As highly lethal avian influenza circulates among poultry in East Asia, posing the prospect of a worldwide human pandemic, most of the countries now affected have virtually no stocks of the medicine needed to treat the virus, according to officials in the region.
"When we have an epidemic, we cry for help," said Santoso Soeroso, a physician with a helpless smile, shuffling along the spartan hallway of the isolation wing in Jakarta's Sulianti Saroso Infectious Disease Hospital. "What else can we do?"
Soeroso said his facility, the premier hospital for treating diseases such as bird flu, has enough influenza medicine on hand to treat eight people. Each of the 33 other hospitals across Indonesia designated to receive bird flu patients have enough, on average, to treat two.
Since early last year, the virus has ravaged poultry flocks in nine Asian countries and killed at least 55 people in Vietnam, Thailand and Cambodia. The World Health Organization has warned that the virus could undergo a genetic change that would make it easier for humans to contract the disease, threatening a worldwide outbreak capable of killing tens of millions of people.
The one effective influenza drug, oseltamivir, marketed under the name Tamiflu, costs up to $40 per treatment, meaning bulk purchases are beyond the means of most developing countries, officials said.
"Even if we spend all of our WHO budget, we still can't buy enough for these countries," said Hitoshi Oshitani, an influenza expert with the World Health Organization in East Asia.
By contrast, wealthier nations, primarily in Europe, already have begun ordering sufficient quantities of the drug to treat up to half of their populations should the disease spread beyond Asia.
In the United States, the government has set aside 2.3 million treatments, each of which includes 10 capsules to be taken over five days. The Infectious Diseases Society of America, based in Alexandria, last month called that amount "totally inadequate," urging the Health and Human Services Department to spend about $1 billion to buy enough oseltamivir to treat about a third of the U.S. population.
The gap between rich and poor raises questions not only about whether Southeast Asian governments will be able to cure their people in case of an epidemic but also whether these countries have enough medicine available to contain an outbreak before it races beyond the region's borders.
Walter E. Stamm, president of the Infectious Diseases Society, said his group had not taken up the question of addressing Southeast Asia's shortfall. He said the best bet for stemming a global bird flu pandemic could be to stop it where it starts. "What goes on where this first strikes has a great impact on the rest of the world," he said.
Roche, the Switzerland-based manufacturer of oseltamivir, has quadrupled production in the last two years, according to company officials. But the production has not kept pace with surging demand from developed countries seeking to build stockpiles. The typical lead time of 12 months for filling orders has grown even longer, Roche officials said.
The current backlog of orders grew after scientists determined last year that bird flu had grown resistant to another common influenza drug, amantadine. Researchers blame this on the widespread use of amantadine by Chinese farmers to treat their poultry in violation of international livestock guidelines.
In Indonesia, bird flu has devastated poultry flocks in at least 18 provinces. Last month, health officials said a farm worker had become the first Indonesian to test positive for the virus.
Yet Sulianti Saroso hospital has little money to address threats on the horizon, Soeroso said. The beds of his rudimentary, three-story facility are already crowded with patients who have polio, diarrhea and, most of all, AIDS.
"We cannot allocate our budget for things that are not here yet because we have such a limited budget," he said. "Antivirals for HIV/AIDS are a much higher priority for us," he added.
But Soeroso acknowledged that he worried there was not enough oseltamivir even for preventive use by doctors and nurses who would care for flu patients. With the entire national supply already divvied up among hospitals, health officials said there was no more to go around.
In Vietnam, the country hardest hit by the disease, the government has fared a little better, stockpiling enough for at least 12,500 people through donations from Japan and the European Union, health officials said.
"If there will be a big epidemic, it would be rapidly used up," said Peter Horby, a WHO epidemiologist in Hanoi. "In the entire context of the health budget, it's not seen as a priority because it is so expensive."
Cambodia has obtained enough oseltamivir for no more than 800 people, health officials said. Much of this is earmarked for doctors and health experts investigating outbreaks.
The Thai government approved funding for the purchase of up to 100,000 treatments this year and signaled it would set aside even more money next year, according to Supamit Chunsuttiwat, a senior disease control expert at the Thai Health Ministry. But he added, "I don't think there is enough stockpile to control a widespread outbreak. We definitely need an international stockpile. There's no way out."
WHO officials, conceding that most Southeast Asian countries will never have enough of the drug to treat their people in case of an epidemic, are now pursuing the more focused goal of accumulating sufficient oseltamivir to snuff out any outbreak within its first few weeks.
Klaus Stohr, chief of WHO's influenza program, said about 120,000 treatments have been stockpiled in Asia, mostly at the regional headquarters in Manila and New Delhi, ready for rapid dispatch to the site of an emerging outbreak. According to scientific models, health officials may be able to extinguish an epidemic if 80 percent of an infected community is given the drug within the first three to four weeks and the number of cases does not exceed about 250, Stohr said.
"Beyond that, global spread cannot be prevented," he added.
Southeast Asian countries are also finalizing plans for one or more similar stockpiles by the end of this year and are looking for wealthier countries to contribute, officials in the region said.
But the hopes of many health officials rest on the proposed establishment of another international stockpile with more than 1 million treatments to be donated by Roche, Stohr said. This supply, also earmarked for use in the early days of an outbreak, would be in place later this year and then increased further early next year, he said.
David Reddy, who heads Roche's pandemic influenza task force, confirmed that discussions were underway with WHO over this proposal but said specifics have yet to be worked out.
Reddy said the company had already taken major steps to address the prospect of a pandemic, and had also offered reduced prices to governments seeking to amass a pandemic supply. He declined to discuss numbers.