ministry, said recently that more than a million birds had died of the flu between January and March, about the same number as died all last year. Unlike Thailand, which quenched outbreaks by killing millions of chickens, or Vietnam, which used mandatory vaccination, Indonesia has tried a mix of limited culling and vaccinating in rings around the cull — so far, with little success.

“The way Indonesian cases have clustered — often infecting just the blood relatives in one family in a village — has given support to the theory that some people are genetically more likely than others to get infected, he noted. “We can’t prove that — it remains a hypothesis,” he said. “But when a village has a lot of people and a large outbreak, and they all have lots of contact — burying or slaughtering or whatever — and only one family gets sick, you have to ask: is there something unique in that family that creates susceptibility?”

Indonesia’s Slow Response to Bird Flu

Jakarta Post reported: The government only acknowledged bird flu had reached the country when the number of victims continued to increase. The absence of a decisive policy has sent poultry farmers reeling toward bankruptcy, as they struggle to keep their businesses afloat amid a general climate of fear and confusion. The same confusion has affected chicken sellers, food stall operators, restaurant owners and household consumers. [Source: Jakarta Post, February 21, 2006]

“Also impeding the fight against the virus are factors like the vastness of the country, high population densities, particularly on Java island, and the generally lax observation of health standards at poultry farms, especially small, backyard farms. The country is also grossly lacking in veterinarians, with only about 10,000, or half the number a country this size should have. And of these 10,000 vets, only about 15 percent work at poultry farms. “In the words of one poultry farmer, the government should have been on the alert and ready to take action even before the outbreak. Malaysia is a good example of this. That country was taking precautionary measures long before bird flu became the threat it is today to Asia and the rest of the world, and now it proudly claims to be free from bird flu Other examples of decisive action have been seen in countries like Hong Kong, Vietnam and Thailand, all of which introduced mass culls at the first signs of an outbreak. Indonesia has remained reluctant to follow their examples, hiding behind the pretext of a shortage of funds. When funds were later made available by the international community, the government turned down the offer.

“It is difficult to avoid the impression that Indonesia has been slow to respond to the crisis, and that this failure will come back to haunt the country. In studies of infected fowl from 2003 to 2005, experts found the symptoms displayed by sick birds have grown less severe over time. Thus, birds infected with the H5N1 virus do not look that different from non-infected birds. How then can we separate the sick birds from the healthy ones? This will not be easy, but the time to take decisive action has long since passed. Now we are suffering the results of our inaction. The country is paying a huge price in human deaths and financial damage to the poultry industry for our initial complacency and denial of the disease. The government announced it would go ahead with mass culls if necessary in a number of provinces. Poultry farmers will receive Rp 10,000 (about US$1) for every chicken killed in the six provinces of Banten, Jakarta, West Java, Lampung, Central Java and South Sulawesi.

Indonesia Neglected, Ignored and Covered up Bird Threat

Alan Sipress wrote in the Washington Post: “Indonesian officials covered up and then neglected a spreading bird flu epidemic for two years until it began to sicken humans this summer, posing a grave threat to people well beyond the country's borders, according to Indonesian and international health experts. Unlike Southeast Asian countries that began to see human cases almost as soon as avian influenza was identified in their poultry, Indonesia had a generous head start to prevent an outbreak among people. But since July 2005, it has registered more human cases than any other country. [Source: Alan Sipress, Washington Post, October 20, 2005]

“Health experts say the Indonesian epidemic started in commercial poultry farms, spread among the tens of millions of free-range chickens raised in back yards across the country and then finally infected people. At each step, the Indonesian government failed to take measures that could have broken the chain, while discouraging research into the outbreak. "If the government had acted sooner to stamp it out, there would be no outbreak. They have wasted so much time," said Chairul A. Nidom, an Indonesian microbiologist who first identified the virus in this country's birds. "What terrifies me is that it just won't affect Indonesia." Indonesia, in particular, is a worry to U.N. and other international experts, partly because it has Southeast Asia's largest population of both people and poultry. The country also has an impoverished health care system that has deteriorated significantly since the late 1990s.

