Too much Tamiflu

The case of a Danish woman developing a drug-resistant strain of swine flu after being given low doses of the Tamiflu vaccine is raising questions about how and when to hand out the vaccine.

On 29 June, Denmark's National Board of Health announced the first known case of H1N1 swine flu resistant to the most popular antiviral drug. The woman was in contact with an infected person and was put on low-dose Tamiflu as a precaution, but she developed flu anyway.

She has now recovered after taking the antiviral Relenza, and the drug-resistant strain appears not to have spread. The State Serum Institute in Copenhagen assumes resistance emerged during treatment with Tamiflu, as low doses can favour the emergence of resistant strains.

It appears to be an isolated case, so on one is ringing alarm bells at the moment, but the case is is causing some questioning of the standard policy to treat those close to swine flu patients as a preventive measure. Doing so, after all, could lead to the development of a more dangerous strain of the flu than the current one -- which could be disastrous. 

British Medical Journal blogger Iain Brassington, a bioethics lecturer at the Centre for Social Ethics and Policy at the Law school at Manchester, points out that this puts governments and medical officials in a bind. Do they risk making things worse down the road by treating people now, or not?

There seems to be an interesting dilemma generated: while governments presumably ought to take steps to ensure the availability of prophylaxis, this also generates a risk that they’re creating a much bigger problem further down the line. I don’t think that this is an argument against prophylaxis per se - of course governments should deal with the threat as it stands at the moment (and anything else would be a counsel of despair), and the threat of resistant H1N1may never be realised - but the point would stand that, in doing what they ought to do now, they may be making things worse in the long run. And that means that meeting the present danger isn’t nearly as morally straightforward as it would seem at first.

I'll be keeping an eye out for more drug-resistant strains.

 

 

Real journal, fake credentials

The ongoing scandal in the medical publishing world took on a new twist today with news that Chiming Wei, founder and editor of a journal on the fledgling field of nanotechnology, appears to have exaggerated his credentials -- claiming to head a program at Johns Hopkins University that doesn't exist and starting a professional society with himself as president and chairman.

Indeed, an investigation of his credentials reveals that he claimed to hold a directorship of a non-existent program, co-authored only two original papers in Nanomedicine (one of which, a co-author says, he contributed to only editorially), and was accused of mismanaging the professional society to the point that some board members resigned and began a new professional group.

"I think that this individual is a good example of a field that is poorly- or under-regulated," Summer Johnson, executive editor of The American Journal of Bioethics, told The Scientist. "Everyone trusted the fact that he appeared to have high quality credentials."

Chiming Wei, president and founder of an organization called the American Academy of Nanomedicine (AANM), has the equivalent of a PhD from a Japanese institution and is a researcher in cardiothoracic surgery, but is not currently affiliated with any university. He started the group in 2005, when he was an associate professor at Johns Hopkins University in Baltimore, MD. The AANM's website lists Wei as Director of the Cardiothoracic-Renal Nanomedicine Program at Johns Hopkins, but according to the university, there is no such program. The Johns Hopkins press office was "unable to find evidence that this program exists," a university spokesperson wrote in an email.

Wei was also accused by experts in the field of adding his name to their journal articles, without permission or contributing in a meaningful way to the articles, in order to bolster his credentials.

Wei denied the accusations.

The journal, Nanomedicine: Nanotechnology, Biology, and Medicine, was established by Elsevier four years ago at Wei's urging.

The Scientist reports that Elsevier, however, did not check Wei's credentials before installing him as editor of a peer reviewed journal.

An Elsevier spokesperson said the publisher never checked Wei's publication record in nanomedicine before giving him the job of editing a nanomedicine journal. "Based on the discussions we didn't feel a need to read through [Wei's] papers, as he was quite knowledgeable on the subject," the Elsevier spokesperson added.

Elsevier has been at the centre of a controversy in recent weeks after revelations that it published several journals that were little more than paid promotional items for pharmaceutical giant Merck & Co.

Pharma publishing wrap-up

I have been blogging about reports of publishing scandals in the pharmaceutical industry of late, and today published a story in the Toronto Star  wrapping up some of them.

From the creation of fake academic journals, to bogus stories submitted to real journals, to falsified results in some of academia's most respected publications – the pharmaceutical industry has been rocked by allegations that the world's biggest drug companies put public relations above public safety.

As consumer advocate Peter Lurie put it recently: "I've seen no shortage of creativity emanating from the marketing departments of drug companies."

