Scott McPherson's Web Presence

Have you noticed the sudden increase in stories related to avian influenza?   The New York Times has published no fewer than three pieces on bird flu in the past three days, including what is happening down in Indonesia.  The Times has covered a medical ethics piece on ventilator triage that is welcome news to all of us who have been preaching that gospel for years. 

A report that I picked up in today's Orando Sentinel is also interesting.  There are precious few Spanish Flu survivors left in the world.  Like World War II veterans, they are dying by the thousands each and evey day.  Soon, there will be no 1918 pandemic survivors left. 

So it is important for us to hear their stories and listen to their grief -- now almost a hundred years old -- and hear their pain, their anguish, their daily horror.   I have mentioned that the United States (and the rest of the world, for that matter) experienced something akin to collective post-traumatic stress disorder from the 1918-1919 flu pandemic, and then experienced a lingering sense of doom with the appearance of Encephalitis Lethargica, a byproduct of the Spanish Flu. 

Read this article slowly.  Do not merely scan it with your eyes.  Take in each and every word of 96-year old Lora Miller.  Then, read the New York Times piece on ventilator rationing and imagine the psychosocial impact such triage will have on American souls.  Then go find someone who scoffs at the idea of preparedness, have them look you square in the eyes and tell you we don't need to prepare for a flu pandemic. Better yet, have them look into Lora Miller's eyes and tell her the same thing.  If they can.

Killer flu: It's a disaster in the making

Are we ready for another influenza pandemic? Experts say no -- but such a calamity is overdue.

Robert McDonald

Columbia News Service

March 25, 2008

It began with a cough. Then came the sniffles, and then a terrible fever.

No one thought it was anything more than the flu. And, indeed, that's all it was. But the year was 1918, and this flu was one of the greatest killers mankind had ever known.

"I heard my father coughing, and I had never heard him the least bit sick before that," says Lora Miller, a 96-year-old Los Angles resident whose father was killed by the epidemic. "He passed away pretty fast. It was a terrible shock. He was so young and strong. I never got over it."

Ninety years after the deadliest flu swept through the world, scientists and health officials say that it could happen again. Not only is the planet overdue for another flu pandemic, scientists say, the United States is due for an influenza virus as bad or worse than the flu that killed more than 500,000 Americans in 1918 and 1919. Experts believe that if a similar pandemic struck again, with modern transportation moving unwittingly infected people quickly around the world, millions of Americans could die.

The federal government has made great strides in preparing for a pandemic -- global virus surveillance has been beefed up, flu vaccine and anti-viral supplies expanded and detailed plans created to deal with a society in crisis. The problem is that no knows how much these efforts will actually help slow down a killer virus.

The pandemic of 1918 and 1919, known as the Spanish flu because it was erroneously thought to have come from Spain, was an unusual killer. Unlike conventional flu viruses, it killed the strong and the healthy, but passed over the old and the very young.

It killed an estimated 20 million to 50 million people worldwide. The disease killed more U.S. soldiers in WWI than were killed in combat.

"The clock is ticking, and we don't know if time's up," says Dr. Bruce Gellin, director of the National Vaccine Program Office at the Department of Health and Human Services. "A flu pandemic could happen at any time."

A flu pandemic is an outbreak of a new type of influenza A virus that spreads throughout the world. Influenza A is a variant of the deadliest type of flu.

Historically, there have been flu pandemics every 30 to 35 years, according to the federal Centers for Disease Control and Prevention. The Asian flu of 1957-58 killed 70,000 Americans, and the Hong Kong flu of 1968-69 killed 34,000.

The 1918 flu killed so many because it occurred at the end of WWI when millions of soldiers were crammed together in battlefields and camps worldwide before returning home. Now, with airplanes bringing people from one side of the world to the other in a matter of hours instead of weeks, officials worry that a pandemic could be far more deadly.

"With modern transportation, a flu pandemic could spread faster than any time in history," says Richard Thompson, spokesman for the World Health Organization. "The death toll would be between 4 to 40 million deaths."

The current flu vaccine would be ineffective against a new flu virus because it was created to fight a conventional flu. It would take months to develop a vaccine to combat a new killer-flu virus, experts said. A pandemic would be well under way before a vaccine would be ready.

Scientists are worried about avian influenza, which has decimated bird populations in southeast Asia in the past 10 years. Pandemic flu viruses are believed to originate from bird or swine viruses that mutate and transfer to humans. So far, the only way humans can catch bird flu is from birds. If the avian virus mutates so that it can spread by human-to-human contact, it could easily become a pandemic flu virus, experts say.

Miller says she dreads to see the effect a flu pandemic would have on society.

She thinks that people in 1918 could handle a disaster like the Spanish flu because they saw death far more often; infant mortality was still high, and the war had killed and maimed millions in Europe.

She is not sure that Americans could handle seeing hundreds of thousands or millions of people dying in just a few months.

