Ethics & Pandemics

Rationing and Priority Setting

A colleague recently had an article published in PLoS Medicine, entitled Priority Setting for Pandemic Influneza: An Analysis of National Preparedness Plans (open access article).  This is an interesting comparative analysis of how countries are planning to distribute resources (specifically, vaccines and antivirals) in the event of a pandemic.  One striking finding is the variation in how countries approach prioritization of scarce resources (indeed, whether they set out criteria for prioritization at all: 38% of the 45 plans analyzed did not prioritize vaccine, and 51% did not prioritize antiviral drugs). 
There seems to be a reasonable degree of consensus around the prioritization of health care workers and those who provide other essential services (although what consitutes "essential" may vary from country to country).  Less agreement exists around the prioritization of children for receipt of vaccines.  Several countries do prioritize children (never at the top, but they appear somewhere in the prioritization scheme).  Others explicitly exclude or de-priortize children (e.g., Canada and the United States). 

Fewer countries prioritize antivirals than do so for vaccines.  Granted, with existing production methods, vaccines will be more scarce than antivirals, and hence, we may need to think more carefully about how to ration a vaccine, but the article rightly points out:

...antivirals may be the first—and, perhaps, the only—pharmaceutical intervention available to many countries in a pandemic. Because it is estimated to take six months to mass produce strain-specific vaccine, and global antiviral production and stockpiling is increasing, priority setting for antivirals may prove to be more critical to pandemic preparedness. (Uscher-Pines L et al., p. 1724)

The notion of a "stockpile" of drugs can be deceiving.  A stockpile isn't necessarily a "surplus," since it can be depleted very quickly if used for rapid response and mass prophylaxis. 

Another striking finding was that "No national plans including prioritization schemes for the distribution of nonpharmaceutical medical resources, such as ventilators and N95 maks.  Indeed, it wouldn't require much of a surge in influenza-related illness for hospital beds and ventilators to become scarce (The CDC provides a tool for estimating surge in demand for such resources here).  And rationing ventilators "at the bedside" (and rationing the beds themselves) may prove to be much more difficult than rationing vaccines and antivirals from afar. 

Granted, the reason that national pandemic plans avoid discussing how to ration finite resources at the local level is precisely because these decisions need to be made at the local level, with local input.  In that sense, silence is completely understandable, even preferable.  But these discussions do need to be taken up sooner rather than later. 

Compensation in Nigeria

According to this article in the Nigerian newspaper The Tide (a government-run regional paper in the Rivers State - I can't vouch for the source), the Nigerian government has stopped paying compensation to poultry farmers who are forced to cull their flocks to contain the spread of avian influenza.  The article isn't entirely clear, but it seems that this decision was due to a shortfall in funds. 

[Dr. Junaid Maina, Director, Livestock and Pest Control at the Federal Ministry of Acriculture] said that the ministry had cash flow problems and that over N50 million [about USD 400,000] compensation was yet to be paid to the affected farmers.

Maina, however, said that the Ministry of Finance was working to make the money available and that the exercise would continue as soon as this was done.

The director said that at the initial stage of the outbreak, the government approved N400 million for its immediate containment and payment of compensation to affected farmers.

Also speaking to the newsmen, Minister of State for Agriculture and Natural Resources, Otunba Bamidele Dada, confirmed the cash flow problem, saying that the ministry was working in conjunction with its finance counterpart to commence payment.

He said that as at August, a total of 915,650 birds had been destroyed, while N107 million had been paid as compensation.

There is probably no need to rehearse the arguments in favor of fair and adequate compensation for poultry farmers, but a situation like this certainly draws our attention to the essential role of national governments in controlling AI.  One hopes, as the article suggests, that the "cash flow problems" are merely temporary, and that the government is able to resume compensating farmers soon.  But failing that, one has to worry about the loss of trust and confidence on the part of the public in the government...."If the government isn't able to compensate me, why should I bother to report if my birds become sick.  Wouldn't I be better off just taking my chances?"  Farmer's would quickly come to realize that the government can't help them out in a crisis.

Actually, reading this article, I was reminded of an firsthand account by a Nigerian poultry farmer posted on the BBC's website back in March:

We are waiting to see but the compensation the government is offering is not enough. We've been told we'll be paid 250 naira ($2) per chicken.

This is neither fair nor adequate. We should be given at least 1,000 naira ($10).We've been told that we'll be compensated this week but I can't be sure it will happen.

I understand why we had to destroy all our birds. As large-scale farmers we don't have a choice - to succeed again as poultry farmers we can only move forwards by completely ridding our area of this virus....

However the small farmers do have a choice. They will not willingly come out and declare their birds are infected unless the government pays them more than what they can get at the market.

What might happen during a pandemic, when it's not only poultry farmers who are affected, but the entire population?   If people lack have doubts that the government is acting in their best interests, how can any mitigation strategies succeed?

UPDATE (10/26): An article from the same newspaper, dated 25 October, suggests that things might be getting back on track:

Compensation will be paid to poultry farmers in the country who lost their birds to Avian Influenza. An official of the Federal Ministry of Information and National Orientation, Mr. Babatunde Bello, made the announcement in Enugu on Thursday.

He was speaking at a one-day workshop organised for the Nigerian Guild of Editors by the ministry and UNICEF.

