U.S. Ponders Rationing Flu Drugs There is some debate over whether the anti-flu drug Tamiflu could lessen or prevent the impact of bird flu. Only one company makes Tamiflu and the orders are flying in from around the world. As a result, the U.S. government is considering rationing or the limited numbers of Tamiflu courses in the U.S.
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U.S. Ponders Rationing Flu Drugs

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U.S. Ponders Rationing Flu Drugs

U.S. Ponders Rationing Flu Drugs

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This is TALK OF THE NATION. I'm Neal Conan in Washington.

Health officials around the world believe that we could--emphasize could--see a pandemic of avian influenza. Just in the past week or so, bird flu has been discovered in animals in Turkey, Romania and Greece. So far, it looks as if it has not spread to people in Europe. In Asia, where it originated, transmission from birds to humans has been rare. When it does happen, though, the disease is deadly, and the fear is that it will mutate into a strain that can pass easily from person to person. If that happens, everyone will be at risk because no one will have immunity.

Right now there's no vaccine for avian flu, and it would take six to eight months to develop one. There are drugs that can treat bird flu. The most effective is called Tamiflu, but supplies of that drug are very limited. Just one company makes it, and governments are grappling with the question about what to do. If there is a pandemic, who gets the drugs? Who doesn't? And who decides? Mike Leavitt, the secretary of Health and Human Services, has already said he's considering how to ration the drug. Right now it's believed that there's only enough for about 1 percent of the US population.

Later in the program, 1599, the critical year in the life of William Shakespeare, but first the ethics of medical rationing. If you have questions about how these decisions should be made about the policies and priorities, our number here in Washington is (800) 989-8255; that's (800) 989-TALK. The e-mail address is totn@npr.org.

And we begin with NPR science correspondent Richard Knox, who broke the Tamiflu rationing story last week.

And, Richard, nice story. Good to have you on TALK OF THE NATION.

RICHARD KNOX reporting:

Thank you, Neal.

CONAN: Before we get started, though, let's make one thing clear. When we talk about a shortage of Tamiflu and avian influenza, we're talking about avian flu. There's no vaccine for that. There is, though, going to be a regular flu vaccine for regular flu.

KNOX: That's right. Yeah, there should be enough for people who want it this year, they think. Although just today we heard that Chiron, which makes a good chunk of it, is not going to come up with as many doses as they said. Still, there should be as many doses around as was used last year.

CONAN: So when you see a flu vaccine available, that's good for the flu that sort of evolves every year, the one we're familiar with every year. But this avian flu--this is a completely different animal.

KNOX: Yeah. It is. I guess it's somewhat reassuring. We can take a little comfort in the fact that the H5N1 virus which causes the bird flu that's been well-established now in Southeast Asia and seems to be spreading to the West--that that virus has been around Southeast Asia for at least eight years. And, you know, there have been millions of people exposed to it and so far only about 117, I think, known human cases of H5N1 and 60 deaths. The World Health Organization stressed this week that this is still a bird disease that only very occasionally crosses over to humans, and there's only one well-documented case of human-to-human transmission in Thailand.

But, you know, viruses play the odds and the odds are that at some point, either H5N1 or some other bird flu virus will acquire the genetic changes that are necessary to touch off the next pandemic.

CONAN: And...

KNOX: So it makes sense to think ahead and, you know, try to plan ahead.

CONAN: And that--the scary statistics is 117 cases and 60 deaths. That's ferocious.

KNOX: Yeah. It's a bad disease. At least it's a bad disease right now when it goes from bird to human. It's not--you know, nobody knows whether--once it acquires the--if it acquires the ability to transmit from human to human to human it will be as virulent a disease. There's just no way of knowing that.

CONAN: Now last Friday, Health and Human Services Secretary Mike Leavitt told you that the government is working on a plan to ration the drug and, again, it's a drug, not a vaccine, Tamiflu. Why would they need to do that?

