A Preview to Pandemic

Students decide who will get a scarce vaccine
April 1, 2011
Image of syringes in vaccine

On a large screen in a darkened lecture hall at the Fuqua School of Business, a television newscaster reports on the spread of a contagious disease. “What began in Shanghai is now global, and it’s causing panic around the world,” the newscaster says. “The disease seems to be fatal for one in five afflicted, and epidemiologists are now very concerned about the rapidity with which the disease is spreading.”

“Of greater concern,” the newscaster continues, “is whether there will be enough vaccine available once it’s produced, who should get priority, who will have to do without. For more on all these ethical dilemmas, we’re going to go live to Duke University now, where professors Sherryl Broverman and Priscilla Wald are analyzing these complex ethical issues.”

The lights come up on Broverman, Wald, and the 105 students participating in this year’s Winter Forum, a three-day event held immediately before the spring semester begins. The Winter Forum, now in its second year, was designed to bring faculty members from different departments together with a diverse group of undergraduates to discuss a single topic. This year’s forum, organized by the Duke Global Health Institute (DGHI), focuses on pandemics.

The session that Broverman, an associate professor of the practice of biology and a member of the DGHI, and Wald, a professor of English, are leading this afternoon is called “Hard Choices: Vaccine Scarcity and the Rationing of Care.” It is just a small part of the forum, which attracted student participants with sessions on emergency preparedness, epidemiology, and lessons learned from last year’s H1N1 scare, among other things. Freshmen, who are accustomed to dining at the East Campus Marketplace, also note the forum’s abundance of good dining as influencing their decision to come back to campus early.

It’s just after lunchtime, and a few stragglers have made their way into the auditorium. They sit down in the aisles, as Broverman takes the floor.

“What ethical paradigms should be used to ration a lifesaving product?” she asks the group. She tells the story of early dialysis machines—they were rare and were offered only to those considered to have “greater social value”—and of syphilis patients during World War II. Soldiers “injured” in brothels had greater access to penicillin than those gravely wounded at the front because they were considered more likely to survive. By contrast, today’s intensive-care units operate on a first-come, first-served basis to establish equity in medical treatment, not to save the most lives, she says.

But during a pandemic, should public-health officials try to save the greatest number of people or stop the spread of the disease? What about the ease of access to vaccines? Should they only be given to people living in cities, which would presumably slow the disease’s spread? Some students think that’s a good idea, and say so.

“So, Montana—they’re gone!” Broverman says with a laugh. “Anyone uncomfortable?”

It’s a remark typical of Broverman’s talk—provocative, thought-provoking, yet also informal. The session doesn’t feel like a class, more like a casual discussion among friends. Perhaps that’s because students have been working with each other in small groups moderated by faculty members from several Duke departments. The students have given their groups names like “Flu Devils” and “Team Viral.”

During the discussion with Broverman, one student questions whether some people are—basically—more useful than others. Another offers up her grandfather as an example of someone who’s “already had his chance,” and therefore should not be in line for immediate vaccination. After the discussion veers toward the consideration of a lottery for vaccines—and whether the winning “tickets” would be transferrable—Wald takes the floor. She soon begins to wonder aloud about poverty and its influence on health crises. Do poorer communities get hit harder by pandemics? Can they be breeding grounds for disease? What about prison populations? Should convicts get vaccines?

“Have you heard the term ‘institutional violence’?” she asks. Many students have not. It’s a term applied generally to the effects of social inequality and in this case, it refers to healthcare problems that may make some people more vulnerable to the disease than others, she explains. Broverman stands to begin wrapping up the session. Taking into consideration what the newscaster described as the pandemic’s imminent spread, and assuming a scarcity of available vaccine, she gives students their charge: “Go to your groups and tell us who gets the vaccines.”

The students and faculty members go to their assigned classrooms, and Broverman and Wald walk into the hallway for some air. Back inside the lecture hall, Marc Sperber, the educational technology consultant for DGHI, is busy updating the Winter Forum’s “active learning space,” a website where the students will post their groups’ recommendations during the reporting stage of today’s session.

Over the course of the three-day forum, students also periodically post reflections on topics related to the discussions they’re having with others. And that newscast? It, along with an entire series that is being used throughout the event to break “news” about the pandemic, is available on the website as well. Sperber says the spots were months in the planning and owe much to the volunteer effort of local newscaster Penn Holderness and expert scriptwriting by Wald and others.

Out in the hall, Broverman and Wald are discussing what they think students will say when they come back to report their recommendations.

“I think they’re going to lean toward ‘utility’ being at the top of their list,” Broverman says. Police, firefighters, and military personnel would be first in line for vaccines, but students may overlook people like trash collectors, those with knowledge of how sewage systems work, or interstate truckers, whom Broverman considers vital to our survival in a pandemic.

Wald agrees, and adds somewhat tongue-in-cheek that the students may consider age to be a significant factor for determining who’d be eligible for inoculation. “I don’t have much hope for people over fifty,” she says.

“I’m curious to see what they do with children,” Broverman replies. She also wonders to what degree students will consider people’s vulnerability to disease when considering to whom they will give the vaccine.

Wald says she thinks one of the forum’s strengths is its ability to introduce new concepts to students who may not have considered them otherwise. “I had a student come up to me and ask who they could talk to about social medicine,” she says. As an English professor who writes a significant amount about biology, she enjoys the multidisciplinary approach that the Winter Forum encourages.

Students file back into the lecture hall, and Broverman and Wald take their places at the front of the classroom. The first group sets the tone for the reports: They place the highest priority on stopping the disease’s spread by giving vaccines to health-care workers first. So do several groups that follow. As Broverman predicted, many of the groups take social utility into account—during a pandemic, transportation would need to flow as freely as possible, order would need to be maintained, and people would need to stay safe. (Curiously, an observer notes, no one mentions the utility of journalists during a pandemic.) One group devises a complex point system for determining who gets the vaccine. Another calls for a lottery.

Then, as the session draws to a close, an interesting thing happens.

A female student sitting in the fourth row who had been checking her Facebook account through much of the early part of the reporting period seems to have acquired a sudden interest in the discussion. While Broverman and Wald field questions and comments from students with flagging energy, she starts surfing a Department of Health and Human Services website, clicking through page after page, learning about federal pandemic policy.

Aaron Kirschenfeld