Terra Incognito
#219
Yesterday’s blog concerned the military’s recently disclosed pandemic preparedness guidelines, and some of the uproar it has inspired in the flu community. Everyone, it seems, expects the government to be able to rescue us in a pandemic. They expect the experts to get it right, and to have all of the answers.
Sometimes, though, there are no clear-cut answers to be found.
This isn’t to say there aren’t better and worse choices out there. Undoubtedly, there are. The difficulty is in divining the difference.
If the H5N1 virus mutates into a severe pandemic strain, we will be entering terra incognito: uncharted territory. The world has changed greatly since the last great pandemic, and our reliance upon our infrastructure is greater. Solutions will be harder to find.
Imagine if you had to decide what to do about any of these issues:
Vaccines: Right now, the United States has 3 million doses of a pre-pandemic vaccine. It is unknown if it will be effective, and it has only been marginally tested for safety. There are plans to purchase another 3 million doses of a newer vaccine, one based on the Indonesian strain of the virus, but once again we don’t know how effective that will be either. A real vaccine will have to wait until months after the pandemic starts.
How do you decide who gets these 6 million doses? That’s only enough to inoculate 1 person in 50. Work is being done on developing an adjuvant, an ingredient that might stretch out the supply, but it is far from certain that it will succeed.
So, do we reserve this vaccine for the military or National Guard? Or do we give it to doctors, nurses, and medics on the front line, folks who will be exposed to the virus every day? How about the elderly, who traditionally suffer from the effects of seasonal influenza the greatest? Or to children, who thus far have been the avian flu’s biggest target? How about utility workers, the people who keep the water and power flowing? Without them, life, and our ability to cope with a pandemic, gets much tougher.
And of course, the possibility exists that the vaccine may have side effects, or will simply not afford any protection at all. You can bet this will be a hot button subject, and no one knows the right answer.
Anti-virals: Tamiflu is one of the few medicines we have in our arsenal to fight avian influenza. It can be given to someone who already has the infection, or to people to protect them from catching it. No one is sure how effective it will be in either role. There are fears the H5N1 virus may become resistant to the drug early on.
Governments around the world are stockpiling it, and there is a limited production capability. The United States hopes to have 81 million doses by December of 2008. Right now, they have less than 1/4th of that.
The `standard’ dose of tamiflu, the one given for seasonal influenza, is 10 pills over 5 days. But early reports from overseas indicate that 10 pills won’t cut it. Twenty, perhaps even forty pills over 10 days may be required. And in prophylactic dosing, each person would need 1 pill a day for the duration of the pandemic.
So, how do you allocate this scarce medicine? Who gets it, and in what quantity?
Do you provide it to healthcare workers to try to keep them healthy and working? If so, few infected patients will receive the drug. If you reserve the drug for only those already stricken, you will still have to decide who among them are the most deserving. Will it be first come, first served? Or should we reserve the drug for special cases? Do you say yes to children, and no to adults? What criteria do you use for dispensing this drug?
You can’t just elect to give antivirals to the sickest patients, either. To be effective, they must be administered as early in the course of the illness as possible. Giving antivirals to the sickest patients may well be the equivalent of throwing them away.
And how much to you allocate to each patient? Do you cut them off after they’ve received their 10 pills dose, and tell them they are now on their own? Or do you continue to give the drug until they either respond, or die?
Bitter choices. Any way you slice it, a large portion of society isn’t going to be happy about the decision.
Hospital Beds/Vents: The decision has been made that only the `sickest of the sick’ will be treated in hospitals, everyone else will be expected to ride out the illness at home. As a practical matter, we couldn’t even begin to treat everyone who caught the virus in a hospital. We’ve approximately 1 million hospital beds, and most of those are already occupied. A pandemic would likely sicken tens of millions at the same time.
But to date, we’ve not seen any `light’ cases of the infection. Hopefully that will change, but to date everyone who has contracted the virus has required hospitalization, and most have required ventilators to keep them alive. If everyone is more or less equally sick and at the same risk of dying, how do you decide who gets hospital treatment, and who gets sent away?
Do you decide based on the patient’s age? There will be a great desire to save the children, but even then, you’d have to decide which children to save. What criteria do you use? Their age? Their education? What makes one child's life more valuable than the next?
Do you evict patients already on ventilators or in hospital rooms in order to make room for flu victims? What if, even with medical care, their odds of survival aren’t that good? Should a flu victim get preference over someone with another, more survivable illness? Or should flu patients be excluded from hospitals altogether, in an attempt to preserve the medical system for those that are more likely to be helped?
These are horrific decisions that we are completely unaccustomed to having to make in our society. And yet, during a pandemic, someone will have to make them.
There are more, as these are but a few examples.
And in each case, there is no `right’ answer. There is no compromise that will make everyone happy. In fact, the choices available are so unpalatable; most of us refuse to even consider the questions.
While I am quick to be critical of our pandemic planning, I certainly don’t envy those that must decide these matters, and even less those who will be called upon to implement them.
The real burden will fall upon doctors, nurses, and medics who will actually have to tell families that nothing can be done. They will have to turn parents with a sick child away, and tell them to go home. Having an edict from on high won’t make that job any easier. But they will need that guidance; they will need someone in authority to make those decisions.
The public, used to having the resources of modern medicine available to them, will likely not understand. They will blame the messenger. And it could turn ugly in a hurry.
If a pandemic comes, we will need leaders with the political courage to stand up and level with the American people. They will need to spell out, in absolutely clear terms, what they can, and can’t do for their citizens.
There are no maps to the future, and no road signs along the way. We will all be entering uncharted territory, and we will all have to accept that there are no easy answers and no good solutions. There are just compromises.
No, it isn’t even remotely fair.
But it is what it is.