KNOX: Well, he made plain that they have to do it, that they're working on a plan because there's a scarce supply of Tamiflu, and so they've got to figure out who gets it, and that by definition is rationing. And I think it's important to understand that the US rations health care all the time, but not explicitly. And he said, `It's really not a happy prospect,' to use his words, to tell people they can't get a potentially life-saving drug, and it's going to be especially painful because other countries are going to have more Tamiflu than we will because we were slow--the United States was slow in ordering up a stockpile.

But I think he understands that after--once a pandemic starts is really the worst time to explain to people why they can't get a treatment, so they're--the plan that they're going to be releasing soon will feature rationing.

CONAN: So that's coming out in two weeks we're told?

KNOX: He said before the end of this month. It could be this week, it could be next week, I guess. I understand it will be only sort of a general guideline for state and local departments, sort of a grocery list on what they ought to be doing to prepare for pandemic flu, and more explicit decisions about how to deploy resources like Tamiflu will come later after they get more details on how a pandemic scenario might unfold.

CONAN: Now I understand that there are other anti-flu drugs that also might work.

KNOX: Yeah. Tamiflu is one of two approved drugs for flu. They're both called neurominadase inhibitors and the other one is called Relenza, and they work by blocking an enzyme called neurominadase that the virus needs in order to be released from infected cells and into the blood so they can infect more cells and make more viruses. Tamiflu is the more widely marketed drug. Relenza has not been pushed very much. In fact, the originator, which is an Australian company, is suing GlaxoSmithKline which has the license to market it because apparently the originator thinks that Glaxo hasn't pushed it aggressively enough.

Both of these drugs work only if they're given very early in the course of flu--that is, within a day or two after the symptoms start. They shorten the course of flu by a day or so and they reverse--excuse me, reduce severity of symptoms by about 40 percent.

CONAN: And...

KNOX: Elderly nursing home patients who got Tamiflu when symptoms began were less likely to be hospitalized or to die. And there's some evidence that both of these drugs are--or at least--sorry, that Tamiflu might have saved some patients in Thailand and Vietnam who got the H5N1 disease.

CONAN: And reducing the symptoms, this is important. I mean, it sounds marginal, but if people are coughing less, they're obviously going to be transmitting this flu less.

KNOX: Yeah. They--one of the reasons for using Tamiflu is to reduce the transmission. But I think it's important to keep in mind that there are two different uses. One of them is for treating people who have the flu, and if H5N1 turns out to be as severe in humans as a pandemic disease as it seems to have been so far as an occasional disease, then it's important that we have something to treat it with because, you know, we want to reduce the death rate. It also could be used as a prophylactic drug to prevent people who've been exposed to those with the flu from getting the disease, and we don't have nearly enough to think about using it that way in the United States.

CONAN: About 1 percent--enough for 1 percent of the population at this point. There's one company that makes this. It's still under patent to the company Roche.

KNOX: That's right. And Roche has said just this week that they will consider licensing it to more companies to get production up faster. The US would like to get a stockpile of about 20 million courses of treatment; that's enough to treat 20 million people. But that's going to be some time in coming. And meanwhile, we've got 4.3 million courses or enough to treat that many people. And there's something like 10 million first-responders in the country. These are health-care workers and paramedics and police and firefighters. If you include other essential personnel like air traffic controllers and the people who run the power plants and so on, the number goes to 20 million or so. And so there really isn't nearly enough Tamiflu to treat people who would be expected to get sick in a pandemic.

By the way, not all of them would be expected to get sick. It's about--Leavitt told me about 30 percent as a rule of thumb. And so that means that the amount we have would--you know, would treat health-care workers probably, but not all first-responders.

CONAN: Richard Knox, thanks very much.

KNOX: You're welcome.

CONAN: Richard Knox is an NPR science correspondent, and he joined us from his office in Boston.