"The world doesn't know fear and fright anymore," Miller says. "You won't want to leave your house. I pray every day that it doesn't come back. Every day."  (bold mine)

Copyright © 2008, Orlando Sentinel

http://www.orlandosentinel.com/features/lifestyle/orl-flupandemic08mar25,0,1859578.story

The New York Times

March 25, 2008

Guidelines for Epidemics: Who Gets a Ventilator?

By CORNELIA DEAN

It may sound unthinkable — the idea of denying life support to some people in a public health disaster like an epidemic. But a new report says doctors, health care workers and the public need to start thinking about it.

The report, by New York State health officials, grows out of the work of a group formed in 2006 to plan for the possibility of an influenza pandemic. The group focused on the breathing machines called ventilators.

Right now, there are enough ventilators to go around. But in an epidemic, there could be a severe shortage of machines and, more important, doctors and nurses to run them. At that point, the new report says, doctors and hospitals would have no choice but to start taking some people off the machines so that others could live.

Removal “is absolutely the crux of the problem,” said a lead author of the study, Dr. Tia Powell, who has spent much of her career studying medical ethics. “There are people who might survive who won’t get a chance at a ventilator if someone who is likely to die even with a vent is using it.”

Before an epidemic strikes, the report says, the public should confront the issue to ensure that any such triage decisions reflect community views, as well as ethical and clinical standards.

“It’s not really a technical solution,” said Dr. Powell, who directs the New York State Task Force on Life and the Law. “It’s values. And the people are the experts on that.”

The report, “Allocation of Ventilators in a Public Health Disaster,” appears in the March issue of Disaster Medicine and Public Health Preparedness, a quarterly journal of the American Medical Association.

The project began in response to outbreaks of bird or avian flu, H5N1 influenza, in Asia. Although just a few hundred people are known to have contracted the disease so far, most of them died of it. So a widespread outbreak would overwhelmingly strain the health care system, not just in machinery, but also in the doctors, nurses and other health care personnel needed to use it.

The report says triage, separating those who will receive treatment from those who will not, should largely depend on the prognosis for recovery, not on factors like underlying health or age.

“We are not interested in quality of life,” Dr. Powell said in an interview. “We are just interested in whether you are able to survive this particular crisis.”

Anyway, she said, age has not been “a particularly sensitive discriminator for survival” in H5N1 flu. Many of its victims have been young.

Though allocating scarce resources is a perennial topic among ethicists and health officials, the authors say their guidelines are the first of their kind in the nation and could be a template for rationing in other catastrophes.

“This kind of thinking, as scary or even horrifying as it may seem, is absolutely critical and is much better done now than on the fly in the middle of a pandemic,” said Dr. Art Kellerman of Emory University, an expert on emergency medicine.

Dr. Kellerman, who was not connected to the study, said that a crisis like a flu pandemic was a matter of when, not if, and that he was “frustrated with people who want to pretend that it won’t be an issue or simply pass the buck to the emergency care physician.”

The guidelines confront that issue explicitly, recommending the appointment of “triage officers” to make ventilator decisions based on information about the number of incoming patients and their conditions, but who will not be involved in caring for them. If doctors and nurses caring for the sick must also make these triage decisions, the report says, the resulting stress can be “corrosive.”

Under the guidelines, “the person who is providing your direct care is not going to be the person who decides whether you stay on the vent or go off,” Dr. Powell said. “You need to know they are advocating for you. They cannot be looking out the door at how many people are waiting for care.”

Dr. Powell noted that rationing — or as she said it is called, “providing alternative standards of care” — was repellent to many Americans. In the early days of kidney dialysis, when dialysis machines were scare, “we were so uncomfortable with that as a nation we essentially made dialysis available to everyone who needs it,” she said. Similarly, she said, much effort has gone into building a fair system for allocating organs for transplant.

But that work “does not really apply to this kind of crisis situation,” she said. “This is a genuine emergency. You are not going to have time to do a careful sorting out, by list.”

So the panel began work by identifying crucial factors for rationing, including these:

• Recognizing that patients deprived of mechanical breathing assistance should continue to receive care.
• Using scarce resources like mechanical ventilators to save the greatest number of lives while continuing to care for patients individually. “As the number of affected patients multiplies, accommodating these two goals will require making increasingly difficult decisions,” the report says.
• Planning, so as not to leave decisions in a pandemic “to exhausted frontline providers.” Public health agencies must accept this obligation, the report says, “despite the difficulties inherent in planning.”
• Applying any plan broadly and consistently.
• Publicizing guidelines, seeking public comments and incorporating suggested revisions.

For ventilators, the group established “exclusion criteria,” conditions that would classify people ineligible for ventilators. It includes recurrent cardiac arrest, metastatic cancer with a poor prognosis, severe burns, end-stage organ failure and neurological conditions with high expected mortality.

