This conclusion is based on an analysis of Israel’s rejections of applications submitted by Gaza patients during 2009, which found a strong correlation between cases considered life-threatening and permit approval rates. It should be stressed that cases which are not defined as life-threatening, and which were denied by Israel, can still be clinically urgent: this includes, for example, conditions that can lead to the loss of limbs, organs, or eyesight.

The organizations argue that Israel must allow every patient requiring medical treatment that is unavailable in Gaza access to treatment outside the Strip without delay.

The policy, which was first adopted on June 2007, is still in effect today. In the past few weeks, PHR-IL has received about 40 applications from Gaza patients whose requests to exit Gaza to receive medical treatment had been rejected by the Israeli security authorities. This is an extraordinarily high number of rejections in a relatively short period of time, which calls for special attention, given that all of these patients suffer from non-life-threatening medical conditions. On June 15, 2010, after 11 individual requests submitted by PHR-IL to the Israeli security authorities had been rejected, PHR-IL submitted a collective request in behalf of the 28 remaining patients, asking the security authorities to reconsider their cases.

Distinguishing between a life-threatening medical state and one that hinders quality of life – while denying medical treatment in cases which are not life-threatening – contradicts the principles of medical ethics. These principles mandate that all patients are entitled to the best available medical treatment, regardless of the urgency of the treatment or the severity of their clinical state.

Such a policy also contradicts international humanitarian law and international human rights law, which uphold the rights to life, physical integrity and dignity. The right to medical treatment is integral to these rights, which are also recognized as fundamental rights under Israeli law.

Dr. Harel Arzi, Specialist in Orthopedic Surgery and PHR-IL volunteer: ‘The difference between causing individuals to suffer from defects on purpose and causing them to suffer from defects or disability by denying them medical treatment for an existing condition – this difference is merely semantic. Whoever prevents patients from accessing medical treatment by restricting their movement is directly responsible for their medical condition, even if he or she did not cause this condition.’

According to the organizations, the withholding of treatment from Gaza patients who do not fall within Israel’s delineated medical criteria is the result of considerations that are foreign to medicine, among which are political considerations. Furthermore, deliberately withholding medical treatment from patients in need in order to achieve political goals is a form of collective punishment, prohibited under international humanitarian law. It constitutes a further layer of Israel’s policy of tightening the closure of the Gaza Strip, imposing hardship on its residents and limiting their movement, and should be halted immediately.

 Full_Report (pdf* format – 73.7 Kbytes)

In her letter to the editors, Chan said “potential conflicts of interest are inherent in any relationship between a normative and health development agency,” and conceded that the agency “needs to establish, and enforce, stricter rules of engagement with industry, and we are doing so.” However, she said she took “issue with the assumption that WHO simply dismisses these hard questions.”

Chan also responded to questions regarding the decision not to disclose members of its emergency committee, which directly advised the WHO about pandemic planning, noting that the “decision not to make these names public was motivated by a desire to protect the experts from commercial or other influences.” She added that committee members had welcomed the anonymity and that “the names will be released when the committee finishes its work, as has always been intended.”

Noting that the BMJ report “will leave many readers with the impression that WHO’s decision to declare a pandemic was at least partially influenced by a desire to boost the profits of the pharmaceutical industry,” Chan countered that “decisions to raise the level of pandemic alert were based on clearly defined virological and epidemiological criteria. It is hard to bend these criteria, no matter what the motive.”

[Economist] MORE than a week after the earth convulsed beneath it, Haiti has still to plumb the depths of suffering and want. The numbers are still only more-or-less informed guesses, but their magnitude is grim: perhaps 200,000 killed, 250,000 more injured and some 3m in desperate need of help. The generosity of the world’s response has also been profound. Barack Obama led the way, dispatching 16,000 American troops and marines, but others, from Europe to Brazil, Cuba, China and Israel, responded too. Immediate promises of aid added up to around nearly $1 billion.

The urgent task is to connect this supply of help with the demand. That is proving extraordinarily hard (see article). Seven days after the earthquake, the United Nations had got food to only 200,000 people. Lessons from other disasters are not always relevant to Haiti. The Asian tsunami, for example, struck a ribbon of remote, mainly rural, areas. The governments of the affected nations could lead the relief effort. But Haiti’s institutions were weak even before the disaster. Because the quake devastated the capital, both the government and the UN, which has been trying to build a state in Haiti since 2004, were decapitated, losing buildings and essential staff. So did many NGOs. The president, René Préval, and his cabinet have been reduced to meeting in a police station.