Our next guest was part of the working group of experts who made recommendations to the Department of Health and Human Services for rationing anti-viral drugs such as Tamiflu. Dr. Andrew Pavia is the chair of the Pandemic Influenza Working Group of the Infectious Disease Society of America. He is with now by phone from his office in Salt Lake City in Utah.

Good to have you on TALK OF THE NATION.

Dr. ANDREW PAVIA (Chair, Pandemic Influenza Working Group; Infectious Disease Society of America): Good to be with you.

CONAN: So what were your panel's recommendations regarding Tamiflu?

Dr. PAVIA: Well, the recommendations are relatively complex because it's sort of a complex problem. We were faced with a couple of questions. One is: Given that we're going to have a limited supply, how do we use it most effectively? Who should get the first doses? The second important question was: How much should we really have on hand to make a real dent in the kind of impact it would have?

CONAN: Unlike flu vaccine, I understand Tamiflu has a pretty long shelf life?

Dr. PAVIA: Well, at this point, the shelf life has been tested out to about five years with absolutely no deterioration. It's likely that it's a good deal longer than that, but they just haven't tested it long enough. Somebody said it's about as stable as gravel. That might be an exaggeration.

CONAN: So if you can stockpile supplies, it'll stay there for a while. It's something that is doable. But are people looking at different strategies, different ideas of how to use the very limited amount that's available if there is a pandemic?

Dr. PAVIA: Well, we started out with the assumption that we were going to need more, because the amount we have right now is really almost meaningless in terms of the amount of treatment that it could do. So we really looked at what sort of numbers we'd have to come up with to start making reasonable use, even then having to prioritize it. So we tried to--we went through a fairly complicated process where we looked at: Who's most likely to die in a flu pandemic? What do we know about the efficacy of drugs like Tamiflu and Relenza? What are the likelihoods of the number of people who are going to be infected and of getting the drug to them in the probably 48- to 72-hour window we have to make a difference. And then we had to really go backwards and decide: What are we trying to do with the drugs? Is it more important to keep society running smoothly or is it more important to prevent the greatest number of deaths and hospitalizations? And we decided that the latter--that is, preventing death was our number one goal and keeping society running was important, but that came second.

CONAN: These are pretty profound questions.

Dr. PAVIA: They are. It was a very long and difficult process.

CONAN: A lot of--these are very difficult decisions to make.

Dr. PAVIA: Absolutely. If you stop for very long and start thinking about what the impact of the decision you're making, which ultimately is whether your neighbor or your grandmother or yourself come fairly high on the list, you can get kind of paralyzed. And so you fall back on just good public-health practice. We had a wide variety of people on the working group. We had ethicists to advise us. We had people with public health backgrounds, pediatricians, infection control people, people with expertise in using the drugs and tried to have as balanced a process as we could.

CONAN: We're going to have to take a short break now. Please stay with us. When we come back, we're going to continue talking about how to ration critical medicine in the possibility of a pandemic. If you'd like to join the conversation: (800) 989-8255; (800) 989-TALK. E-mail: totn@npr.org.

I'm Neal Conan. It's TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.

We're discussing what might happen if a flu pandemic broke out in the United States and the government had to decide who gets treated and who doesn't. Our guest is Dr. Andrew Pavia, chair of the Pandemic Influenza Working Group of the Infectious Disease Society of America. Of course, you're invited to join us. Who do you think should make such decisions and how, on what basis? (800) 989-8255; (800) 989-TALK. E-mail is totn@npr.org.

And, Dr. Pavia, I guess if the government's going to decide who gets the drug, that would suggest that the government had control of the supplies of the drug that are available.

Dr. PAVIA: Well, the current drug that's out there represents--there are two pots. There's a small amount that's in the stockpile that's currently a little over four million treatment courses, and then there's what's in the commercial supply chain. At this point, we don't think that either of those are going to make a tremendous dent. We think that what really has to happen is you have to develop a large stockpile, probably the government is going to have to buy that and stockpile that. And then, yes, government would control the drug.

CONAN: That in itself would be controversial.