The allegations have come to light thanks to lawsuits in the United States and Australia seeking compensation for drug costs that the plaintiffs claim were too high. The suits allege the drug companies skewed academic investigations into their products, thereby driving up the price they could charge.

Trudo Lemmens, an associate professor of medical law at the University of Toronto, says it should not be left to the civil courts to uncover what he calls "publishing as marketing."

"You have to ask yourself, why isn't there more regulatory control?"

Lemmens would like to see tougher conflict-of-interest rules and more oversight of how drug trials are conducted, and the results published.

Obviously more is published online in the full story, on the Star's Healthzone website.

Merck troubles mount

Merck & Co., in the middle of $41.1 (US) billion merger talks with Schering-Plough Corp., is facing more troubles as the Food and Drug Administration in the United States demands that warnings of dangerous side effects from its top-selling asthma drug be boosted following growing evidence of problems.

AstraZeneca and Cornerstone Therapeutics are facing similar orders.

After 15 months of investigation, the Food and Drug Administration said Merck & Co. Inc., AstraZeneca and Cornerstone Therapeutics will have to raise label warnings about psychiatric problems reported by a handful of patients taking their drugs.

"Patients and healthcare professionals should be aware of the potential for neuropsychiatric events with these medications," the FDA said in a posting to its Web site.

A spokeswoman for Merck said the language already appears in Singulair's label, but will be raised to the "precautions" section. It's now listed in a section about various side effects reported by patients.

"We've been working with the FDA since Singulair came to market and every time we update the label it's in cooperation with them," said Merck spokeswoman Pamela Eisele. ...

The exact language of the labeling updates has not been released, but the FDA said it could mention a slew of psychiatric problems, including: "agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior — including suicide — and tremors."

The move comes just weeks after a former research subinvestigator at Vivra Asthma & Allergy, an asthma research and treatment centre, went public with allegations that its Singular trails were knowingly skewed and falsified.

Trials of Singular, Serevent, Foradil, Flovent, Xolair, Accolate, and Xopenex conducted at the Tucson, Ariz., facility of Vivra Asthma & Allergy were corrupted by protocol violations and outright falsifications, says Robert Davidson, M.D., a former clinical research subinvestigator (SI) at the facility. ...

Davidson charges that during aggressive recruitment schemes in the late 1990s, patients with abnormal EKGs, multiple risk factors for coronary artery disease, arrhythmias, pulmonary embolisms, rheumatic fever histories, acute illnesses, and even pituitary tumors were enrolled with impunity in trials that earned investigators as much as $10,000 per patient.

Patients were “prescreened” for asthma drug trials with medically unnecessary pulmonary function tests (PFTs) without their knowledge or consent and had medication dosages reduced in apparent efforts to qualify them for the lucrative trials.

Staff could be seen entering rooms where placebos and real drugs were mixed and unblended, invalidating entire studies sent to the FDA as data for new drug applications.

The brazen “study buddy” and “crossover” arrangements, as staff referred to them, included churning or serially enrolling patients into clinical trials despite risks to their health and early terminations, coercing unwilling patients to participate, and directly falsifying patient study diaries, say documents filed by Davidson in a federal complaint.

Merck stands by its drug.

"For the millions of people suffering from either asthma or allergic rhinitis, SINGULAIR is an important treatment option for appropriate patients," said Scott Korn, M.D., vice president, Clinical Risk Management and Safety Surveillance, Merck Research Laboratories.

Merck held a conference call with drug reps late Friday to talk about the FDA order, but according to BNET Pharma and CafePharma.com, things didn't go well.

Naturally, Merck management scheduled a conference call for drug reps who tout Singulair at 6p.m. on Friday (an hour guaranteed to please reps hoping for a stress-free weekend). Unfortunately, many reps only received the note scheduling the meeting at 7 p.m. — one hour after the call started. From CafePharma:

I found out about a 6PM teleconference after 7PM. Gotta love management.

Other reps had difficulty navigating Merck’s dial in system:

First, they give vague directions about the teleconference (you had to go on to Comm. Central to get the dial-in number). Then they start 15 min late trying to get their s$%t together. Then TC says that this is a great opportunity to show our customers how committed we are to patients. When is the last time these people were in the field? Completely out of touch. Another Monday am to dread.

Those who did dial-in on time were kept on hold, just as they had been at an earlier conference call at 8 a.m. which apparently only got started at 8.20 a.m.:

This morning the the other S teleconference scheduled for 8 AM starts after 8:20 AM. What is going on inside? Half the country is on hold listening to music. I got work to do guys. I have to move and make calls.