Into that vacuum stepped the United States. Inevitably the dispatch of marines, Black Hawks and an aircraft-carrier looked to some like an invasion (after all, they have been there before). A brief caricature of great-power prickliness ensued as the Americans took charge of the airport and seemed to some others to give priority to their own flights. But by mid-week the airport was receiving three times as many flights as it did before the earthquake. The American forces are well-equipped for the vital task of setting up a supply chain for aid. That is what they are doing under a sensible division of labour eventually hammered out (the Brazilian-led UN peacekeeping force remains in charge of security, and the UN will co-ordinate the aid effort). Certainly most ordinary Haitians seemed pleased to see the Americans.

They are just desperate for water, food, fuel, medicines and shelter. Contrary to some reports, there were only isolated cases of looting and fighting. But delay and disarray has cost many lives. The longer it lasts, the more likely that desperation turns to violence. The UN called for more peacekeepers. Brazil offered 800; it may take weeks to muster the rest. If ever a situation cried out for the UN to have a standing army at its disposal, as The Economist has urged, this is it.

From relief to building a better country

Amid such chaos, it might seem premature to think about a long-term strategy for rebuilding Haiti. Actually, it is vital. Already Haitians’ resilient response to disaster is creating new facts on unstable ground: the spontaneous refugee camps around the capital will be hard to shift. Even before the earthquake Haiti was poor, environmentally degraded and aid-dependent and had few basic services. This means that “building back better” must be more than just a slogan. It also means that time is short before the world’s generosity turns to cynicism.

Fortunately there is a blueprint, drawn up by Haiti’s government and presented to donors last year. It calls for investment to be targeted on infrastructure, basic services and combating soil erosion to make farmers more productive and the country less vulnerable to hurricanes. The pressing question is who should do it and how. Haiti’s government is in no position to take charge, yet the country needs a strong government to put it to rights. Paul Collier, a development economist who worked on the plan, reckons that the answer is to set up a temporary development authority with wide powers to act.

Given the local vacuum of power, this is the best idea around. The authority should be set up under the auspices of the UN or of an ad hoc group (the United States, Canada, the European Union and Brazil, for example). It should be led by a suitable outsider (Bill Clinton, who is the UN’s special envoy for Haiti, would be ideal, perhaps to be followed by Brazil’s Lula after he steps down as president in a year’s time) and a prominent Haitian, such as the prime minister. To provide services, it should work with aid groups.

Some will object that this would undermine a democratically elected government. But there is not much left to undermine. Done well, it could create a state in Haiti able to do more than preside over chaos and corruption. Otherwise the suffering of the past ten days risks being repeated.

The businesses registered with the city’s Department of Health to offer the vaccine through employee health clinics, and a department spokeswoman said they were sent doses as part of a plan to reach more high-risk adults. “When vaccine first became available, we directed all available doses to pediatricians, ob/gyns, community health centers and private and public hospitals,” said the spokeswoman, Jessica Scaperotti. “Then, as vaccine became more available, we expanded it to adult providers.”