Dr. PAVIA: Well, I think that if you don't go that route, then you have tremendous problems with equity. You have those who can afford it, those who live near pharmacies having access, and what we'd really like to see is a rational approach where people most likely to benefit, people most likely to die if they don't get the drug are the ones who have first access. And I think the only way to do that in a real mass disaster situation, which is what a pandemic is, is to have some sort of rational process that people have had input into and believe into, but that's executed by the state and local--the state and federal government.

CONAN: And when you're talking about the mass disaster scenario, I mean, we're talking 1918 Spanish flu.

Dr. PAVIA: Well, yes. But you have to remember that although we talk about avian flu as being very concerning for causing the next pandemic and it looks as if it has the potential for being 1918-like, even an ordinary flu pandemic, which will happen regardless of what happens with avian flu, is a very big event, and there will be a tremendous impact on our hospitals, there'll be a tremendous impact in terms of deaths and we need to be prepared for any sort of pandemic, anything from a mild one to a catastrophic one.

CONAN: So maybe more on the scale of--What?--1968 and the Hong Kong flu.

Dr. PAVIA: Exactly.

CONAN: OK. Ethics are central to this discussion about rationing Tamiflu and other antiviral drugs, and let's turn now to someone who's wrestled with some of the moral and ethical complexities of drug rationing. Kathy Kinlaw is director of the Center for Ethics at Emory University in Atlanta, Georgia. She's also a member of the Centers for Disease Control Ethics Subcommittee, and she's with us by phone from her office.

Very good of you to be with us today.

Ms. KATHY KINLAW (Director, Center for Ethics, Emory University): Glad to be here.

CONAN: Well, we've presented some of the outlines of this. What are the ethical problems that you've been considering?

Ms. KINLAW: Well, Andrew's done a great job of already mentioning some of these. I mean, at the essence of this issue is the fact that we are moving out of the territory of what can--found simply from scientific information and into the realm of values, and those are values that I think we have to explore carefully and that we need to be able to articulate how this decision-making process is moving forward, who's a part of the process and to do that in such a way that we build confidence in the public and among health-care professionals, and we're justifying clearly on an ethical basis how these tough decisions have to be made.

CONAN: And there would be a period--I mean, obviously you can't begin to develop a vaccine until the actual virus erupts, and it would take six to eight months from the eruption of the virus and the beginning of the pandemic. That would be a terrible time and confidence in government would be shaken.

Ms. KINLAW: You know, I think that's a very good point. This is an era in which I think a lot of people are concerned about trust in our government and in our health-care system. And so in that context in particular, our being able to think carefully about this ahead of time as much as possible and to have a way to respond during that time period, as you say, between recognition of new viral strains and the ability to intervene will be important.

In fact, you know, the use of--whether it's vaccination for influenza or whether it's use of antivirals for a number of flu illnesses, there is a broader context that I think will be powerful for us to be able to talk about ethical intervention. And such things as what can be done to increase the vaccine production and the production of antivirals so that we ha--we can minimize the amount of allocation decisions that we have to make. Can we do anything to shorten the time between recognition of new viral strains and the creation of the intervention? How do we balance the utilization of vaccines and antivirals? So there are quite a number of issues that may help us maximize the preparedness and minimize the need to allocate in that time frame you mentioned.

CONAN: There are also going to be decisions made about--well, the drug industry as it exists today. This Tamiflu, the most effective drug, is still under patent to one company, Roche. We mentioned earlier, they're in discussions I think with one Indian company to produce more and maybe with others. But I think we saw a quote from a leader in Thailand, a country that might be more directly at risk, saying, "If people start dying, we have no choice. We're just going to make this ourselves."

Ms. KINLAW: Well, it does raise an interesting question. This is clearly an issue at the intersection of health care, of public policy decisions and of the private industry. And the question of whether it's justified for responses to occur on a local basis in the face of lack of preparation on a more central level is a difficult question. Even just last year in the shortage around vaccines for a regular flu season, we watched the difficult decisions being made on local levels for those who had received the vaccine about how to fairly distribute that. There have been some very important discussions I think subsequently about this question of balancing central control, of vaccine and antivirals, with the ability to make local decisions.

