Posted: January 10, 2006
This page is categorized as:    link to Pandemic and Other Infectious Diseases index
Hover here for
Article SummaryWhen Jody Lanard and I wrote this long column, there was a shortage of Tamiflu. Officials and physicians argued that the available supply should be saved for current use against the seasonal flu and government stockpiles against a possible pandemic – but should not be stockpiled by individuals. We wrote the column to expose the many illogical, inconsistent, and inaccurate arguments being used against personal Tamiflu stockpiling, but we conceded that the competition with other uses was a valid issue. Now the Tamiflu supply exceeds the demand; “excess” manufacturing capacity has been mothballed. The competition argument is dead in the water. Officials and physicians still oppose personal Tamiflu stockpiling, but the only arguments they have left are the specious ones analyzed in this column.

The Dilemma of Personal Tamiflu Stockpiling

It’s debatable either way, but opponents’ specious arguments forfeit public trust.

By now almost everyone who reads newspapers or watches TV news has heard of Tamiflu – the antiviral drug that many hope will help during an influenza pandemic, and that many fear will be in extremely short supply if and when a pandemic materializes.

Responding to both the hope and the fear, significant numbers of people have obtained their own personal Tamiflu stockpiles. But personal Tamiflu stockpiling has been almost universally criticized by government officials, medical organizations, and individual physicians – not just as selfish (which it manifestly is), but also as foolish, unnecessary, futile, counterproductive, and panicky.

There is a good case to be made against personal Tamiflu stockpiling. But most of the arguments put forth against stockpiling are outrageously bad. So we want to explore the anti-stockpiling case, both as a matter of policy and as a matter of communication. In this column we address the most solid argument against personal stockpiling: that Tamiflu is a scarce medical resource, and that in a national crisis Tamiflu can be allocated more wisely by the government than by the free market. We also address the many anti-stockpiling arguments that we consider specious. And we try to figure out what might impel opponents of personal stockpiles to sink to such arguments.

All this may seem like overkill to many readers. Why expend so much effort rebutting specious arguments against personal Tamiflu stockpiling, when we assert at the outset that the issue is genuinely debatable? Two reasons: People’s decision-making gets harder when experts treat a genuine dilemma as if it were a no-brainer. And public trust is undermined when experts support their one-sided assessment of a controversial issue with arguments that are not grounded in fact, logic, or mutual respect.

What do we mean by specious arguments against personal stockpiling? We will categorize and dissect these arguments below. Among them:

  • Insulting arguments like: “As soon as people get a bad cold, they’ll grab their Tamiflu and waste it” and “You might forget where you put your stockpile.”
  • Arguments not based on data like: “The chance of a pandemic is low” and “People who take Tamiflu when they don’t have the flu are likely to launch a Tamiflu-resistant strain of flu.”
  • True but logically irrelevant arguments like: “Your Tamiflu might reach its expiration date before you need it” and “A pandemic isn’t happening yet.”

And many more. But first here is a quick primer on Tamiflu basics.

Tamiflu Basics

link up to indexNobody knows when the next flu pandemic will start, or how severe it will be, or whether it will be caused by the novel H5N1 “bird flu” strain that has received so much recent attention. But if it’s soon, and if it’s severe, and if it’s H5N1, then Tamiflu might (or might not) significantly reduce mortality and morbidity. It will be sorely needed. Based on current manufacturing capacity, a vaccine against the pandemic virus will probably remain unavailable to most people for the duration of the pandemic; it will be unavailable to all at the start of the pandemic.

The world’s supply of Tamiflu is much, much less than the world will need if the pandemic comes and if Tamiflu works. How to allocate the available Tamiflu is thus a serious dilemma.

Actually, it is two serious dilemmas. One dilemma is the choice between national stockpiles and an international stockpile: Should wealthy, developed countries like the United States accumulate most of the world’s supply for their own use, or should the supply be distributed more equitably among the world’s nations, or should it be centralized for international agencies to use in an attempt to abort a pandemic whenever and wherever it starts?

The second dilemma is the choice between national stockpiles and personal stockpiles: Should affluent and forethoughtful individuals accumulate their own Tamiflu supplies, or should each country’s Tamiflu be centrally controlled by that country’s government? This column is about the second dilemma, and especially about the way it is playing out in the United States.

You can barely detect this dilemma by reading what has been published about Tamiflu stockpiling. Nearly everything in print supports government stockpiles and opposes personal stockpiles. If you want your own Tamiflu, according to the virtually unanimous opinions of the experts, you’re not just selfish. You’re irrational.

We don’t see it that way. To us it looks like a true dilemma: what’s best for you and your family (get your own stockpile) versus what’s best for the whole country (hope that all the Tamiflu will wind up in a government stockpile, to be allocated where it will do the most good for society at large).

Most of what we have read isn’t just one-sided on the Tamiflu stockpiling issue. It is wrongheaded, offering many arguments against personal stockpiling that are empirically false and logically nonsensical. For months we have been angrily collecting examples, waiting for rebuttals that never came. The anti-Tamiflu statements that so infuriate us may not be intentionally dishonest; they may be self-deceptive or just poorly thought-through. And we accept that they are well-intentioned. When various authorities offer absurd reasons why you shouldn’t want your own Tamiflu, they may or may not believe their reasons, but surely they believe they are benefiting society by dissuading as many individuals as they can from seeking a stockpile.

But it never benefits a society to try to mislead its citizenry. In an earlier column, we used the phrase “misleading toward the truth” to describe inaccurate arguments advanced by the U.S. Department of Agriculture in support of its accurate claim that the risk of catching mad cow disease in the United States is infinitesimal. What’s going on with respect to Tamiflu stockpiling is much worse than misleading toward the truth. It is misleading toward half the truth. It focuses on one horn of the stockpiling dilemma, and deploys specious arguments to make the other horn disappear. It thereby distorts a real decision real people are trying to make in real time.

Worse still, the effort to mislead will probably backfire. Sooner or later, people will probably realize they were misled, and learn to mistrust those who misled them. If an influenza pandemic happens, we will need to trust our leaders – and some will have forfeited that trust.

Before we start parsing the arguments that are advanced against personal Tamiflu stockpiling, starting with the one really solid argument, here are the medical basics.

Tamiflu (generic name: oseltamivir) is an antiviral medication that works against most but not all strains of flu – it is not effective against flu strains that have become resistant to it. Used preventively during an outbreak, Tamiflu significantly reduces the likelihood of illness. Used as a treatment (if taken promptly after the onset of symptoms), it may significantly reduce the duration and severity of illness.

Please take note of this distinction between prevention (the medical term is “prophylaxis”) and treatment. In a pandemic, governments will have to allocate their stockpiles between these two uses. They will make their allocation decisions knowing that they don’t have nearly enough Tamiflu to cope with a severe pandemic, and knowing that prophylaxis (for many weeks) requires far more Tamiflu per healthy person protected than treatment (for five days) requires per sick person treated.

To the extent that they choose prevention, therefore, those in charge won’t even think about trying to protect everyone; they will focus on protecting people they most wish to keep healthy, those in essential occupations. To the extent that they choose treatment, they probably still won’t have enough for everyone who’s sick; the priority will still be those in essential occupations whose recovery is most important, plus those who are considered most vulnerable and likeliest to die without the drug. If the pandemic is severe, most experts expect that the needs of vulnerable populations will give way to the need to protect and treat the people whose skills are most crucial to keep society running.

Personal stockpiles, meanwhile, will almost necessarily be used for treatment rather than prevention, because few ordinary individuals can accumulate enough Tamiflu to keep taking it for weeks or months to ward off the flu. Most individual stockpilers will wait to get sick.

Two older drugs, amantadine and rimantadine, are also approved in the United States for both prevention and treatment of flu – not just pandemic flu, any flu that isn’t yet resistant to them. But because resistance to these two drugs develops rapidly, the U.S. Centers for Disease Control and Prevention currently recommends using amantadine and rimantadine for prevention (preferably as a secondary line of defense after vaccination). For treatment the CDC recommends either Tamiflu or a fourth anti-flu drug, Relenza, which has so far escaped the furor over Tamiflu.

Amantadine and Rimantadine No Longer Working in U.S.

On January 14, 2006, the U.S. CDC announced that amantadine and rimantadine should no longer be used in the U.S. for either treatment or prevention against the currently dominant seasonal flu strain, H3N2, because of a “sharp increase in resistance since last year.”

(The CDC reported that 91% of the 120 Influenza A isolates tested at CDC so far this year are resistant – up from 11% of the isolates tested last year, and 1.9% the year before.)

The ineffectiveness of amantadine and rimantadine against the 2005–2006 seasonal flu virus obviously worsens the competition for Tamiflu and Relenza. These are now not just the drugs likeliest to work against a pandemic strain, but also the only drugs that work against the currently dominant seasonal strain. We retract our argument, which was supported by the pre-January 14 CDC guidelines, against the various state Tamiflu-prescribing guidelines that recommend Tamiflu (rather than amantadine or rimantadine) for prophylaxis of high-risk patients during flu outbreaks in such settings as nursing homes.

Update added: January 14, 2006

Both high-risk and low-risk people can get vaccinated against the seasonal flu (except when there’s a vaccine shortfall and the available supply is reserved for the high-risk groups). But it is primarily the elderly and other high-risk patients who are likely to get prescription drugs as well (or instead). Antivirals – mostly amantadine and rimantadine – are used preventively for high-risk patients, especially in nursing homes when they have flu outbreaks. And antivirals – including Tamiflu and Relenza – are used to treat high-risk patients who catch the flu, if they get to a doctor before it’s too late for the medicine to work. Medically, most low-risk people rely for prevention on vaccination or nothing at all; if they catch the flu, they get through it on chicken soup and over-the-counter palliatives.

Enter H5N1, the novel flu strain in birds that currently poses the greatest threat of launching an influenza pandemic – a worldwide outbreak that might (or might not) be far, far deadlier than the seasonal flu. Both amantadine and rimantadine are believed not to work against H5N1; the virus already seems to be resistant to them. Nobody knows whether, how long, or how well Tamiflu or Relenza would help in a pandemic. But they might help. The World Health Organization, the CDC, and the vast majority of influenza experts see Tamiflu and Relenza as cornerstones of pandemic preparedness.

But there isn’t enough of either drug to go around in a pandemic. Tamiflu in particular is in very short supply, relative to the sudden demand. And because Relenza is harder to administer (it is inhaled rather than ingested, and can cause problems in some people with pre-existing lung conditions), Tamiflu is the drug everyone wants.

Three key distinctions underlie much of the discussion about personal Tamiflu stockpiling: prevention versus treatment, seasonal use versus pandemic use, and high-risk patients versus patients in high-value occupations versus everybody else. Here is how these distinctions play out with respect to Tamiflu:

  • Seasonal/prevention – This use of Tamiflu has never been common, and is unlikely to become common any time soon for anyone. Hardly anyone, high-risk or not, takes Tamiflu throughout the entire flu season every year. Seasonal prevention is mostly about vaccination, plus amantadine or rimantadine for some high-risk patients who weren’t vaccinated or are deemed to need the extra protection.
  • Seasonal/treatment – Tamiflu has been used this way for some high-risk patients and fewer low-risk patients since it came on the market in 1999. It has been used a lot only in Japan. Elsewhere it has not been popular. Some doctors now say they are worried that the Tamiflu they need to treat their high-risk patients who get the seasonal flu will be diverted to personal pandemic stockpiles instead. And some patients may now be more interested in Tamiflu treatment for the seasonal flu, because the drug now has such a high profile. The new interest in Tamiflu as a possible hedge against a pandemic has thus increased the demand for Tamiflu for seasonal use as well, both for high-risk patients (an entirely legitimate use) and for lower-risk ones (more indulgence and fad than medical necessity – though it does shorten a bout of the flu by a day or two).
  • Pandemic/prevention – Governments are expected to use much of their stockpiled Tamiflu this way, trying to keep society’s infrastructure going by keeping essential personnel (but not the rest of us) healthy. This will require a lot of Tamiflu – a daily capsule for the duration of each outbreak in a given region. Very few individual stockpilers will have enough Tamiflu to use it before they actually get sick
  • Pandemic/treatment – Governments will use some of their stockpiled Tamiflu this way too, treating the patients whose recovery is most needed to keep society going or whose vulnerability makes them likeliest to die without the drug. Treatment requires a lot less Tamiflu per patient than prevention; the current recommendation is two capsules a day for five days (though the actual optimal dose won’t be known until after a pandemic begins). Even so, most governments (including the U.S. government, at least so far) won’t have nearly enough Tamiflu to treat everyone who gets the flu in a severe pandemic. This is the gap personal stockpilers intend to fill for themselves and their loved ones.

All this is predicated on the assumption that Tamiflu remains in very short supply. If we go years without a pandemic, if Roche licenses more companies to manufacture Tamiflu, and if the supply increases to the point where there is plenty for even a severe pandemic, the Tamiflu allocation dilemma will more or less disappear. Working to enlarge the Tamiflu pie is a better long-term solution than arguing about the best way to slice it. But for now the pie is pretty small.

Similarly, the dilemma will disappear if better antiviral drugs than Tamiflu are invented and inventoried in huge amounts, or if the time needed to develop and manufacture enough vaccine customized for a specific pandemic flu virus is shortened from years to mere weeks.

But for now and the foreseeable future, the dilemma is real. The available Tamiflu will be in your stockpile or someplace else; it will be used to protect you and your loved ones or for some other purpose. The question is which use of Tamiflu is best … and for whom.