Bello said the compensation would be paid from the World Bank’s 50 million Dollars Avian Avian Influenza Emergency Programme.

Under the programme, he added, payment would be based on the fair market value of the birds lost, in addition to the on-going relief payment of N250 per bird to farmers.

Bello’s clarification came as poultry farmers accused the Federal Government of reneging on its promise to compensate them for losses incurred to the rampaging Avian Influenza.

 

Preparing for HPAI

The FAO and OIE recently put out a manual on Preparing for Highly Pathogenic Avian Ifluenza (link to PDF).   There is a section on financial support that addresses compensation for affected farmers, including alternatives to cash compensation, rightly noting that, "it can become a very expensive undertaking....It is important to consider what the cost of compensation might be and how it would be funded should a major outbreak of disease occur."  Notably the FAO's guidelines do advise governments to ensure that small holders are also compensated. 

What's interesting is what seems like the underlying assumption (at least to me) that the barriers to disease reporting and containment are almost entirely financial.  Admittedly, this is an important part of the overall picture--one that cannot be overlooked.  But  certainly there are other barriers as well.  Compensating farmers is one thing, but what about the social impact when authorities descend on a village to contain an outbreak.  Notably, the manual has a picture of of three men in "space suits" standing outside a Chinese village that has been cordoned off.  If this is the image that people have of bird flu, they may think twice about reporting sick animals.

Even if fair and adequate compensation is offered, the potential for social disruption and public apprehension in the midst of rapid response measures make it tempting to keep quiet.  Near the back of the HPAI manual is an example of a leaflet that could be used to inform people about bird flu, what it is, and what to do about it.  Among other things, the example informs farmers of their rights and responsibilities in the event of an outbreak.  Again, the "rights" are described in strictly economic terms:

Owners will be compensated for slaughtered birds as part of the measures for preventing the spread of the disease. Compensation will also be paid for destroyed poultry products and equipment according to their market value.

I'm sure this would be reassuring to farmers, but aren't there other rights that they would want to be protected?  Freedom from retalitation and discrimination?  The right to be kept informed about what measures are being taken, and why? 

New Zealand's Ethical Framework

Purely by accident, I stumbled across a draft document from the National Ethics Advisory Committee of New Zealand, entitled Ethical Values for Planning for and Responding to a Pandemic in New Zealand (dated July 2006). It's similar in many respects to a report put out last year by ethicists at the University of Toronto on pandemic preparedness. 

The New Zealand report identifies five procedural values (which it describes as "values informing how to make decisions"), namely:

• Inclusiveness: including those who are affected, from all cultures and communities, and taking everyone's contribution seriously
• Opennness: informing people of what decisions have been and will be made, what is coming next, and taking care that decisions are seen to be fair
• Reasonableness: making decisions based on a fair process, using the best available evidence, and reflecting cultural diversity
• Responsiveness: being willing to make changes when relevant information or context changes, and enabling others to contribute and challenge decisions
• Responsibility: taking responsibility for decisions, and helping others to take responsibility for their decisions and actions

The report also identifies substantive ethical values (described as "values informing what decisions to make"): 

• Minimization of harm: protecting people from harm and accepting restrictions on personal freedom when needed to protect others
• Respect: enabling people to make their own decisions when possible, restricting personal freedoms as little and as fairly as possible
• Fairness: prioritizing resources fairly when in short supply, enabling people to receive what they are entitled to, and minimizing inequalities
• Neighborliness (also described by the Māori word whataungatanga): caring for neighbors and family members and working together
• Reciprocity: honoring one's special responsibilities (e.g., health care workers), and providing support for those who provide care
• Unity (Māori: kotahitanga): showing solidarity and a commitment to strenghten individuals and communities

There is a great deal that is worth commenting on here, but what I found most striking is the way the report parses the meaning of fairness. Often, we see discussions about the need to distribute resources fairly (or equitably or justly). But it's somewhat less common to see discussions that mention existing inequalities as a barrier to the just distribution of resources.  The report later explains that in 1918, the Māori had five to seven times the mortality of non-Maori New Zealanders (it’s not clear if this is all-cause mortality or influenza-related mortality, but in any case, it parallels data from other countries in 1918).  It goes on to say that:

In common with many other indigenous populations, Māori have poorer health status than the general population. Reducing such inequalities in health status is one of the goals of the New Zealand Health Strategy and He Korowai Oranga: Māori Health Strategy. The existence of these health inequalities is also an indication that, from a health perspective, Māori are a vulnerable population. This suggests that protection of the Māori population in the event of a pandemic will require particular attention.

On this point, the report concludes that:

Māori involvement is essential in order to ensure that Māori are not disproportionately affected by a pandemic and that the best whānau [= family, extended family] outcomes are achieved should a pandemic occur

It goes without saying that if when the next influenza pandemic occurs, everyone will be susceptible.  At the same time, it is entirely reasonable to predict that not everyone will be affected equally.  The burden of disease will likely parallel the patterns we see for many other diseases and health conditions: poor countries are more severely affected than wealthy countries, and disadvantaged groups within countries (e.g., indigenous populations and ethnic minorities) are more severely affected than the rest of the population.  In this respect, it would be interesting to see if a country like New Zealand, which seems to be addressing health disparities proactively, might succeed in minimizing inequalities more than a country without such an approach.