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Over the weekend, a news story broke that a federal task force had released recommendations for triage of victims of a future flu pandemic.  The task force comprised doctors and researchers from well-known universities, medical organizations, and government agencies including the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The story was picked up by the Associated Press and other news organizations.  Here's the story:

Triage plan details whom to let die during a pandemic

Treatment blueprint gives severely hurt, elderly lower priority

Lindsey Tanner, Associated Press

Monday, May 5, 2008

Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding whom to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux, a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

Their recommendations appear in a report published today in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

To prepare, hospitals should designate a triage team with the Godlike duty of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific and include:

-- People older than 85.

-- Those with severe trauma, which could include critical injuries from car crashes and shootings.

-- Severely burned patients older than 60.

-- Those with severe mental impairment, which could include advanced Alzheimer's disease.

-- Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report will be among many the agency reviews as part of preparedness efforts.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield." The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said. While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans, even if they don't follow all the suggestions. He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list "was emotionally difficult for everyone." That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

"You never know," Devereaux said. "SARS took a lot of folks by surprise. We didn't even know it existed."

http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2008/05/05/MNM210GNVM.DTL

I have told the story before.  Back in late 2006, HHS floated a trial balloon:  Let the governors of the states decide how best to distribute vaccine and antivirals during a flu pandemic, once the first responders were taken care of.  I sent my friend, then-governor Jeb Bush, an email that included the balloon from HHS.  I concluded in the missive,

"Jeb, Who do you vaccinate in a pandemic?  Your future or your past?"  I also told Jeb that, blessedly, he would not have to make that decision -- but his successor very well might.

The answer to my rhetorical question is very, very clear to me:  It is whoever is at highest risk.  If it's 1918 all over again, I would not hesitate to treat and vaccinate the most vulnerable first, based on mortality:  Young adults 18 to 40.  That might rankle the ire of AARP, but that is just too bad.

Allow me to explain why.

Look at the results of the Spanish Flu pandemic of 1918-19.  Depending on whose book you read, the life expectancy of an American dropped by anywhere from ten to twelve years in the wake of that pandemic.  That is how many youthful Americans died, both from World War I and the Spanish Flu.  We know today that more American soldiers died from flu than from contact with the enemy. 

We know that the most likely person to die in 1918 in the United States was a pregnant woman aged 27.  Her chances of dying if she acquired the Spanish flu were 55 in 100. 

America was able to weather that pandemic storm and prosper because making babies and building families were still the preferred projects in the eyes of American youth.  Now let us look at the realities of today.  We cannot say that with any confidence whatsoever. Political leaders must look at a pandemic within that context, and not just within the context of administering care for people. 

Were it not for immigration (legal and otherwise), the United States would have lost population from 1990 to 2000.  That is because people are not having babies in sufficient quantities to replace the people who are dying.  This fact is borne out in every single projection regarding future imbalances in Social Security, Medicaid, Medicare and federal entitlements in general.  Medicare is already out of balance, according to a good friend of mine, a Federal economist with the Department of Labor.  That means recipients of Medicare are pulling money out of the system faster than wage-earners  are paying into it.  Soon, Social Security will be the same way.  And by 2042, according to the Comptroller of the Currency, 100% of the Federal budget will be taken up by these entitlements.  No defense.  No transportation.  All entitlements.  What a mess.

Again, this is because there are fewer people being born than there are people dying.  And if you think this is bad, you should look at the looming danger about to befall Europe.  At least we grew:  Europe did not, and as a result has to import its labor now, with consequences we can see on televisions nightly.  Of all the nations of the earth, only Australia grew the "old fashioned" way.

From the Website of the Population Reference Bureau:

The more developed countries in Europe and North America, as well as Japan, Australia, and New Zealand, are growing by less than 1 percent annually. Population growth rates are negative in many European countries, including Russia (-0.6%), Estonia (-0.5%), Hungary (-0.4%), and Ukraine (-0.4%). If the growth rates in these countries continue to fall below zero, population size would slowly decline. As the chart "World population growth, 1750–2150" shows, population increase in more developed countries is already low and is expected to stabilize.

http://www.prb.org/Educators/TeachersGuides/HumanPopulation/PopulationGrowth.aspx

Imagine a scenario that takes the 1918 pandemic and extrapolates that pandemic's societal impact across today's population and across today's social and economic realities.  Take the 675,000 who died in the US and assume half were 18 to 40, as we always say in our presentations.  Now imagine if we took the 2.5 million Americans who would die if 1918 broke out all over again.  Imagine if we took more than one million Americans between 18 and 40 and just erased them from the map.  We also erase their earnings potential across their lifetimes.  We erase their incomes, their contributions to society, their ability to buy homes, their ability to build businesses, their ability to help mold a new America.  And we erase their ability to pay the taxes that will be needed to keep the nation afloat. 

That is where pandemic flu also crosses the line into the illegal immigration debate.  It is simple economics.  If a million younger wage earners die, a million more must take their place.  The United States will have no choice.  It will have to import its labor from wherever it can take it, and it will reshape the nation's future permanently. 

Forget the IMF, World Bank, CBO and British government projections of a drop of nearly 6% in global GDP.  Imagine if that drop maintained itself for years, maybe even decades..

In short, were a flu pandemic to erupt today, and if we do not try to save our future wage earners, leaders and mothers and fathers, we will surely bankrupt the nation and plunge the world into economic depression.  Without a national pandemic triage strategy to debate in the sunshine, and without the proper national resolve, we may wind up dooming the United States to its darkest period since the Civil War.  And this is assuming only a 2.5% Case Fatality Rate.  What if it is worse?  Heck, the CFR from SARS was nearly 10%! 

If H5N1 "goes pandemic," we know the CFR -- and the death curve -- are potentially even more depressing.  Sure, elderly people die.  But 90% of the deaths due to H5N1 infection are people under 40, and younger children suffer disproportionately.  Elderly people do not die in the same percentages when infected by H5N1.

The United States, therefore, simply cannot afford to treat all its people equally in a pandemic.  It must have a national triage strategy, saying that based on the mortality of the disease, certain age groups must come first for Tamiflu, for ventilators, for vaccine.  It means others will have to take a back seat or, regrettably, not get a seat at all.  And I doubt if there will be any real legal consequences for these decisions, since any flu pandemic invoking this level of triage will certainly also invoke a national state of emergency, maybe even martial law.  Those declarations pretty much wipe out any legal standing for dying plaintiffs.

So in the next pandemic, who gets the ventilator?  The 29-year old woman, or the 69-year old man?  Who do you save, your future or your past?

Is it really that hard to decide?