The Public Health Argument against Personal Stockpiles

link up to indexWe start by underscoring what we consider the one really persuasive argument against personal stockpiles: the scarcity argument. If a pandemic were to start today, there would not be nearly enough Tamiflu for everyone who needed it. Governments in many developed countries have amassed Tamiflu stockpiles, and many have backordered much more Tamiflu to add to their stockpiles. But the manufacturer, Roche, can’t make it fast enough. If a pandemic comes soon – and if Tamiflu helps – governments will face difficult choices about how best to ration their limited supplies. As noted above, two main rationing strategies are in contention:

  • Use the Tamiflu to treat the most vulnerable flu victims, those you think are likeliest to die if untreated. (The elderly, the immuno-compromised, and people with chronic diseases are the usual candidates during seasonal flu outbreaks; no one knows yet who the high-risk groups will be in the next pandemic.)
  • Use it to protect and treat the people we most need to keep healthy in a severe pandemic – healthcare workers, certainly, and people working on a vaccine; probably cops; maybe waterworks technicians, morticians, truckers, and others who can help keep society’s infrastructure functioning.

It is debatable which uses for Tamiflu should have top priority. And it’s a debate that ought to happen now, before the pandemic, with broad public involvement. Although most experts favor the second strategy, especially if the pandemic is severe, different national governments (and different local governments) may well make different rationing decisions.

But if you are neither especially vulnerable nor especially useful, you’re not going to be on anybody’s list. If you don’t have your own Tamiflu, you probably won’t get any. If you do have your own Tamiflu, every capsule in your stockpile is one less capsule available for the government to allocate to someone whose health is a higher priority than yours. Worse yet, you may not get sick, in which case your stockpile may be wasted while someone else dies for lack of it. Pandemics don’t infect everybody. Past flu pandemics have had “attack rates” of about 30 percent. If you set aside enough doses of Tamiflu for yourself and your family, on average 70% of that Tamiflu won’t get used at all; the other 30 percent will get used on the comparatively low-priority people in your household who catch the flu.

Of course some doses may also go to waste in the government’s stockpile, waiting for the “right” people to get sick – a point that is rarely mentioned.

Still, it’s obvious that society as a whole is better off if the government has all the Tamiflu. A small amount is needed each year to treat high-risk patients who get the seasonal flu. (Tamiflu has never been used much except in Japan, but the CDC does recommend it for this use.) The rest belongs in a government stockpile, waiting for a possible pandemic. Given the current demand/supply situation, it might be wise for the government to control the seasonal supply of Tamiflu as well – partly to make sure there’s enough for high-risk patients who get the flu, and partly to practice allocating and distributing the drug on the basis of need. If that sounds like a challenge in a normal flu season, imagine it during a pandemic.

This public health case for a government Tamiflu monopoly is not unassailable. We can think of four possible rebuttals, though we find none of them very persuasive.

You might try to argue that the government is so unlikely to allocate its Tamiflu stockpile wisely and efficiently that your capsules will actually do more good for society in your hands than in the government’s hands. But even in an era of minimal trust in government, it’s not easy to make a convincing case that in a pandemic the free market would dispose of scarce Tamiflu more effectively than a thought-through government allocation strategy. We have read many government pandemic contingency plans. Most of their protocols for allocating antiviral drugs are vague, half-baked, and much in need of ongoing public debate. But from the perspective of the greatest good for the greatest number, even the pretty bad plans make far more sense than leaving the drugs in the control of those individuals who happened to buy some.
You might try to argue that a lot of the government stockpile won’t get to the right people quickly enough. If used as a treatment, Tamiflu should be taken as soon as possible after the onset of symptoms, within 48 hours at the outside. Our national experience with Hurricane Katrina leaves room for skepticism that the feds can get their chosen recipients a dose that fast in the midst of worldwide chaos. On the other hand, if the government focuses on protecting healthy people in essential occupations, the prospects for effective allocation look brighter. (But most stockpiles won’t last very long if used for prevention. The preventive dose recommended so far is one capsule a day for the duration of each pandemic wave, which may last up to two months, compared to a currently recommended treatment course of ten capsules over five days.)
You might try to argue the libertarian position. Our country has a long history of respecting people who think ahead and take action to take care of themselves and their loved ones. We call it self-reliance. Perhaps the government should confine its efforts to protecting those who didn’t think ahead or couldn’t afford to take appropriate action. It is possible to approve of government Tamiflu stockpiling for those who don’t have their own and still disapprove of any effort to dissuade people from having their own.
If your philosophy of government, like ours, is more communitarian than that, there’s still one argument left: that there is no real competition in the first place between your pandemic stockpile and the government’s pandemic stockpile, since your stockpiles come through different supply chains.

Before Tamiflu got hot, it was arguable that individual Tamiflu orders were actually building the market – encouraging Roche to increase its manufacturing capacity and thus indirectly facilitating the government’s ability to get more too. Now that Roche is maxed out and says it’s already doing everything it can to make more, that argument is gone. But Roche still claims that it fills massive government stockpile orders from a different quota than its normal pharmacy distribution channels for the seasonal flu. It has escrowed its supply for pharmacies, doctors, hospitals, and other routine users, it says, so the backlog in government orders won’t deplete that supply. But the run on Tamiflu for individual stockpiles did start to deplete that supply – to the point where the company imposed a moratorium in the U.S. and some other countries, preferring to save what was left for the annual flu season. Leave aside for now the competition between squirreling away Tamiflu in personal pandemic stockpiles and using it to treat the seasonal flu. We’ll talk about that later. If individual use and government use have separate production quotas, then each course of Tamiflu that ends up in individual hands means no less Tamiflu in government hands – and it means one less citizen competing for the inadequate government supply in the event of a pandemic.

Well, okay. But we’re about to attack the specious arguments made against personal stockpiles. We don’t want to start with a specious argument on behalf of personal stockpiles. How impermeable is Roche’s hypothetical fence between the individual supply and the government supply? Not very. The U.S. government is free at any time to nationalize the individual supply – at least the part that is still in the hands of wholesalers, doctors, or pharmacies inside the U.S. border. (At present, Roche produces Tamiflu only in Basel, Switzerland.) Or it could do what it did during last winter’s flu vaccine shortfall: urge voluntary rationing, and rely on the states to impose a compulsory rationing policy. If a pandemic comes, the government will presumably do something along these lines, commandeering any Tamiflu that’s still available. It doesn’t have to wait. It could decide tomorrow to issue a fiat to doctors: “Thou shalt prescribe Tamiflu only for high-risk patients who actually have the flu. The rest of the Tamiflu goes to Washington.” In short, Roche’s fence is permeable. A Tamiflu capsule you forgo is a capsule that may end up instead in the government’s stockpile.

It may be arguable that the fences between countries aren’t all that impermeable either. To the extent that Roche allocates its non-governmental Tamiflu supply where the market is strongest, then a course of Tamiflu you buy today will at least wind up in your country and not some other country. (Advantage Japan, which has the strongest market.) So a U.S. Tamiflu customer does presumably increase the total U.S. Tamiflu stockpile. We don’t see why this would be an improvement for the world, but it is an improvement from a narrowly national perspective.

With that exception, U.S. society as a whole is better off if individuals are dissuaded from stockpiling any Tamiflu for themselves and their loved ones, so as much of the U.S. supply as possible ends up in government hands.

However, none of this means that you shouldn’t rationally want your own Tamiflu supply. It means that the government shouldn’t let you have it.

That is, it is an argument for centralizing the country’s Tamiflu supply. So far the U.S. government hasn’t chosen to do this. Nor have the various state governments. They will when they do. Until then, you are legally entitled to purchase your own Tamiflu supply, as long as you can find a doctor willing to write you a prescription and a pharmacy that has any left.

Here’s the core of the Tamiflu stockpiling dilemma. The government, which is supposed to act in the interests of the overall society, hasn’t yet mandated how the available Tamiflu is to be allocated. So every individual has to decide whether to act voluntarily in the interests of the overall society (and hope other individuals do likewise) or to act in the interests of self and family instead. And that individual’s doctor has to decide whether to look first to the patient’s needs or to look to society’s needs. This is a well-explored ethical issue, known in the literature as the “Commons Dilemma.”

The dilemma is only partly about fairness. It isn’t fair for forethoughtful and affluent people to have Tamiflu while their neighbors go without. Nor is it especially fair for the government to decide which of its citizens are most important to try to keep alive. (A lottery would probably be the fairest solution.) At least as important as fairness is wisdom. What is the wisest way to allocate the Tamiflu? There is no one answer. What’s wisest for you and your loved ones simply isn’t what’s wisest for society at large.

A widespread, well-informed public debate about how best to use our nation’s scarce Tamiflu supply might help produce a populace that understood the dilemma, supported the government’s plans, and looked askance at personal stockpiling. Instead, the government is saying as little as possible about the tough rationing decisions it will face if a pandemic materializes. It is trying to build a consensus against personal stockpiling without the discussion that might justify that consensus. Rather than a thoughtful balancing of individual versus societal priorities, people are served up specious arguments that insist they have no valid use for a personal stockpile in the first place.

The case for rationing Tamiflu is reminiscent of the case for rationing organ transplants. We don’t have enough donated kidneys to go around either, so in 1984 the U.S. Congress set up a nonprofit organization to decide who gets one and who doesn’t. The task is ethically and emotionally daunting, but it needs to be done. Sometimes, sadly, we have to tell prospective transplant recipients that we don’t have a new kidney for them, that all the available kidneys are going to people higher on the priority list. But nobody ever tells prospective recipients they shouldn’t even want a new kidney – merely because they don’t need it imminently or because it might not work anyway. As we shall see, both of these arguments are routinely used as reasons why you shouldn’t want a Tamiflu stockpile.

The scarcity/rationing argument does show up as one of the arguments against non-government Tamiflu stockpiles. Here, for example, is a passage from the August 8, 2005 Atlanta Journal-Constitution:

Ben Schwartz, senior science adviser for the National Vaccine Program Office of the Department of Health and Human Services, said the government is concerned that corporate purchases of Tamiflu could threaten the nation’s response to a flu pandemic.

“Our ability to purchase drugs nationally depends on having that drug available,” said Schwartz, an architect of the U.S. pandemic flu plan. “If companies purchase it, that will potentially decrease what is available.”

This is the straightforward, respectful, solid argument against private stockpiling. It belongs in the debate. But most of the experts and authorities who oppose personal (or corporate) Tamiflu stockpiles don’t advance the scarcity/rationing argument very aggressively. It presumably underlies their opposition. It is certainly the only sound justification for that opposition. And it is the crux of the dilemma they are avoiding. But hardly anyone wants to say straight out that there are people whose health is a higher priority than your health, and thus the government should hoard all the Tamiflu for them instead of letting you hoard it in case you need it. Apparently this is very hard for anyone, and especially for doctors, to say. It appears hard for many even to think. So they resort to other arguments instead – even when the only ones left are specious.

Typology of the Specious Arguments against Personal Stockpiles

link up to indexPersonal Tamiflu stockpiling is an ethical dilemma. One horn of the dilemma is the incontrovertible fact that, from society’s perspective, more important uses can be found for a scarce medication than sitting in your medicine cabinet in case you or your loved ones need it some day. The other horn is the equally solid fact that, from your individual perspective, there is no more important use. Rationally, you ought to want some Tamiflu.

But we’re not quarreling with the judgment that society is better off if the stockpile is centralized. That’s simply true. Nor are we quarreling with the judgment that the government should preempt the decision – or that doctors should ask the government to preempt it rather than face the ethical dilemma in the privacy of their offices. We think that makes a lot of sense.

We’re not even quarreling with the judgment that as long as the decision is left in the hands of individual doctors, they should put society’s interests ahead of the interests of the patient in the room. We think that judgment is debatable either way, though the debate so far has been scanty and one-sided.

What makes us furious is the use of specious arguments to dissuade patients from asking for Tamiflu and doctors from giving it to them. No good can come from supporting a defensible position with indefensible arguments. Sooner or later, the bad arguments crumble – not in every case, but usually. When they do, public acceptance of the defensible position they were invoked to support often crumbles too. People who find they were misled become outraged. And outraged people are in no mood to think objectively about the merits of the debate.

Worse, public trust in those who made the bad arguments also crumbles. This is where risk communication (which is our area of expertise) meets ethics (which is not). It is a good thing when people lose trust in those who have misled them. But we can ill-afford to limp through a pandemic after having lost trust in the medical and governmental establishments that told us we were stupid to want Tamiflu. They are free to tell us that our prudent, rational desire for a Tamiflu stockpile ought to give way to society’s needs. They need to stop telling us that the desire isn’t prudent or rational in the first place.

Here, then, is a typology of the arguments offered why you shouldn’t want Tamiflu – and why we think they are nearly all dishonest, disingenuous, or self-deceptive.

“You’re incompetent” arguments:

1. You’re likely to take your Tamiflu when you don’t have the flu. Many or even most people are too anxious about an influenza pandemic to exercise any self-control. As soon as people get a bad cold, they’ll grab their Tamiflu. This wastes a very scarce medical resource.

link up to indexWe actually know of one case where someone apparently took Tamiflu unnecessarily. Here’s the story, from a listserv for risk professionals:

There is a wide range of physician practices out there. For example, my dad’s physician will gladly prescribe him small “stockpiles” of antibiotics, Tamiflu, etc., for him to use without needing to be seen by a physician. Granted, my dad is in his mid-eighties, and reasonably well educated scientifically and medically (for a non-physician), so the doctor may have made an educated judgment that there is little need for him to come in and be seen when he believes he is ill. However, that practice recently resulted in my brother taking Tamiflu when he developed a high fever and cough, at a time when there were not yet any cases of seasonal influenza in the entire county where he lives. Even a quick phone call to a doctor’s office, without needing to be seen in person, could have informed him that Tamiflu would not be effective against whatever it was that he had, and allowed him to save his supply of a scarce and life-saving medication for use when it might actually be beneficial.