CONAN: Local decisions like what, quarantine?

Ms. KINLAW: No. Local decisions about who distributes the vaccine.

CONAN: I see.

Ms. KINLAW: Who actually receives it.

CONAN: I see.

Ms. KINLAW: As Andrew was just saying, a lot of the vaccines and antivirals that we currently have are distributed through private channels, whether it's through physicians' offices or hospitals or HMOs or through your local drugstore or your local grocery. And that sort of typical channel for distribution is one that I think respects a good bit of local autonomy. As we look at issues like pandemic flu or our concerns about a large-scale new virus such as the avian flu, then we begin to ask: Is this now at a point where we need to look at more centralization of distribution of those resources?

CONAN: Let's get some callers on the line in this discussion. Let's talk first with Fernando. Fernando's calling us from San Antonio.

FERNANDO (Caller): Hi. Good afternoon.

CONAN: Afternoon.

FERNANDO: I was having an interesting conversation with my father-in-law, 75-year-old father-in-law who made the comment, if worst-case scenario should happen, he wouldn't want the vaccine simply because he felt that it would be wasted on him. You know, he said, `I'm 75. I have respiratory problems. I have heart disease. Why would you want to waste the vaccine on me? Give it to somebody younger who really needs it. I've lived my life.' And that got me to thinking, `Well, who will get it?'

CONAN: Yeah. Kathy Kinlaw, I'd like to hear from you on this and I'd like to hear from Dr. Pavia on it as well.

Ms. KINLAW: Yeah. Very good. Well, you've seen the prioritization, groups probably for normal influenza vaccination where there is a recognition that those who are most at risk of hospitalization or of death are, you know, higher in the prioritization list and, of course, people 65 years of age or older and particularly those with comorbid, rather, conditions of a respiratory nature are high, high on the list. Now the identification of those people is based on the reality that those people will be most at risk of hospitalization and most at risk of death. But it doesn't necessitate that individuals actually go in and are immunized.

And I think it's a very interesting question that a lot of our older citizens are asking questions about whether their actions are ones that benefit their grandchildren or just younger generations in general. I can understand that kind of personal place. It may be, though, important for some of our older citizens to realize there are caregivers for them and there are other people that they may impact in their life also, and so the encouragement, again, to take care of those who are most likely to need hospitalization or most likely be at risk of dying may be an important commitment to and from society at large.

CONAN: Could you try that one more time? I'm not sure I got that. I mean, there's going to be a tremendous amount at risk. Obviously, the elderly are most at risk and, as you say, they would put a strain on medical resources, but these are important decisions. This is--these are vast decisions.

Ms. KINLAW: These are very difficult. And, again, you have to realize, as I mentioned earlier, it's sort of making transparent what is the ethical reasoning for why we've given priority to somebody in Fernando's father's position is because of the increased risk that he would be at risk of either a significant health problem and need hospitalization or would be at risk of death. That would be a beneficent sort of based ethical concern from us as a society to say we want to minimize that huge suffering that would be possible, not only for him, but also perhaps for other people who would be impacted by his severe illness or death.

CONAN: Let me bring Dr. Pavia in on this. That in--you said the priority was to prevent the largest number of deaths. Do you prioritize older people, middle-aged people? What about infants? As I understand, Tamiflu has not even been tested on very young babies because of the ethical problems involved in trials.

Dr. PAVIA: Yeah, that's a very important issue. We have no antiviral drug that's approved right now in kids under one year old. That's something we're trying to address as quickly as we can, but run into some roadblocks with that.