She called large employee health clinics an important outlet for reaching at-risk adults. The firms had to sign an agreement to administer vaccines only to the highest-priority groups identified by the CDC, including pregnant women and adults between the ages of 25 and 64 who have medical conditions that put them at risk of complications from the flu, she said. But criticism of the move showed how much tension has emerged as thousands of children and others considered at risk of complications have waited hours in lines to be inoculated. Rep. Frank Pallone (D-N.J.) demanded an explanation from government officials. “I am concerned that the distribution of the vaccine is resulting in favored treatment for the privileged,” he said. The vaccine, which is paid for by the government, is being distributed to state and major city health departments, which then decide where to send the doses. Doses are sent to providers and clinics that applied. New York City has received more than 800,000 doses. In a letter, CDC Director Thomas Frieden asked state and local officials to review their vaccine-distribution plans. “Any vaccine-distribution decisions that appear to direct vaccine to people outside the identified priority groups have the potential to undermine the credibility of the program,” he wrote. The CDC said 35.6 million doses of vaccine were available as of Thursday. The agency recommends which groups should get the vaccine first, and jurisdictions must agree to follow those recommendations, but the CDC doesn’t sign off on which providers get the vaccine, a spokesman said. Goldman Sachs has received 200 of 5,400 doses it ordered. A spokeswoman said the firm “will supply it only to employees who qualify based on the requirements laid down by the CDC and Department of Health.” Citigroup spokesman Alex Samuelson said the firm received limited supplies of vaccine and they were being provided “only to employees in high-risk categories as defined by the CDC.” A Morgan Stanley spokeswoman confirmed that the firm received 1,000 doses it ordered. But it has decided to send them to several hospitals in or near New York City after hearing that many hospitals don’t have the vaccine yet. —David Enrich, Susanne Craig and Aaron Lucchetti contributed to this article. Write to Betsy McKay at betsy.mckay@wsj.com

In a normal flu season, 90% of deaths are in elderly people. But since September, 88% of deaths have been in people under age 65 — with almost a quarter of the deaths in young people under age 25.

“It is almost completely reversed. Nearly 90% of our fatalities are occurring in people under 65,” CDC respiratory disease chief Anne Schuchat, MD, said at a news conference. “This illustrates this H1N1 virus is disproportionally affecting the young.”

As might be expected from the death toll, most people hospitalized with severe H1N1 swine flu are young. Surveillance data from 27 states show that more than half of swine flu hospitalizations — 53% — are in people under age 25. Only 7% of people hospitalized with swine flu are elderly.

While the majority of severe H1N1 swine flu cases are in people with conditions that put them at risk of flu complications, not all these conditions are severe. Well-treated asthma, for example, is common. And pregnancy isn’t an illnesses at all. Yet the risk is there.

“Completely healthy pregnant women are coming down with horrible, horrible illnesses — and, tragically more deaths,” Schuchat said. “And some conditions like asthma which is well controlled. So even if you have diabetes that’s well controlled, if you have asthma that’s well controlled, we want to you think of yourself as a higher risk and recommend that you be vaccinated.”

H1N1 Swine Flu Vaccine Rollout Still Bumpy

If you’re thinking of taking the CDC’s advice and getting the H1N1 swine flu shot (or sniff), it’s time to start making plans.

The flu.gov web site has a flu vaccine finder that links to each state. Most states have detailed information that show which providers near you will be offering the H1N1 swine flu vaccine.

The first vaccines are going to health care workers and people at risk of flu complications. So far, about 13 million doses have been available to states, more than half in the form of flu shots. States have placed orders for about 11 million of those doses; those orders are being filled quickly.

Spread nationwide, that means not everyone who should get the vaccine will be able to get it this week, or even next week. Availability is increasing, but it’s unlikely that the vaccine will reach everyone who wants it before the end of November.

Will that be too late? The CDC’s mantra is, “It’s too early to say it’s too late.”

Schuchat points to what happened in 1957, when pandemic flu hit hard in the early fall — and was followed by a second wave of flu.

“In 1957, the pandemic hit early around September/October, like what we’re seeing here. They had another big wave after the first of the year,” Schuchat said. “And I think we have an opportunity right now to try to limit the disease and to protect as many people as we can with the vaccine as it becomes available.”

Meanwhile, Schuchat said, the CDC is not planning to stop its H1N1 swine flu effort when all 250 million doses of the vaccine have been delivered.

“At CDC, we’re planning a long response. We don’t want to let our guard down too soon on this,” she said.

SOURCES:

Anne Schuchat, MD, director, National Center for Immunization and Respiratory Diseases, CDC, Atlanta.

CDC news conference.

The plan, which would guide Florida hospitals on how to ration scarce medical care during a severe flu outbreak, also calls for doctors to remove patients with poor prognoses from ventilators to treat those who have better chances of surviving. That decision would be made by the hospital.

The flu causes severe respiratory illnesses in a small percentage of cases, and patients who need ventilators and are deprived of them could die without the breathing assistance the machines provide.

In June, Florida Surgeon General Ana M. Viamonte Ros sent the draft guidelines — which had already undergone a series of internal revisions — to 16 state medical organizations for their feedback.

