In a Pandemic, Who Gets to Live?

Nov. 12, 2008— -- As if wars and economic crises and natural disasters weren't enough, here's a challenge for some future president that few people even want to think about: Some day, perhaps soon, a president will have to decide whose lives are the most important to save, and whose lives are "nonessential."

This isn't going to be a doomsday story, because most people will survive the next influenza pandemic, which some public health experts believe is past due. It's not a question of "if," it's a question of "when," and one study from Harvard University estimates that the pandemic will kill somewhere between 51 million and 81 million people, mostly in developing countries.

Hundreds of organizations and institutions around the world are developing plans for dealing with the expected pandemic, and one challenging theme is begging for more public discussion. Some people will be more important than others in fighting the disease as it spreads quickly around the planet, and many more will be left to pretty much fend for themselves.

Who Is 'Essential'?

The top of the list is an easy one. Doctors and nurses will be vital, so they end up in the win column. Others essential to public health and safety will be next, but after that, the going gets tough. A provocative new study argues that the list needs to be broadened. Some truck drivers, for instance, may be just as important as doctors.

"The secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself," according to the study, authored by Nancy E. Kass, professor of bioethics and public health at Johns Hopkins University, and experts from several government agencies.

In a study published in the current journal Biosecurity and Bioterrorism, Kass and her colleagues argue that a pandemic could precipitate societal collapse on many levels, threatening the availability of resources "such as food, water, and gasoline."

What it boils down to is this: Medical professionals won't be very successful if the truck driver doesn't show up with the necessary medications because he couldn't get fuel for his vehicle.

So, people who might have been thought of as nonessential are indeed essential if the wheels of society are to keep rolling along. Someone to deliver fuel to the service station. Someone to keep the truck operational. Someone to drive it.

That doesn't mean every truck driver gets to live. But those who are part of a "minimally functional societal infrastructure" should be near the front of the line.

But how does anyone develop plans that will guarantee cultures continue to function, even as millions are dying? It's a huge challenge.

The Trickle-Down Effect

And, of course, there's the trickle-down effect. It would likely require a presidential decree to designate broadly who gets preferential treatment in response to the disaster. But who's going to make the decision on a community level? The study notes that for any plan to be successful, it must be perceived as "fair," but is that even possible?

Many citizens would likely be told to stay home from their nonessential jobs because the "hallmark" of a pandemic is the ease and speed that a poorly understood virus can spread from one person to another. So, isolation reduces the chance of exposure. But who's going to pay the bills if there is no paycheck?

And, of course, there's that familiar American concern: Can you really trust the people at the top to make the right decisions? Another study found that 72 percent of Americans thought "wealthy and influential persons" would receive a vaccine first if shortages existed.

All of this would be happening during a time of great confusion. Nearly a century after the Spanish flu killed approximately 50 million people around the world, scientists are still trying to answer some fundamental questions about the 1918-20 pandemic. Researchers are re-examining records of 24,000 mortalities in the United Kingdom to try and answer a basic question.

The Most Vulnerable

Young children and older adults are normally the most vulnerable to an influenza pandemic. But the records show that healthy young adults were most likely to die during three waves of the epidemic.

"We don't really understand why children and older adults were at lesser risk," said John Mathews of the University of Melbourne, who is leading the research. Theories abound, but no one is sure, all these years later.

The effort to respond to a pandemic will place some people at greater risk, simply because they will have to be around other people, and that's part of the price they will pay to be on the survivors list.

But some, no doubt, will refuse to show up for work.

Another study out of Johns Hopkins found that nearly half of the public health employees in Maryland said they would stay away from work rather than risk exposing their families to the virus. Physicians and nurses were more likely to show up than support personnel. Clerical and some technical personnel were less likely to work, chiefly because of their perception of the value of their own roles.

Two-thirds of the public health workers in that study said their role is not important in combating a pandemic, and thus, they were less likely to show up.

The new study emphasizes that if essential workers fail to come through, the entire structure of any society will begin to unravel. And thus, the aftermath of the epidemic could claim more lives than the virus.

And you wonder how many people underestimate the potency of an influenza pandemic. We all have to struggle with the flu from time to time, so how can it be all that threatening? But in the United States, an average of 36,000 people die each year from influenza, and 200,000 are hospitalized. And contrary to what happened in the United Kingdom nearly a century ago, elders and young children are the most common victims.

Those are large numbers, but they shrink compared to projections for a global pandemic. The Harvard University study extrapolated the number of deaths during the 1918-20 pandemic to the worldwide population in 2004. It estimates that 62 million persons would die each year from the pandemic. About 96 percent would be in developing countries.

Of course, we've learned a lot since 1920, right? True enough, but analyzing a specific virus and finding a treatment can still take time, and by its very nature, time is on the side of the virus. It's not something anyone really wants to think about. But it's coming, anyway.