increase the global supply of pandemic vaccines. The agency predicted that by 2010, the world might be able to produce enough to immunize 4.5 billion people per year. But as WHO acknowledged, this would still fall short of what would be required to protect everyone on Earth.
Even with these scientific advances, Vietnam has long suspected it would be at the back of the line if it waited for someone else to come up with a vaccine. Health officials in Hanoi—as well as those in Bangkok, Jakarta, and other Asian capitals—often told me they were sure industrialized countries would look after their own people first. And even if there were enough to go around, who could afford it? The drug industry “can’t provide vaccines to the world free of charge,” stressed Wayne Pisano, chief executive of French vaccine-maker Sanofi Pasteur.
Van had no illusions. “If another country develops this vaccine, the cost will be very, very high,” she explained. “Vietnam is still very poor and could not afford a vaccine with a high cost. We need to provide this essential vaccine through local production at an affordable cost.”
She had been down this road before. In 1997 she had been involved in developing a local vaccine against hepatitis B, which at the time infected at least 15 percent of all Vietnamese. The availability of this low-cost alternative to imported vaccines allowed Vietnam to immunize millions of children against the potentially fatal disease. Five years later, using genetic engineering, Van’s company produced a new generation of vaccines against both hepatitis A and B. She crowed at the time that Vietnam was one of only three countries able to make them. The potential savings were tremendous. At sixty cents per dose, the locally produced hepatitis A vaccine cost less than one-fifteenth the price of those on the international market.
In the 1970s, Van had studied biochemistry in the Soviet Union before returning to get her doctorate in Vietnam. She had done subsequent training in Japan, Russia, and twice at the CDC in Atlanta. For most of her three decades at the institute, hepatitis had been her specialty. But after bird flu erupted in 2003, one of her mentors, a senior Vietnamese virologist who had earlier developed the vaccine that helped eradicate polio in their country, suggested that Van tackle influenza. He told her to hurry. “It was difficult at the beginning, because we did not have the experience,” she recounted, smiling and laughing softly. “But it isn’t really new for me. Any vaccine has similar steps and similar techniques.”
With Japanese assistance, Van’s researchers obtained samples of the flu virus and then engineered a prototype vaccine strain by reverse genetics. The team began growing vaccine in monkey kidney cells, the same method the institute had used in making hepatitis A and polio vaccines. But before clinical trials could begin, WHO asked Vietnam in February 2005 to apply the brakes.
A special WHO delegation, which included officials from agency headquarters in Geneva and the U.S. Department of Health and Human Services in Washington, was sympathetic to Vietnam’s predicament. “No licensed H5N1 vaccine for human use is available from vaccine manufacturers and future availability to Vietnam is doubtful,” the mission wrote.
But the visiting officials objected that Van’s approach was too hazardous. Her team had flouted international guidelines by using monkey kidney cells, which were unapproved for making flu vaccines and might allow the virus to mutate into epidemic form. The use of cancer cells to accelerate the growth of the vaccine strain could introduce another fatal ingredient. Moreover, her lab lacked strong enough safety measures to ensure that the new, genetically engineered strain would not escape. The WHO mission also raised “serious ethical reservations” about the institute’s plan to ask its own scientists to volunteer as guinea pigs. The issue was coercion. “There are concerns that the volunteer ‘spirit’ may not be universally shared and some volunteers may feel uncomfortable and unable to state that for various reasons,” WHO wrote.
Members of the delegation later told me they had received official guarantees from Vietnam that it would abandon the program. But Van had been in those two days of meetings and came away with a different impression. “I believe in our procedures and all the laboratory testing,” she said. “I’m sure our vaccine is safe. So I’m not concerned.”
Clinical trials would go ahead in five months, Van told me. The first phase would involve about twenty volunteers. She would be one of the first. If production stayed on schedule, her company could deliver a half-million doses by the end of the year.
When senior health officials in Geneva and Washington read Van’s comments on the front page of the
Finally, in early 2008, clinical trials began. It was the same vaccine, developed in monkey kidney cells. And it was initially tested, as long planned, on researchers at the institute, ten in all. Then the vaccine was tested on what Vietnamese officials described as thirty student volunteers at the country’s Military Medical Institute, with larger trials planned. “Good results,” Van reported. Her institute planned to start mass production by late 2009. Each dose would cost 30,000 Vietnamese dong, or a mere $1.80.
If Van confronted global inequities with determination and forbearance, Indonesia’s Siti Fadilah Supari was far less patient. And on a crisp Geneva morning on a climactic day in 2007, Dr. Supari was already running late. Her scheduled flight on a British airliner had been grounded. But she had been lucky enough to find a later flight to Geneva, this one on Lufthansa. She had flown through the night and, once on the ground, had to wait again, this time for nearly everyone else on board to file out. There had only been room for her at the very back of the plane, even though she was a cabinet member from the world’s fourth-largest country.
Supari, Indonesia’s health minister, was scheduled to give her speech in half an hour, and she was still on the plane. “Dear God, help me!” she thought. As she descended a stairway from the jetliner and headed finally for the VIP lounge, she was welcomed by a delegation of fellow Indonesians, including her country’s ambassador at the UN mission in Geneva. They exchanged pleasantries. Then her colleagues handed the minister a draft of the address she would give at the meeting. When Supari read what they had written, she felt wounded. “I was thoroughly shocked,” she recalled. “They had no idea of the core of the problem.”
By that time, in November 2007, Indonesia had long since become the epicenter of the bird flu outbreak. More people were dying of the virus there than anywhere else on Earth, and many flu specialists feared Indonesia would ultimately be the source of a pandemic. Yet for more than a year, Indonesia had refused to provide virus samples from the overwhelming majority of its cases to WHO-affiliated labs, leaving the world blind to the evolution of the virus. The danger was grave. If the pathogen was mutating into a pandemic strain, no one might know. This could preclude the world from launching an effort at rapid containment before the virus spread or making emergency preparations in case it did. Without current samples, scientists would be hampered in developing vaccines against the pandemic strain, monitoring the effectiveness of antiviral drugs, or producing updated diagnostic tests to identify the virus elsewhere.
WHO had convened a special meeting of representatives from more than a hundred countries to address complaints raised specifically by Supari over how the developing world shared virus samples and what health benefits it received in return. The speech penned by her colleagues explained that Indonesia’s objective was to safeguard the lives of those in poor countries by winning them better access to pandemic vaccines. But Supari’s fight had gone beyond that by now. It was no longer a technical dispute over the distribution of vaccines. It was a wider struggle over fundamental inequities in the global health system embodied by WHO. In short, she told her colleagues, she was taking aim at the “oppression between nations.” Supari chided them, informing them she had her own draft and that was the one she would deliver.
Supari stopped at her hotel only long enough to change clothes. Then she dashed for the Palais des Nations. Initially erected as the headquarters of the League of Nations in 1919, the monumental building now served as the European seat of the United Nations. The meeting itself was running late, and Supari was allowed to proceed with her speech.
For ten minutes she skewered the long-standing system under which countries like Indonesia freely provided virus specimens to WHO labs and they in turn supplied them to commercial drug makers. The countries of origin were rarely told what purpose their samples were put to. “We do not really know whether they are used for research and publication or they are shared with vaccine manufacturers for vaccine production. Or maybe they are utilized for the development of biological weapons,” Supari told the audience. Her hyperbole was startling for those accustomed to the diplomatic palaver of Geneva. She pressed on, lambasting the arrangement in which developing
