Towards effective emerging infectious disease surveillance: Cambodia, Indonesia, and NAMRU-2

Emerging infectious diseases (EIDs) pose international security threats because of their potential to inflict harm upon humans, crops, livestock, health infrastructure, and economies. The following questions stimulated the research described in this report: What infrastructure is necessary to enable EID surveillance in developing countries? What are the cultural, political, and economic challenges that are faced? Are there generalizations that may be made to inform engagement with developing countries and support EID surveillance infrastructure? Using the U.S. Naval Area Medical Research Unit No. 2 (NAMRU-2) as a common denominator, this report compares barriers to EID surveillance in Cambodia and in Indonesia and presents key factors—uncovered through extensive interviews—that constrain disease surveillance systems. In Cambodia, the key factors that emerged were low salaries, poor staff and human resources management and the effect of patronage networks, a culture of donor dependence, contrasting priorities between the government and international donors, and the lack of compensation for animal culling. Cambodian authorities have resisted a compensation scheme thus far, with speculation suggesting that the reason for this is the government’s concern that the possibility for corruption among poultry-holders is too great a risk. The Cambodian military has also played a part. The government ceased a merit-based salary supplement scheme for civil servants (including laboratory employees funded by the Global Fund to Fight Aids, Tuberculosis and Malaria) after the military is alleged to have demanded similar pay incentives which donors had no interest in funding. In Indonesia, the key issues emerging as barriers to effective surveillance include poor host-donor relationships, including differing host-donor priorities and a misunderstanding of NAMRU-2 by Indonesian Authorities; low salaries; a decline in the qualifications of personnel in the Ministry of Health; poor compensation for culling; and difficulties incentivizing local-level reporting in an era of decentralization. Conflict between external and host actors was given the greatest emphasis, with “viral sovereignty” the primary problem. The Indonesian government perceived unfair treatment when it was asked to pay millions of dollars for a vaccine developed from a sample it originally provided for diagnostic purposes to the U.S. government through NAMRU-2. A poor host-donor relationship is a major barrier in Indonesia, which exhibits greater political and financial autonomy than Cambodia and other less-developed countries. Ultimately these differences are symptomatic of Cambodia’s and Indonesia’s different levels of development and their roles within the international community. This context demonstrates the primary difference in existing barriers to surveillance between the countries. Thus, it is reasonable to hypothesize that other developing countries face similar barriers along a continuum from one extreme (Cambodia, where a genocide resulted in the death of a quarter of the population) to another (Indonesia, where state-of-the-art-labs can be run by Indonesians educated in countries such as France and Australia with some donor funds). Scientists are fully capable of fixing technical problems in surveillance systems, but non-technical barriers have been more difficult to confront. Not surprisingly, the primary challenges impeding surveillance are observed on the human resources side of the equation. When it comes to viral sovereignty, technology transfer has been proposed as a possible solution to enable resource-constrained countries to produce their own vaccines. Yet this is easier said than done; international development has tried for more than six decades to raise living standards with limited success. What is certain is that Indonesia’s human resources are already capable of producing some vaccines given sufficient technology, while Cambodia will require a decade or more to develop such a capability. It is clear that in Cambodia, technology transfer is necessary but not sufficient. Many of the key factors emerging from interviews with in-country practitioners are the direct result of the existing level of development and, as such, are perhaps beyond the scope of health and scientific agencies at this point. Nevertheless, greater understanding is a critical first step in mitigating negative outcomes.