Thursday, December 02, 2004
Rationing Influenza VaccineThe second article is a Sounding Board piece, The Fragility of the U.S. Vaccine Supply. It is written in an apolitical style, which is characteristic for medical journals. The authors are to be commended for their restraint.
Thomas H. Lee, M.D.
Volume 351:2365-2366 December 2, 2004 Number 23
[...] With the flu-shot crisis, everyone — including the patients — knows that the shortage is not artificial. The problem is not some company's unwillingness to pay for care or society's reluctance to suffer a tax increase. Patients are not questioning physicians' financial motives. And most patients say they want their flu shots to be saved for patients who are sicker than they are.
The flu-shot shortage may never be repeated, and we may never again be as successful in persuading doctors and patients that the rationing of care is appropriate. After all, the American Way is for each person to try to get everything that might be beneficial. However, this season's experience suggests that, if the need is genuine and clearly understood, physicians and patients can deal with limited resources and unlimited demand with grace and dignity. [...]
When I read it, I felt inspired to use it as source material to criticize the Bush Administration. After all, there was evidence that we had advance notice of the possibility of a vaccine crisis, yet nothing had been done. It is true that this did not turn out to be a big issue in the election, but only because nobody understands what the term "national security means," and what the priorities should be.
<rant-tangent>The fact is, the flu season this year will kill more Americans that any terrorist attack ever has. And over time, influenza probably will kill more Americans that terrorists ever will. Unless, I suppose, terrorists use influenza as a biological weapon, and deploy it successfully. That, of course, would be incredibly stupid: whatever group would use it, it would kill more of them than it would of us.
Background on Influenza"National security," as defined by the Bush administration, means protecting national pride; it has nothing to do with protecting actual people. The bogus war on terror in Iraq probably will kill more Americans than it will save, but for some people, at least their pride will be intact.
Epidemics of influenza typically occur during the winter months and have been responsible for an average of approximately 36,000 deaths/year in the United States during 1990–1999. Influenza viruses also can cause pandemics, during which rates of illness and death from influenza-related complications can increase dramatically worldwide. Influenza viruses cause disease among all age groups. Rates of infection are highest among children, but rates of serious illness and death are highest among persons aged > 65 years and persons of any age who have medical conditions that place them at increased risk for complications from influenza.
Now we know why pride is one of the "deadly sins." </rant-tangent>
Anyway, back to the point. I wanted to use the second NEJM article to criticize the Bush administration. It turns out, though, that the facts do not support such as criticism. At least not the facts that I could find in a couple of evenings.
The main point of the second NEJM article is that the Institute of Medicine (IOM) released a report in 2003 (Financing Vaccines in the 21st Century: Assuring Access and Availability. summary, full report) that addressed the problem of the potential for vaccine shortages. It was published on August 4, 2003, probably too late for there to have been any hope of forestalling the current crisis. The NEJM article goes on to discuss the recommendations in the IOM report, and to point out the political problems inherent in any attempt to implement the recommendations. The main problem is that it is going to cost a lot of money to ensure an adequate vaccine supply, and of course nobody in Washington wants to spend the money.
But wait. That IOM report was a follow-up to a previous IOM report (Calling the Shots) first published in 2000; coincidentally, starting in the year 2000, there was a series of shortages of various vaccines:
The pneumococcal conjugate vaccine, introduced in 2000, had a considerably higher price than previous vaccines and local, state, and federal governments had difficulties identifying funds to purchase the vaccine. In addition, temporary shortages of several vaccines occurred beginning in late 2000. Consequently, in 2002, the National Immunization Program of the Centers for Disease Control and Prevention (CDC/NIP) asked the Institute of Medicine (IOM) to carry out a study [...]The division of The Dept. of Health and Human Services that is responsible for vaccines is the National Vaccine Program Office. They were aware of the 2000 IOM report, and the 2002 vaccine shortages, as is evident from a glance at their web site. That might mean that the government had plenty of lead time, yet failed to act.
Well, no, the facts do not bear that out. The NVPO had several conferences about the problem, asked the IOM to come up with concrete proposals, and that led to the 2003 report, Financing Vaccines. So they were doing something. The only way to turn this into a criticism, then, would be to demonstrate that, although the Administration was doing something, they were doing it with inexcusable slowness. Recall, though, that the second NEJM article pointed out the problems that face any administration that tries to address the potential for vaccine shortages. I did not quote the details. Interested persons can follow the link and read it for themselves. Basically, it would be a particularly gruesome form of legislative sausage making. It would necessitate hundreds of millions of dollars in government funding, all for something that is not a particularly hot political issue. And there would be no definite payoff. The only benefit that would accrue would be that something really big would not happen. There's no glory in that.
In fact, there are substantial risks. Those of you old enough to recall the 1976 epidemic-that-wasn't know that Gerald Ford took a lot of political heat for his decision to mobilize a large-scale vaccination effort against swine flu. He lost to Jimmy Carter later that year. It will be a long time before the Republican Party forgets about that.
In conclusion, I must say that I could not find a way to turn this into a criticism of the current Administration. I still think they're pretty inept, but not because of their handling of our Nation's vaccine situation. If there is blame to be assigned, we have to look at the failure of leadership (among myriad other factors) that has led us to value our individual pride over our collective health.
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