The A List

Bush

The United States has only enough Tamiflu stockpiled to cover about 2% of its population.²⁴⁷¹ Who’s going to get it? Given their mobility and multiple daily contacts, should vaccines and antivirals go to schoolchildren, college students, and workers in hopes of slowing the spread of the virus? Or should we target those at highest risk of death, like pregnant women or those with serious medical conditions?²⁴⁷² The issue has been fiercely debated.²⁴⁷³

The World Health Organization recommends that priority be given to “essential” personnel. But who is essential?²⁴⁷⁴ “When we had our meeting in Maine,” said the state epidemiologist, “we literally almost had fistfights break out between the medical community and those on the front line, such as firefighters and the sheriffs. Because who really is considered critical?”²⁴⁷⁵

How about utility workers who maintain the electricity, water, and heat supply? Should we provide for the doctor but not the nurse? Health care workers may not go to work unless we cover their families as well, for fear of bringing work home with them in the form of a deadly infection. As one financial analyst’s report commented, “One can only imagine the furor and upset caused by giving potentially lifesaving medication to only one member of a family.”²⁴⁷⁶

Antiviral rationing raises not only ethical and legal questions, but distribution and security issues as well. Black markets, theft, and fraud are considered probable.²⁴⁷⁷ Riots are imagined at the distribution centers.²⁴⁷⁸ “Historically, whenever there’s a crisis,” a medical historian notes, “you’ll find stockpiling, hoarding, black marketeering and generally bad behavior. It’s been going on since Hippocrates.”²⁴⁷⁹ Earning public trust by communicating clear, transparent guidelines now should lessen the chances of panic later, and help with the most effective distribution of these scarce resources.²⁴⁸⁰ “So we’re going to have very little stuff and it’s already stuck away in stockpiles that people will protect with their lives,” UN bird flu czar David Nabarro points out. “And yet we’re going to have to find some way to ration these things so that they are given to the folk who need them the most.”²⁴⁸¹

Countries have formulated different priority lists. While Australia embraces funeral directors among those first in line,²⁴⁸² Canada places key “decision-makers” such as “elected officials” at the top the list.²⁴⁸³ Britain also includes prominent politicians and adds workers at the BBC over pregnant women, children, and sick patients.²⁴⁸⁴ The mayor of London has stockpiled more than £1 million worth of Tamiflu for his personal office and staff—nearly 100,000 tablets.²⁴⁸⁵ The United States also intends to prioritize “key government officials.”²⁴⁸⁶ “That’s a different mind-set than people are used to,” explained Nebraska’s chief medical officer, “and it’s going to be a little bit controversial.”²⁴⁸⁷

In 2004, the Vietnamese army was criticized for confiscating all the foreign donations of Tamiflu, even refusing to share with veterinarians working with infected flocks.²⁴⁸⁸ The military commandeering of national supplies may not, however, be exceptional.

The Pentagon has long claimed first dibs on the U.S. Tamiflu stockpile, insisting that “top priority for use of vaccine or antiviral medications is in forward deployed operational forces.”²⁴⁸⁹ Given President Bush’s suggested militarization of the pandemic response, imagine the conflict this could create between troops in the streets and critical first-responder medical personnel, fighting over the limited supply and further threatening the public health response.²⁴⁹⁰

At this point, there will be none left over for the general U.S. population.²⁴⁹¹ Do the math: Excluding military appropriation, there are nearly ten million health care workers and more than two million public safety workers such as police and firefighters, more than twice the mid-2006 stockpile.²⁴⁹² Even among countries with the highest per-capita stockpiles in the world, like Australia, only 10% of the national stockpile is expected to reach the general population.²⁴⁹³