From the Editor: It Never Changes (Until It Does)

Sep 01, 2005


Patrick Clinton
My wife and I were talking the other day about avian flu, and we concluded that it was time to talk to our doctor about stockpiling some Tamiflu. Actually, it would be more accurate to say that I was regaling my wife with projections about avian flu, interspersed with grisly pages from John M. Barry's history of the 1918 pandemic, The Great Influenza, figuring that if I riled her up enough, she'd take on the job of arguing with the doctor.

It worked, sort of. That is, Sue got riled up and called the doctor, but we didn't end up with our prescriptions. I had figured that might happen. I can think of lots of reasons a doctor might not want to write that script:

First, it's pretty pricey for something that might or might not work. But I don't care. If I want to spend $350 for five courses of a med that may sit unused in the medicine cabinet until it expires, why not? My insurance company, which apparently doesn't believe in prevention, won't pay. But I will.

There's the efficacy question. We don't really know what's going to happen to the H5N1 as it mutates. By the time it breaks out as a pandemic, it might be resistant to Tamiflu. Again, who cares? It might not develop resistance, and again, I'd take that risk.

Other objections? She could say that she doesn't believe that avian flu is going to cross over into humans. (Hah!) Or that she's confident a vaccine will be available in time. Or that it's unethical for private citizens to stockpile a medication that should be amassed on a national or international basis. (Fair enough, though at the moment, I'd argue that private purchases might do more to encourage more capacity than to eat up the supply.)

If she wanted to turn us down, there are a great number of reasons she could have given. But I was honestly boggled by the reason she gave. "For this drug," she told my wife, "you have to come to the office when you're actually sick so we can see you. We don't prescribe it in advance."

Huh? Apparently my doc and I have different visions of what an avian flu pandemic could amount to. She's picturing a regular flu season, but a little worse. Me, I'm thinking about 1918: a third of the population sick, sky-high mortality, hospitals filled beyond capacity, and medical personnel incapacitated or worse. Will I go see her if I'm ever struck by avian flu? Probably not. On the one hand, she'll have so many patients that I'll be as likely to get past the receptionist as the fourth sales rep in line on Friday afternoon. And if H5N1 lives up to expectations, I'll be too ill to get there. Oh yes, and unless the government does a much better job than we're currently seeing, there'll be nothing to prescribe for anyone.

In short, she's betting on continuity, and I'm betting on disruption. I hope she's right, but I think I am.

Most of us bet on continuity most of the time. That usually works out, but when it doesn't, the costs can be enormous. How do you tell when the exception comes? That's the hard part.

We're not just talking about diseases and drugs, of course. Look at the pharma industry today. Change is bubbling around through the industry, its customers, and its regulators, like virus in a Chinese chicken farm. Maybe it will never amount to much, but maybe the right combination of ingredients—regulatory zeal and public outrage, a changing marketplace, and maybe a bit of good or bad luck in R&D—will come together in that sudden shift (kind of like an antigen shift in virology) and we've got a whole new ball game. At that moment, it's going to be perfectly clear what should have happened.

The signs are all around. Should pharma be doing the equivalent of taking two aspirin and calling in the morning or building an ark? It's getting to be time to lay down your bets.

Patrick Clinton is Pharmaceutical Executive's editor-in-chief and can be reached at