“Tri Satya Putri Naipospos, Indonesia's national director of animal health, told the Washington Post that officials had known chickens were dying from bird flu since the middle of 2003 but kept this secret until last year because of lobbying by the poultry industry. She also revealed that the government had not set aside any money this year to vaccinate poultry against the virus though officials had trumpeted this as the centerpiece of their strategy to contain the disease. Naipospos repeated her allegations in an interview with the influential local newspaper Kompas. A day after the article was published, the Agriculture Ministry fired her.

“U.N. officials complained that her dismissal had set back efforts to fight the virus, faulting the government for ousting what they call its most respected animal health expert at the height of a crisis. Naipospos alleged that bird flu has never been a priority in the Agriculture Ministry. Until recent months, she added, the ministry was even unwilling to tap its $3 million emergency account to pay for disease control measures. "They could not see the potential threat until there was an actual threat," she said in an interview with The Post last week. "I talked to the minister about it many times. He said a disease outbreak is not a national emergency, not a disaster."

“When the virus first appeared in Indonesia in the summer of 2003, government officials were divided over whether the sudden death of hens on a commercial farm on Java island was caused by bird flu or a less virulent ailment, Newcastle disease. Nidom, a professor at Indonesia's Airlangga University, was called in. Within two months, he said, his laboratory research had determined that the ailment was indeed bird flu and was genetically related to a strain found seven years earlier in southern China.

“But the owners of major poultry companies, who have personal ties to senior Agriculture Ministry officials, insisted that any containment efforts be done secretly, Naipospos recalled. These eight farming conglomerates, which handle 60 percent of the country's poultry, feared that publicity would harm sales of chicken and eggs. Naipospos said owners even lobbied Indonesia's president at the time, Megawati Sukarnoputri. "They said, 'It's better to do it with confidentiality. Do a hidden, silent operation,' " Naipospos recounted. "I said, 'It won't work if you do a silent operation. This is a disease that can't be hidden. It's too risky.' "

“In late January 2004, Nidom broke ranks and announced his findings to the Indonesian news media. A day later, the Agriculture Ministry confirmed the bird flu outbreak. But already the disease had spread across Java and on to Bali and Sumatra islands. "It was too late. The virus was everywhere," Nidom recalled. In the fall of 2004 with human cases mounting in Vietnam and Thailand, Nidom was growing increasingly nervous about the prospect of the epidemic spreading to Indonesians. He arranged an October conference at his university to examine bird flu and invited four of the world's premier influenza researchers, from the United States, Japan, Hong Kong and mainland China. Shortly before its scheduled start, a senior agriculture official contacted Yoes Prijatna Dachlan, the head of Nidom's institute, and demanded that foreign participants and all media be banned, Dachlan said. Dachlan, chairman of the university's Tropical Disease Center, said he rejected the conditions and canceled the gathering. Nidom said officials threatened to have police break it up if it proceeded.

“Through the summer of 2005, avian flu continued to spread, often unreported, and containment efforts remained unfunded. The disease reached two-thirds of the country's provinces. Then in July, a father and two daughters in an affluent Jakarta suburb died of respiratory disease. The father tested positive as the country's first bird flu victim. Health investigators concluded that his daughters likely died of the same cause. Responding to public anxiety, Apriyantono went on television to oversee the culling of several dozen pigs and ducks on a farm 10 miles away. But when the cameras left, the campaign stalled. Officials backed away from a vow to kill about 200 swine in the area. Thousands of chickens, identified by health experts as the leading suspects in the outbreak, escaped slaughter.

“As suspected human cases mounted last month, government officials said they would take extraordinary measures. Apriyantono said he was changing course and would order a mass slaughter of poultry in any area declared highly infected. But one month later, Apriyantono acknowledged that he has yet to define such an area. As a result, he has now directed that culling be limited to the specific property where an infection is detected and that neighboring birds be spared.

Indonesia’s Response to Bird Flu Slowed by Decentralization

Donald G. McNeil Jr. wrote in the New York Times, The biggest obstacle to beating the disease, international flu experts say, is the country’s decentralized government. Health officials in the capital, Jakarta, have been described as having powers extending no further than their office walls, while real power resides with the governors of the 33 provinces and the elected bupatis, or regents, of 480 districts. “It’s a real mishmash,” said Dr. Jeffrey C. Mariner, a veterinary medicine professor at Tufts University who is helping the United Nations Food and Agriculture Organization train new veterinary workers. “You have to sit down with each decision-making unit and get them all on board. It’s hard to mount a coordinated response.”[Source: Donald G. McNeil Jr., July 21, 2006]

“As a result, the country is not only slow to report human cases, it no longer even reports poultry outbreaks to the World Organization for Animal Health in Paris. But decentralization is not a principle that Indonesians are likely to abandon. Like the former Yugoslavia, the country is contentious mix of ethnic and religious rivalries, with 245 million people living on about 6,000 populated islands formerly held together by harsh central control from Jakarta.