This is pretty much what Roger Baxter, an infectious disease expert at Kaiser Permanente, feared when he told The New York Times, “They hear ‘bird flu’ on the radio and they’ll take their Tamiflu that day.” Kaiser announced it would no longer dispense “just in case” Tamiflu prescriptions. Many experts share this opinion about patients. According to a joint statement by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America: “Personal stockpiling would likely lead to inappropriate use and wastage.”

At an October 2005 meeting of the Infectious Diseases Society, however, The New York Times reported: “[O]ne speaker asked the audience how many had a supply of anti-influenza drugs at home. A fair number of hands, though clearly a minority, were raised. He then asked how many were thinking of it. Most of the remaining hands went up.” This isn’t necessarily hypocritical, only elitist. Many doctors apparently figure they can handle the temptation to take Tamiflu prematurely, but their patients can’t.

There is no evidence that this kind of waste of Tamiflu is widespread now, nor that it would be widespread once a pandemic began. But doctors who believe a particular patient shouldn’t be trusted with Tamiflu have an obvious option: Prescribe the Tamiflu, let the patient buy it now, and require the patient to store it at the doctor’s office, to be dispensed only on doctor’s orders. Of course this option has problems of its own, such as whether patients can trust their doctors not to reallocate their Tamiflu to a needier patient, and whether it makes any kind of sense to make an extra trip to your doctor’s office at the start of a pandemic. Our point is only that denying the patient otherwise useful medication is not the usual response to compliance concerns. There are ample precedents for supervised medication – patients with dementia; Antabuse in alcohol rehab programs; drugs that might otherwise get sold on the street like methadone; treatment protocols that are notorious for patient noncompliance (tuberculosis treatment, for example).

The notion that most patients shouldn’t be trusted with Tamiflu is insulting. Tamiflu stockpilers are highly motivated to use their Tamiflu wisely, not to waste it. Doctors can promote wise use of Tamiflu by educating their patients. How hard is it? “If at all possible, call me before you take this. If you can’t reach me, and you know there is pandemic influenza in our town, and you get these symptoms, take the drug – fast. Don’t worry if you forget the symptom list. When the pandemic comes, the symptoms will be scrolling across the bottom of your TV screen.” We doubt there are many readers of this column who haven’t been on the receiving end of far more complicated take-home instructions from their physicians than this one.

What’s stunning about this “you’re incompetent” argument is its inconsistency. If doctors were routinely contemptuous of their patients’ ability to follow instructions about when and whether to start using a medication, then Tamiflu would be just one more case in point. But Tamiflu is one of a handful of notable exceptions.

During the 2001 anthrax scare, Ciprofloxacin was another exception. And indeed some people did start taking Cipro unnecessarily. But the big Cipro problem was noncompliance among asymptomatic patients who were instructed to take Cipro because they might have been exposed to anthrax: Over half failed to complete their 60-day prophylactic course of the antibiotic. This is a much higher rate of misuse than the percentage of those who secured their own just-in-case Cipro who actually took it. People who got their own Cipro were mostly worried that the government might not be able to mobilize the national stockpile in time if the anthrax poisonings escalated. The poisonings didn’t escalate, and most of the Cipro went unused.

Something about pandemic influenza (and bioterrorism) makes doctors much more inclined than usual to infantilize their patients. The argument that patients should be deprived of just-in-case medicine because they’ll probably misuse it is so out of character for physicians that something else must be behind it. We are not sure what it is. One very tentative hypothesis: Perhaps horrific scenarios such as a severe influenza pandemic or a major bioterrorist attack stir up unacceptable feelings of helplessness and incompetence in many physicians. Perhaps these feelings are then projected onto their patients – ironically, onto the most self-efficacious of their patients: the ones who are appropriately skeptical about the ability of others to protect them, and are taking steps to protect themselves and their loved ones.

In general, and for good reasons, doctors prefer to see a patient before the patient starts taking prescription medications. They give out just-in-case prescriptions mostly in two situations: if the patient faces a possible emergency (like a heart attack or a bee sting) when there will be no time to go find a doctor; and if the patient faces a scarcity situation (like travel in third world countries) where either the drug itself or good medical attention is likely to be hard to find. To accept that a possible pandemic fits these specs, a doctor must first accept that in the middle of a severe pandemic the doctor is likely to be unavailable and the medicine (Tamiflu) is almost sure to be unavailable. We suspect many doctors find these realities threatening, perhaps too threatening to wrap their minds around.

A final point: If people are really that anxious about a pandemic and about the government’s ability to cope with it – so anxious that doctors are worried they will jump the gun – isn’t there a mental health argument for personal stockpiles as a way to give patients a sense of control and thus mitigate their anxiety? Give them their Tamiflu, teach them not to use it until they need it, and help them calm down. But in fact we don’t see this over-anxious “panic” among the people we know who have obtained Tamiflu. The people we know, and know about, are getting on with their daily lives, while preparing for this newly recognized threat on what they hope is the distant horizon. This spirit was captured well on a special Flu Wiki Christmas page, when one of the regulars wished everyone “a nice holiday in 2009 … when hopefully our Tamiflu expires unopened.”

2. You won’t know when you need your Tamiflu. So many viruses can cause flu-like illnesses. Without testing, no one can know if you actually have influenza. That’s why nobody should take Tamiflu until a physician has diagnosed your illness.

This is a whole lot less insulting than the first “you’re incompetent” argument. And it’s true that it takes lab work to diagnose influenza reliably. But the argument is disingenuous. During the annual flu season, most cases of influenza are not lab-confirmed; doctors log them as “flu-like illnesses” and treat them as flu. And not a single pandemic plan we have seen anticipates requiring a laboratory diagnosis before a patient gets Tamiflu from a national stockpile.

Once a pandemic has started, people with a flu-like illness will mostly be assumed to have the flu. Lab confirmation will be used to track changes in the virus, not to conserve Tamiflu by checking each individual case. In fact, patients will be lucky to get through to their doctors on the phone to describe their symptoms and get the doctor’s okay to begin taking Tamiflu (if they have any stockpiled). Those who can’t reach their doctors would be wise to self-diagnose rather than wait. (Remember, Tamiflu must be started within the first two days of the illness.) And very few doctors will require a probable flu victim to come to the office or the hospital for an in-person diagnosis – far less to wait for the results of a lab test.

3. Following the protocol for taking Tamiflu is too difficult for the average patient.

In fairness, we haven’t seen this argument too often. Still, it does show up. “It’s a difficult drug to use properly,” University of Rochester expert John Treanor told Bloomberg News on December 5, 2005.

The case that patients won’t be able to use Tamiflu properly is even weaker than the case that they’ll decide to use it when all they have is a bad cold. The current recommendation is to start within two days of the onset of symptoms, and then take one capsule twice a day for five days. Doctors routinely trust their patients with medications requiring far more complex treatment protocols than Tamiflu, without deciding they need to appoint a medical guardian or act in loco parentis themselves.

4. You might forget where you put your Tamiflu.

Several state and county Tamiflu prescription guidelines helpfully point this out as one of their arguments against stockpiling. Rebuttal seems superfluous.

“It’s futile” arguments:

5. The Tamiflu might not work. The evidence that Tamiflu is effective against H5N1 is unclear; there are more lab studies on mice than clinical studies on actual patients. Most actual patients got to the hospital too late to find out whether Tamiflu would have worked if they’d got there sooner. And even if it works now, evidence is mounting that H5N1 may quickly develop resistance to the drug – so quickly that it could make a comeback even in the individual patient.

link up to indexThis is all true. Tamiflu isn’t guaranteed to do the job. Neither is staying home as much as possible, or washing your hands a lot. Most precautions aren’t guaranteed; risk managers play the odds.

Interestingly, this argument is seldom advanced as a reason why organizations shouldn’t stockpile Tamiflu – only individuals. Why are governments around the world spending millions on Tamiflu? Why does the World Health Organization recommend that they continue to do so, and why did WHO draft a plan advising its own facilities to consider stockpiling enough Tamiflu to treat 30 percent of WHO employees and their families? Why is the U.S. State Department pre-positioning Tamiflu at its embassies worldwide, for government staff and their dependents? Why do these collective gambles make any better sense than an individual bet on a Tamiflu stockpile?

This is what makes all the “it’s futile” arguments so insulting – as insulting as the “you’re incompetent” arguments. An imperfect, not-guaranteed government stockpile is nonetheless essential. But according to these arguments, an imperfect, not-guaranteed personal stockpile is stupid.

6. Even if the Tamiflu works now, H5N1 is a moving target. It will require some degree of mutation or reassortment for H5N1 to launch a pandemic: It needs to “learn” efficient human-to-human transmission. If a pandemic virus arises from H5N1, it may or may not still be vulnerable to Tamiflu.

Same answer.

7. There may never be an H5N1 pandemic. The next flu pandemic, when it comes, may be from an entirely different strain. And that strain may be resistant to Tamiflu.

Same answer. Most precautions are against risks that may never materialize. On the Flu Wiki and elsewhere, Tamiflu stockpilers routinely tell each other how much they hope they’ll never need their Tamiflu. Nor is this an unusual sentiment. People with fire insurance don’t normally hope their homes will burn down.

8. Even if there is an H5N1 pandemic, and even if Tamiflu continues to be useful against H5N1, it may all happen too late for your Tamiflu. According to its label, the drug has a five-year shelf life. What if the pandemic comes after the Tamiflu has expired?

Same answer. Fire extinguishers often expire before they’re used too; that’s usually seen as a reason for maintenance, not for going without a fire extinguisher. Also, Tamiflu’s shelf life keeps getting longer. It’s a new drug; it has lasted five years so far without losing potency; we don’t actually know how much longer it may last.

Still, as a rule people should replace expired medications, not use them. If you have Tamiflu and you never need it, prove to your doctor that you are not a hysterical nincompoop. When it expires, take it back and request a refill. By then, the supply should be more robust.

9. The chance of a pandemic is low.

On October 28, 2005, Chicago pediatrician Bennett Kaye explained to the Associated Press that he tells patients stocking up on Tamiflu “is definitely a bad, bad idea.” Why? “Parents should not be worried about their kids catching bird flu this year unless they’re planning on visiting a chicken farm in Vietnam.” Well, Kaye is right so far. Even working in backyard Vietnamese farms, hardly anyone catches bird flu. Kaye will continue to be right unless and until a flu pandemic begins. If and when that happens, his patients will start getting sick. What will he say to them then? “Now it is definitely a good, good idea to have Tamiflu. Sorry, I don’t know where to find any.”

Similarly, here’s what John Treanor, one of the nation’s foremost influenza vaccine researchers, told Bloomberg News on December 5, 2005: “Hoarding is a panic thing…. There’s no reason to hoard Tamiflu. The likelihood of a pandemic is extremely small.” We doubt that Treanor has said this to his funders; he is the Principal Investigator for one of the U.S. clinical trials of an experimental H5N1 vaccine, working long hours to develop a standby vaccine to be stockpiled against a possible pandemic.

Treanor cannot mean literally that there is unlikely ever to be another influenza pandemic. Odds are he means only that the next pandemic might not come for years (#8), and might not be H5N1 when it comes (#7). Even so, Treanor presumably thinks the odds of an H5N1 pandemic are high enough to justify his urgent effort to develop a vaccine. But he wants us to think that the odds of any pandemic (H5N1 or not) are not high enough to justify our wanting a cache of the drug that currently looks likeliest to help, while we wait for him to get his vaccine off the ground.

10. Tamiflu is not a vaccine. It can’t protect you in the future if you take it now. It is effective only while you are taking it.

Like the other “it’s futile” arguments, this one is technically accurate but irrelevant. The misperception some people have that Tamiflu works like a vaccine rarely misleads people who have looked into what’s known about pandemic influenza and made the decision to stockpile some Tamiflu. If they planned to take it immediately like a vaccine, they wouldn’t be accused of “stockpiling” or “hoarding” – words that concede they know they’re saving it in case they need it.

11. Pandemics can last as long as two years, and can be “hot” locally for months at a time. No individual could possibly accumulate enough Tamiflu to keep protecting himself or herself throughout the pandemic.

Again: true but irrelevant. It’s hard to find a private stockpiler who intends to use Tamiflu to ward off influenza for the duration of a pandemic. People know it can work that way, but they know they’ll never have enough Tamiflu to use it that way. Everyone we’ve talked to plans to wait to get the flu (if hand-washing and social distancing fail), and then to start taking Tamiflu as quickly as possible in hopes of reducing the severity of the disease and improving the odds of surviving.

Yet the accusation persists that stockpilers expect to have enough to take indefinitely. A November 15, 2005 Wall Street Journal article was entitled, “A False Sense of Security: Why It Doesn’t Make Sense to Stock Up on Tamiflu.” The headline refers to individual stockpiling, of course, not government stockpiling. Here is one reason why personal stockpiling “doesn’t make sense,” as explained by health reporter Tara Parker Pope: “[T]he flu drugs protect you only as long as you are taking them. If you are the only one in your neighborhood taking Tamiflu during an outbreak, it isn’t going to do you much good because you will be as vulnerable as everyone else the moment you stop taking the drug.”

