| Home > Events > Disease, Disaster, Democracy > Conference Speakers > Roundtable 1 Roundtable I: Who Receives the Limited Doses of Pandemic Flu Vaccine?
An Exercise in Shared Decision-Making Background | Issues and participants | Purpose and scenario | Summary | Audio Transcript
Peter Singer (moderator):
My name is Peter Singer. I am the moderator of this afternoon’s session. I’ve got two qualifications to do that. One is in November our center released a set of ethnical guidelines for pandemic influenza planning—the University of Toronto Center for Bioethics. The second is that I’m a frustrated talk show host. I want to be reborn as a talk show host, so in about an hour we’ll see whether that is a realistic aspiration. I just want to start by introducing the panelists, and then I’ll do just sixty seconds of framing. We’ll get right into a scenario and we’ll get moving. I’ll just go from right to left: This is Nelson Ortega who is executive director of Centro de la Comunidad in Baltimore, Maryland. And this is Sarah Landry, and Sarah is the director of public policy for vaccines for GlaxoSmithKline, but formerly [she] was the associate director of policy and program operations for the National Vaccine Office in the U.S. Department of Health and Human Services. This is Carol Jordan. Carol is the director of communicable disease and epidemiology at the Montgomery County Department of Health and Human Services in Maryland. This is Dan Hanfling. Dan is the director of emergency management and disaster medicine for the Inova Health System in Falls Church, Virginia. Peter Gudaitis is the executive director and CEO of New York Disaster Interfaith Services, and Maggie Fox is a health and science correspondent for Reuters. So that’s our panel. A great variety of expertise. We’re going today on the “twenty-twenty-twenty plan.” For about twenty minutes we’re going to simulate what a public engagement exercise in relationship to allocation of vaccines could look like. We’re going to use that as a model. I’m going to focus narrowly, as I’ll say in a second, not too narrowly, but I am going to focus a little bit on the last week’s, or two week’s ago issue of whether to treat the healthy folks or treat the people who are sick—just to help focus it because we only have twenty minutes. But, the real purpose behind that first twenty minutes is to simulate what one could do in real time—as an issue comes up in the media—to engage people in discussion. Just imagine the first twenty minutes is [a] webcast public forum for Canadians moderated by Peter Mansbridge. For people in the United States, moderated by Neil Cavuto; I heard him the other day. So, that’s twenty minutes of simulation. The next twenty minutes, we’ll say, what does that twenty minutes look like in terms of public engagement around this question we’re focusing on—namely, allocation of vaccines? Is that the best way to do it? Not so much why you would like to engage the public, because we covered a lot of that this morning, but how you would do it. I mean, is this idea of a panel and web casting the way to go or [some] of the other things [that] we heard [about] this morning? And we’ll ask our panelists that. The last twenty minutes we’ll get into a question and answer [session with] the audience, more broadly, on either the scenario and the issues there—and we might do a little interaction and voting on the first twenty minutes, or on this broader question of public engagement around vaccine allocation as the specific example with an emphasis on “how to.” Sound okay? Any questions before we go ahead? Peter Singer (moderator):
Great. I’ll just start by reading a scenario and kicking off the first 20 minutes. This is about who receives limited doses of pandemic flu vaccine. The scenario goes like this: In September (and we’re really talking about this year, September 2006), the novel strain of H5N1 virus begins to spread rapidly throughout several Asian countries, with increased and sustained person-to-person transmission. In response, on September 20th, 2006, the World Health Organization officially declares the onset of an influenza pandemic. In late September, the CDC informs state health departments that H5N1 vaccine will not be available until March 2007 (about six months later) despite emergency efforts to produce vaccine against the novel strain. CDC will distribute vaccine through the Strategic National Stockpile to state health departments in batches as it is produced and according to the state’s population. State health agencies expect to receive enough doses to vaccinate 20 percent of their populations initially, with comparable portions coming each month thereafter, starting in March 2007—20 percent per month in terms of an up-scaling. With this knowledge, your city’s health agency begins to review and update its plans for distributing the first and subsequent batches of the vaccine. At the health officer’s briefing for flu vaccine planning, the mayor wonders aloud which 20 percent of the city’s residents get to stand in line first for the flu vaccine shipment and how everyone else will live with that decision. The health officer explains that broad federal guidelines do outline priority categories, but she estimates that the city residents who populate the top priority groups far exceed the initial allotments of vaccine. Peter Singer (moderator):
With that, Sarah, I think the question that is on many people’s minds—before we zero in on the priority and allocation issues—is why is there scarcity? Why do we have to prioritize in the first place? Why can’t you guys just make enough vaccine a month later? Forget about this 20 percent a month, six months later! What’s the problem there? Sarah Landry:
The assumption is that vaccines are like cars and you just flip a switch and you pull things off a conveyor belt. Vaccines are made with living organisms, and they’re fickle. We’re working with strains that don’t always grow well in [inaudible]. The influenza virus is constantly changing, which is part of the reason you have to have a new vaccine produced every year. We’re not in a position where we can stockpile excess vaccine, have it ready to go and send it out at a moment’s notice. I think there’s another issue here with pandemic flu, which is, you’re trying to balance having supplies available, but making sure they closely match what will emerge as the pandemic flu strain. You’re hedging your bet. What you see the federal government doing right now is stockpiling pandemic-like vaccines, but there’s no way of knowing whether or not the vaccines that have been stockpiled will, in fact, be effective if a pandemic virus emerges. I think the bottom line is that vaccines are complicated products to make and that they do require time to be produced. You can’t stockpile and have everything waiting in a cabinet waiting to go. It takes time to grow the viruses, fill and finish into a vaccine and make sure it’s safe. Peter Singer (moderator):
Sarah, this is a real scenario of scarcity. The folks who wrote this didn’t make things up and things will really be scarce. Carol, you may be the person closest to this hypothetical health officer in this scenario. It says here, that you’re talking about this vaccine—which 20 percent of the residents, the mayor is helpfully wondering aloud, “Who’s going to get it?”—and the health officer explains that broad federal guidelines do outline priority categories, but you think the top priority groups exceed those guidelines. Tell us a bit, if you can, about those federal guidelines and who would actually get this vaccine according to those guidelines. Carol Jordan:
Right. The federal guidelines are spelled out really clearly. I believe it’s the vaccine manufacturers first and the people who deliver the vaccine, then the health care workers and so forth and then the elderly people that are ill. A lot of the controversy about this is the issue of the children, because healthy children fall way down on the list. I think that’s one of the hardest things for us all to take, even though a lot of time—as Roger Bernier spoke about earlier today—we spent a lot of time dealing [with this issue in] the PEPPPI Project and really struggling over that particular issue. I know that our Canadian friends did the same thing. It was not an easy priority list to come about. But at this point of time, in a local government situation, I’d be getting really nervous, because I would know that it would almost be the same as the shortage we had in the ‘04 -‘05 normal flu season. Only the panic and the fear and the dread would be a hundred times multiplied. There’s no right answer here about how to approach this. I know [that] in the ‘04 -‘05 season what we did in our particular county, which has a million people, is we tried a flu lottery system—that is just is one way to approach the situation—about two years ago. I know it was not perfect. In our county, in the public health sector, we normally give out about four or five thousand dosages a year, and the private sector does pretty much all the rest. When we opened up the lines for the flu lottery, within two days, 22,000 people called in and they were all in the “high-risk” CDC categories. So, it was a big dilemma. At that moment, we had 800 dosages to give out to 22,000 people. For many people it was the first time they’d ever gotten a flu vaccine, but because of the shortages and the scare, they really wanted to get it. I think we would be faced, in this situation you’re talking about right now, with making some really difficult decisions about how to give out that limited resource to a much larger population of people that fall into the initial high risk categories, and basically doing the best we can with that situation. It pretty much comes down to first-come first-serve and having a call-in to make appointments or some kind of flu lottery system, whether it’s a weighted lottery or a regular kind of lottery system. I’ll say more, but I’ll stop there. Peter Singer (moderator):
Terrific, thank you, Carol. I have those National Vaccine Advisory Committee guidelines here. Maggie, let me ask you this, because it’s a way to frame it, and actually the U.S. and Canadian guidelines are quite similar, for the Canadian content folks in the audience. Maggie, you’re sitting there minding your own business on May the 10th, or May the 9th, in your Reuters office, and along comes this science article by a couple of bioethicists at the NIH. You write this article put out by Reuters, “Bird flu rationing proposal favors youth.” You write about this in your article—everybody agrees—we heard this from the PEPPPI guys too—that the “continuity of society” people go first. Most people d the healthcare workers, the vaccine producers, the critical infrastructure, the first responders, etc. Both the existing U.S. and Canadian guidelines then say you go to vulnerable people next. Older people with a couple of health conditions, people who have been admitted with pneumonia, essentially people who are at high risk of dying; that’s where you go next. May 10th, you’re sitting there and this thing comes along and it says—what? Can you just explain that and pick up the story from there? Maggie Fox:
Actually, I got it in under embargo, so this was before May 10th. But I read the article and they’re making the argument that, in fact, in the case of a pandemic, you don’t necessarily want to go to the older people. You want to save the people that have the most valuable life years left, which they argue would be people who have actually invested some time in life, but still have a lot of life to live. This works out to be people 14 to 25—and would be very controversial. They go on to make the argument that young children haven’t lived enough yet to have invested anything in their life, old people had their shot at it and these are the people that have the most to contribute to society, and it’s the most efficient use of the scarce resources that they have. Peter Singer (moderator):
So, on May 11th, you have Maggie’s article and many, many other articles from all around the world saying, “You know what? Those U.S. and Canadian guidelines got it wrong!” The people— actually the 180 million people in priority group four that the U.S. guidelines put at the bottom of the list—should actually be second according to this article. Dan, let me just check something with you before we go on. Part of the reason that the vulnerable, high risk groups are next (after the first responders, health care workers, etc) is because we think we can save lives by vaccinating those folks. But, some people say that the 1918 pandemic actually hit the 13 to 40 year olds that Zeke is writing about. I just want to check out [something]…are we really saving more lives by vaccinating the vulnerable 25 million or so people first? Dan Hanfling:
It is a difficult question to answer, obviously, because it really hits at the ethical issues of what is a life, whose life is worth what, and is one life worth more than another? I can tell you that from the perspective of healthcare clinicians—I think there are many in this room that would echo this sentiment—we are spending an awful lot of money at the very end of life. It raises the question as to whether that really is the appropriate allocation of what already are scarce resources in the delivery of day-to-day healthcare—aside from this potential scenario of pandemic influenza or some other emerging infectious disease. It is actually with great interest that I read this article and the commentary about this proposal because it begins to frame the question of relative values of life, and important in that is the engagement of healthcare professionals who do dabble at that very border of making some of those decisions. Peter Singer (moderator):
Sarah, you’re trying to get in here and we’ll let you go now. But, I’m still wondering, even if you assume everyone’s life is of equal value, is it true, in your opinion, that someone who gets flu in a pandemic in the 13 to 40 age group is actually less likely to die than someone who gets the flu in the—you’d think that’s true… Dan Hanfling:
You know, there are a lot of scientific reasons going back to 1918-1919 that can explain why the relatively young population was at much greater risk, and it had to do with immune modulation and the effects of one’s own immune system in responding to the virus. Again, as Eric [Toner] said earlier, what might pandemic influenza look like? We don’t know. But, certainly based on the 1918-1919 model, there is some reason to believe that that [younger] age group may be more adversely affected, so maybe that should be the target of counter-measures. Peter Singer (moderator):
Sarah, fire away. Sarah Landry:
I think one of the things that we haven’t talked about and [that] needs to be factored into this equation, is the effectiveness of the vaccine in different populations. I think one of the other considerations that needs to be explored—actually in the PEPPPI dialogue we did spend quite a lot of time talking about this—is the fact that the vaccine does not work as well in the elderly population. From an ethical perspective, does it make sense to use something that doesn’t work as effectively in a portion of the population versus spreading it out across more members of the [other] parts of the population? I just want to throw that out as another thing we need to consider. Peter Singer (moderator):
But just to be clear, the PEPPPI guys rejected Zeke’s proposal in the sense that they were going for the vulnerable people second, even to the point that they were cutting down on the first group, so they could get more of the vulnerable people. There’s a pretty good consensus that those 13 to 40 year olds don’t go next, right? Sarah Landry:
I think we’ve had some assumptions that we were working under up front--that issue did come up. But, you’re right, [about?] the end of the discussion. …[NOTE: portion of roundtable not transcribed at participant’s request]… Peter Singer (moderator):
Everyone agrees pretty well—in all the media stuff and about Zeke’s article that elicited this—that everyone’s okay with health workers, first responders, critical infrastructure, vaccine, [etc., coming first]. Pretty well there’s consensus. The real question is who comes last, and who comes next, and actually who comes last, which is more to the point, which is why Sarah is laughing and she’s absolutely right. So Peter, what would the folks having interfaith dialogue in the New York Disaster Interfaith Services think about the women and children last idea that Zeke promoted? Peter Gudaitis:
I want the other question. [Laughter]. Peter Gudaitis:
I think one thing that this chart, if you will, doesn’t take into consideration at face value is the cultural implications. Will the diverse communities of New York City accept these norms versus the ones they brought with them from the rest of the world, or from their own indigenous cultures? When you look at communities that have faced genocide--like the Jewish communities or the Native American communities--where this sacrifice for youth is a higher value than anything else, to perpetuate the race. When you have faith traditions that have come from various parts of the world that don’t value these priorities, then how do you get that population to accept this system? I’m not sure that you can. The debate depends on so many unknowns as well: What is the critical need in the community in terms of the distributions of services in a city that is dependent on mass transportation and not individual transportation? Our population [in NYC] requires subways, buses. There are very few cars, although it doesn’t seem like it when you visit. How is the population going to move around? “Critical personnel” becomes many other things other than the medical community. There are many unknowns, and until the pandemic is understood better, it is very difficult to make these decisions in advance. I don’t think New Yorkers, typically, are going to accept somebody else’s edict about how they’re going to live their lives. I don’t really think it’s as simple as throwing a chart up and saying, “This has all been thought through, the government has decided, and this is what it’s going to do,” because, frankly, nobody really trusts the government at the moment, given its enormous failures in the humanitarian aid process in the past several years since 9/11. Peter Singer (moderator):
Peter, you raised a number of very interesting points: the different cultural histories of people, the decision making in advance, the trust factor. I want to zero in on those in a minute. Remember, in our second 20-minute part of the show, we’re going to focus on how much advanced public involvement would actually help clarify priorities in this scenario, and you’ve touched on exactly where we want to go. Before we go there, I just want to bring closure to this first 20 minutes in the following way. Having run a bioethics center for 10 years, you know what my favorite scene in a movie is, right? It’s Yul Brenner [from] the King and I [who says]—“on the one hand, on the other hand”—people must be familiar with that scene. I just want to pin you all down. Before we close this part, and really reflect on what the potential benefit of a discussion like this in the wake of a paper—like that Science paper might be—to revisit the planning priorities of U.S. and Canadian federal governments. Let’s just pin you down a little bit. Everyone, or most people agree, Maggie, with the first responders, the health care workers, the critical infrastructure, etc., first. There is some discussion about how many and who exactly they are. The question now—in the wake of this paper that you wrote so beautifully about—is who goes next? Is it the 150 or so million Americans that are 13 to 40 and completely healthy on this life cycle ideal? Or, is it the 30 million or so—and you wouldn’t even get them all in the first month—who are vulnerable, sick, chronically ill, 65 and over, and have more than one or two health conditions? Who do you think should go next and why? Do you think those federal guidelines should be revisited? From all that you’ve heard from interviewing on your article and so on, where did you end up on this issue? Maggie Fox:
You’re asking me to express an opinion. As a journalist who writes on this matter, I have no opinion. One question that I would really like to address as a journalist who is writing about this is the fact that our society seems to have made this decision, and people have made it on their own. Every year, 36,000 people die of flu and the vast majority of them are over 60. We’ve already made that decision, these people have made the decision for themselves, [and] our society accepts it. “They’re old, something’s going to take them, [and] it may as well be flu.” Nobody ever says that, nobody ever comes out and says that. And Katrina also illustrated that. Who were the people who were left behind? I think society sometimes doesn’t make the decisions out loud, but they’re quietly made by default. This may occur in this situation as well. I can tell you as a mother of a five year old—I don’t fall into any of the categories and neither does she—there was a bitter discussion in our newsroom about the priority groups. Peter Singer (moderator):
Maggie, journalists don’t have opinions, but surely your opinion is not that the U.S. Federal Government and Canadian Government should not say one thing in their plans, namely that they’re going to vaccinate sick, old people first, then do something else? That can’t be what your opinion is, can it? Maggie Fox:
They haven’t really spelled it out. The National Pandemic Plan doesn’t say who gets vaccinated first; in fact, it leaves that wide open. Perhaps they want to leave this up to the individual communities. That’s one of the shortcomings people see in the plan…is that it doesn’t give specifics. Peter Singer (moderator):
Except that it does recommend as priority group 1B, after you got the health care and first responders, “High risk patients, over 65 with a chronic condition” increases the risk of severe influenza. “Patients aged six months to 64 years with two such conditions, etc.” It does say in both the U.S. and Canadian plans: high-risk people next. You’re not saying that’s not what they’re going to do, are you? Maggie Fox:
I have no idea what they’re going to do. Peter Singer (moderator):
Okay. We’ve heard that theme before. Which is—and we’ll come back to that in the second 20 minutes—there is only so much you can plan in advance because things could look quite different. You’re making that point and I think someone else made it earlier. Peter, what’s it going to be? Is it going to be as it is now, in the U.S. and Canadian plans, with the vulnerable people in the next group or should this now be revisited and get the 150 to 180 million healthy 13 to 40 year olds as the second group in the plan? That’ll take you quite a few months, right? That’s 60 percent at 20 percent a month to get through those folks, and then we’ll get to the sick and old people. What do you think? Do we need to revisit the plan or leave it as is? Peter Gudaitis:
Honestly, I don’t think I know enough to answer the question and I don’t think anybody does. We just don’t know how the pandemic flu is going to affect the population. And until we do, I think it’s irresponsible to make that decision. I recognize that we want to have some plans in place. But, what happens if the 1918 flu is the model, and it does really impact those generations? Then it would make sense at the time to shift the plan. But right now, we just don’t know. To pretend that we do, creates another idea that we know something that we don’t. Peter Singer (moderator):
That’s a good note of humility. That’s the very point that Arlene King, who is responsible in Canada for these plans in part, made in response to this article, namely that the thing may look very different at the time and whatever plan might need to be revisited. Point of fact is that there still are plans that talk about vulnerable people second. Dan, what’s it going to be? Dan Hanfling:
What you’re talking about is the burden of uncertainty. We sort of balance scientific evidence versus the best available scientific knowledge. As reflected by the two previous comments, I think that the public-at-large is going to have to understand that there is that uncertainty. And given the introduction to the dialogue—the same dialogue that we’re having here—to recognize that there are no hard and fast rules. And that whether it’s the 1918 scenario or the 1957 scenario, or some other emerging infectious disease with yet a whole other characteristic of symptom complexes, that we’ll have to make decisions as we go along. I think the most important thing to emphasize—from all the stakeholder groups that we’re making those decisions with—is it’s in good faith with the best intentions possible. Peter Singer (moderator):