But the state has not yet publicized the guidelines or solicited input from the general public. The Florida Department of Health released a copy of the draft plan at the request of ProPublica, a nonprofit news organization, which provided it to the Sun Sentinel.

The document addresses one of the most heart-rending issues in medicine: What to do if the number of people in need of ventilators and other treatment dramatically exceeds what is available.

The goal, the plan says, is to focus care on patients whose lives could be saved and who would be most likely to improve. While it says those decisions are not to be made based on patients’ perceived social worth or role, the plan calls for different rules for some populations.

The list of conditions that disqualify hospital admission would be applied to most people only in the two most severe levels of a pandemic. However, they would also be applied in the first level ofa pandemic for patients transferred to hospitals from “other institutional facilities,” such as nursing homes and mental health facilities.

Florida’s planning effort reflects a growing acknowledgment that hospitals across the nation would be unable to cope with the flood of patients that a severe influenza pandemic, like the one that gripped the nation in 1918, would unleash. That resource gap is in the spotlight now, as the country is battered by a second wave of pandemic swine flu, also known as the H1N1 virus.

“What we have seen are real stresses, particularly on the emergency departments,” Thomas Frieden, commissioner of the Centers for Disease Control and Prevention, said at a press conference last week.

The H1NI virus is much milder than the 1918 flu, but a small proportion of H1N1 patients, including some who have no risk factors and are young and healthy, develop severe breathing problems requiring mechanical ventilation and life support.

So far, intensive care units in the U.S. haven’t been overwhelmed with people needing ventilators.

“That’s something that we’re tracking closely,” Frieden said.

In Winnipeg, Canada, all regional critical care beds were full at the peak of the outbreak last spring, and in Mexico, patients experienced long delays before being admitted to ICUs. Four died before being transferred from the emergency room.

Florida health officials believe that the number of severely ill flu patients will likely remain at a manageable level, provided residents get vaccinated, that they know when to stay home and when to seek medical care (visit myflusafety.com or call               877-352-3581         877-352-3581 for information), and that the existing flu strain does not mutate into a more virulent form.

In the case of a much severer scenario, Florida’s draft guidelines call for hospitals to turn away anyone whose doctor has signed a “Do Not Resuscitate” order, which instructs rescuers not to revive a patient whose heartbeat or breathing stops.

A recent report from a panel of national experts convened by the Institute of Medicine urged states not to use DNR orders for this purpose, because they reflect preferences about end-of-life planning “more than an accurate estimate of survival.”

The Florida plan also calls for intensive care unit patients and those using ventilators to be reassessed after 48 to 72 hours.

Those whose chances of survival have significantly worsened would be taken off the machines or discharged from critical care to make way for others who may have a better chance of survival. If needed, they would be given palliative care to keep them comfortable.

One goal of Florida’s plan is to “reduce or eliminate” the legal liability of health care workers who, in good faith, deny or withdraw treatment from some patients in an emergency. The plan includes sample executive orders that the governor could issue to shield workers and authorize hospitals to implement the guidelines.

The draft document also outlines how the health care system should stretch critical resources before moving to ration care.

The guidelines suggest reusing supplies, canceling surgeries that are not absolutely necessary, training staff to perform additional tasks and drawing on stockpiles. The general public’s responsibilities include treating certain sick family members at home and monitoring public health messages.

Florida’s draft guidelines aim to provide the “greatest good for the greatest number” when doing the best for all patients is no longer possible.

That goal needs to be balanced with an effort to distribute scarce resources in the least discriminatory way, said professor Ken Goodman, who directs the University of Miami bioethics program and the Florida Bioethics Network.

“Among the ways we can do that is to somehow take the evidence about what we think works and bolt it to the values that I think are uncontroversially shared: Namely, life is good, suffering is bad.”

He said that methods included in the draft are still imperfect: “It’s a very difficult problem to figure out how the world of science can help ensure that our strategies for allocating resources are fair and effective.”

Viamonte Ros will have final approval authority and the plan will remain voluntary and subject to review, according to Doc Kokol, the health department’s information officer.

The Florida health department’s original goal was to have a final draft of the plan ready by December.