As always, a precaution doesn’t have to be perfect to be worth taking. Stockpilers would love to have enough Tamiflu to use it for prophylaxis. They wish they did. They know they don’t. That’s no basis for telling them they should do without Tamiflu altogether.

12. A pandemic isn’t happening yet.

“We’re trying to explain to parents that avian flu is really not a concern at this point for their children,” Maryland pediatrician Kathryn Mandal told Bloomberg News on December 5, 2005. She added that she has refused to give prescriptions to about ten parents who requested a stockpile for their children.

Most or all of those parents know full well that there is no pandemic “at this point.” They also know that when there is one, Dr. Mandal will not be able to help their children get Tamiflu.

“More harm than good” arguments:

13. Taking Tamiflu unnecessarily will increase your risk of possible side effects and allergic reactions.

link up to indexTamiflu does have some side-effects, but as medicines go it is comparatively benign. It would have to be. It’s sold mostly to reduce – by a day or two – the duration of the seasonal flu, a disease from which the vast majority of patients make a full recovery. If Tamiflu does more good than harm when taken by a healthy young person with the seasonal flu, it would certainly do more good than harm when taken by people afflicted with a far deadlier strain of influenza that has launched a pandemic (assuming that strain is susceptible to Tamiflu). The argument about side-effects, then, hinges on the word “unnecessarily.” It’s really just another version of the first argument: that you’re too incompetent to save your Tamiflu till you really have the flu.

It is up to doctors to know whether their patients have specific diseases (such as some kidney diseases) or are on specific drugs (such as methotrexate) that complicate a decision to prescribe Tamiflu. And it is up to doctors to inform patients about side-effects. This is a routine, everyday part of the practice of medicine, often for drugs far more dangerous than Tamiflu.

14. Taking Tamiflu unnecessarily will increase the probability of a flu virus becoming Tamiflu-resistant. If that happens, we will have lost a potent weapon against the seasonal flu – and our best weapon against a possible pandemic.

How diseases become drug-resistant is an extremely complicated issue. We are not going to be able to do it justice. Fortunately, we don’t have to do it justice to demonstrate how specious the most frequently used resistance arguments are when applied to personal Tamiflu stockpiles.

There’s no question that viruses (including flu viruses) tend to acquire resistance to the drugs used to combat them. Every time you use any antibiotic or antiviral, you increase the probability that some bacterium or virus in your body will “learn” how to fight off that particular medication. If you then pass on the resistant bug to others, pretty soon there will be sick people for whom that medication does little or no good.

But for resistance to develop when you take the medication, the soon-to-be-resistant virus or bacterium has to be in your body in the first place. If you have the flu and take Tamiflu, you may end up helping to launch a Tamiflu-resistant strain of influenza – but presumably you think it’s worth the risk, because you have the flu, and the Tamiflu may help. If you take Tamiflu when you don’t have the flu and there is no flu circulating around you, you are profoundly unlikely to launch a resistant flu strain. Tamiflu resistance simply isn’t a problem when the flu bug isn’t there.

To be fair, there is always the possibility that you’ll start taking Tamiflu when you’re not sick, and then you’ll be exposed to the virus – in which case the virus may become Tamiflu-resistant. This may be a fairly sizable risk if you’re surrounded by people with the flu and you’re taking your Tamiflu for weeks and weeks. In other words, it may be a fairly sizable risk when someone uses Tamiflu preventively (whether it’s in the middle of a pandemic or in the middle of the annual flu season). If you mistakenly take your five-day treatment supply when you get a bad cold, the resistance risk is tiny.

All this is true, of course, regardless of whether the Tamiflu you take came from your own stockpile or a government stockpile or a doctor’s on-the-spot prescription. The most appropriate use of Tamiflu (that is, taking it quickly when you have the flu) adds to the resistance risk, wherever the Tamiflu comes from. One kind of inappropriate use of Tamiflu (taking it when you imagine you have the flu) is far less likely to lead to resistance. If it turns out that lots of people use their Tamiflu when they don’t have the flu, then the reduction in opportunities for the virus to develop resistance will be an advantage of personal stockpiling over most other Tamiflu uses.

There are some unnecessary ways to take Tamiflu that really can contribute to resistance. Here are three:

number 1
The most obvious example is starting to take Tamiflu after you have been sick with the flu for two days or more. It’s too late for the Tamiflu to do you much good, but the flu virus in your body can still acquire Tamiflu resistance.
number 2
Similarly, it is arguably “unnecessary” to take Tamiflu for the seasonal flu if you are in a low-risk group. It can still save you some genuine discomfort, so it isn’t indefensible for you to want it. Still, it’s pretty clearly a low-priority use for a scarce medication – and it does add to the resistance problem.
number 3
The use of Tamiflu for prevention of the seasonal flu is also mostly unnecessary, since there are two other plentiful drugs available for that purpose. The risk of resistance in this case probably isn’t trivial, since you’re taking the drug for many weeks when there’s a lot of flu going around. (Please note: We haven’t found much published information on the extent to which the prophylactic use of Tamiflu leads to increased resistance. Our discussion of this point is not solidly grounded in medical evidence.)

But these aren’t the unnecessary Tamiflu uses that provoke the most opposition. In the rhetoric of those who sound so annoyed about personal Tamiflu stockpiling, “taking it unnecessarily” mostly seems to mean freaking out when you have a bad cold. Most stockpilers we know understand how important it is to wait till they actually have the flu. They know they don’t have enough Tamiflu to use it preventively, and they know they won’t be able to get more if they jump the gun and take it before they’re sick with the flu. Most stockpilers, in fact, plan to get through the seasonal flu (if they catch it) without using their Tamiflu; they want to save the Tamiflu for a possible pandemic. But if they somehow screw up and start taking their five-day course of Tamiflu prematurely, their error is very unlikely to create a Tamiflu-resistant flu virus.

Many states have issued guidelines strongly recommending against personal Tamiflu stockpiling. These guidelines offer lists of reasons why stockpiling is a bad idea, including statements to the effect that “indiscriminate and inappropriate” use of Tamiflu could contribute to resistance. But many state guidelines also say that one of the highest priorities for using Tamiflu should be for prophylaxis (prevention) in high-risk patients during the annual flu season. Given the plentiful supplies of amantadine and rimantadine, which are recommended by the CDC for prophylaxis, this use of Tamiflu, in most cases, seems indiscriminate and inappropriate to us. It seems far likelier than personal stockpiling to contribute to the development of resistance.

Virginia’s and New Jersey’s guidelines are more accurate. The key sentence on Tamiflu resistance in both documents reads: “Inappropriate or widespread use may lead to resistance” [italics added]. Most states’ guidelines and most expert statements about Tamiflu resistance do not mention “widespread” use as a risk factor – though it is surely the main risk factor. They focus solely on “inappropriate” use – by which they seem to mean stockpiling your own Tamiflu and then taking it when you don’t have the flu … and as far as we can see, when you don’t have much chance of contributing to resistance either.

The frequent rhetorical linkage between causing Tamiflu resistance and taking Tamiflu when you don’t have the flu is so nonsensical that it’s a tip-off that there are strong emotional forces at work. It keeps taking us by surprise. What is the powerful motivation – beyond just wanting to discourage stockpiling – that leads intelligent, medically trained people to claim (and apparently believe) that you can create a drug-resistant strain of flu when there’s no flu around? We don’t know.

Here’s one more effort to clarify the resistance muddle.

When people who are sick with H5N1 use Tamiflu, they may well contribute to the development of a Tamiflu-resistant variant of H5N1. This seems to have happened to some Vietnamese patients
When people who are sick with the seasonal flu use Tamiflu, they may well contribute to the development of Tamiflu-resistant variants of the seasonal flu strains. This is happening in the U.S., and happening much more in Japan (which uses much more Tamiflu). Since different flu strains can reassort (mix and match), resistant seasonal strains may indirectly contribute to Tamiflu resistance in the eventual pandemic strain as well – whether it’s H5N1 or some other strain we haven’t started worrying about yet.
When people use Tamiflu preventively – when they are likely to encounter a flu virus but aren’t sick themselves – they may contribute to the development of a Tamiflu-resistant strain of whatever flu virus they encounter while taking the drug. This is true both during a pandemic and during the annual flu season.
When people use Tamiflu in the absence of any flu at all, the risk of resistance is extremely low – if not zero. The only way to make it lower still is to throw all the Tamiflu in the trash.

So what’s the likeliest way of producing a Tamiflu-resistant pandemic flu virus? Using Tamiflu during the pandemic. What’s the second-likeliest? Using Tamiflu in a last-ditch effort to smother the first sparks of a pandemic by dosing everyone in the vicinity of a novel flu virus outbreak. Third-likeliest? Using Tamiflu to treat or prevent the seasonal flu. A very distant fourth, virtually out of the running? Using Tamiflu to treat a case of flu you mistakenly think you have. Yet it is this use that opponents of personal stockpiling routinely insist is likely to launch a Tamiflu-resistant strain of influenza.

15. People who have the flu may use their Tamiflu incorrectly – not taking enough or stopping in the middle. This increases the risk of resistance.

This argument is much more sensible than its predecessor – and than most of the arguments in our typology. It is true that taking too little of a medication increases the likelihood of a resistance problem. (Picture a bloody-but-unbowed virus murmuring, “What doesn’t kill me makes me stronger.”) It’s also true that people often stop a course of medication in the middle, either because they feel better (“it worked already”) or because they don’t feel better (“it’s not working”). We suspect this will be less of a problem in mid-pandemic than it is in many other situations. The motivation to survive will keep people going for the requisite treatment course – which at present is only five days of two capsules a day, though it may be lengthened as more information surfaces. And especially if a lot of people have Tamiflu, the media will be full of information about how to take it.

Still, we can imagine a flu-afflicted family in mid-pandemic trying to share its one precious blister pack of Tamiflu. It is important to tell patients why they shouldn’t take half a treatment course – for individual health reasons as well as public health reasons. We can also imagine a sick family sharing its Tamiflu in the hope that by day three or four the government’s stockpile will have arrived. It’s hard to disapprove of that, even though the cavalry may not come in time and the result may be an increased risk of resistance.

But the risk of resistance is real whenever a drug is used in the presence of its target pathogen – even when it’s used properly. In a recent Vietnamese study, a 13-year-old girl suffering from H5N1 was treated with Tamiflu one day after her symptoms started. There is no indication she was given an incorrect dose. Yet she developed resistance. Reacting to this study, a Toronto infectious disease expert warned Canadian television network CTV that people shouldn’t try to build up a personal Tamiflu stockpile. “Before you didn’t really have this risk to others,” Dr. Neil Rau said in a December 22, 2005 story. “Now you’ve got this risk to others by stockpiling this drug … because you might take this drug in a very chaotic fashion and become a sort of a walking mutated virus bomb.”

For Dr. Rau, in other words, the finding that Tamiflu resistance developed in a patient who seems to have used the drug correctly demonstrates that you may contribute to resistance by using the drug incorrectly. This is all too typical of the illogic that pervades medical and governmental efforts to discourage personal stockpiling.

There is also recent research suggesting that the currently recommended dose of Tamiflu might not be enough to do the job against H5N1. If that’s true, individual stockpiles and government stockpiles may both turn out not to go as far as everyone hoped. And people who stockpiled “more than they needed” – and were even more excoriated than ordinary “hoarders” – may turn out to have been prescient.

16. Having Tamiflu may give people false confidence. It may therefore deter them from other useful precautions, such as frequent hand-washing.

In the empirical literature on risk and precaution-taking, false confidence makes only an occasional appearance. Far more commonly, precautions come in batches. We’ll bet our mortgage that, on average, people who have stockpiled Tamiflu take more other precautions before and during a possible pandemic than people who haven’t.

Yet many opponents of personal Tamiflu stockpiles advance the false confidence argument. “Tamiflu is not a panacea,” they intone, as if Tamiflu stockpilers imagined it were. We especially like the title of this December 14, 2005 letter-to-the-editor, posted on the Salon website: “Tamiflu: Panacea, or False Sense of Security?” Could it possibly be neither one? The stockpilers we know about do not perceive Tamiflu as a panacea, and it does not give them a huge sense of security. It is one of several ways they are coping with the uncertain risk of a pandemic.

The notion that stockpilers are so ill-informed about Tamiflu that they imagine it’s a panacea is especially amusing to the early stockpilers, the ones who asked their doctors for Tamiflu scrips before the media got interested in bird flu. Many had to tell their doctors what avian influenza was, why they were worried about it, and why they thought Tamiflu might be wise to have on hand.

D.A. Henderson is one of the world’s most eminent epidemiologists, the former head of the WHO team that wiped out smallpox. On October 19, 2005 he told Reuters: “I think Tamiflu is being regarded now as the panacea of all panaceas.”

“It’s human nature,” Columbia University epidemiology professor Stephen Morse echoed, in a December 5, 2005 Bloomberg News story. “There’s almost a talismanic quality to it…. It’s like having an amulet to ward off evil: It can give a false sense of security.” (Our historian daughter Alison Sandman tells us that in the fourteenth and fifteenth centuries, when amulets were most common in western culture, they weren’t seen as panaceas but as sensible precautions. They were used right along with other precautions, not instead of them.)