We really struggled with the issue that you've been talking with Kathy about; that is, should we use drugs and vaccines on those most likely to respond, those who are going to have the best outcome, or should we use it--at least if there's reasonable chance of response, should we really go in order of death and impact? We decided, you know, for the recommendation, to go based on who was most likely to die and have the greatest impact on the health-care system, because if somebody occupies a hospital bed for 20 days, whereas, you know, you could treat a bunch of people with milder illness in that bed--you could treat maybe three or four different people--you'd like to keep them out of that bed so you can keep things moving.

The other really hard issue with this is that vaccine doesn't work as well in the very old and the very sick, so we actually had different priorities for drugs vs. vaccine. And with vaccine, the number-one priority group--and this a relatively small number of people--was front-line health-care workers--that is, those who are in the emergency room and in the intensive care unit--and those who are making the vaccine and the antivirals. I mean, so the very first drugs out--I'm sorry--doses of vaccine rolling off the assembly line are slated to go to those groups, because if they get sick and the rest of the vaccine doesn't come or the rest of the drugs don't come, or if the ICU shuts down, then everyone's in a huge amount of trouble.

With antiviral drugs, we targeted as the number-one group people who already have influenza, who are sick enough to need to come into the hospital, because we know those people are the ones who are now critically ill and have a high risk of dying. And we have pretty good evidence that, at least with normal flu, we can intervene at that point and make a real difference with drugs like Tamiflu and Relenza.

But I think what Kathy was suggesting is that it's important that we, as a society, think about whether this is important. We've never really been a women-and-children-into-the-lifeboats-first kind of society that has a lot of people choosing not to get treatment or not to get protection so that others may survive. And if that's what we want to do, that's not something that an expert committee decides. That's for society to decide.

CONAN: Dr. Pavia, thanks very much for being with us today. We appreciate your time.

Dr. PAVIA: Thank you.

CONAN: Dr. Andrew Pavia, chief of Pediatric Infectious Diseases at the University of Utah, and joined us by phone from his office in Salt Lake City.

And you're listening to TALK OF THE NATION from NPR News.

And let's see if we can get another voice in on the conversation. Joining us now is Arthur Caplan, chair of the department of medical ethics at the University of Pennsylvania. He's with us by phone from his office at Penn.

Nice to have you back on the program.

Dr. ARTHUR CAPLAN (University of Pennsylvania Bioethicist): Hi. Thanks for having me.

CONAN: I wonder, can Tamiflu be distributed ethically? Doesn't rationing suggest that a lot of people are going to lose out?

Dr. CAPLAN: Well, I think there are really two senses of ethical or, if you will, fairness that come into play here. One is what you've been talking about, which is how substantively you decide who to give it to. Do you save the most lives? Do you try to keep the most health-care workers going so that they can, you know, produce more benefit? Do you try and prevent infection?--which is another issue that comes up. It puts children more to the front. But there's also what we in the trade call procedural fairness, and that is: How do you get people to support these rules?

Some listeners will remember when we had the shortage of flu vaccine last time, there are a lot of rules. People were talking a lot about rules, but there were a lot of folks undercutting those rules. So you have to get buy-in. And what we're doing right now on the show helps, because as people understand the rationale, as they understand that people are going to try and lay out the rules, they'll buy in and cooperate. The more transparent the rules are, then even when you're rationing, even when you're saying someone can't get something--think of those who wait on waiting lists for organs; about half the list dies, but the people aren't running up and down the street screaming and yelling. They know that the system has a set of rules, that they're applied conscientiously; they buy in and, even in the face of death, they're willing to abide by those rules.

CONAN: Well, let me--here's an e-mail exactly on this point from Andrea Robertson(ph). `My wife, who works at a pharmacy in a wealthy area--and they're already experiencing wealthy people stockpiling Tamiflu. With this happening, how much is even going to be available to ration when the decision is finally made? And will there be a distinction?'

And let me ask you about this, Kathy Kinlaw. Is there going to be a distinction between rich and poor?