All this comes amid allegations that Merck used fake academic journals and suppressed negative drug trail results.

In a final note, the American Journal of Bioethics blog, blog.bioethics.net, has congratulated this blog on its coverage of Merck and other drug companies of late.

I couldn't be more pleased that [insert gratuitous but sincere praise:] outstanding Toronto Star writer Stuart Laidlaw has been rigorously following the Merck/Elsevier scandal. It's practically flattering that he's listening to bioethics' and in particular bioethics' publishing voices, and he's quoted The American Journal of Bioethics Editor's Blog [that'd be the fancy-pants name for blog.bioethics.net] on his own Toronto Star Medical Ethics blog. However...the old adage that "the enemy of my enemy is my friend" may not apply to taking on the admittedly incredible ethical missteps by Merck ... and its publishing mules, comprising a whole fleet of bogus journals made to fool academics and clinicians.

You'd think that Merck would have learned from Vioxx and their New England Journal mistake (oops, forgot to send that data...) where publishing is concerned. You'd think ANY publishing company would learn that presenting the appearance of peer review for sale, then refusing to be transparent about just how much it COSTS to buy a peer reviewed journal. But you'd be wrong.

The thing is ... Stuart ... these guys are not, well, did you see the movie The Insider? [note to pharma lawyers and publishers of all kinds: I live on a small island in the Pacific...really...]

Summer Johnson, PhD

Let's hope she's wrong.

'Nonsense' science article offered publication -- for a fee

Using a bit of mischief, researchers at Cornell University and the New England Journal of Medicine have exposed the dangers of open access scientific journals after they were able to get a nonsensical article past editors of the Open Information Science Journal recently.

All they had to do was submit an $800 (US) "access fee" to the journal, blogger Bob Grant said in his blog for The Scientist magazine.

Philip Davis, a PhD student in scientific communications at Cornell University, and Kent Anderson, executive director of international business and product development at the New England Journal of Medicine, submitted the fake manuscript to The Open Information Science Journal (TOISCIJ) at the end of January. Image:

Davis generated the paper, which was titled "Deconstructing Access Points," using a computer program -- called SCIgen -- created at the Massachusetts Institute of Technology. He and Anderson signed the work using pseudonyms (David Phillips and Andrew Kent). The two listed the "Center for Research in Applied Phrenology" (CRAP) as their home institution on the paper, which featured fictitious tables, figures and references.

"I wanted to really see whether this article would be peer reviewed," said Davis. "[Our paper] has the look of an article, but it makes no sense."

Davis told The Scientist that he got the idea for this "little experiment" after receiving scores of spam emails soliciting article submissions and invitations to serve on editorial boards of open access journals from Bentham Science Publishers, TOISCIJ's publisher. According to its website, Bentham publishes "200 plus open access journals" that cover disciplines from bioinformatics and pharmacology to engineering and neuroscience. "One of the things that made Bentham catch our eye," Anderson said, "was that they were so aggressively soliciting manuscripts."

The two wrote about the incident today on the Scholarly Kitchen, the Society for Scholarly Publishing blog that they run.

The journal claimed the article had been peer-reviewed -- standard practice for scholarly journals -- but the two researchers received no review notes on their article. They were tempted to pay the $800 to see if their article would actually be published, but decided that would be unethical.

Grant tried to get the journal's side of the story, but was not successful.

I called Richard Morrissy, who's listed as the US contact for Bentham Science Publishers on the company's website, but he declined to answer my questions and instead directed me to his supervisor, Matthew Honan, who works in Bentham's France office. Honan does not have a phone number, according to Morrissy, and he did not reply to an email (which was CC'ed to Bentham's marketing team in Pakistan) by the time this article was posted.

Despite the obvious humour here, the incident also points to potential dangers, especially as one of the world's leading pahrma companies Merck & Co. finds itself in a fake publishing scandal of its own.

Open access journals generally charge authors fees to publish research papers. For example, BioMed Central journals charge up to $2265 in "article processing fees," and publishing in the PloS family of journals costs authors between $1300 - $2850. With institutional libraries, including Cornell's, and granting institutions, such as the Wellcome Trust and the Howard Hughes Medical Institute, offering to pay open access publication fees for faculty authors and grantees, the potential for abuse may be increasing. "It's almost an inevitability that you might have several publishers tempted to take advantage of this relatively easy money," said Anderson.

