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JAKARTA - Indonesia averaged one human bird flu death every 2 1/2 days in May, putting it on pace to soon surpass Vietnam as the world's hardest-hit country. The latest death, announced Wednesday, was a 15-year-old boy whose preliminary tests were positive for the H5N1 virus. It comes as international health officials express growing frustration that they must fight Indonesia's stifling bureaucracy as well as the disease.
"We're tying to fix this leak in the roof, and there's a storm,'' World Health Organization spokesman Dick Thompson said. "The storm is: The virus is in animals almost everywhere and the lack of effective attention that's being addressed to the problem.''
Indonesia, a massive archipelago of 17,000 islands that is home to 220 million people, has a patchwork of local, regional and national bureaucracies that often send mixed messages. The ultimate impression, officials said, is often that no one is truly at the helm.
"I don't think anyone can understand it unless you come here and see it for yourself,'' said Steven Bjorge, a WHO epidemiologist in Jakarta. "The amount of decentralization here is breathtaking.'' He said health ministry officials will often meet with outside experts to formulate plans to fight bird flu, but the schemes are rarely realized. "Their power only extends to the walls of their office,'' Bjorge said, adding their advice must reach nearly 450 districts, where local officials decide whether to take action in a nation that spans roughly the width of the United States.
Indonesia has undergone a sometimes rocky transition to democracy since dictator Suharto was ousted in 1998. Many powers once held in Jakarta have been given to regional and community governments. But the process has been haphazard, and funding and policy decisions are often at the whim of inexperienced officials, mayors and village heads.
National government officials concede the problem. "The local government has the money, thus the power to decide what to prioritize,'' Wibisono said. "If some district sees bird flu as not important, then we have a problem.'' Indonesia has logged at least 36 human deaths in the past year - 25 since January - and is expected to soon eclipse Vietnam's 42 fatalities. The two countries make up the bulk of the world's 127 total deaths since the virus began ripping through Asian poultry stocks in late 2003.
Attention has been fixed for the past week on one village on Sumatra island where six of seven relatives died of bird flu. An eighth family member was buried before samples were collected, but WHO considers her part of the cluster. Experts have not been able to link contact between the relatives and infected birds, which has led them to suspect limited human-to-human transmission may have occurred. But no one outside the family of blood relatives - no spouses - has fallen ill and experts have said the virus has not mutated in any way.
Scientists believe human-to-human transmission has occurred in a handful of other smaller family clusters, all involving blood relatives. Experts theorize that may mean some people have a genetic susceptibility to the disease, but no evidence supports that. The disease remains hard for people to catch and most human cases have been traced to contact with infected birds. Experts fear the virus will mutate into a highly contagious form that passes easily among people, possibly sparking a pandemic with a death toll of millions.
Experts say the best way to battle bird flu in Indonesia is to tackle it in poultry. But that message is not getting through to all levels. Many local governments have refused to carry out mass poultry slaughters in infected areas and vaccinations have been sporadic at best. Such measures have helped other hard-hit countries like Vietnam and Thailand to curb outbreaks. Both have strong central governments that have taken a leading role in ensuring plans are carried out at the village level.
The U.N. Food and Agriculture Organization has been working with officials to improve poultry surveillance in Indonesia and quicken response times to outbreaks. But public awareness and bio-security standards remain low in the densely populated countryside, home to hundreds of millions of backyard chickens. "It's not quite so easy here, where you have to have the local authorities and provincial authorities and national all on board,'' said Jeff Mariner, an animal health expert from Tufts University in Massachusetts working with the FAO in Jakarta.
"We find outbreaks every week scattered throughout Java. It's a diffusely endemic disease. In most districts, you can find it at any time,'' he said. "It's a staggering undertaking in a decentralized country.''
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