Ms. KINLAW: Well, as Art was just saying, I think the question is, will there and should there be? Certainly from an equity issue or fairness issue, I would hope not. I mean, I hope we would fairly distribute these resources across our total population. But the fact that we do still have a lot of local control in the way these are distributed opens the door for that kind of inequity. And, as Art was saying, programs like this but also just public engagement around this issue is going to be very important in order for individuals to make decisions based on their understanding of how these recommendations were made.

Also, there has to be a buy-in. As Andrew was saying, there's a bit of a shift in the group recommendations, the tiering recommendations, coming out now to include more clearly health workers who are involved in direct patient care as an explicit population. That's in order to keep the health-care system going, in order to decrease transmission of disease.

CONAN: Mm-hmm.

Ms. KINLAW: If people understand that, then I think people will be willing to follow through on the recommendations. But it will be an individual choice for each of us.

CONAN: Kathy Kinlaw, we're going to let you go. Thank you very much for being with us.

Ms. KINLAW: Thank you.

CONAN: Kathy Kinlaw, director of the Center for Ethics at Emory University in Atlanta. She joined us by phone from her office there. We'll continue with Arthur Caplan after we come back from a break. This is NPR News.


CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.

And here are some of the other stories NPR News is following today. Supreme Court nominee Harriet Miers has submitted her answers to a lengthy questionnaire from the Senate Judiciary Committee. The written material is not likely to settle the most important questions about how she would perform on the Supreme Court bench. And the trial of Saddam Hussein is set to begin tomorrow in a heavily guarded courtroom in Baghdad's Green Zone. Initially, Saddam faces charges in connection with the 1982 murder of 143 Shiites from the town of Dujail. Those stories coming up later today on "All Things Considered" from NPR News.

And a correction in this conversation that we're having about the ethics of medical rationing and the possibility of an avian flu pandemic. Earlier we said the drug company Roche, the maker of the flu drug Tamiflu, is in discussions with an Indian company to make more. In fact, the Indian company, Cipla, has said that it would make a generic version of Tamiflu. That action would violate Roche's patents in some places, something which the company opposes.

We're talking about this issue now with Arthur Caplan, chair of the department of medical ethics at the University of Pennsylvania. And if you'd like to join the conversation, it's (800) 989-8255; (800) 989-TALK. Or e-mail us: totn@npr.org.

And, Arthur Caplan, that raises the very question: What about Roche and its ethics? Should it make this drug as widely available as possible?

Dr. CAPLAN: Well, I have to say, Neal, if you're in a situation where an epidemic is impending--and we're not there yet; we're worrying about it, we're thinking about it, we're trying to plan for it, but the virus has not mutated into the easily transmissible form--then my answer is yes. And I think, moreover, governments, including ours, should step in and make it, not just Roche, but, you know, say, `Roche, you're going to turn the formula over to Merck or Pfizer or whoever else and we've got to get moving.'

I was astounded, again, at the reaction last year to the flu vaccine shortage. We didn't waive our rules that allowed for shots to come in from overseas. We held to the manufacturing standard that, if they hadn't been approved here, even if they were approved in France, we couldn't use them. That just makes no sense to me. The first obligation in rationing is to minimize the need to ration.

CONAN: Let's get another caller on the line. This is Roger, Roger calling us from San Antonio.

ROGER (Caller): Yeah. Hi. Hi, Neal. I guess I have one comment and one question. The first comment is really I'm amazed that we're finding ourselves in the same situation we were last year. It seems like we didn't really learn our lesson about that, as far as the vaccinations for--the flu vaccine for last year.

CONAN: Not...

ROGER: My question really is, though, about the pandemic in 1918. What I remember about that is, is the majority of people affected were those in the non-critical age group that was, like, mainstream, like--people between 20 and 40 that were mainly affected by the pandemic. And so I find it kind of curious that there's a lot of correlation between this flu, this avian flu, and people keep talking about the pandemic of 1918, but when it comes down to rationing, everyone keeps mentioning the groups of, you know, children and the elderly.