“The regions prefer having more self-government, and “decentralized units get very wary when the center takes on emergency powers,” said Dr. David Nabarro, chief pandemic flu coordinator for the United Nations. Dr. Mariner, of Tufts, said shortages of trained veterinarians and slow compensation of farmers have also been major obstacles to crushing the outbreak. He and nine colleagues from Tufts and the F.A.O. are training local people to find sick birds and rapidly test them, cull flu-infected flocks and vaccinate others in a ring around the sick ones. But each trainee needs two to three months of class and fieldwork to become proficient, he said, and then many of them must, in turn, become trainers. “By February, we should have enough for 157 districts on three islands,” he said. Asked how long it would take to train enough disease-trackers to cover all 480 provinces, he said “I don’t have an answer — maybe two or three years?”

“Another problem, he said, is the sheer profusion of backyard chickens. The outbreak is not a big problem in commercial flocks, but “in the country, every household has poultry,” he said. “Retired people here keep chickens like other retirees take up woodworking. It’s household food, and income, and something to do. Asking Indonesians to give up their chickens is like asking Americans to give up their dogs and cats.”

“Until recently, he said, many farmers refused to let their birds be killed because they received only vouchers that could take six months to be paid. “Now we’re seeing the districts willing to advance money, so people are paid in a few days,” he said. “That’s begun real cooperation.” The government pays about $1 per bird — just a bit below market value, which veterinary experts suggest is the best way to get compliance but to forestall the temptation to breed just for the culling payments. Indonesians also raise fighting cocks, songbirds and trained doves worth much more than $1, he said, but they are paid nothing extra, giving the owners little incentive to cooperate.

“Making matters harder, some outbreaks begin in remote villages that may themselves be estranged from local government. For example, Kubu Sembilang, the village in the Karo District in northern Sumatra where the flu killed seven members of one family, was a Christian and animist village, while northern Sumatra is a center of highly observant Islam.Some wary villagers there blamed witchcraft for the deaths and refused to take the antiviral drug Tamiflu that the authorities had offered.

Human-to-Human Transmission of Bird Flu in Indonesia

Reporting from Jandi Meriah, Indonesia, Alan Sipress wrote in the Washington Post, Dowes Ginting, a wiry 32-year-old, had watched disease burn through his family over the previous two weeks, killing six and sickening two others, including himself. International health experts grew increasingly concerned when laboratory tests confirmed they were sickened by bird flu, the largest cluster of the disease ever recorded. [Source: Alan Sipress, Washington Post, August 30, 2006]

“Health investigators have concluded that the eight-person cluster in Sumatra began with Ginting's older sister, who fell ill in late April. They suspect she was infected with bird flu from live chickens sold in a market where she peddled oranges, limes and chili peppers, or from contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu.

“Several days after she became sick, the extended family gathered in the village of Kubu Sembilang for a feast of roast pig and chicken curry to celebrate the annual harvest festival. That night, many of the relatives slept in the same small room with the sister, who had developed a serious cough. By the time she died, a sister, a brother, two sons, a niece and a nephew had become ill. Flu specialists said the final victim, Dowes Ginting, in turn likely caught the virus from his infected son. Pigs in the village where the family lived also tested positive for bird flu.

“Health experts have concluded this was the first time the bird flu virus was passed from one person to another and then on to a third person. "None of us thought it was bird flu. We thought it was black magic," said Anestia Tarigan, the wife of the youngest Ginting brother, Jones, the only victim to survive. "Everyone in the family was getting sick and no one else was. Someone had put a spell on our family. Black magic is very common in our place."

Image Sources: Wikimedia Commons

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Global Viewpoint (Christian Science Monitor), Foreign Policy, Wikipedia, BBC, CNN, NBC News, Fox News and various books and other publications.

Last updated November 2012

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