But with public health workers scrambling to cope with other aspects of the H1N1 pandemic, that is now unlikely, state officials said.

“People would like to have that policy,” said Goodman, who chaired an ethics meeting on these issues at Jackson Memorial Hospital in Miami last week. He said that staff at the hospital have drawn up their own draft plan to cope with a potential surge of patients needing care. Florida plans to accept public input after the guidelines are revised by health officials. Kokol wrote in an e-mail that that “will likely include regional meetings for public input as well as electronic receipt of comments.”

In many states, that type of input has been largely absent. Groups of doctors, lawyers and ethicists have hammered out the plans with little engagement with the public or with groups that represent children, the elderly and those with chronic illnesses or disabilities.

When Utah tested a similar plan in late August, the drill revealed difficulties that Florida clinicians and patients are likely to encounter.

Utah family physician Pete DeWeerd had to tell a mock patient’s mother that her 7-year-old daughter, who had cerebral palsy and was suffering from the flu, would be turned away from the hospital and likely die.

“I don’t like to tell you this,” he said he told her, “it feels unfair, but our list is our list is our list.” He added: “It was awful. You get a huge lump in your throat.”

Dr. Tom Kurrus, medical director of St. Mark’s Hospital in Salt Lake City, called it “emotionally draining” when mock patients and family members yelled, screamed and took issue with who was denied treatment.

“The major weakness in our preparedness had to do with security,” he said.

Kurrus said that although the exercise was covered widely in Utah’s media, the public isn’t aware that the disaster plans call for rationing.

“Even with the scenarios played out and the discussions entertained, they still don’t understand,” he said. “It’s, ‘Why can’t I get into the hospital, why can’t grandma get put on a respirator?’”

Goodman, the University of Miami ethicist, said open conversation about the complex, value-laden decisions that will determine who receives treatment in the most extreme circumstances is crucial, and that hospital, state or federal guidelines should always be subject to revision.

“This should be an ongoing process that includes new evidence as it becomes available and that includes, in an open society, the participation of citizens,” he said.

Sheri Fink is a reporter for ProPublica, a nonprofit journalism organization in New York City. To see more of her stories about emergency preparedness, go to propublica.org/sherifink

http://www.sun-sentinel.com/news/nationworld/sfl-swine-flu-crisis-propublica-sboct18,0,2027387,full.story

In an interview just prior to his address, Dr. Anand Kumar said he wanted to give the audience “the flavour” of what hospitals can expect to see when the second wave of the pandemic is expected to come this fall and winter.

“I think it’s an absolutely massive onslaught of incredibly sick young people that I had never imagined I would see in my life,” Kumar said of his experience treating patients in Winnipeg’s intensive care units. “It’s startling, and more than a little frightening, especially when you don’t know what the ceiling of this is going to be.”

The two-day conference, which has drawn together about 150 health-care professionals and experts from across the country and around the world, is focused on how to manage severe cases of the swine flu and prevent them from deteriorating. Also on the agenda are discussions about Canada’s vaccine strategy — under attack this week from the Canadian Medical Association Journal — the use of antivirals, medical ethics and clinical care guidelines. The sessions are closed to media.

Most cases of swine flu in Canada have been mild, but there is a subset of patients who are getting very sick. At least 72 deaths have been linked to H1N1 and more than 1,366 people have been hospitalized. Of those patients, more than 240 have spent time in intensive care units.

Despite the rather ominous description offered by Kumar, he said young and healthy people shouldn’t be scared and that the vast majority of people who contract the virus recover well.

Hospitals, however, know they need to prepare for an onslaught of critically ill patients in the event the pandemic worsens.

[BBC] The 64-year-old man was a neighbor of the first two people to die from the plague in Ziketan in Qinghai Province.

Police have set up checkpoints around Ziketan, as medics are disinfecting the area and killing rats and insects.

Pneumonic plague, which attacks the lungs, can spread from person to person or from animals to people.

A spokeswoman for the World Health Organization, Vivian Tan, earlier said an outbreak such as this was always a concern, but praised the Chinese for reacting quickly and for getting the situation under control.

A BBC correspondent in Beijing, Michael Bristow, says that unlike in the past the authorities are being very open about this outbreak.

Local officials in north-western China have told the BBC that the situation is under control, and that schools and offices are open as usual.

