Emerging Infectious Disease Surveillance in Southeast Asia : Cambodia, Indonesia, and the Naval Area Medical Research Unit 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 paper: What infrastructure is necessary to enable EID surveillance in developing countries? What cultural, political, and economic challenges stand in the way of setting up such infrastructure? And are there general principles that might guide engagement with developing countries and support EID surveillance infrastructure? Using the U.S. Naval Area Medical Research Unit No. 2 as common denominator, this paper compares barriers to EID surveillance in Cambodia and 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, the effect of patronage networks, a culture of donor dependence, contrasting priorities between the government and international donors, and a lack of compensation for animal culling. The Cambodian military has also played a part. The government ceased a merit-based salary supplement scheme for civil servants after the military is alleged to have demanded similar pay incentives that 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 animal culling; and difficulties incentivizing local-level reporting in an era of decentralization. As the interviews with in-country practitioners revealed, low levels of development in general are the main impediments to building EID surveillance infrastructure and are perhaps beyond the scope of health and scientific agencies at this point. Nevertheless, promoting greater understanding of these issues is a critical first step in mitigating negative outcomes