On November 12, 2005, Boca Raton infectious disease specialist Donald Heiman went even further. Heiman told the Boca Raton News that the temptation to “call the doctor and ask for Tamiflu is counterproductive” because the focus on a Tamiflu quick fix saps momentum from more important priorities like vaccination research. We are still trying to imagine the vaccine researcher or research funding organization that might be deterred by too many Tamiflu stockpilers.

Like vaccine researchers and their government funders, stockpilers see Tamiflu as just one potentially useful precaution to be tried in the absence of a vaccine. They know the Tamiflu may not work. And they know a vaccine may come far too late for most people. A false sense of security about pandemic preparedness can be found in people who are relying on the government to save them with a vaccine miracle. Similarly overconfident Tamiflu stockpilers are extremely uncommon.

Those who advance the false sense of security argument against personal Tamiflu stockpiles seldom employ that argument against other useful but imperfect precautions. Hand-washing, for example, is also not a panacea, a fact that few commentators find it necessary to point out. And nobody claims that excessive confidence in hand-washing might endanger your health or undermine vaccine research. The concern about false confidence is invariably reserved for personal precautions of which the speaker disapproves. In the case of pandemic preparedness, that usually means stockpiling Tamiflu.

17. Having Tamiflu may provoke envy and rage in those who don’t have it, thus endangering the possessor.

Might the Tamiflu “haves” end up needing to defend themselves, and their Tamiflu, against the Tamiflu “have-nots”? This sort of scenario is a staple of post-doomsday science fiction. There may be some truth to it.

But we haven’t seen it argued – possibly because it applies even more persuasively to government, hospital, and pharmacy stockpiles than to individual stockpiles. A Latin American government official commented privately that she’d rather her country had no Tamiflu at all than only a little, since rationing an inadequate Tamiflu supply might easily lead to social unrest, even to riots.

At present the United States certainly has an inadequate Tamiflu supply – enough for 2.3 million people so far (if the currently recommended dose turns out to be sufficient). More is on order, and the number should soon rise to enough for just over four million people – in a country of nearly 300 million. That’s why it makes sense to have your own personal stockpile – and why it probably doesn’t make sense to tell people you have it. (Reporters sometimes ask us if we have our own Tamiflu stockpile. We decline to answer.)

18. Tamiflu costs a lot.

Well, sort of. One ten-capsule blister pack is $79.99 on today – less than three cartons of cigarettes. (The price at your local drugstore, if it has any Tamiflu in stock, should be comparable. Note that some authorities warn that much of the Tamiflu available on the Internet may be counterfeit.)

When cost is raised as an argument against personal Tamiflu stockpiles, the point isn’t usually that you shouldn’t waste so much money on Tamiflu. (Those who imagine that stockpilers intend prophylactic use make this point; multiplying out how much you’d need to pay for enough Tamiflu to protect your family for months.) Usually the point is that it’s not fair for those who can afford the Tamiflu to be the ones who get it. A joint statement of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, for example, notes that “IDSA and SHEA also are mindful that neuraminidase inhibitors, such as oseltamivir, are expensive and, if shortages occur, persons who do not choose to stockpile or cannot afford to stockpile would have less access to the drug.”

It is certainly true that the more affluent you are, the easier it is for you to spring for the cost of Tamiflu. And the more worried you are, the likelier you are to deprive yourself of other things (three cartons of cigarettes, maybe) so you can afford the Tamiflu. It isn’t fair for affluent and worried people to better their chances of survival at the expense of their less affluent or less worried neighbors. This is, of course, part of the reason why the government should monopolize all the Tamiflu – although it’s unlikely that any government allocation plan will be fair either, even if it ends up being the best way to help society get through a pandemic. If you find the fairness argument ethically persuasive, you might want to consider buying up as much Tamiflu as you can for distribution to healthcare centers that serve the poor.

Does Anyone Favor Personal Stockpiles?

link up to indexWe have found precious few statements in which medical or government authorities, or even individual physicians, spoke out in favor of personal Tamiflu stockpiles. Those we found faced quick criticism from their peers.

In February 2005, Swedish scientist Hans Wigzell told the press: “I will stockpile my own antiviral medication and I know of other doctors who are doing the same to protect their families.” Wigzell is senior science advisor to the Swedish Prime Minister, and former president of the Karolinska Institute. According to The Local, an English-language digest of Swedish news, an official from the Swedish Institute for Infectious Disease Control “reacted angrily and called Wigzell’s comments careless and inappropriate, citing concerns that self-medication could lead to resistance.” The Wall Street Journal reported that “critics on radio and television shows denounced Dr. Wigzell as a scaremonger.” Wigzell responded to his critics: “There is nothing wrong with people wanting to protect their families with medication when a global influenza epidemic is at our front door.”

In October 2005, similarly, a spokesperson for a World Health Organization regional office in Asia said positive things about personal stockpiling on Hong Kong’s RTHK radio. His remarks were quoted in the Bangkok Post as follows: “We do recommend that in the average household you do have Tamiflu if you can afford it, and if you can find it in the present circumstances. It will in the case of a pandemic possibly, lower the symptoms – that’s all. It will not stop a pandemic but it might make you feel a little bit better, it might make you feel a little bit stronger. In the end, you might survive rather better than if you didn’t have it.” (This was the only example we found in which any WHO employee publicly endorsed personal Tamiflu stockpiling.) According to the Post, Hong Kong officials and doctors “rejected the advice,” and worried that the statement could provoke “panic-buying of Tamiflu,” which “will create even more stress.” The Post noted that “the Hong Kong government has also advised people not to stockpile Tamiflu … and warned that improper use might render it powerless against the [bird flu] virus.”

Most national, state, and local governments also oppose personal stockpiling. But we did find one government that is at least open to it. The New Zealand Ministry of Health FAQs page on antivirals and pandemics includes this very respectful exchange:

I’m worried about bird flu and an influenza pandemic. Is Tamiflu available, should I wish to add it to my first aid kit?

This is something you will need to discuss with your doctor. Tamiflu is a prescription-only medicine in New Zealand and is not subsidised by the Government.

Whether it is prescribed by a GP to a patient or not, at the patient’s request, is at the discretion of the GP. The issues that would have to be covered in a consultation would then be the specific indications for the use of the medicine and the importance of timely administration, emphasising that the best way to prevent influenza is by vaccination.

The Ministry of Health cannot restrict the prescribing of a registered medicine which is not Government funded. With a prescription, Tamiflu can be purchased at community pharmacies, but some pharmacies may have to order in stock.

It is worth noting that any community prescriptions for Tamiflu will not come from the Government’s national stockpile.

The health departments of New Jersey link is to a PDF file and Virginia link is to a PDF file have published guidelines that – like most states’ guidelines – recommend against personal Tamiflu stockpiling. The anti-stockpiling arguments, including many of the ones in our typology, are collected in a section entitled “Problems with prescribing oseltamivir.” But unlike many other states’ Tamiflu guidelines, the New Jersey and Virginia guidelines include two additional sections: “Reasons to consider prescribing oseltamivir” and “Recommended topics to cover in patient education if oseltamivir is prescribed.”

There is only one place where pro-stockpiling statements, often alongside anti-stockpiling statements, are plentiful: non-governmental pandemic-focused websites. Many of these statements are compatible with our position in this column. (Some aren’t.) Here are a few quotations from Flu Wiki’s forum on personal stockpiling:

  • “I have not one single doubt that those who have gone to the trouble and expense of obtaining Tamiflu for themselves and their loved ones will do far more [during a pandemic] to benefit themselves, their families, their neighborhoods, this country, than anything our current leaders will ever do.”
  • “If those who took this seriously enough to be proactive and get antivirals survive and thus become resistant, they may also be proactive enough to help others during a pandemic.”
  • “Then there is the argument that it would be bad if people started to use it improperly and/or unnecessarily and that medical advice is important. Well I know that it is a prescription drug and certainly would try to get all the medical advice over the phone that I could before giving or using it, but that seems a sort of paternalistic reason for saying that I should not have it.”
  • “My wife and I are retired. We do not have a lot of income. We chose to stockpile Tamiflu again at great financial sacrifice. We believed 6 months ago that it would never be delivered by our government to an old couple in North Dakota. So we bought it while it was available.”
  • “In a capitalist economy, demand stimulates supply. So the more people buy and stockpile Tamiflu, the more Roche and the Generic crowd are going to make in order to supply the demand. If no one buys Tamiflu, then no one will be bothered to make it. Why would they? If having Tamiflu makes you feel safer, by all means, buy some and stash it away. Hopefully it will sit in the cupboards, never used…. Much to everyone else’s amusement.”
  • “In my opinion, it is much better that there be a cadre of folks in the country that have access to the drug and hopefully have taken the time to learn how to use it properly for use during the pandemic than for the drugs within the National Strategic Stockpile to remain in warehouses guarded to the last man by the US Army waiting for orders from FEMA that never arrive.”
  • “If you haven’t made up your mind yet, the [state] recommendations are food for thought. If you have, fine. Whichever way you decide, you have nothing to apologize for.”

The New England Journal Commentary

link up to indexThe December 22, 2005 issue of the prestigious New England Journal of Medicine includes a commentary on personal Tamiflu stockpiling that embraces many of the anti-stockpiling arguments listed above. Written by doctors Allan S. Brett and Abigail Zuger, it is entitled: “The Run on Tamiflu – Should Physicians Prescribe on Demand?” It isn’t the most offensive piece we’ve ever read about personal Tamiflu stockpiling. Its arguments are typical. But it is the piece that finally provoked us to write this column.

What follows is a detailed textual analysis of this one anti-stockpiling article. Readers who have already read enough of our case against the (specious) case against stockpiling may want to skip to the next section, where we say something new.

The New England Journal article begins by noting – correctly – that a patient request for just-in-case Tamiflu is an ethical dilemma for the doctor. But the authors do not acknowledge that the ethical dilemma exists precisely because it is best for the patient if the doctor provides the desired prescription, but best for society if the doctor declines (or, rather, if all doctors decline), so the Tamiflu will still be there if the government needs to ration it. Instead of wrestling with this excruciating dilemma, the authors make it go away – by denying that society’s interest and the patient’s interest conflict. They assert explicitly that the public health perspective and the individual perspective “both point in the same direction in this instance.” Thus they have no trouble urging doctors to just say no.

Their argument begins this way:

Physicians are trained and licensed to practice medicine according to scientific evidence and professional standards. When there is at least a modicum of benefit from the perspective of conventional medicine, physicians should generally defer to patients’ requests, and a patient’s weighing of benefits and harms should drive the decision. But if a patient requests an intervention that falls outside the boundaries established by scientific evidence, a physician is not obligated to provide it.

This makes complete sense. If the patient asks for something reasonably sensible and medically defensible, the doctor ought to go along. If the patient asks for something that the doctor knows to be futile or even harmful to the patient, the doctor should refuse.

So why do the doctors writing this article think they know that individual Tamiflu stockpiles are futile or even harmful to patients? Remember: This horn of the dilemma has to do with benefit or harm to the individual patient. The other horn has to do with benefit or harm to public health. The doctors are not addressing that yet. Why do they think a personal Tamiflu stockpile would not provide even a “modicum” (their word: “a small or moderate or token amount,” according to the dictionary) of benefit to the individual patient? Their answer begins with this key sentence:

In the case of avian influenza, a human outbreak in any given geographic area is currently a purely hypothetical concern; physicians are not required to dispense medications for hypothetical scenarios when it is not yet possible to determine who is at risk.

In other words, doctors don’t have to prescribe for a “hypothetical” outbreak before they know who’s going to be endangered. This is disingenuous. Every doctor knows that in previous pandemics the entire population was at increased risk (over the baseline risk during a seasonal flu outbreak). And every doctor who writes about pandemic preparedness ought to know that one major concern is a possible rerun of the 1918 Spanish Flu pandemic, which killed huge numbers of healthy people.

Bear in mind that doctors prescribe for hypothetical problems all the time. They instruct cardiac patients to carry nitroglycerine in case their hypothetical heart attack actually happens. They urge patients with severe allergies to carry an EpiPen in case a hypothetical insect stings them. They make sure parents of young children have a bottle of ipecac handy in case a child swallows a hypothetical poison. They tell their patients who are traveling overseas to take all sorts of medications with them, to be taken if, hypothetically, they are needed under circumstances that might make them difficult to obtain. In each case, the doctor prescribes a medicine that isn’t needed yet – and may never be needed, and may not work if it is needed – because the doctor realizes that it will be too late to prescribe it later, if and when the need arises.

Exactly the same is true for Tamiflu. There is precedent, in fact, for prescribing Tamiflu and other antivirals for a hypothetical outbreak of influenza. The prestigious Advisory Committee on Immunization Practices recommends pre-approved orders for these drugs in nursing homes, to expedite prophylactic administration when flu breaks out.

If a pandemic happens while the Tamiflu scarcity continues, we know with near-certainty that individual prescriptions for Tamiflu will no longer be filled, and that government stockpiles will be insufficient for everyone. No one is quite sure yet how the government stockpile will be dispensed. This is why many organizations have tried to amass their own stockpiles, to be used when needed by employees and their families. (Among these organizations is the U.S. Department of State. On October 19, 2005, the State Department website described its plan to “pre-position the drug Tamiflu at its Embassies and Consulates worldwide, for eligible U.S. Government employees and their families serving abroad.”) If the patient is going to have Tamiflu during a pandemic – when the chances of catching influenza are estimated to be roughly three in ten – the patient needs to obtain the Tamiflu now.