In a second, we’re going to go see how much of a use it is actually to engage the public in these scenarios, with input in those decisions ahead of time. Carol, where do you end up on this thing? Carol Jordan:
I just wanted to add one thing to what Dan just said because I agree with what he said. Just one other comment with what we did with the flu lottery two years ag Most of the people that were “chosen” to get the vaccine were elderly people, although there was a real cross-section of our community in terms of racial and ethnic and so forth. Many, many of the elderly people that came in asked, “Can I give my dosage to my grandchild who has asthma?” We cannot ignore that sentiment from the elderly population. They were speaking very loudly that they were being very selfless in their want to take care of the children and their family. I’m not sure whether that sentiment went beyond their immediate family—an altruism for their whole community—but so many came in that said, “I would like to give my dosage to my grandchild.” Peter Singer (moderator):
That might be what you were talking about in terms of theory versus practice because that sentiment, for instance, makes a lot of sense. It’s not exactly captured in either the U.S. or the Canadian plan. Sarah, where do you end up on this? Sarah Landry:
I think I can echo what a lot of people have already said. To the point that Carol just made, I think that one of the “Aha!” moments at the PEPPPI project was when the woman representing AARP got up and said, “Look, my constituents are not going to want the vaccine for themselves, they’re going to want the vaccine for their grandkids, and how are you going to handle that, and are you going to be in a position to allow them to give the vaccine to their grandchildren?” That’s something you need to be prepared to deal with. I think there are realities and there are experiences from past shortages that we can see how this will play out. One of the things I would like to reflect on is—now all the flu seasons are a blur so I can’t remember which flu season it was—the one that was particularly bad for children in Colorado. When you look back on that experience, there were 160 kids that died for that flu season—those were children, young infants, young toddlers, who were otherwise in good health. When you compare that to the 36,000 primarily senior people in this country who die from the flu every year, you don’t get the same level of outrage. I think we do know that when children start dying from pandemic flu, there will be a lot of outrage in this country. The other points that I wanted to make are: In the discussions in the pandemic flu planning process, I think there is some expectation that some of these decisions will have to be made at a local level, and Peter touched on this when he talked about New York City’s critical workers may be very different than in Texas, where oil is an important commodity that we want to protect. Ideally, I think there has to be a lot of flexibility for local decision-making. I think there is a huge need to go back and have a discussion about this. My experience from both the PEPPPI project and some research that we have done on communication in focus group testing, is that people’s greatest concern is about fairness and equity, and that was pre-Katrina. Because of that, I think there is even more of a need to be upfront and honest well in advance about what the expectations are going to be. On some levels, this discussion is moot, because we don’t have enough [vaccine] right now to vaccinate the health care workers and people at the very top. Unless we get more people getting flu vaccine every year and increase our capacity, there is[n’t] much to discuss for the first few months, beyond the first tier. Peter Singer (moderator):
According to this chart, actually in the first month or so you can deal with that critical level. Then the question is, in April who gets it? Nelson, where do you end up there? Then I want to get to this burden of uncertainty, advanced decision-making question really to engage whether why, and especially how, one would engage the public in this discussion ahead of time…keeping in mind the various caveats that have come up. …[NOTE: portion of roundtable not transcribed at participant’s request]… Sarah Landry:
We’re guessing what the strain that will emerge and cause the pandemic is, because it hasn’t emerged yet. So we could start, and we have started making vaccine against potential pandemic flu strains. But it’s not clear that H5N1 will be the virus that is responsible for the next pandemic. On some level, it’s waiting for that infection to emerge before you can really make a true vaccine against that. We’re doing a lot to hedge our bets and do some insurance. The Department of Health and Human Services is planning on stockpiling a lot of different vaccines, against a lot of different strains. But, the virus doesn’t exist yet on some levels. You can’t make a vaccine— …[NOTE: portion of roundtable not transcribed at participant’s request]… Sarah Landry:
Not the pandemic strain. I think this is an issue that would be worth having a public discussion on. Is it worth investing a lot of money in developing a vaccine and stockpiling it for all Americans for a virus that may never emerge? That’s the trade-off as a society that we have to discuss. Peter Singer (moderator):
So what I want to do now is, just capping off this 20 minutes, is to turn to you all to get a sense of how this would look in practice. At the moment, there actually are guidelines—both the U.S. and Canada [guidelines] say, “First responders, health care workers, critical infrastructure, first.” The current, existing guidelines do deal with the sick, the vulnerable, the elderly, women and children next—a group of about 30 million people. You’re getting into them in April. There’s this article that says, “No, deal with the 13 to 40 year olds next.” That’s a group of 180 million and that would take you at least 2 or 3 months to get through them and then go. I just want to do a quick show of hands—the existing federal guidelines, both in Canada and the U.S. say “After the first responders, health care workers, etc., go to the sick and vulnerable, that 30 million group next.” The proposal out of those bio-ethicists says, “No, go to the other folks next.” So let me just ask, who thinks that the existing guidelines—keeping in mind all the issues of flexibility and uncertainty that came up—who thinks the existing guidelines should remain the same, be changed, or [do] you want to abstain? Who thinks the existing guidelines should remain the same, going to those vulnerable groups next, the 30 million people? Show of hands. Existing guidelines remain the same? Vulnerable people after first responders, etc.? Okay, three people. I think there’s going to be an “abstain” group here. Who thinks that the existing guidelines should be changed? Should we go to the 150 million healthy people and leave the vulnerable women and children last? The 150 healthy people next? Who wants to abstain? Okay, so let me just try this again. [Laughter] Sarah Landry:
There are some other options— [Laughter] Peter Singer (moderator):
I don’t know whether you expected that or not, but that just really freaked me out. So let me just try this again. You see what you just did now though, you’re agreeing with the new proposal as opposed to the existing guidelines; is that right? Then I want to get into the value of advanced decision making. This is the PEPPPI fellow. Roger Bernier:
You’re provoking a lot of different feelings inside me here. First, I’m not sure you’re portraying the recommendations that are out there accurately. Peter Singer (moderator):
They didn’t say women and children last. That’s true. Roger Bernier:
No, but you’ve included critical infrastructure in there. I don’t think there’s as much critical infrastructure included in the current recommendation as you’re implying. In fact, I think that what came out of PEPPPI, is that the citizens and stakeholders felt that assuring a functioning society was the highest priority, but again, they were very critical about making sure it was done properly. You have to portray the current recommendation as not as including as much infrastructure as you have. Peter Singer (moderator):