The report cites “much public comment” about whether it would be better to emphasize ventilator access for children rather than the elderly. And it lists kidney failure as a reason to withhold ventilator support, in part because patients needing dialysis already place increased demand on scarce nursing resources.

When a ventilator is removed from a patient who depends on it, the report says, health workers should follow their institutions’ existing guidelines for withdrawing life support and provide palliative care like sedation, so patients do not experience “air hunger.” In an epidemic, the report adds, “facilities should prepare for a significant increase in demand for palliative care.”

The guidelines are online at http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/.

Dr. Powell said she had discussed them at meetings of professional societies and at medical centers around the state and added that she hoped the new report would draw more public attention. One likely step, she said, would be to hold discussions by focus groups.

“The guidelines are intended to reflect the values of New Yorkers,” she said. “And if they don’t, we want advice on how to revise them.”

Dr. Kellerman of Emory said the report should not be allowed to gather dust. “It is important that those guidelines be out there and discussed and struggled with right now,” he said.

Many hospitals already struggle with chronically scarce resources like intensive care beds, he said, and in a pandemic the problem would be far, far worse.

Dr. Kellerman said he was not optimistic. In the first place, he said, the public tends to “tune out” on such disturbing questions. Or, he said, they may accept the guidelines only “until it’s their family member. Then people often feel very differently.”

http://www.nytimes.com/2008/03/25/health/25vent.html?ref=science

The triage story reminded me of an email I sent to then-governor Jeb Bush in the autumn of 2006.  Readers of this Blog know that Jeb is a longtime friend of mine, and I served him in several capacities during his two terms as governor of Florida.  I sent Jeb a pandemic vaccine story in '06 and asked him the rhetorical question:

"Do you vaccinate your future, or your past?"

No doubt, he was relieved he did not have to make that decision.  That is a question not to be brushed off or taken lightly.  The decisions on who to save and who not to save will be made all over our nation the next time a killer flu strikes.  Many (and I would hazard most) current pandemic plans do not account for what age group will be stricken and what age group should get priority treatment.  The last time I saw Florida's panflu plan, for example, it did not address the issue of triage by age, or vaccination by age.  It just called for treating the sick and vaccinating the most vulnerable; namely, the elderly and small children.

But believe it or not, there are much, much larger issues at stake in a pandemic.  Let's consider H5N1 as the pandemic strain.  We already know that in its current state, H5N1 kills the young in far greater percentages than the old.  If H5N1 or another influenza exhibited the same propensity for killing the young in large numbers, what fate shall befall the Republic?  In other words, do we vaccinate our future or our past?  I say we vaccinate our future first.  After the first responder community, we vaccinate young adults, then the younger, then the rest.

The Feds say that an influenza pandemic comparable to 1918's will cause more than 2.5 million estimated American deaths.  By their numbers, and factoring in 1918's statistics for killing young adults (roughly half), an influenza pandemic could kill as many as a million Americans between ages 18 and 40. Considering H5N1's track record, it could even begin to wipe out people under 18 in even greater numbers.  Now look at the cumulative lost wages and lost taxes from over one million productive young people who would no longer be with us. 

I think you can see where I am going. Today, there are already fewer Americans than we need to maintain the current federal budget.   The Comptroller of the Currency says that if left unabated, by 2042 the entire Federal budget will be consumed by entitlement spending.  That is because Boomers such as myself will be retiring in greater and greater numbers, with fewer young people behind us to pick up the financial slack.  If we triage in a pandemic based solely on who needs care, a severe pandemic could mean the total bankruptcy of the Union.  It could also mean that any surviving American youths would be working non-stop for the sole benefit of the entitlement class in this nation.  To prevent that last sentence from coming true, a pandemic would also very well mean a very liberal (and at that point, a very necessary) revamping of American immigration policy.  We will need people to replace the million-plus lost wage earners. 

It is estimated that the average life expectancy of the nation dropped anywhere from ten to twelve years in the aftermath of the 1918 pandemic.  That was a direct result of the loss of so many young people to the Spanish Flu as well as losses due to World War I.  Just keep in mind that more American soldiers died from the flu than died from combat in 1918 and 1919. 

I don't know if you agree with me, or not.  But these issues need to be discussed.  So we must listen to, and learn from, the voices from the past.  And then, we must make decisions as a nation that ensures we protect our future when we pass out antivirals, try to keep people alive with ventilators until the vaccine comes, and then jab people with vaccines.  We must think of our children and grandchildren. At any rate, whether you agree or disagree, the debate must come now, rather than on the fly, as said in the NYT piece: “This kind of thinking, as scary or even horrifying as it may seem, is absolutely critical and is much better done now than on the fly in the middle of a pandemic,” said Dr. Art Kellerman of Emory University, an expert on emergency medicine.

I'm not saying we need to make age the sole determinor of who lives and who dies.  But we need to decide on a balance, with an eye toward favoring the young whenever and wherever medically possible. 

I think Lora Miller would approve.