The second-most stunning flaw in Brett and Zuger’s commentary is their failure to mention this well-established reality. The most stunning flaw is their failure to acknowledge the conclusion that arises from this reality: that it is genuinely better for the individual patient to have a stash of Tamiflu than not. Could the authors possibly not have realized that it’s now or never for their hypothetical patient? Could they possibly not have seen this as relevant to the question of whether the individual patient is better off or worse off with Tamiflu in the cupboard?

It is better for the individual to have Tamiflu in the cupboard. It is better for society if the government controls all the Tamiflu. Those are the two horns of the ethical dilemma. You have to wrestle with the dilemma. You have to agonize over it. You can’t just make one of the horns go away by not mentioning it.

After this extraordinary false start, the authors continue to build their case against personal Tamiflu stockpiling:

If a human outbreak occurred, it is unclear whether the virus would be generally susceptible to oseltamivir and whether this drug would still be the treatment of choice. Moreover, in an epidemic, any indicated drug could be used in several different ways – for preexposure prophylaxis, postexposure prophylaxis, or treatment after symptoms have appeared. If oseltamivir were dispensed well in advance of an outbreak, patients would probably use their stockpiles in a chaotic fashion, rather than optimally for any of these indications. Indeed, some or most of it would no doubt be wasted on viral illnesses other than influenza.

There are three arguments here: (1) The Tamiflu may not work. (2) Another drug may work better. (3) The patient is likely to use the Tamiflu suboptimally, “in a chaotic fashion” – in fact, “some or most of it would no doubt be wasted” on illnesses other than flu.

The first two arguments are true. The Tamiflu may not work, and another drug may work better. But Tamiflu is so far considered the best bet – no guarantees – for pandemic preparedness. That’s why so many governments are amassing their own stockpiles, and why the World Health Organization, the CDC, and other respected organizations recommend national stockpiling. And doctors routinely try to provide a “modicum of benefit” for their patients, often against long odds, by prescribing treatments that may not work (including treatments with horrendous side-effects). Finally, it is blindingly clear that if Tamiflu does turn out to be the treatment of choice in an actual pandemic, the average doctor will no longer have the ability to help sick patients get any. Failing to acknowledge these points is beyond disingenuous.

As for the third argument, the authors provide no citation for their patronizing claim that patients would waste their Tamiflu or use it chaotically. No doubt some would, just as patients occasionally misuse their nitroglycerine or their EpiPens. But if most patients are truly this incompetent, the rules for prescribing all medications should be altered. There are certainly published data about patients failing to take antibiotics properly – including patients who are doctors and the families of doctors. There are also published data about doctors unwisely and unnecessarily prescribing huge quantities of antibiotics for patients to take for symptoms that were clearly not bacterial. Thus it is surprising to see unusually forethoughtful patients singled out as misbehaving – and as misbehaving not because they want to take the drug now but because they want to stash it away for possible future need.

If Doctors Brett and Zuger believe they have patients who are likely to misuse Tamiflu, they need to spend more time educating those patients on its proper use. First, we recommend that they spend more time listening to how their patients plan to use their Tamiflu, subjecting the hypothesis of probable misuse to the empirical test of a respectful two-way doctor-patient conversation.

What is most remarkable about these three arguments – Tamiflu may not work; another drug may work better; the patient is likely to misuse the Tamiflu – is their irrelevance. Remember, this horn of the dilemma is all about the individual patient’s welfare. If the Tamiflu doesn’t work, or if another drug works better, is the patient worse off than if she had no Tamiflu? Not unless you hypothesize a situation where there is plenty of some soon-to-be-unveiled preferable medication to be had, but our patient steadfastly stands by her Tamiflu, refusing to avail herself of the better treatment. Hypothetical indeed! The same is true if the patient uses the Tamiflu suboptimally, or even wastes it entirely. Brett and Zuger do not claim that Tamiflu might actually harm the patient. But absent a dangerous side-effect, it is inconceivable that the patient is better off facing a possible pandemic with nothing than with Tamiflu. If the probability of a flu pandemic is significantly greater than zero, the patient is self-evidently better off with Tamiflu in the cupboard.

Having cavalierly (or obliviously) disposed of the individual’s case for wanting Tamiflu, the authors find it easy to argue that public health interests should prevail. “From a public health perspective,” they rightly assert, “preventive or therapeutic interventions should be optimally allocated across a population.” Notice how the grounds of the argument have shifted. Individuals shouldn’t want Tamiflu stockpiles in part because the Tamiflu might not work. Government stockpiles are needed because the Tamiflu might work.

Now the authors can mischaracterize the ethical dilemma as “the tension … when a person demands an intervention that is perceived as conferring individual benefit but that might contribute to net harm to the public health” [italics ours]. The personal Tamiflu stockpile isn’t just perceived as conferring individual benefit. It really does. It really contributes to net harm to public health too. That’s the dilemma! If this New England Journal commentary was intended to explore the personal stockpiling dilemma and help doctors think it through, it fails as balanced discussion, because it illegitimately makes one horn of the dilemma disappear. If it was intended to help doctors persuade patients not to want to stockpile Tamiflu, it fails as risk communication, because it insults the patient’s competence and fails to acknowledge the patient’s valid and rational arguments for personal stockpiling.

Next Brett and Zuger return to their public health argument:

The current supply of oseltamivir is inadequate to meet the demand that would arise in the event of an avian influenza pandemic. Moreover, personal stockpiling of oseltamivir depletes the supply available for patients who could benefit from the drug during the usual human influenza season: a person who is assertive enough to ask for a prescription does not necessarily need the drug more than unassertive people do. The likely confusion about whether to use stockpiled oseltamivir for prophylaxis or treatment and the probability that much will be used for illnesses other than influenza are relevant from the public health perspective as well. Finally, the inappropriate or chaotic use of oseltamivir will increase the risk that resistant strains of influenza virus will develop. These considerations strongly suggest that random stockpiling of oseltamivir would confer no benefit to the overall population and would probably confer harm.

How could Brett and Zuger have written the first sentence of this paragraph – that in a pandemic there won’t be enough Tamiflu for everyone who needs it – without pausing to reconsider their earlier assertion that patients have no good reason to seek a personal stockpile now? But in any case they’re right; public health during a pandemic is indeed better served if all the scarce Tamiflu is systematically allocated.

But then the authors go off the rails. In the second sentence they assert that personal Tamiflu stockpiling “depletes the supply available for … the usual influenza season.” This is technically true but amazingly off-target. Consider four facts. One, in the U.S. we have other drugs (amantadine, rimantadine, and Relenza) that are FDA-approved for treating the seasonal flu (though the CDC does recommend the first two mostly for prophylaxis). Two, we have a vaccine against the seasonal flu, enough for about 80 million Americans. Three, the seasonal flu has much lower rates of mortality and morbidity than are feared with respect to an influenza pandemic. And four, until pandemic concerns provoked a run on Tamiflu, the drug was languishing; it was seldom prescribed in the U.S. or most of the world (Japan was an exception).

Healthy people usually take nothing for the flu; doctors treating high-risk patients can choose among amantadine, rimantadine, Tamiflu, and Relenza. Granted, Tamiflu is now trendy and there will be increased demand for it as a treatment for the seasonal flu. Do Brett and Zuger support this new demand? Do they want to see Tamiflu frittered away (especially on low-risk patients) during the annual flu season, when there are approved alternatives? Why aren’t they worried about increasing the chances of Tamiflu resistance in the circulating strains of flu – thereby also increasing the chances of Tamiflu resistance in any pandemic strain that might emerge from reassortment with circulating flu strains? In the face of the pandemic risk, Brett and Zuger are on solid ground when they argue that government Tamiflu stockpiles are a higher societal priority than personal Tamiflu stockpiles. On what ground can they argue that using Tamiflu against the seasonal flu is also a higher priority (except in situations where the patient is at high risk and none of the other three drugs will do)? This argument is so commonly advanced, and so thoroughly incomprehensible, that it almost seems as if commentators are okay with any use of Tamiflu, so long as it doesn’t end up in people’s personal pandemic preparedness stockpiles.

The apex of irrationality is the claim later in the paragraph that “the inappropriate or chaotic use of oseltamivir” will increase the risk that resistant strains of influenza virus will develop. Now, it isn’t impossible for inappropriate use of medicines to contribute to resistance; stopping a course of antibiotics in the middle can do so, for example. But remember what type of Tamiflu misuse Brett and Zuger have been fretting over: “Indeed,” they write, “some or most of it would no doubt be wasted on viral illnesses other than influenza.” Here is one thing we can safely say about people who take Tamiflu when they don’t have the flu: This error is profoundly unlikely to lead to resistance in an influenza virus not present in their bodies. It is overwhelmingly the appropriate use of Tamiflu – that is, its proper use by people who have the flu – that threatens to produce a Tamiflu-resistant strain of influenza. In this context, if we are hopeful of using Tamiflu against an eventual pandemic strain (which could result from a novel flu virus like H5N1 reassorting with a human flu), we should think twice before prescribing it profligately for the seasonal flu.

Brett and Zuger recommend “explicit directives” from federal and state agencies, telling doctors not to prescribe Tamiflu for personal stockpiles. That would make sense – as would a directive not to prescribe Tamiflu for the seasonal flu either, except as a last resort – as part of a government effort to centralize the national Tamiflu stockpile for allocation in a pandemic. But even in the absence of explicit directives, Brett and Zuger think doctors face a fairly easy choice, since they insist that the public health perspective and the individual perspective “both point in the same direction in this instance.” They conclude their commentary with these words: “[P]hysicians should decline any request for a prescription for the purpose of stockpiling oseltamivir, optimally with an explanation that reflects the reasoning here.”

It is arguable whether or not physicians should decline to help their patients stockpile Tamiflu. The answer depends on whether physicians owe their primary allegiance to their patients (who have a valid expectation that they may need the drug) or to public health (which has a higher use for the drug on behalf of society at large). If physicians do decide to decline, we hope they will come up with more coherent and more respectful reasoning than that offered by Brett and Zuger.

Your Decision, the Government’s, the Doctor’s, or Roche’s?

Much depends on whose decision it is. Who decides whether you get some Tamiflu?

If it’s up to you….

link up to indexRationally, you ought to want some Tamiflu. Only altruism – and faith in the government – could justify deciding to do without. To optimize its potential benefit to yourself and your family, keep your Tamiflu at room temperature. Don’t tell a lot of people you have it. (You don’t want to provoke a fight or a break-in if the pandemic happens.) And don’t use it until you have the flu. If you catch the flu during a normal flu season, think about whether to save your Tamiflu anyway. Most people not in high-risk groups get through a bout of the flu without professional help, so if you wouldn’t have sought antiviral treatment in the past, you’ll probably want to save your Tamiflu for a pandemic. Remember that it might not work, and that even if it does you’re better off not getting sick in the first place – so you still need to think about hand hygiene, social distancing, and other aspects of personal pandemic preparedness. If your Tamiflu reaches its expiration date before there’s a pandemic, take it in to your doctor to prove you didn’t use it inappropriately or chaotically – but don’t discard it until you’ve filled a new prescription.

How do you tell if you have the flu? In normal times, use the helpful diagnostic chart “Is It a Cold or the Flu?” on the website of the U.S. Department of Health and Human Services. Note that the current (as of January 2006) Food and Drug Administration website page on “What to Do for Colds and Flu” says you “usually do not have to call your doctor right away,” advising instead to wait and see if your symptoms get worse or last a long time. But for Tamiflu to work it has to be started within 48 hours after the onset of symptoms; within 36 hours is even better. Think about that. The official U.S. government advice for coping with the seasonal flu is predicated on the assumption that nobody expects you to take Tamiflu. Brett and Zuger (and many others) don’t want patients stockpiling Tamiflu for a possible pandemic so it will be available instead for a use the government’s standard advice routinely rules out. If you want to take Tamiflu for your seasonal flu (or for a pandemic flu), you can’t wait to see how your symptoms develop.

Things may be different during a pandemic. For one thing, the list of typical symptoms – the “case definition” – may change. And it will be hard to get medical care quickly; hospitals and doctors’ offices will be swamped. With luck, patients may at least be able to get telephone guidance early enough to start medication, if it’s indicated and if it’s available. If the pandemic has reached your town, and you can’t reach a doctor, and your symptoms sound a lot like what your TV set or health department website is describing, you’ll probably have to decide on your own to start taking your Tamiflu.

If you can’t find any Tamiflu to stockpile, think about stockpiling Relenza instead. Almost everything we say in this column about Tamiflu is true of Relenza as well: It may or may not work in a pandemic; the more it’s used the greater the chances of a resistance problem; it is in short supply, so somebody needs to make difficult allocation decisions; etc. There are two main differences. First, Relenza is contraindicated for more patients than Tamiflu; many of the elderly, in particular, have breathing problems that rule out a drug that can cause bronchospasm. And second, Relenza has had enormously less publicity than Tamiflu. (Google hits for “Tamiflu”: 4,810,000. For “Relenza”: 767,000.) It wouldn’t be crazy to work toward a societal consensus that Tamiflu should be reserved for government pandemic stockpiles and for treating high-risk patients with the seasonal flu, while Relenza should be available to people with no contraindications on a first-come first-served basis for personal stockpiles.