By the way, here's an excerpt from the opening of the article in question:

"Compact symmetries and compilers have garnered tremendous interest from both futurists and biologists in the last several years. The flaw of this type of solution, however, is that DHTs can be made empathic, large-scale, and extensible. Along these same lines, the drawback of this type of approach, however, is that active networks and SMPs can agree to fix this riddle."

 

Merck publishing scandal widens

Pharmaceuticals giant Merck & Co. is refusing to answer questions about a growing scandal involving its publication of fake scientific journals that were, in fact, little more than promotions for its products.

Originally thought to have published six such journals, it now turns out Merck bought and paid for nine journals -- with 13 more in the works.

News of the fake journals broke in April in The Scientist when it reported that Merck had paid Australian publisher Elsevier to print Australasian Journal of Bone and Joint Medicine (AJBJM), without revealing that the publication was created and paid for by Merck.

The "vast majority"of articles in AJBJM during its 2002 to 2005 publishing life were favourable articles about Merck drugs Fosamax and Vioxx -- two medications that have been linked to dangerous side effects.

Fosamax is an osteoporosis drug that has been linked to cancer.

LegalView reports on the recent Fosamax side effects, which have caused patients to not only consider new medications but to discuss the potential for a Fosamax class action lawsuit as well. In January, two medical journals, The New England Journal of Medicine and the Journal of the American Dental Association provided a one-two punch against the drug’s manufacturers, Merck and Co., reportedly linking the drug to such side effects as esophageal cancer and jaw bone die-off. Patients of the osteoporosis drug are advised to contact a medical professional to discuss the drug and its alleged dangers.

Vioxx, an anti-inflammatory, was pulled off the market after independent studies found a link to increased heart attack and strokes.

Merck, in what Summer Johnson calls "passing the buck" in the respected blog.bioethics.net, is refusing to answer questions about the publishing scandal, referring all questions to Elsevier -- which says it is reviewing its policies and admits the publications never should have been called journals.

Johnson is having none it:

Simply because Elsevier took the bait doesn't mean Merck is off the hook. Elsevier is rightfully taking the heat for agreeing to create entire divisions of publications that an Elsevier spokesperson admitted "should not have been called 'journals'." What an admission! What to call a publication such as these really is the question--perhaps they will fade into oblivion such that we will not have to give them a name. Not a chance. ...

If Elsevier really wants to put this scandal behind them, they must throw the doors open wide and disclose everything--including how much they were paid. Eventually the facts will come out. When they do--and I'm only guessing the figure is astronomical--Elsevier will look like they were hiding some very dirty laundry. Merck already is passing the buck and leave Elsevier holding the bag. Thus far it looks like they are succeeding. 

The nine fake journals are: The Australasian Journal of Bone and Joint Medicine, the Australasian Journal of Neurology, the Australasian Journal of Hospital Medicine, the Australasian Journal of General Practice, the Australasian Journal of Cardiology, the Australasian Journal of Cardiovascular Medicine, the Australasian Journal of Clinical Pharmacy, the Australasian Journal of Clinical Practice, and the Australasian Journal of Musculoskeletal Medicine. 

The 13 planned fakes are: The Australasian Journal of Pediatrics, the Australasian Journal of Obstetrics and Gynecology, the Australasian Journal of Dentistry, the Australasian Journal of Infectious Diseases, the Australasian Journal of Pain Management, the Australasian Journal of Respiratory Medicine, the Australasian Journal of Sexual Health, the Australasian Journal of Psychiatry, the Australasian Journal of Asthma, the Australasian Journal of Gastroenterology, the Australasian Journal of Hospital Pharmacy, the Australasian Journal of Depression, the Core Journals in Oncology. 

 

The ultimate silk purse

Researchers in China claim to have figured out a way to coax cells from any part of a pig's body -- they used cells from a pig's ear and bone marrow -- into any type of cell in the body, just like embryonic stem cells.

The breakthough could set the stage for pigs being raised to grow organs for humans for transplantation, the researchers say.

Lead researcher Dr Lei Xiao, of the Shanghai Institute of Biochemistry and Cell Biology, said many other attempts had been made to transform adult cells from animals such as pigs into "pluripotent" stem cells, but they had failed.

He said: "Therefore, it is entirely new, very important and has a number of applications for both human and animal health."

Dr Xiao's team reprogrammed cells taken from a pig's ear and bone marrow, using a cocktail of chemicals introduced into the cells via a virus.