But to prevent the plague spreading, the authorities have sealed off Ziketan.

About 10 other people inside the town have so far contracted the disease, according to state media.

No-one is being allowed leave the area, and the authorities are trying to track down people who had contact with the men who died.

Initial symptoms of pneumonic plague include fever, headache and shortness of breath.

The local health bureau has warned anyone with a cough or fever who has visited the town since mid-July to seek medical treatment.

According to the WHO, pneumonic plague is the most virulent and least common form of plague.

It is caused by the same bacteria that occur in bubonic plague – the Black Death that killed an estimated 25 million people in Europe during the Middle Ages.

But while bubonic plague is usually transmitted by flea bites and can be treated with antibiotics, pneumonic plague is easier to contract and if untreated, has a very high case-fatality ratio.

An increasing number of Western countries are signing agreements with vaccine makers guaranteeing them a certain number of doses should a pandemic occur. By locking up the supply in advance, they are making it even tougher for poor countries to get access to the shots they would need, critics say.

Leaders from the World Health Organization and the United Nations are set to meet with drug-company executives in Geneva starting Tuesday, in part to hash out possible solutions to the vaccine problem.

The emerging battle between the haves and have-nots underscores a major weakness in the global health system: Pharmaceutical companies have severely limited capacity to produce flu vaccines in emergencies.

Agence France-Presse/Getty Images

A flu-vaccination campaign in Panama City this month. Developing nations are sounding alarms about being left out in case of pandemic.

The WHO estimates drug companies will be able to produce between one billion and two billion doses of vaccine a year for a pandemic, depending on how much active ingredient is needed per dose. That is far short of the world’s population of 6.8 billion.

Wealthy countries — including the U.K., Canada, Sweden, Switzerland, Denmark and Austria — have been moving quickly to snap up the available capacity, ordering enough shots to cover much of their populations. The U.K. says it has a four-year, £155.4 million ($236.62 million) contract with GlaxoSmithKline PLC and Baxter International Inc. that guarantees delivery of up to 132 million doses of vaccine. The Netherlands is considering placing an advance order for 34 million doses, a spokeswoman for the health minister said.

The U.S. government has taken a slightly different approach, cutting deals with drug companies to boost capacity. The U.S. this year awarded Novartis AG $486 million toward the construction of a vaccine factory that will be able to produce 150 million doses within six months of a pandemic being declared — a deal that gives the U.S. first dibs on the vaccine, according to Andrin Oswald, Novartis’s head of vaccines and diagnostics.

The WHO hasn’t yet declared a swine-flu pandemic, nor have drug companies started producing pandemic vaccine in large quantities. Once they do, it will take four to six months for the first doses to become available.

Meanwhile, developing nations are sounding alarms about their vulnerable position. In a recent statement, health ministers from the Association of Southeast Asian Nations, including Indonesia, Cambodia and Vietnam, said “access to effective pandemic vaccines is a major problem in this region,” and called on the WHO for help.

“There is no mechanism to make sure we will get the medicines to those who need them,” says Sangeeta Shashikant, legal adviser to the Third World Network, a nonprofit group that promotes the interests of the developing world.

WHO vaccine official Marie-Paule Kieny said the organization is talking to vaccine manufacturers “to try to ensure access for developing countries.”

Anders Tegnell, a director of Sweden’s national board of health and welfare, said Swedish officials discussed the ethics of the issue before signing an accord with Glaxo for pandemic vaccine.

“If we have advance purchase agreements or not, still the bulk of production will most likely go to rich countries, because that’s the way the market works,” he said.

He said pandemic flu vaccines might not even be the best investment for poor countries, which are battling more pressing health problems, including HIV and malaria.

Drug companies say they recognize the problem of getting vaccines to poorer nations. A Baxter spokesman said the company will “be taking our lead from global health authorities” about how to “manage multiple priorities.” A Glaxo spokesman said the company is “absolutely committed” to providing pandemic vaccine to poor countries.

Glaxo on Friday said it plans to start producing a pre-pandemic vaccine against the current strain of the A/H1N1 virus causing the swine-flu outbreak. There is no guarantee this vaccine would work during a pandemic if the virus mutates significantly. Glaxo said it plans to donate 50 million doses of this pre-pandemic vaccine to the WHO for use in the developing world.