You are not obliged to put a higher priority on your own health and your children’s health than on public health. We will all be better off if everyone leaves the Tamiflu (and even the Relenza) unclaimed until the government gets around to seizing it, hoarding it, and eventually allocating it where it’s most needed. Of course if you decide to do without, the odds are pretty good that someone less altruistic than you are will take the blister pack that might have been yours. Given that it is still legal for doctors to prescribe Tamiflu for their patients to stockpile, you can’t guarantee that the medicine you forgo will end up in government hands. Still, you may choose as a matter of personal ethics not to seek a personal stockpile. It is an admirable position to take.

If it’s up to the government….

link up to indexRationally, the government ought to want a Tamiflu monopoly. The U.S. government was slow to stockpile much Tamiflu. When it first started working on pandemic preparedness, it bet mostly on vaccine development instead. (This was a reasonable judgment call.) So the U.S. has less Tamiflu stockpiled, proportional to population, than many other developed countries. The government has ordered more, but so have scores of other governments, and we’re near the back of a long line. We’ll be in better shape after Roche opens up a Tamiflu factory in the U.S., as planned; once a pandemic seems imminent, most experts predict that Tamiflu imports and exports will cease, and only countries with their own factories will have a continuing supply (if they can get the raw materials). But right now, the U.S. has a serious Tamiflu shortfall compared with many other western governments.

In some ways that shortfall makes it harder for the U.S. government to decree that all available Tamiflu should be in centralized stockpiles. Having passed up earlier opportunities to order a significant amount of Tamiflu for a national stockpile, is the government really entitled to take “your” Tamiflu instead? On the other hand, having passed up earlier opportunities to order a significant amount of Tamiflu for a national stockpile, the government really needs “your” Tamiflu. Bottom line: The rational thing for the government to do is to swallow its embarrassment and seize control over what’s left of the Tamiflu supply. And the rational thing for you to do is try to get yours before that happens.

If it’s up to the doctor….

link up to indexNow the hard case: What if it’s up to the doctor?

It’s not difficult to conjure up scenarios in which the interests of a particular patient and the interests of society are in conflict. Some of these issues have long been settled. Suppose a horrible person is sick and it’s clear that the world would be better off if he died. The doctor must treat him anyway, putting the patient’s medical interests ahead of society’s non-medical interests. Other issues are still unsettled. If the horrible person tells the doctor details about crimes he’s planning to commit after he recovers, as a rule the doctor must respect patient confidentiality, putting the patient’s non-medical interests ahead of society’s non-medical interests. But this is such an uncomfortable principle that we keep carving out exceptions where the doctor is obliged instead to rat the patient out to the authorities: if the patient plans a serious crime of violence, if the intended victim is a child, etc.

When the medical interests of one patient come up against the medical interests of another, the doctor is allowed to decide whose acute need is greatest. Doctors do that every time they triage the patients in the waiting room, bumping a patient with chest pain to the head of the line and making less sick patients wait. “She has an emergency” trumps “I have an appointment.” During last winter’s U.S. flu vaccine shortfall, similarly, doctors who had some vaccine doses but not enough for all their patients often reserved the limited supply for their high-risk patients. This seemed pretty obviously unobjectionable when the high-risk patient was an actual person: “I have an elderly patient coming in tomorrow who needs this dose more than you do.” It seemed more debatable when the high-risk patient was hypothetical: “There may be patients in the weeks ahead who need this dose more than you do.” (As with stockpiled Tamiflu, some of the vaccine that was hoarded for high-risk patients ended up wasted.)

The same decision seemed more debatable still when the high-risk patient was somebody else’s hypothetical patient. Many doctors told reporters that they agreed with the rationale for reserving scarce vaccine for high-risk populations, but they wanted it to be official policy so they wouldn’t have to be the ones to decide that their own patients should go without. Very quickly, many states legally reallocated the available vaccine supply, preempting the decisions individual physicians would otherwise have had to make. In the remaining states, the various medical associations (and the federal government) recommended “voluntary” reallocation. That didn’t mean just that they were asking lower-risk patients to volunteer to do without the flu shot. They did ask low-risk patients to stand aside. But they also asked doctors to “volunteer” to refuse to vaccinate their low-risk patients, and instead to turn over all or most of their vaccine to local governments, to be reallocated to people in the high-risk categories.

Judging from the news reports, most doctors went along. The reports don’t reveal whether they went along without thinking about it much, or because they considered it obviously the correct decision, or only after agonizing over the ethical dilemma. The virtual absence of coverage of any protests from doctors, or even of spirited medical debate, strongly suggests that it wasn’t the third possibility. But the dilemma was real, whether doctors agonized over it or not: Should doctors deprive their very own patients of a medically useful intervention in order to benefit others who need it more? Your patient wants the shot; you have some vaccine left; it is a legally permissible and medically indicated use that will confer on your patient at least a “modicum” of benefit; you haven’t committed the vaccine to a needier patient of your own – but the government would prefer that you give it away for somebody else’s needier patient who might or might not turn up wanting it. Medical codes of ethics can be read to support either choice. We don’t think it was the no-brainer it was usually considered to be. It deserved debate and careful thought.

Near the end of the flu season, the CDC issued a news release thanking 17 million healthy Americans for voluntarily forgoing the flu shots they usually got. The release gushed with praise for our generous self-sacrifice. It didn’t mention that in the vast majority of cases we had no choice; state governments, medical societies, and our individual doctors made the choice for us. Dozens of news outlets covered this announcement under the headline, “Millions stepped aside to let sick, elderly get flu shots.”

The Tamiflu dilemma is obviously similar – that is, if you accept our contention that the patient is better off with a personal stockpile and society is better off with a centralized stockpile. The patient’s medical interests conflict with society’s medical interests. What’s a doctor to do?

Perhaps the ethical policies of the American Medical Association will help. Policy E-2.03 is entitled “Allocation of Limited Medical Resources.” It begins: “A physician has a duty to do all that he or she can for the benefit of the individual patient.” It goes on to offer fairly specific guidelines for “decisions regarding the allocation of limited medical resources among patients” – focusing particularly on organ transplants. Then it returns to its starting premise: “The treating physician must remain a patient advocate and therefore should not make allocation decisions.” Sounds clear enough. The AMA seems to be saying that deciding who needs the scarce resource most should be left to governments and medical institutions; that insofar as the individual doctor has a choice, the doctor must look to the needs of the patient in the room. Give that patient some Tamiflu!

The Australian Medical Association’s Code of Ethics is remarkably similar. Article 1.1(a) almost settles the matter at the outset: “Consider first the well-being of your patient.” Article 3(b) adds clarification: “Protect clinical independence as it is essential when choosing the best treatment for patients and defending their health needs against all who would deny or restrict necessary care.” Article 4(c) nails it: “Use your special knowledge and skills to minimise wastage of resources, but remember that your primary duty is to provide your patient with the best available care.” In other words, allocation of scarce resources is somebody else’s top priority; the doctor’s top priority has to be to “provide your patient with the best available care.” Give that patient some Tamiflu!

But principles are one thing, applications another. On November 1, 2005, the American Medical Association issued a news release that addressed Tamiflu. It didn’t say whether doctors should prescribe it if asked – thus bypassing the doctor’s ethical dilemma. It said patients shouldn’t ask. Here’s why:

Stockpiling of antivirals, such as Tamiflu, to have on hand “just in case” is not recommended for individuals because of the risk that symptoms not related to avian flu will prompt people to initiate unnecessary treatment. In addition, these drugs are needed to confront the real risk of human flu-related illness and deaths that occur annually in the elderly and other high-risk individuals.

Needlessly taking an antiviral may contribute to the problem of resistance to that antiviral drug, which would then make the drug less useful in the event of an actual avian flu outbreak. Responsible use of antivirals for flu is critical to the health of Americans – and the health of people throughout the world.

The arguments are familiar. Don’t get your own Tamiflu because you’re too incompetent to wait till you have the flu – leave aside that doctors routinely trust patients with other medications to be used if and when they are needed. And don’t get your own Tamiflu because we need it for the seasonal flu – leave aside that we have other drugs for the seasonal flu (not to mention a vaccine) and have only sparingly prescribed Tamiflu in the past. And don’t get your own Tamiflu because when you use it needlessly you’ll contribute to resistance and make the drug less useful in a pandemic – leave aside that people who use their Tamiflu when they don’t have the flu are far less likely to produce Tamiflu-resistant flu viruses than people who use it when they have the flu … and that if doctors are worried about resistance during a pandemic the last thing they should want to do is prescribe Tamiflu profligately for the annual flu, which might end up reassorting with a novel virus. The sound argument for not getting your own Tamiflu – that the government needs to allocate what little we have to the highest-priority uses, and you don’t make the cut – isn’t even mentioned.

As for the Australian Medical Association, on September 29, 2005 its President, Dr. Mukesh Haikerwal, had this to say on ABC Radio’s “The World Today”:

There is no need to turn into panic, there’s no need to be buying these tablets and there’s no need to be buying the sprays right now. We don’t have a pandemic of influenza…. At this point in time we have no reason, within Australia, to prescribe the Tamiflu. There is no bird flu. There may be some influenza there, but it’s certainly not at pandemic levels.

This is insulting on its face, implying that Australians think there is currently a pandemic, and that the judicious, forethoughtful decision to buy a scarce drug in advance is tantamount to panic. But advising against Tamiflu stockpiling in Australia is less foolish than the same position is in the United States. Australia has an enormously bigger per capita government Tamiflu stockpile than the U.S. – quite possibly enough to treat everyone who falls victim during a pandemic. On the other hand, it would be a daunting logistical task for the Australian government to get its Tamiflu to everyone who’s sick within 48 hours of the onset of symptoms. Personally, we’d rather have it in the cupboard.

Moreover, Haikerwal undercuts his own case elsewhere in the interview, when he emphasizes that there will be more important uses even for Australia’s substantial stockpile than treating the sick: “We need to be using the tablets and the sprays for people who are well, to keep them well, whilst the vaccine is being developed, and that’s where we need to use the stockpiles wisely.” So Haikerwal thinks the government not only needs a stockpile (even though there’s no pandemic yet); it needs to save its stockpile for strategic use to keep society going, not squander it on vulnerable populations or ordinary people who happen to get sick. This is a sensible policy, more hard-nosed than most American experts are willing to sound in public. We would vote for such a policy. But if Australia plans to use its stockpile for healthcare workers and cops, why wouldn’t ordinary Australians want a personal stockpile as well?

And if a patient wants a personal stockpile, on what ethical basis does that patient’s doctor decide that a government stockpile or a prospective future patient is a higher priority?

If it’s up to Roche….

link up to indexIt may all be moot anyway. If you can persuade your doctor to prescribe Tamiflu for you, you may or may not be able to find a pharmacy that has any.

The problem isn’t that there’s no Tamiflu left. Roche does have a multiyear backlog of government orders, but in late October 2005 the company said it would continue to sell into the North American pharmacy market – but only to areas currently experiencing seasonal flu outbreaks. The stated goal was to help prevent personal stockpiling.

The October 27 Reuters story was headlined: “US hoarding prompts flu pill maker to halt supply.” (Vocabulary note: When the word “hoard” is used in the media, it almost always refers to individuals. Governments “stockpile.” There’s an exception, however: Not surprisingly, non-western sources sometimes talk about western government stockpiling as “hoarding.”) Here’s how the Reuters story starts:

ZURICH (Reuters) – Drug maker Roche halted supplies of its Tamiflu pill to the United States on Thursday to head off hoarding by consumers fearing bird flu….

Roche Holding AG said it had halted deliveries of Tamiflu to the United States and Canada until the start of the flu season. Media coverage of the spread of the deadly H5N1 strain of bird flu had driven sales higher, the company said.

“This resulted in increased demand for Tamiflu in part from individuals who are doing private stockpiling and at the moment there is no influenza circulating and the threat of a pandemic has not [materialized],” a spokeswoman said.

“Our priority is to ensure that Tamiflu is available for seasonal use and to fulfill government orders,” she added.

Health care information collector Verispan said more than 67,000 U.S. Tamiflu prescriptions were dispensed for the week ending October 21 – quadruple the demand from the same week last year….

In an interview with the Canadian Press, Roche’s Paul Brown said that “prioritizing for the seasonal epidemic … is a corporate-wide priority.” He added that the decision wouldn’t affect the company’s efforts to fill orders from governments for their own stockpiles. In other words, Roche says it has two supply streams. One is earmarked for massive government orders, to be stockpiled against a possible pandemic. The other, reserved for private use, was running out before the flu season even began. So Roche made its own judgment that having Tamiflu available later to sell to people sick with the annual flu is a higher use for the remaining supply than selling it now to people worried about a pandemic. Roche, ironically, decided to hoard its Tamiflu.

Also on October 27, another Roche spokesperson told The New York Times that the company would provide twice as much Tamiflu for the seasonal flu in 2005-06 as it did in 2004-05. If you believe what Roche is saying about a separate supply for governments, this doubling of the Tamiflu available for the seasonal flu has to come at the expense of how much is available for personal stockpiles.

You can understand Roche’s position. Until people started worrying about a pandemic, Tamiflu sales were disappointing – so much so that the drug’s inventor, Gilead Sciences, was suing Roche for not marketing it adequately. In most of the world, healthy people got through the flu with nothing, while those in high-risk populations were mostly given amantadine or rimantadine, both older and cheaper medications. (These two drugs remained commonly used for both prophylaxis and treatment, despite a rise in seasonal flu viruses resistant to them.) Then along came H5N1, a much more frightening influenza strain said to be already resistant to amantadine and rimantadine but not (yet) to Tamiflu. Tamiflu was suddenly hot.