Tests showed that the reprogrammed cells were capable of becoming any of the cell types that make up the three layers in a developing embryo.

Dr Xiao said pigs were a potentially ideal source of organs for transplant, as their organs were similar in function and size to those found in humans.

In its blog,the American Journal of Bioethcis quipped that the breakthrough could help save the pig's reputation after the swine flu scare.

Medical researchers have long looked to pigs as a potential source of human organs in a field known as xenotransplantation, saying it could help with chronic shortages of organs from transplant.

Professor Chris Mason, an expert in regenerative medicine at University College London, said: "This breakthrough to produce pig stem cells potentially reinvigorates the quest to grow humanised pig organs such as pancreases for diabetics and kidneys for chronic renal failure.

"The clinical use of humanised porcine tissues and organs (xenografts) has moved a long way forward in recent months with successful small-scale clinical trials.

There's a certain "yuck" factor for many people, however, and animal rights activists and religious groups have objected to the idea.

Dr Sebastien Farnaud, science director of the Dr Hadwen Trust for Humane Research, said: "Persisting with highly speculative research that would see us use sentient animals as little more that living organ grow-bags, is not only ethically unsupportable but also scientifically dubious.

"Creating pig stem cells does not necessarily remove the risk of organ rejection but even more worrying is the risk of infecting patients and the wider public with pig viruses."

Flu ethics articles available free

Articles and editorials published in the American Journal of Bioethics over the past few years on pandemics and how to handle them are now available for free to help health officials figure out what to do about swine flu.

Presumably, for in the general public, the articles will also provide something to measure the actions of health officials and politicians against.

Here's a list of available articles:

Ethics, Pandemics, and the Duty to Treat by Heidi Malm, Leslie P. Francis, Robert Hood, Thomas May, Saad B. Omer, Daniel Salmon 2008; 8(8):4

OPCs: Carrots and Sticks: Keeping Healthcare Workers on the Job in a Public Health Disaster by Tia Powell 2008; 8(8):20

Health Care Workers' Willingness to Work in a Pandemic by Dorothy E. Vawter, J. Eline Garrett, Karen G. Gervais, Angela W. Prehn 2008; 8(8):21

Suppose They Gave an Epidemic and Nobody Came? by Neil Schluger 2008; 8(8):23

Not in My Job Description by Joanne Godley 2008; 8(8):25

Specifying the Duty to Treat by Michael J. Selgelid, Yen-Chang Chen 2008; 8(8):26

Ethics and Epidemics by Daniel K. Sokol 2008; 8(8):28

A Duty to Treat During a Pandemic? The Time for Talk is Now by Tracey M. Bailey, Thomas J. Marrie, Rhonda J. Rosychuk, Olive Yonge 2008; 8(8):29

The Duty to Care in a Pandemic by Joint Centre for Bioethics Pandemic Ethics Working Group 2008; 8(8):31

Without Consent: Moral Imperatives, Special Abilities, and the Duty to Treat by Nadia Sawicki 2008; 8(8):33

Public Health and Duties to the Population during a Pandemic by Kenneth Kirkwood 2008; 8(8):35

Remembering the "Pan" in "Pandemic": Considering the Impact of Global Resource Disparity on a Duty to Treat by Alison Reiheld 2008; 8(8):37

Healthcare Professionals and the Reciprocal Duty to Treat During a Pandemic Disaster by Darren P. Mareiniss 2008; 8(8):39

Pandemic Influenza and the Duty to Treat: The Importance of Solidarity and Loyalty by Mitchell A. Klopfenstein 2008; 8(8):41 EDITORIAL: A 1918 Flu Memoir by Ricki Lewis 2008; 8(8):3

EDITORIAL: Don't Be Chicken: Bioethics and Avian Flu by Laurie Zoloth, Stephen Zoloth 2006; 6(1):5

EDITORIAL: Risk and Trust in Public Health: A Cautionary Tale by Matthew K. Wynia 2006; 6(2):3

EDITORIAL: Markets and Public Health: Pushing and Pulling Vaccines into Production by Matthew K. Wynia 2006; 6(3):3

EDITORIAL: Strange Bedfellows? Reflections on Bioethics' Role in Disaster Response Planning by Jessica W. Berg, Nicholas King 2006; 6(5):3

EDITORIAL: Ethics and Public Health Emergencies: Rationing Vaccines by Matthew K. Wynia 2006; 6(6):4

EDITORIAL: Ethics and Public Health Emergencies: Restrictions on Liberty by Matthew K. Wynia 2007; 7(2):1

EDITORIAL: What Vaccination Programs Mean for Research by Jeffrey P. Kahn 2007; 7(3):3

EDITORIAL: Ethics and Public Health Emergencies: Encouraging Responsibility by Matthew K. Wynia 2007; 7(4):1

EDITORIAL: Mandating Vaccination: What Counts as a "Mandate" in Public Health and When Should They Be Used? by Matthew K. Wynia 2007; 7(12):2

Such articles would normally cost about $37 (Canadian). No word on how long they will be available.