CONAN: Is that right, Arthur Caplan? And in that--if Roger's right, shouldn't, then, people in that age group be the first to get priority for the flu?

Dr. CAPLAN: Well, I think it's the principle that drives the substantive decisions about who should get a scarce therapy. If it turns out that the people most affected, because they're exposed the most, are airline workers or people 20 to 40 who are high school teachers and elementary teachers, because the bug spreads there, then my principle would be shift away from the elderly, go to the place where you can get the greatest yield for your resource, both saving lives and--I have to come back to this again--preventing the transmission of infection. So what I mean is, if you're a 70-year-old person but you don't come out of your house and very few people come to visit you, you're not likely to get infected, even if you're 70, whereas if you're someone who is a day-care center worker, I think, sadly, you're likely to get infected with many things. That's the--lot of kids running around, you know, spreading viruses of all sorts everywhere.

So the principle, I think, ought to be: Get the most yield, in terms of health benefit and transmission protection, out of whatever you've got. So I don't care whether you're 20 or 70, part of it is part of--who's likely to be infected first.

ROGER: Yeah, but I guess what I'm curious about, though, is the fact that if it's already been distributed...

Dr. CAPLAN: Oh, true. True.

ROGER: ...to keep the pandemic from happening, and it's really affecting a different age group, there's a chance a large part of that's going to be already distributed to the wrong people. And then you have the fact of the government having to move quickly, which we've seen in the past really hasn't been very effective.

Dr. CAPLAN: That I would argue--I would agree. I mean, I think you're correct; you have to lay in a plan, and so we do, and we may have a maldistribution, but that takes me back to your other point, which I couldn't agree more with: We don't seem to have learned from last year. Not only do you need some ability of at least the state level and probably the federal level to get in there and seize the supply and redirect if the virus goes in a direction we don't anticipate or we've got to move things from one part of the country to the other because that's where the outbreak happens, you also need to have enforcement. Remember, Kathy was saying before the break people were stockpiling it. I hear that, too, and I hear companies stockpiling. Well, somebody ought to be in there telling the pharmacists, you know, `There's a limit on sales. And if you violate it, we're not going to send you any more Tamiflu to sell at your drugstore or drugstore chain.'

So I think rules are great, and I think being able to get people to buy in to them is important to compliance, but you need a stick. Somebody's got to be wielding a stick here to make sure that the rules get followed.

CONAN: And it's not just pharmacists; it's doctors, as well.

Dr. CAPLAN: Oh, yeah. I mean, last year, remember, some of the people who gleefully undercut the rules, if you will, were doctors and private patients who just came in and said, `I want it,' and they gave it to them. I remember student health services were vaccinating everybody because they had it. Right here in Philadelphia, the VA had a lot of flu vaccine. Our main hospital here didn't have any, and we couldn't get any sharing going because we didn't have any authority to tell a federal institution, the VA, to kind of divvy up the supply. So you need somebody who is able, if you will, to both make rules and enforce them, and I haven't heard much about that yet.

CONAN: And I have also not heard--I mean, this requires a lot of faith--as you said, the organ donor system--that's one thing, but this requires a lot of faith in government and institution--that there is a substantial fraction of the country that has very little faith in that.

Dr. CAPLAN: I have to agree with that. I think that Katrina has got us all nervous that federal agencies can't get there fast, can't respond. We saw gross inequity break out in terms of rescue and then health-care delivery in terms of how that worked out. So we've got to rebuild that faith. One way to do it is to make it clear that you're willing to step in and penalize those who hoard or those who cut in line. And, you know, it seems to me that could still be done, and it could be done as part of our preparation, but I just haven't heard anybody talking that way.

CONAN: Roger, thanks very much for the call.

And, Arthur Caplan, as always, thank you for your time. We appreciate it.

Dr. CAPLAN: My pleasure.

CONAN: Arthur Caplan is chair of the department of medical ethics at the University of Pennsylvania, and he joined us by phone from his office at Penn.

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