For Roche, there are two problems with selling into the pandemic stockpile market. First, there’s the distinct possibility that Tamiflu will turn out not to be effective against the version of H5N1 (or some other novel flu virus) that launches a pandemic. And second, there’s the distinct possibility that there won’t be a pandemic for years, even decades. Why sell a product that people keep on their shelves and may end up not being able to use, when you can sell a product that people use up – and come back for more the next time they get the flu? Companies are obliged to think about their shareholders. Absent any significant protests from customers or physicians, it makes good business sense for Roche to pivot on the possibly short-lived pandemic surge in Tamiflu popularity to try to establish the product as the drug of choice for the seasonal flu.

Does it make good medical sense to use the limited Tamiflu supply that way? Certainly it makes sense for those patients who are high-risk and for whom the cheaper drugs fail (if used prophylactically) or are contraindicated. But does it make sense for the average low-risk person home sick with the flu, who would have made it through on chicken soup in years past but now thinks only Tamiflu will do? If you’re worried about a pandemic, or worried about resistance, presumably you ought to have strong reservations about Roche’s commercial decision to sequester Tamiflu in hopes of expanding – doubling this year – the seasonal market for its product.

Unless we’re missing something, there are three sensible uses for Tamiflu, one debatable use, and one really dumb use. The three sensible uses, contending for the limited supply: (a) Let governments save it for a possible pandemic. (b) Let individuals save it for a possible pandemic. (c) Prescribe it for high-risk patients who have the seasonal flu and shouldn’t take the other, cheaper and more plentiful drugs. (There are two other sensible uses, though neither applies yet in the United States: to treat patients who have been unlucky enough to be infected with H5N1, and to try to ring-fence the first human-to-human pandemic influenza clusters in a last-ditch effort to stop an embryonic pandemic.)

The debatable use for Tamiflu is to use it throughout the annual flu season to protect high-risk patients who don’t yet have the flu – using up Tamiflu and risking increased resistance, when those patients could rely instead on vaccination, or on the other two drugs that are more plentiful and considered already useless against H5N1. And the really dumb use for Tamiflu is to prescribe it for everyone who has the annual flu and wants it. Those are the uses that have the best long-term payoff for Roche.

Nonetheless, many medical authorities have supported the Roche decision, and we haven’t found any that protested it. Even before Roche decided to hoard its Tamiflu in a seasonal stockpile, many doctors were saying that it was preferable to save the available Tamiflu for the upcoming seasonal outbreak than to give it to personal stockpilers. “Wouldn’t you feel terrible if you had a prescription sitting in your drawer and an elderly person or child died because they couldn’t get access to Tamiflu?” infectious disease specialist Gwen Huitt asked the Denver Post on October 20, 2005. “I understand there are people who have lost faith in the government’s ability to protect them,” Huitt added, “but this [stockpiling] is not prudent.” What Huitt sees as a loss of faith is simply a fact; governments cannot protect everyone from a pandemic, and are not promising to do so. In view of this fact, personal stockpiling, though clearly selfish, is just as clearly prudent.

There has been no organized opposition to Roche’s moratorium.

It is clear that most doctors, like Dr. Huitt, put an appropriately high priority on having some Tamiflu available to treat their high-risk patients who get the seasonal flu – especially those for whom the other three antivirals don’t work or are contraindicated. That shouldn’t take much Tamiflu, judging from past years, but it is clearly an important use. It is also clear that most doctors (at least most who have been quoted on the subject) approve of government Tamiflu stockpiles against a possible pandemic, and fervently disapprove of personal pandemic stockpiles.

As for the use we termed debatable – prophylaxis of high-risk patients during the annual flu season – it apparently doesn’t seem debatable to the medical profession. Most of the states that have published new guidelines for prescribing Tamiflu in the past three months list this as their number two priority, second only to treatment of high-risk patients who are actually sick. Their priority is a bit surprising, since the CDC’s recent antiviral recommendations suggest using amantadine or rimantadine for prophylaxis of high-risk patients exposed during outbreaks, and switching to Tamiflu only for treatment, if the prophylaxis fails.

It’s much less clear how doctors propose to deal with what we termed the foolish use of Tamiflu: treating low-risk patients. We can’t find any endorsements of this use. But we can’t find any condemnations either, whereas condemnations of personal stockpiling are commonplace. We tentatively conclude that the medical profession would rather give Tamiflu to a low-risk patient with a routine flu case than to a healthy patient who wants to stockpile it for a pandemic. This is hard for us to fathom, especially for physicians who say they’re worried about Tamiflu resistance. It seems almost Orwellian. Saving Tamiflu for a possible pandemic is condemned as wasting it, unless it’s the government doing the saving. Wasting it (relatively speaking) on a low-risk patient with an ordinary case of the seasonal flu is apparently an acceptable use.

Now leave aside the medical question and the profitability question, and ask the ethical question. The demand for Tamiflu right now greatly exceeds the supply. Under this condition of scarcity, does it make good ethical sense for the allocation decision to be left to the commercial judgments of a sole-source pharmaceutical company? We see the various ethical cases for putting this decision in the hands of patients, or for leaving it up to doctors, or for believing the government should preempt it. But does anyone think it’s ethically best if Roche decides?

We didn’t think so.

Why All the Specious Arguments?

link up to indexOne more time: There is one really solid argument against personal Tamiflu stockpiles, that as long as the drug remains in short supply, society as a whole will be better off if the entire supply is centrally controlled for optimal use – both seasonal and pandemic use. That is, there are people who are at higher risk from the flu than you are, and there are people society will need to keep functioning in a pandemic more than it will need you. The doses you want to squirrel away for yourself and your family will do more good for society elsewhere. Since there’s a severe shortage of Tamiflu, you are rational to want your own stockpile, and society is rational to want you not to have it.

Nearly all the other arguments against personal stockpiles are deeply flawed.

Some of the flaws seem to result from opponents’ almost willful ignorance of what people actually plan to do with their stockpiles. It is hard to tell whether most opponents of personal Tamiflu stockpiling have talked in detail with people who have or want Tamiflu stockpiles. We suspect most of them haven’t. Certainly the anti-stockpiling literature has very few quotations from stockpilers. Even journalists haven’t quoted them much. In risk communication, it is gospel to try to understand your target audience’s concerns, opinions, intentions, and behaviors – and to acknowledge them – before trying to persuade the audience to adopt a different viewpoint or practice. Sometimes, if you listen hard enough, the target audience persuades you to change your own mind instead.

A formal survey of Tamiflu stockpilers would help enormously. We believe we have talked with more stockpilers than most of the opponents of stockpiling, and we hope we have listened harder to what they’re saying. But we, too, are only guessing about what “most” stockpilers are thinking and planning.

Still, it is hard to believe that not listening to stockpilers is the core failure of stockpiling opponents. So many of their arguments aren’t just ill-informed about stockpilers. They exhibit fundamental errors in logic or medicine. And yet these arguments are advanced incessantly, and hardly anyone seems to be pointing out the flaws.

Part of the problem is that the most solid argument against personal stockpiles is so difficult to advance without sounding hard-hearted. It is comparatively easy to argue that we should allocate the available Tamiflu to the neediest, most vulnerable members of the population – that’s what the government argued during last winter’s flu vaccine shortfall, and there were very few objections voiced. But if there’s a severe pandemic while the U.S. has no vaccine, and enough Tamiflu for only two or three percent of its population, nobody really thinks the government will allocate what little it has to the most vulnerable. The Tamiflu will be needed to keep society’s infrastructure going; the top priorities will be healthcare workers, cops, power plant and water treatment technicians, farmers, morticians, etc. Saying this out loud doesn’t just sound hard-hearted. It sounds terrifying.

Understandably (though unwisely), most government officials seem especially reluctant to engage in a candid public discussion about the need to ration Tamiflu in an influenza pandemic catastrophe. Offending people and terrifying people are not considered smooth political moves. We have higher expectations for doctors – that they would talk straight with their patients, and that they would fight for their patients. But doctors, too, find it difficult to confront their patients with offensive or frightening truths about Tamiflu rationing in a pandemic. And doctors apparently find it difficult to advocate on behalf of their individual patients’ medical needs while they are simultaneously urging the government to impose a national resource allocation policy that is optimal for public health.

Moreover, arguing that the United States Government needs the available Tamiflu more than you do won’t necessarily persuade you not to want it for yourself. Wanting Tamiflu for yourself is literally selfish. But it is also rational – especially since the U.S. government had plenty of time to augment its own stockpile and chose not to, and since it still chooses not to take the matter out of your hands by nationalizing what’s left. Probably the single biggest factor behind the increase in private Tamiflu demand in the U.S. has been the publicity accorded two facts: The government thinks it needs a Tamiflu stockpile, and the government’s stockpile is sorely inadequate. The solid reason why you shouldn’t have a personal stockpile, in other words, is also a reason why you should.

Maybe this is the whole answer. Maybe the opponents of personal stockpiling simply don’t want to sound hard-hearted and terrifying, and don’t want to see their case for sacrificing “your” Tamiflu for the greater good turn into a reason for you to want it all the more. So instead of advancing the solid argument against personal stockpiling, they advance illogical, misleading, and insulting arguments instead. This is unlikely to be a conscious, thought-through decision to mislead the public in order to improve public health. We believe it is at least partly unconscious – a sort of willed self-deception.

Or maybe something more is going on – something so visceral it keeps officials and experts and physicians and medical societies from thinking clearly. Our tentative guess is that they are themselves terrified of a pandemic, terrified especially of how impotent they will feel in a severe pandemic, how little they may actually be able to help.

High levels of fear accompanied by low feelings of self-efficacy are the ideal conditions for denial. Perhaps many medical and governmental authorities are in a weird kind of denial about the prospect of a pandemic. They don’t actually deny that a pandemic is possible. But if the authorities have convinced themselves that a pandemic is extremely improbable, then they might feel entitled to urge the public not to take precautions that the authorities find unpalatable – precautions they would be obliged to admit were rational if a pandemic were not so improbable in their minds.

One suggestive piece of evidence for this is the frequency with which stockpiling opponents claim that since there isn’t a pandemic yet, there is no reason for people to want Tamiflu. Perhaps the “logic” that underlies this non sequitur goes something like this: Even though H5N1 has been around since 1997, there is no pandemic yet; therefore a pandemic is exceedingly unlikely; therefore I don’t have to feel helpless; therefore I am entitled to tell people not to amass private Tamiflu stockpiles but to rely on me instead.

(We have seen a pattern something like this before, when the U.S. public health profession decided that a bioterrorist smallpox attack was so unlikely that it felt right to oppose a smallpox vaccination program, even a small, voluntary one. See “Public Health Outrage and Smallpox Vaccination: An Afterthought.”)

Even if stockpiling opponents accept the reality that influenza pandemics happen at a rate of about three a century, they might still be resisting the possibility of a pandemic so catastrophic that society breaks down and normal procedures for providing medical care to those who need it fail. After all, they can tell themselves, 1918’s Spanish Flu was one of a kind (so far), and medicine has made great strides since then. Of course no one knows the probability of another pandemic as severe as 1918’s. But as Hurricane Katrina amply demonstrated, society can break down and normal medical procedures can fail. Denial of this possibility may have a lot to do with the reluctance of authorities and experts to take pro-stockpiling arguments seriously, and with the reluctance of doctors to relinquish control over when patients take home their medicine. And it may have a lot to do with the willingness of opponents to advance specious anti-stockpiling arguments without feeling dishonest.

Closely related to denial about the prospect of a severe pandemic is projection of feelings of inadequacy. We noted this earlier when we discussed the strange proclivity of physicians to imagine that their patients are incompetent to hang onto a blister pack of Tamiflu without using it “inappropriately” or “chaotically.” Officials and doctors may be denying not just the fact that a severe pandemic might happen, but also the fact that if it happens there will be relatively little they can do to help the sick. When unacceptable feelings must be denied, they are frequently projected onto others. We have speculated elsewhere that in a crisis public officials may imagine that the public is panicking or about to panic because of their own projected panicky feelings about their ability to manage the crisis. Something similar could be going on now with respect to officials’ and physicians’ feelings of helplessness to cope with a severe pandemic.

It is hard to read many of the anti-stockpiling diatribes or the state Tamiflu prescription guidelines without a strong sense that the authors are “protesting too much.” Something unconscious and disavowed seems to be at work. But we haven’t got much faith in our hypotheses about exactly what it is. We would love to hear any thoughts readers may have.

This is what we know for sure:

Whether you ought to try to get your own Tamiflu stockpile is ethically debatable. It is clear that you’re better off with it than without it, but it’s also clear that society is better off if the supply is centralized.
The people who tell you not to get your own Tamiflu stockpile are giving mostly dishonest or disingenuous or nonsensical reasons. We’re not sure if they know that or not. We think they mostly know how they feel – that people are stupid and wrong for wanting to stockpile Tamiflu.
That kind of illogical, disrespectful argumentation is all too likely to backfire. If there is a pandemic, trust in our doctors and government officials will be essential. Their specious arguments against personal Tamiflu stockpiling threaten to undermine some of that trust.

Copyright © 2006 by Peter M. Sandman and Jody Lanard

For more on infectious diseases risk communication:    link to Pandemic and Other Infectious Diseases index
      Comment or Ask      Read the comments
Contact information page:    Peter M. Sandman

Website design and management provided by SnowTao Editing Services.