Swine flu on Facebook

The American Journal of Bioethics has set up a Facebook group to provide up-to-the-minute information on the current swine flu outbreak.

Launched today, pandemic.bioethics.net is your leading source for bioethics news, commentary and scholarship related to swine flu (H1N1), vaccine research, public health policy and more.

Whether you want up-to-the minute news updates, to comment on what we are writing here at bioethics.net, or to post your own news stories and to write your own comments via Twitter or Facebook, pandemic.bioethics.net is the primary source on the Internet for ethics and pandemics.

Available starting today also via our website, AJOB and Taylor and Francis have made available all pandemic-related publications for a six-month period. Links to those publications are available at blog.bioethics.net and pandemic.bioethics.net.

To learn more and to join in on the dialogue, visit us on Facebook, bookmark our URL, or select any of the links above.

Summer Johnson, PhD

The group already has links to several articles related to pandemic planning, including one on mandating vaccinations, another on ensuring people live up to their responsibilities during a pandemic and one on rationing vaccine.

It's an open group, so anyone can join and invite others to join.

Swine flu ethics

Hong Kong says it will detain in hospital anyone arriving there who has a fever, at least until it can be proven that they don't have swine flu.

Hardly a surprising reaction by a place that was the epicentre of the SARS outbreak six years ago, but it raises interesting ethical questions about the needs of the many versus the rights of individuals.

Is it ethical to effectively jail someone merely on the suspicion of illness? On the other hand, with thousands, perhaps millions, of lives at stake if this thing becomes a pandemic, would it unethical not to detain people?

Tough questions, to be sure, but ones that I suspect we'll be hearing more about in the coming days as swine flu continues scaring people around the world.

Detention sounds like an easy answer, but it raises some practical problems. For one, will people avoid getting treatment for fear that doing so will get them detained? If even a handful of people react that way, the results could be catastrophic. On the other hand, can we count on people to do the right thing and get tested -- and stay indoors if diagnosed -- without strict controls?

Local health authorities are meeting around the world to discuss theses issues.

Another practical concern is deciding who will get vaccinated against this new flu. Health care workers will almost certainly be top of the list, but even the details of that could be up for debate. I wrote in the Toronto Star last fall about a study that argued that not all medical staff should get the flu shot during a pandemic. Why would a foot doctor be needed. it asked.

Better, it said to direct some of the vaccine to truckers and public works staff to ensure that food, water and electricity remain available through any health crisis.

"It takes a lot of people to keep society going," says Nancy Kass, a professor at the Johns Hopkins Berman Institute of Bioethics and lead author of the study in the most recent edition of the journal Biosecurity and Bioterrorism.

Traditional pandemic planning calls for giving first priority for medical treatment to hospital staff and "first responders" to a crisis, such as firefighters and ambulance workers, so that the immediate health crisis can be dealt with effectively.

But as Hurricane Katrina showed three years ago, the study argues, "the after-effects of a disaster can be as damaging as the precipitating event," as electricity and heat are cut off, clean water becomes scarce and sewage starts to back up.

"There could be widespread social chaos, significant outbreaks of other infectious diseases, and severe anxiety, with the possibility of social degeneration, looting, or even violence as people try to secure needed supplies," the study says.

Even people whose homes were not damaged by the hurricane had trouble getting food, electricity and gasoline, Kass says in an interview.

Up to 40 per cent of the workers whose job it is to keep the lights on and the water flowing could be absent from work after a pandemic, the study says. That's enough to cause a breakdown of such services.

I will be watching to see how the many ethical issues play themselves out with the swine flu story.

Meanwhile, blogger Janet D. Stemwedel (aka Dr. Free-Ride) has been keeping track of how various airlines and others are responding. From a Canadian perspective, both Air Canada and WestJet are waiving fees for changing Mexican travel plans.