When the first human case of bird flu was discovered on Indonesia's Sumatra island this fall, provincial officials raced to investigate. But local health officers were unavailable to help them because they were busy vaccinating thousands of young children against a polio outbreak.
Within the last six months, Indonesia has moved to the front lines of two global health crises, seeking to curb the spread of both bird flu and polio before they spill across the border.
"It has stretched resources and capacity to the limit," said Thomas Moran of the World Health Organization's office in Jakarta, the Indonesian capital.
Faced with the fastest growth of new polio cases on Earth, Indonesia launched a campaign this summer to immunize about 24 million young children. Then, just as officials were preparing in July for the first of three nationwide rounds of polio vaccination, Indonesia detected its first human case of bird flu and since then has registered more cases of the disease than any other country.
Since January 2004, more than 60 people have died of bird flu in Vietnam, Thailand, Cambodia and Indonesia. The virus has also spread through parts of Russia and to Eastern Europe.
Indonesia's two-front battle is straining the country's sorely underfunded health system, which had sharply eroded since the 1997 Asian financial crisis and was already unable to provide basic care across much of the far-flung archipelago.
"We've become a red zone for bird flu because it's endemic in livestock and infected humans here," said Ida Fitriati, deputy health director in Lampung province on Sumatra's eastern tip. "We're overwhelmed by this."
Health experts said the country needs funds to monitor possible cases, improve laboratories for testing and enhance medical facilities and supplies to include a larger stockpile of antiviral drugs.
Health officials said they worry that efforts to contain bird flu and polio could drain funding from other disease control programs that have begun to make progress in recent years.
Indonesia ranks third in the world for a high burden of tuberculosis, according to the WHO. Attempts to improve the detection of new cases regained momentum two years ago after stalling in the wake of the financial crisis and political upheaval after the ouster of longtime dictator Suharto in 1998.
Malaria remains endemic on many Indonesian islands, worsening in the late 1990s before foreign funding for control programs helped reverse the trend. Dengue and diarrhea-related diseases are epidemic.
"Anyone trying to manage public health, especially with an avian influenza risk, is faced with an extremely difficult and complex decision about how to get the maximum good out of limited resources," said Steven Bjorge, the WHO official in Indonesia responsible for managing bird flu, malaria and several other diseases.
Fitriati, who oversees communicable diseases for Lampung, a province of seven million people, said her team of six investigators responds to reported avian influenza cases one morning and polio the next, often venturing to isolated hamlets in the island's mountainous interior. Local health staff, she added, lack the expertise to verify outbreaks themselves, and communication is so spotty that days can pass before provincial experts are notified.
Indonesia had been free of polio for a decade when a traveler from the Middle East carried it to the main island of Java early this year. The crippling virus quickly reached 10 provinces and infected at least 288 people. After repeated immunization drives, the disease was contained where it first surfaced in western Java, health officials reported. But just a short ferry ride away across the Sunda Straits, Lampung province is now recording the most new infections with more than two-thirds of the 24 cases centered in its district of Tanggamus.
Bird flu also first appeared in Java, infecting at least five people in and around the capital Jakarta. When the virus spread, it likewise jumped to Lampung, sickening a man and his young nephew, again in Tanggamus.
Although there have been only a few confirmed cases of bird flu, international health experts predict the virus could develop into a new form easily passed among people, potentially devastating Indonesia and the world beyond.
But at the Pagelaran public clinic in Tanggamus, health officers admitted they had no program to monitor bird flu or prepare for a wider outbreak. Their preparations consist of a lone poster on the entrance of their low white building warning of the danger.
Bird flu remains a concern for agriculture officials, explained Edy Susanto, 41, a local paramedic.
Susanto, who directs the clinic's immunization program, shuffled into his tiny, tiled office, apologizing for the rat droppings that litter the floor. He opened the rusty clasps on the 15-year-old freezer in which he keeps the vaccines, lifted the cover and motioned to the contents. It was almost empty.
"For us, it's hard to answer the parents when they ask why the vaccines have run out," he said, smiling sheepishly and raising his eyebrows. "We can't answer it. It's not in our hands."
He complained that health workers are forced to scavenge for unused syringes in other medical offices or scrape together money to buy their own. The refrigerator with which they usually make ice for transporting vaccines into the field is broken. He said there is also a shortage of doctors. The physician who serves as the clinic's director is often absent during the busy morning hours because he runs his own, better-paying practice, he said.
"There's been less money and support since the financial crisis," Susanto concluded. "Money is our unending problem."
At the provincial health department, Fitriati agreed that the Indonesian health system has slipped. "The function of local health posts has deteriorated. And since they don't function well, some people don't use them any more," she said. "It's not only Lampung. This is the picture in other provinces of Indonesia."
I Nyoman Kandun, Indonesia's national director for communicable disease control, estimated that half the village health posts in the country no longer operate. And although the central government has enough money to buy vaccines for all Indonesian children, officials in the cash-strapped districts are unable to pick them up from the provincial health office, according to Kandun.
Now devoting much of his time to soliciting money from foreign governments and agencies, Kandun said he is finalizing his "shopping list" for bird flu programs that require financial support.
The emergency polio campaign to immunize the country's children has already cost the central government more than $12.5 million for the first two rounds, with foreign donors paying nearly an equal sum, he said. For the third round, scheduled for Nov. 30, Indonesia can muster only $2.7 million, leaving a shortfall of $10 million.
Kandun said last week his fundraising efforts have whittled that deficit to $1.4 million.
Special correspondent Yayu Yuniar contributed to this report.