The dilemma of personal Tamiflu stockpiling - Part II

Yesterday, we noted that some people object to the idea of individuals buying a personal supply of the antiviral drug Tamiflu for use during a possible flu pandemic.

Looking at this as both a policy issue and a risk communications issue, risk consultants Peter Sandman and Jody Lanard have reviewed 19 of these objections in a 37-page analysis. Yesterday, I listed the 19 objections for you to think about for yourself.

As I noted yesterday, these are experts talking. Sandman & Lanard have consulted for the World Health Organization and the U.S. Centers for Disease Control and Prevention, among many others.

With this article, I think their main purpose was to warn public leaders about the risk of losing public trust when they use illogical arguments. As a byproduct of that discussion, they're also telling you and me why most arguments against personal Tamiflu stockpiling are without much merit. It's valuable insight for all parties.

Their article - "The Dilemma of Personal Tamiflu Stockpiling" - notes two serious dilemmas. First, should there be an international stockpile or national stockpiles? Second, should there be national stockpiles or personal stockpiles? Their discussion focuses on the second question - basically, should the stockpiles be nationalized?

Specious arguments will cause a loss of trust in leaders

From a consultants' perspective, Sandman & Lanard think all but one of the objections listed are specious. (Or, as they express it, "the arguments offered why you shouldn't want Tamiflu ... are nearly all dishonest, disingenuous, or self-deceptive.") They're angry at the misinformation -- and that no one has been challenging it. (Their article was published/posted January 10, 2006.) They write:

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. [snip] 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. [snip] 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.

Quick background: Tamiflu is an antiviral drug which fights influenza ("flu") viruses. It's effective in treating the regular seasonal influenza. And as of this writing (March 2006), the World Health Organization expects Tamiflu also will be effective on a pandemic H5N1 flu virus. But that's not certain. Right now, Tamiflu supplies are limited. It will take time to manufacture enough for a pandemic, if such occurs. In the interim, some businesses and individuals are buying their own supplies. Some people object to such supplies or stockpiles. [For more details, see my post: What is Tamiflu? How does it work? Who needs it?]

The scarcity/rationing argument

OK, let's look at the objections. Here's what Sandman & Lanard have to say about the validity of each, beginning with the "scarcity/rationing argument."

1) Since there isn't nearly enough Tamiflu if a pandemic started soon, society as a whole is better off if the government has all the Tamiflu and can decide how to ration it. That decision should be left to government, not to individuals. Tamiflu stockpiles should be nationalized.

Out of the entire list, this is the only argument which Sandman & Lanard accept. They call it "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."

They say if a pandemic occurs and antiviral drugs are still in short supply, governments probably would choose between two rationing strategies for using the drugs:

• Treat the most vulnerable flu victims - those you think are likeliest to die if untreated.


• Protect and treat the people we most need to keep healthy in a severe pandemic - those who can help keep society's infrastructure functioning. (This is probably the rationing approach governments would favor.)

Sandman & Lanard add:

...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.

[snip]

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.

When the dust settles, Sandman & Lanard accept the premise of the scarcity/rationing argument and believe that "society as a whole is better off if the government has all the Tamiflu."

I'm not sure I agree that the scarcity/rationing argument is valid. I'll explain in a later post. [UPDATE: See my subsequent post.]

What's wrong with all of the other objections

The rest of the objections, all of which Sandman & Lanard consider specious, can be grouped somewhat by theme:

• Insulting, "you're incompetent" arguments, like: "As soon as people get a bad cold, they'll grab their Tamiflu and waste it."


• Arguments not based on data, like: "The chance of a pandemic is low."


• True but logically irrelevant arguments, like: "Your Tamiflu might reach its expiration date before you need it."

Below, I've summarized their comments on a few of the arguments, to give you a taste of their analysis. But I suggest you read their discussion in full.

Here's the first group.

"You're incompetent" arguments

2) 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.

