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Who lives? Flu crisis may make us pick
Experts are divided on who gets the limited vaccine in case of a pandemic.
By LISA GREENE, Times Staff Writer
Published May 29, 2006

Imagine the worst: A deadly new strain of flu speeds across the globe, and as it approaches the United States, the reality is grim.

There isn't enough vaccine to prevent people from getting the virus. Not enough medicine, hospital beds or even ventilators to treat the sick.

Whom do you save?

What was once an abstract philosophical dilemma has become an urgent health policy question. The most immediate danger, Asia's killer bird flu, hasn't turned into a worldwide epidemic because it hasn't yet developed the ability to spread easily from person to person.

But public health officials must prepare for the threat of a disease that could spread with explosive speed. A global epidemic could kill nearly 2-million people and hospitalize nearly 10-million just in the United States. If a pandemic hits any time soon, scientists estimate that there may be only enough vaccine for about 10 percent of the population during the first year of the illness.

"In a situation like that, we will have to choose,'' said Dr. Greg Poland, director of the Mayo Clinic Vaccine Research Group and a member of the advisory committee on vaccines for the federal Centers for Disease Control and Prevention. "We're not used to that. We want everyone to get on the lifeboat.''

But in this instance, most people won't fit. And already, some of the nation's top ethicists and flu experts disagree about who should go first.

"I'm not a fan of the rules as they've been presented,'' said prominent bioethicist Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "I'm not sure they've explained why they're doing what they're doing.''

The priority vaccinations

The guidelines now listed in the federal pandemic flu plan call for health care workers and vaccine producers to be vaccinated first. Few argue with that; without them, there will be nobody to care for the sick.

"If you have doctors and nurses that don't come to work, you have nobody taking care of flu patients,'' said Dr. Bruce Gellin, director of the National Vaccine Program Office for the federal Department of Health and Human Services.

After that, the guidelines call for certain vulnerable groups to be vaccinated, such as pregnant women, and then people older than 65. Healthy children would come last, along with other healthy people ages 2 to 64.

It's more than an abstract policy for LeeAnne Cochran.

The 27-year-old Tampa resident was watching her three kids make their way to a park play gym one afternoon last week. She had a quick reaction to who should get the first vaccine: "The kids, I think.''

But her youngest child, 6-year-old Chelsey, was listening.

"No, you should get it first,'' she told her mother.

"But I don't want my kids to die,'' Cochran said.

"We don't want you to die!'' Chelsey said.

"But you have a whole life ahead of you.''

Is it that easy? Should Chelsey, Marissa and Devin get vaccine before, say, the elderly? Before their grandmother?

"I don't know,'' Cochran said. "It's a hard decision. Yeah. I'd have to say the kids. It's kind of selfish. But I have three kids.''

That question has been a key point of contention for scientists as well.

"There was substantial discussion of priority for children," Gellin said. "It's not as if they were ignored ... healthy children have been at low risk in prior pandemics.''

Does age matter?

It's the age question that has incited the most debate. In setting the guidelines, the federal group assumed that this pandemic would be similar to earlier ones in 1957 and 1968, and that the elderly would be among the most at-risk for severe illness and death.

But others question whether that's true. In the worst flu pandemic, the 1918 Spanish flu that killed more than 40-million people around the globe, the most deaths occurred among healthy young adults.

What would really save the most lives?

"Government policies have been, the people most likely to get sick, the people most likely to be in danger,'' Caplan said. "But you could argue that in real scarcity, it makes sense to take into account the best chance of surviving. Instead of the 85-year-old with pneumonia, you could say you're going to treat the 30-year-old.''

Caplan and colleagues recently put together a group, the Ethics of Vaccines Project, to discuss such questions.

Protecting children makes medical sense, Poland said. Some studies show that vaccinating children for regular flu decreases the spread of flu in the whole community. Children gather together in school, swapping homework, hugs and germs at a rapid rate.

"Children tend to be super-spreaders,'' Poland said. "So in reality, if I give it to a 2-year-old, I'm protecting the 2-year-old, the parents, the sibling, the grandparents. If I give it to an 80-year-old, I'm probably not going to protect the same number.''

That depends on the nature of the pandemic, Gellin said. Who gets vaccinated could change depending on who gets sickest.

"All this is shaped by how a pandemic looks,'' he said. "You need to have a process that would allow that kind of flexibility - to have some understanding of how it's playing out.''

Also, studies that show vaccinating children provides a protective effect on the community reflect situations when enough vaccine was available to cover all the children, Gellin said. In a pandemic, that might not happen.

Underlying the medical questions are more philosophical choices. Whom do you want to save? How do you decide which lives have the most value? Dr. Ezekiel J. Emanuel, chair of the Department of Clinical Bioethics at the National Institutes of Health, recently upped the debate with a provocative essay in Science magazine.

Federal guidelines suggest saving the most lives, rather than giving people a chance to live more years or their natural lifespan, wrote Emanuel and a co-author, expressing their personal opinions, not federal policy.

The two propose giving younger people higher priority based on that idea, then combining it with what they call an "investment refinement." They would give a higher priority to 13-year-olds than 2-year-olds, balancing the teenagers' "more developed interests, hopes and plans" that have not yet come to fruition.

The federal guidelines follow the same philosophical principles as vaccination for a normal flu season, Emanuel said.

"It's a completely different situation,'' he said. "The potential for mortality is high. The potential for social chaos is completely different ... the principles underlying pandemic flu (vaccination) need to be realigned too.''

Some say protect children

Others also argue for protecting children as a philosophical choice.

"The thing that would make the most sense to me, is not to prevent deaths, but to preserve as many quality years of life as possible,'' said Dr. John Sinnott, clinical director of the Signature Program in Allergy, Immunology and Infectious Disease at the University of South Florida College of Medicine.

How choices are made is an essential part of the equation, too, Caplan said. Although there have been some government-sponsored forums on the topic, Caplan said there hasn't been nearly enough public debate.

"The person who's more informed is more likely to comply,'' he said. "Part of the reason to have a discussion of the rules is so people will follow them. It's all the glue you've got.''

Other hard decisions would have to be made as flu spread. Who would get flu medicine, such as Tamiflu? Ventilators? Beds in hospitals' intensive care units?

Some of those decisions would be similar to those made with vaccine, doctors said. Health care workers, once again, would be high priorities for getting Tamiflu, an antiviral medicine that could reduce the severity of the flu. But other decisions might mean uncomfortable choices: giving beds to the extremely sick - but not the frailest of all.

"When you're really overwhelmed, you start to ration by triage,'' Caplan said. "Let go of the people so injured and sick that you don't know if you can help them. Like on a military field ... we do it a lot in war.''

And that, doctors say, is what a true pandemic would be.

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