Right. Except that I was lumping U.S. and Canada. And the Canadian ones, I think, actually contain more critical infrastructure on top. Roger Bernier:
Then there’s a third option which I think is the one that the PEPPPI group came up and was different from the expert recommendations that would assure the functioning of society in a very tight way, then go to the vulnerable. The other groups didn’t compete so well. But anyway, that’s just making sure the options are well presented. But the other thing I just want to say [is] I don’t think a lot of people voted. I think what’s happening here is that in a way we’re not familiar with how, as a group, we can actually work through these things. These people up here were uncomfortable by these choices because they haven’t had the opportunity yet to truly engage with one another and learn from each other and actually achieve the working through that you can when you do the political thing in the correct way. This whole alliance is left with these dilemmas and no time to learn and interact and then you say, “Vote.” I don’t like the approach. Peter Singer (moderator):
That’s a good segue to the next twenty minutes, which is how you would have an advanced discussion. As you know, the cynic would say, “You’ve got a group of folks that spend a lot of time thinking about it (I take all your points). How would you then engage the public ahead of time, given all the difficulties that we’ve run into [with] this panel?” The uncertainty, the theory versus practice stuff, the learning that you talked about…I want to turn now to that question of how you would engage the public, given the well-placed comments that you just made. Maggie, what do you think? Is it [of] value actually to have a discussion in advance about vaccine rationing which is what we’ve been talking about? How do you do it and what thoughts do you pick up? Maggie Fox:
I can only speak from my experience. I’ve been writing about the threat of bird flu for a few years, and I’ve had a hard time getting my organization interested. It’s recently become interested, but I find that you have to repeat the message a lot before people become involved or engaged. You have an initial flash of interest and then people lose interest. They can’t keep it present in their minds, and there does seem to be something about the human nature that doesn’t want to act on anything until it’s an imminent crisis. There’s probably a good reason for that because otherwise you’d be flapping about, reacting to everything. I think you have to have kind of a gradual buildup and let people think about things in the background. Then, you wait and see how things shake out. That’s not very satisfying in this context, when you want to have some answers. But sometimes you do just have to wait and see how things occur before you really get into it hard and heavy. I’m already finding now that, again, in the context of writing new stories, we’re repeating ourselves. The old news becomes the new news because it’s so old everybody forgot about it! Everybody[ has] already forgotten what the original U.S. plan was that accounted for two million people dying in the 1918-like pandemic. When the plan was republished again with more details—
that was the lead again, “As many as 40 percent of the people could be out of the workplace…”—
I said, “We wrote that back in September. That’s old.” But it was so old, it was new again. I think it’s a long process. Peter Singer (moderator):
So given the difficulties we’ve seen in this conversation—even about a narrow question like the existing guidelines in the new article—[in trying] to stay focused, I think the upshot of this morning is, we should engage the public on a question like vaccine allocations. Given these comments and the stuff we were saying before, how should we do that? Dan? Go ahead. Dan Hanfling:
I would just put [in this]: How we’re doing that now needs to be considered in the context of how we would choose to do it with respect to pandemic influenza. We talked about injury prevention. How many people still don’t wear seat belts, get thrown from windshields and end up in trauma centers? We talked about stroke identification and chest pain identification as the onset of heart attacks. How many people blow that off for weeks on end before they come in with debilitating illness or injury for the health care system then to pick up the pieces, and hopefully return them to some level of good health? We don’t do a good job at that now, with the sorts of issues that we confront day in and day out, so I think it’s just important to state that in the context of how we’re going to do that with respect to pandemic influenza. Peter Singer (moderator):
Sarah, what do you think? Sarah Landry:
Well, I was going to say some of what we should do differently—we can learn from the national recommendations. I think the recommendations were strong in certain ways, but they were public health focused. They did not reflect across society and across interests. And I think many times what you hear in discussions and what we saw from the PEPPPI experience, is that when you have other people that aren’t [acting] as public health experts and looking at this from a medical perspective, their position may be very different, which is why we saw critical workers move up so high. I remember Carol sharing her experience from the shortage, and there was no way that she was going to vaccinate people without a policeman there to make sure there was order. Those kinds of things have to be taken into account. I think one of the lessons is to make sure that you have broad representation across all sectors of society. But also I think, to Dan’s point—and again, this is based on some of the lessons we learned from communications research—there is an enormous amount of apathy. I think the public is concerned, but they would get angry in focus groups when you talk to them about this and there was nothing that you had to offer them. Frankly, short of washing hands, there isn’t a lot that can be done, so I think it’s a very hard message and hard discussion to have with people. People want to do something and I think to do this discussion, you have to be prepared to have them having some input—maybe helping to set up guidelines as well. One of the other things that came through in the PEPPPI discussion was that many people felt that there should be some expectations on the people that got the vaccine. If you’re a healthcare worker and you got vaccinated, you should be expected to show up for work. I think that would carry through with other parts of society. I don’t know if that makes sense, but those are some of the suggestions. Peter Singer (moderator):
Peter, what if anything would you do, between now and September 2006, when the scenario has the pandemic breaking out, to engage your community in New York on the question of allocation of flu vaccine? Peter Gudaitis:
I think that the public looks for leadership that they perceive as having moral authority, whether that’s elected officials they trust or religious leaders or community leaders. I don’t know whether or not engaging the “guy on the street” versus a group of recognized leaders that have moral authority in the community are the right panelists, if you will, to have the discussion or not. That depends enormously from community to community. I know in New York City, there’s been an enormous amount of so-called public input into the 9/11 Memorial and as you can all read in the papers on a daily basis, the whole thing falls apart every few weeks. I do think there’s an enormous question mark hanging over my head about how New York can handle that kind of a discussion and whether or not the decision making process would meet at the end of the day with the public’s approval. At the same time, there are communities across this country that are enormously corrupt, where there are serious gaps between public trust and moral leadership in the community that is commonly recognized. So, the federal government does have to take a significant voice in the process and inform that discussion, even at the local community level. I also recognize that people want information that they can understand. So, I don’t think it’s simply an issue of a moral decision-making process about how the decision gets made. People are going to want to understand the facts and the science. I’m an educated person but I haven’t taken a science course since AP Bio in twelfth grade, and I think the average American is not going to understand the science of the pandemic, particularly in the early onset months until somebody can actually as a matter of fact say, “The elderly are not the most at risk; we should be vaccinating the youth.” Or, “The youth is not at risk; we should be vaccinating the elderly.” I think it’s a matter of science as much as it is a matter of moral interpretation on the matter. Peter Singer (moderator):