Albert Garcia, a spokesman for France’s Sanofi-Aventis SA, one of the largest vaccine makers, said while the company has signed loose agreements with France, Italy, Australia and the U.S. to supply vaccine in the event of a pandemic, the deals don’t specify the number of doses, the price or the timing of delivery. Sanofi feels it is “not ethical for us to sell vaccines that don’t exist at the moment,” he said.

Access to antivirals such as Tamiflu, used to treat a person already infected with the flu, are also an issue. Roche Holding AG, which makes Tamiflu, has donated millions of doses to the World Health Organization and increased its production to meet rising demand. It has also authorized a handful of generic companies to make and sell the drug in the developing world, in order to increase overall supply. But it is facing pressure to allow more widespread generic production.

Indian generic maker Cipla Ltd. threw down the gauntlet this week by saying it plans to sell a generic version of Tamiflu to buyers in Mexico, where the drug is protected by patent. The company will sell the drug for $10 per pack, less than Roche’s price in Mexico of €15 ($20) a pack, under contracts that indemnify Cipla against lawsuits, Cipla Chief Executive Amar Lulla said in a phone interview.

David Reddy, the head of Roche’s pandemic flu business, said “we see no rationale for generic supply, given that we are able to meet all of the needs of” Mexican buyers.

— Jeanne Whalen

And so is Obama’s hand-washing recommendation, echoing the wise counsel that our parents gave us when we were children and that Ignaz Semmelweis gave to medical students in the maternity clinic at the Vienna General Hospital in 1847. It is an ethical imperative, meant to mitigate the harm we might do to others. That hand-washing also diminishes your own chance of becoming ill makes it more desirable, though it does not further elevate the moral status of the act. In ethics, intent counts; the reason why you wash your hands matters. (That’s not to deny, of course, the virtue of sparing the community the costs of your infirmity — medical care, missed work — a rationale sometimes used to justify seatbelt or helmet laws.)

Those presidential dictates, while fundamentally ethical, are not universally applicable. Some employees, particularly low-wage workers, risk losing pay or even getting fired if they stay home from work to avoid infecting their coworkers. If we expect individuals to act ethically, we have a societal obligation to protect them when they do — for instance, by guaranteeing paid sick days to all.

Another argument for a community response, for the practice of civic virtue: even if someone displays impressive individual rectitude, he may still unknowingly infect other people with swine flu (or, if you prefer a more pork-chop-friendly designation, the H1N1 virus). Dr. Michele Barry, the dean of Global Health at Stanford University, says, “You may not be aware you are transmitting it early on.” People can be contagious for as long as six days before displaying any symptoms — and, she adds, “longer in kids and immuno-compromised folks.”

Some healthy people have taken aggressively individualistic action, asking a friend or relative who is a doctor for prescriptions for Tamiflu, an antiviral medication, to keep around the house just in case. To make such a request is unwise, to honor it unethical. In most cases, doctors “should certainly not be in the business of writing prescriptions for those they have neither examined nor taken a medical history” from, says Dr. Tia Powell, who is the director of the Montefiore-Einstein Center for Bioethics. And while it can be awkward for a doctor to turn down the aunt who will host the family’s next Thanksgiving dinner, that is what medical ethics requires (as I discussed in “The Ethicist” in 2005, responding to a query about avian flu).

A healthy person should not ask such a thing even of his or her own physician. To hoard antiviral medications can make them unavailable to those in immediate need. Temporary local shortages have been reported from New York to Honolulu. Even if there were unlimited supplies of antiviral agents, Barry would caution against their prophylactic use, except by people traveling to the center of the epidemic, because using such medications improperly can breed Tamiflu-resistant strains of the virus.

Thus some individual actions, like the presidentially endorsed washing of hands, are genuinely ethical, while others, like stocking up on antiviral medications, are not. Each must be judged on its merits. What’s more, universally esteemed acts do not obviate the need for community actions. And even those we deem outside the realm of ethics, that we consider to be matters of etiquette, can still be valuable social lubricants. Samuel Johnson was a great defender of politeness, calling it “fictitious benevolence” and asserting that “the want of it never fails to produce something disagreeable.”