Sandman & Lanard say there's no evidence such waste is widespread or would be during a pandemic. However, if a doctor really believes a patient can't be trusted with Tamiflu, there's an obvious option: Prescribe the Tamiflu and require that it be stored at the doctor's office, to be dispensed only on doctor's orders. This option has problems of its own, obviously. But the point is: In other situations, a doctor who thinks a patient won't take medicine properly doesn't simply refuse access to the medicine. Rather, he/she supervises access. (Sandman & Lanard give examples.)

"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," Sandman & Lanard say. And how hard is it to educate patients? Doctor: "If possible, call me before you take this. If you can't reach me, and you know there's 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."

Sandman & Lanard add:

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.

3) You won't know when you need your Tamiflu. 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.

Summary of Sandman & Lanard: This is true; 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. ...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.

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

Summary of Sandman & Lanard: "Doctors routinely trust their patients with medications requiring far more complex treatment protocols than Tamiflu." The current instructions for Tamiflu: start within two days of first symptoms; take one capsule twice a day for five days. It's just that "difficult."

5) You might forget where you put your Tamiflu.

Summary of Sandman & Lanard:

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

6) 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.

Summary of Sandman & Lanard: "This 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 it? "Why do these collective gambles make any better sense than an individual bet on a Tamiflu stockpile?," Sandman & Lanard ask.

"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 [considered] essential. But according to these arguments, an imperfect, not-guaranteed personal stockpile is stupid."

7) 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.

Summary of Sandman & Lanard: Same answer as #6.

8) 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.

Summary of Sandman & Lanard: Same answer. All of that may turn out to be true, but it's no reason not to take precautions. "Most precautions are against risks that may never materialize. ...People with fire insurance don't normally hope their homes will burn down."

9) What if your Tamiflu expires? 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 your supply of Tamiflu has expired?

Summary of Sandman & Lanard: 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." Replace the expired medications. In five years, the supply should be more plentiful.

10) The chance of a pandemic is low.

Summary of Sandman & Lanard: "On October 28, 2005, Chicago pediatrician Bennett Kaye explained to the Associated Press that he tells patients that 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.'"

11) 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.

Summary of Sandman & Lanard: "Technically accurate but irrelevant." Virtually everyone who has learned about pandemic influenza and decided to stockpile some Tamiflu understands it's not a vaccine but an antiviral. And besides, "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."

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

Summary of Sandman & Lanard: "Again, true but irrelevant." People know Tamiflu can be used as an ongoing preventative, but they also know they'll never have enough to use it that way.

"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."

13) A pandemic isn't happening yet.

Summary of Sandman & Lanard: "'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."

Well, by now, you get gist of what Sandman & Lanard think. I'll stop recounting their specific responses to each objection to personal supplies of Tamiflu. Suffice it to say, they disagree with every one of the other objections in the last group below.

"More harm than good" arguments

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

15) 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.

16) People who have the flu may use their Tamiflu incorrectly. They might not take the right dosage or might stop taking it in the middle of a course. This increases the risk of resistance.

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

18) Having Tamiflu may provoke envy and rage in those who don't have it. This could endanger the person who possesses the Tamiflu.

19) Tamiflu costs a lot.

I've only given you a taste of the Sandman-Lanard article and hope I have in no way misrepresented it or weakened its force. Their article has many illustrative examples and in-depth discussion, including thoughts on why doctors and others put forth such specious objections. I recommend you read it in full.

I think that Sandman & Lanard have performed an extremely valuable and needed public service in providing this discussion. Writing it took them a lot of time. But the whole Tamiflu stockpiling debate is important in its own right ... and as an example of needed discussions concerning pandemic preparation ... and as an example of the really harmful miscommunication that occurs in circumstances such as this. Faced with this pandemic threat, we cannot afford misinformation and disinformation [Glossary].

[UPDATE: To see my thoughts on the scarcity/rationing argument - the only argument Sandman & Lanard accept - see "Is there a role for Tamiflu in personal pandemic planning?"]

If you need general background information on Tamiflu and antivirals, see my post "What is Tamiflu? How does it work? Who needs it?"

If you want your own supply of Tamiflu, go buy some. Don't feel guilty.