Carol, what, if anything, would you do between now and when a pandemic breaks in Montgomery County to engage citizens of your county on decision-making around vaccine allocation? Carol Jordan:
We have a very strong senior citizen lobby group in Montgomery County, and they make up a pretty large percentage of the population. So this would be particularly difficult in counties that have a large elderly and senior citizen population. I know with PEPPPI, we spent three or four long days together, really looking at every aspect of this problem. The group was so diverse—there was a chief from an Indian reservation on the group. There was a woman who was the president of an anti-vaccine activist group. So it wasn’t just healthcare people and the average citizens sitting around. These were people who had special interests and really wanted to make sure that their thoughts were heard. One of the things that I think is so important—we’re going out, and I’m sure everybody on this panel is—is really doing a lot of public forums, speaking engagements, getting people just to understand our dilemma in making this decision. So that somehow or another, they feel like the fairness and the equity that Sarah talked about [which] is so important, even when we were doing that lottery and people came in with sob stories and brought their sick husbands with them that hadn’t been chosen. They wanted, somehow, to know that we’re sticking to the rules of how we said we were going to do this because there were these priority groups and we worked out this system. So the fairness and equity really leads to a lot of trust in the government who’s going to be running this operation. I think that is so important. But if people understand that for the first six months or so, vaccines and antivirals are not going to be an option, then they need to feel that they’re not completely helpless. And they need to find out other self-care options, so that they can be as self-sufficient as they possibly can. Not 100 percent safe because no one will be 100 percent safe. But one of the things that we’re developing is a stay-at-home toolkit as part of our advanced practice center in Montgomery County funded by NACCHO. And it’s all the information people need to stay at home and take care of a sick person and not get sick themselves, and whatever they need to do to, at least, know the rudiments of self care and how they can get through the crisis with their own family. Peter Singer (moderator):
Nelson, Maggie, we’re going to open up in a second. But any thoughts on before a pandemic happens? I’m hearing a lot of caveats, frankly, about public engagement and I’m hearing a lot of the difficulties in it. But what I’m not hearing is how we’ll actually connect those voices you’re hearing. Carol—back to our guidelines—I’m sure they actually inform your local action which might be the most important thing. Maybe that’s the wrong question as to how they get back to the guidelines, but [I’m] hearing a lot of caveats and not hearing a lot of, “Gee, we should really engage the public and see what they think about this vaccine allocation thing.” Peter, Nelson, Dan and Maggie and then I just want to open up. Let’s be quick and then we can open up. Peter Gudaitis:
I really appreciate what she just said. I think that the idea of teaching the population how to care for themselves—that sense of empowerment goes a long way [in contrast to] the sense that the only thing that’s going to save me is the vaccine and if you don’t get it, we’re dead. That snowball effect, even if it’s completely false, is emotionally and spiritually catastrophic to the community. Anything that the government can do and anything local non-profits can do to empower the community to feel that they can be more resilient, can recover or prepare to take care of the children and the elderly in the home or whatever. I think that has got to be a first approach because we know we won’t have the vaccine for that initial period of time, and so, giving the community some sense of control over their own destiny in the pandemic. For that matter, what the United States can do for the world, because we do have part of that within the U.S. culture, which is we’re here, we’re going to take care of ourselves, but we also have this altruistic spirit, which is something that should be applauded. We’re also supposed to lead the world in these initiatives, or at least collaborate with other capable partners in doing so. I think that would go a long way to proving that we’ve done as much work on the front as those of us that have been leaders supposedly in this effort to help the community feel maybe more resilient. Peter Singer (moderator):
Great. Let me get maybe Dan and Maggie and Nelson a couple comments. But while I do that, I want to ask anyone who has some questions or comments they want to make to come to the microphone now, so we have enough time. I’d like to try and focus the discussion on—given what we’ve just been through—how one would engage the public, say between now and when the pandemic happens, say, on the vaccine allocation issue? But, also, feel free to diverge more broadly if you like. Dan, you’ve been trying to get in and then we’ll take a question. Dan Hanfling:
I just want to add another real caveat, which is that we are now here, insiders talking about the outside world, outside constituencies. We’ve got a lot of work to do on the inside of the tent as well. In a workforce attitudinal survey that we did in our health system, we found that one-quarter to one-third of our healthcare workforce who are educated, who are dealing with biological disease everyday—they’ve gone beyond high school AP Bio—they may be deliberately absent for one reason or another or may fall ill. So we’ve got real workforce issues that come up around these discussion points and to which this level of discussion has to be focused towards them as well. You can’t forget that. Q&A Session Peter Singer (moderator):
Helen? Helen Branswell:
Hi, I’m Helen Branswell, a medical reporter for Canadian Press. I want to pick up on something that Sarah and Carol Jordan mentioned. This is a really fantastic discussion to be been hearing. After three years of covering this topic, I am so delighted to hear people talking about this publicly. But don’t you think you also need to be talking publicly about the fact that [for] most of the world, including most Americans, vaccine will not be available anytime in the first couple of waves of a pandemic? If it’s H5N1, that virus is proving to be extremely difficult to produce an effective vaccine for in the kinds of quantities the world would need. Vaccine is not going to be a big player if there is an H5N1 pandemic in the next three or four years. If we’re setting up the public to think that that’s the answer, we are going to have a real, real big problem. Peter Singer (moderator):
Sarah, Carol, you both talked about it, if you will, information and expectations management, that’s really what Helen is asking about. Sarah Landry:
No, I think it’s a fair point and we do need to manage expectations. Sometimes when I’m asked by people, “What can I do now to prepare for a pandemic in addition to thinking about the things that are often talked about [like] stockpiling water [and] emergency planning for your family?” The other thing [is] that if we want to have sufficient vaccine in this country to protect Americans, we need every American to get a flu vaccine on a seasonal basis. That’s a hard message because that doesn’t guarantee that you’re going to get protected should that virus emerge, but we need to build that capacity now and we have an opportunity now to start building that. You’ll gain something for doing that too; you’ll have improved health and be protected from the flu for that season. I think we do have to be honest with people that there are limited supplies—that frankly, there’s not even a guarantee we will have a vaccine. I’m from the vaccine manufacturers, and we are doing our best, and we hope we have a vaccine that will work, but potentially the pandemic strain may not grow. Those are the things we all need to be aware of. Peter Singer (moderator):
Michael? Michael Allswede:
Thank you, Peter. I’m Michael Allswede from the Strategic Medical Intelligence Research Group at the University of Pittsburgh. First, I want to give you ten out of ten Donahue units on your MC efforts here. [Laughter and applause] Peter Singer (moderator):
Notice Roger’s not clapping, but I’m going after him later. Go ahead. [Laughter] Michael Allswede:
Secondly, I’d like to commend the panel for wrestling with a very difficult issue. And next, I’m going to disqualify myself as a social scientist. I don’t have any ability to comment upon the allocation other than to ask the heretical question that, shouldn’t we be talking about geographic allocation in the way that the scenario was constructed? As you’re pondering that thought, I want you to consider for a moment that from the time you get your shot, it takes five to seven days to get an IgM response, ten days to two weeks to get an IgG response, [and] about three weeks to get a cellular-mediated immunity response. And so, vaccination does not mean you’re immune at the time you get it. What it means is that in the future, at some point, you’re going to develop immunocompetence. Should we not be using the vaccine where it matters the most, which would mean where the flu is not yet? Then we can prepare those individuals. Specifically, I want to address the issue that six months into an event, a first responder is going to be exposed, arguably in almost every city. Secondly, those who are vulnerable, with the weak and the sick and the ill, may lack the ability to competently respond to the vaccine and develop immunity, so shouldn’t there be a medical utility argument that goes into this as well, and isn’t geography a part of that argument? Thank you. Peter Singer (moderator):
Thanks, Michael. I want to pick up particularly on the geography argument. Should we be vaccinating where the thing isn’t? Forget about the vulnerable, and the young, and the “this and that.” Who’s got another theory, as they say in Monty Python? Who wants to handle that? Carol? Carol Jordan:
I’ll start and then maybe Dr. Hanfling will want to add to it. First of all, for a social scientist, you really got a lot of that clinical information right on target. Good job. There are going to be such tight controls on the limited amounts of vaccine, and it’s really going to be handled at the national level and then sent out to the counties, so it’s going to be very tightly controlled. You’ve raised issues that we discussed in other venues as well, not today, but I just can’t imagine if you have sick and dying people that the vaccine would be sent to someplace where the people are not affected at this point in time, just because of the scarcity of the vaccine. I personally can’t imagine that. Peter Singer (moderator):
Eric, do you have any thoughts on this? On the geographic thing? Then we’ll head over there. Eric Toner:
As usual, I think Mike has a really provocative idea because it’s really interesting. I do think, however, from a logistical point of view, it’s going to be hard to know where the virus is and where the virus isn’t. And I think the virus will be everywhere very quickly, so I think from a practical standpoint, it’s not likely to happen. But, an intriguing idea. Peter Singer (moderator):
So Mike, you’ve got to write about that, put it in Science, Maggie will cover it and see what happens. Fire away. Laurie Escher-Pines:
Hello, my name is Laurie Escher-Pines. I’m a doctoral student at Johns Hopkins. We’ve been talking a lot today about public involvement like it’s a checklist item in this process of planning. My question then is, what is our responsibility to actually use public input, and what if the public is wrong? What if the public suggests something that is discriminatory or that doesn’t take science into account, and will that affect legitimacy if we involve the public, but then we don’t use their recommendations in any way? Thanks. …[NOTE: portion of roundtable not transcribed at participant’s request]… Peter Singer (moderator):
Carol, you want to take it in, I think? Carol Jordan:
I just have a quick comment to that. One of the other things I do is HIV care, which I’ve done for about twenty years. The Ryan White legislation really mandated a system of public engagement that was ongoing, powerful, and continuous. We have to have as part of the planning process, for any of the priority settings or any of the services that we decide on, a group of planners there that includes the ultimate stakeholders, the people that are affected by the disease themselves. That process can make your hair white sometimes, but at other times, you know that it’s not just healthcare providers who have their own point of view for the whole population sitting around a table. It’s every voice is heard at that table in terms of setting priorities and how the services should be and the quality of the services and so forth. So, it’s way beyond the checklist that you were suggesting. It goes far beyond that. Peter Singer (moderator):
Got another couple of comments from Sarah and Dan. Just want to point out that we’ve got about five minutes left, so one more question, little bit of summarization, two more comments, audit and feedback—fire away. Sarah Landry:
I wanted to add that I’ve had similar experience to what Carol was saying about HIV populations. I worked in HIV/AIDS National Institute of Allergies and Infectious Diseases early in the epidemic. I will say in the early days, many of the activists were not welcomed into discussions and I think what you saw change was there was an acceptance; that there was a perspective that was important to hear, and if nothing else, many times investigators learned that the studies they had planned were not going to be feasible and “implementable.” These were just not going to be accepted. So, I think to your point about what if they’re wrong, if they were wrong, or if their scientific understanding is incorrect, I think it just speaks to the fact that we need to do a better job of working with them to help them understand the issues. Peter Singer (moderator):
Dan, I’m going to go over here and let you be the first responder to whatever this question is and you can always sneak in your answer to the last question in the next one. Dan Hanfling:
Let me answer this question, though, because the public is wrong now. I mean a view of the trenches of emergency departments—where I work overnights on weekends—is that the public is often wrong. We have to expect that they are going to be wrong in the context of making decisions around this very complex issue. I think the other point back to Mike Allswede’s question about geographic distribution, is here we are talking about a U.S.-Canadian approach to pandemic influenza. In this day and age, if we’re not considering the geopolitical implications of not only distributing vaccine within North America, but really looking at the hotspots, as D.A. Henderson spent a career doing across the globe, then we’re making a big mistake. Peter Singer (moderator):
Thank you. Ana-Marie Jones:
Hi, I’m Ana-Marie Jones, Executive Director of CARD, Collaborating Agencies Responding to Disasters. My issue is that if we fight human nature, we’ll lose. Not just sometimes, but absolutely all the time. People will prioritize based on their own personal decisions. On the Titanic, the only group that had a 100 percent survival rate was first class children. Other groups totally prioritized around the income-earner, making sure that the income-earner stays alive and healthy to keep the family moving forward. I’d just say however we organize this, however the priority list looks like, there’s going to be X amount of people for whom that is totally not going to work. The other side of that is to make sure that whoever is at the bottom of the list, and I mean the very bottom, they’re at the top of the list for alternative methodologies and strategies. There are tons of things like alternative medical strategies, there’s pre-positioning of supplies, there are tools, there are all sorts of things, and we need to break away from this idea that we have this magic bullet called a vaccine. It’s not a magic bullet under the best of circumstances and it sets up a false expectation. That is going to be one of your bigger problems, dealing with that and the trust issues. We also have to acknowledge the fact that we have trained the public that there are certain groups that are the responders and people are basically the victims waiting to happen. Until we acknowledge what is, it’s very difficult to engage people in a conversation for what could possibly be. Our philosophy is that we’re not preparing our communities for disasters; we’re preparing them to prosper. So looking at this as an opportunity to build those communities into self-helping, self-nurturing, self-generating communities. [That] is absolutely the opportunity that is before us. My question would be: Have any of you considered how to put those alternative strategies in place? Has this conversation even been raised in some of the areas where you’re discussing this? Carol Jordan:
Part of our pandemic flu planning has included all of those issues. I think you and I talked about it over drinks last night actually. We’re doing a lot of work with special populations and the invisible people; the people that normally don’t even come forward for flu shots during the normal flu season, people that have health disparity issues, whether it’s racial or ethnic minorities in our county and across the United States. I think our planning cannot be just the perfunctory things about how to get the vaccine to people. It’s very clear that the human aspects—knowing how people react during a fear and crisis situation that it’s a normal kind of reaction—all of those things have to be taken into place, so I appreciate your comments. We still have a lot of work to do on that though. Peter Singer (moderator):
Thank you. Élaine, last question to you. Élaine Chatigny:
If I may, it’s not so much a question as just something that’s been really nagging at me, and one lady before me, I think, made the comment. And I don’t know if I’m hearing it explicitly [or] if it’s nuanced in anyway or if I’m reading something between the lines that’s not there. I think consultation and engagement is not a proxy, or it doesn’t replace decision making in the sense that when we encourage government decision makers to engage with public citizens and consult with them, we constantly have to remind them that ultimately they have been elected to make decisions and to make healthy public policies. But it’s an input; it’s a source of insight. It’s different than opinion research, which is opinions, which can be more knee-jerk, if you will. But good deliberative dialogue processes or other methodologies that allow you to have a conversation with people about the trade-offs, the difficult choices that as a society we all have to make. We make tradeoffs in our daily lives anyway. We’re accustomed to that. We’re hard-wired to do it. It’s an important input to the overall process that the government decision makers have to engage in. For example, what we’re proposing in Canada is consultation as one component of overall decision-making. I think that I hear sometimes that if you engage citizens at all, whatever they tell you, you have to act on it. No. There is a risk associated with ignoring the values and the beliefs that people here hold deeply. But, you have to manage that if you make a decision. You have to be able to explain why that’s not being acted upon. But that’s life, isn’t it? I felt that it was important for me, anyway, to articulate that our view in Canada in encouraging consultation is not to usurp the responsibilities that government leaders and decision makers have. Peter Singer (moderator):
Thanks, Elaine. That’s a point well taken. Before I summarize in thirty seconds, Maggie, I just wanted to ask you what’s the headline in engaging the public in vaccine allocation before a pandemic hits? Maggie Fox:
It’s not going to be engaging the public. I think part of the problem here is that very phrase “engaging the public” is really vague, and it’s academic speak, and you have to come up with something more like, “What’s your vote on this? What’s your opinion, what’s your vote?” I was sitting here thinking that if you want to encourage people to get the flu vaccine every year, what they’re doing is voting for public health capacity. They’re voting for the companies—it’s like shopping at your favorite store. If you want your favorite store to be there, you’ve got to shop there, so that they stay in business. “Keep it in business.” It’s going to have to be something along those lines, something snappy that people can understand—“I’m doing this, expressing my opinion in order to take part.” Peter Singer (moderator):
Great, thank you. Let me summarize for thirty seconds before I thank the panelists on your behalf. What I got out of this was number one: From the morning sessions, it’s clear that people think public voting, whatever the right word is, is a good thing. Number tw When you actually sit down and try to do it on a specific scenario, it isn’t that easy. Part of the reason it isn’t that easy is the point that Roger made when he wasn’t clapping, which is, you could do this with 300 people for a couple days, and that gives you a really in-depth and good discussion with feedback. I think your PEPPPI thing is a really, really great example of that. The question is how you might upscale that from 300 to 300 million using mass media, not to 300 million, but a much, much larger group of people. What became really clear to me was [that] the main uses of public discussion before an event around an issue like this is actually getting some good information out and some reasonable expectations out. It’s actually the stuff you can’t do—can’t have a vaccine against the strain for six months; even in six months, it might not work. All that expectation management, if you will, it might actually be one of the main reasons to do [citizen engagement] as opposed to the feedback to change your guidelines which was what I was hammering away at earlier on. Your point Peter—and Carol, you made this point as well—around the importance of engaging local community. And even if you don’t get the feedback and change your guidelines based on Zeke’s article and Maggie’s thing about it. Carol, your discussions with your local community will likely guide what you do later on. So, it’s this more nuanced, more subtle, difficult-to-measure stuff at the interstices that actually may be the main point. Having said that, all those caveats leave me with the idea: we better get out there and start trying some models. PEPPPI is a great example of that. Because the way to answer this question of how to engage the public, of course, is not a sort of theoretical simulation but actually getting out there and doing it, seeing if it works, trying something else given that it doesn’t, and learning a lesson as we go along. So with that, I know that wasn’t a perfect summary, just some reflections on what came up, I want to thank our panelists. I want to especially thank Roger and Eric. Roger for your intervention, and Mike. I want to thank our panelists on your behalf. I want to thank all of you for being involved and thank you very much. Now we can move on to the next one. [Applause] Monica Schoch-Spana:
To Peter for a wonderful job as a moderator and to our panelists again. We’re going to take a break for ten minutes and start sharply at 3:15 to consider our second Roundtable Discussion. The concern was raised in this panel if we don’t have vaccine, then what do we have? Some of those issues will be addressed in the second panel regarding mass casualty care. So please return promptly by 3:15. Thank you. Proceedings of the May 23, 2006 Summit: Disease, Disaster, & Democracy Transcription by CastingWords | 
