## Staying Alive --- Odds and Outs

First, it seems useful to do some calibration to see just how "paranoid" one should be. To focus the discussion, let's consider with the US Government's scenario where there are 2 million pandemic deaths in the US. This is a horrifying number, but one needs to put the 2 million in perspective.

First, 2 million is "only" about 2/3 of one percent of the population. Thus, if you are a random US resident, and if the government's worst case scenario unfolds, you have "only" about a probability p=0.0066 of dying in the pandemic.

Would you like to cut your own probably down from p to say a fifth of that? That would make your personal p about 0.0010, or a one-in-a-thousand shot. This seems to be a practical goal that is still worth the price of a little a planning.

### The Non-controversial Basics

• First, everybody is better off if person-to-person contact is minimized.
• If you are quarantined then for heaven's sake, stay quarantined.

Schools should have a very low threshold for closing, and rational parents should have an even lower threshold for keeping their kids out of school. If you have toyed with the idea of home schooling, this is the time to get serious. Staying alive does depend on luck, but you tilt the odds in your favor by minimizing exposure ("social distancing") and by paying close attention to hygiene, especially washing your hands and disinfecting items that you bring into your house.

The benefit of using a N95 mask is a little more speculative. In aggregate, they may not help much because very few people will take the trouble to train themselves to use the masks appropriately. The must be correctly fitted, and --- most important --- they must be removed in a way that avoids accidental post-use contamination.

Also, simple physics suggest that masks have a high hurdle to clear. A single virus and an N95 mask have about the same relationship as a golf ball and a tuna net. The single virus goes through easily. Where the masks help is in stopping those big wads of virus that have the analogous size of a softball --- or even a basketball. These wads can be stopped, and it is worthwhile to stop them.

There is even some empirical evidence that masks can help. In the SARS epidemic N95 masks made a useful difference. They reduced care giver infection from 6% (per shift!) to 1% (per shift!). Here of course, the medical personnel were trained in the proper use of the masks.

Finally, t here are two hidden benefits of the use of masks. First, the wearer will touch his face less often and thus cut down on one of the principal means by which one becomes infected. Second, a mask wearer is likely to be accorded more than the usual "social distance," since --- at the beginning at least --- it is likely to be assumed that the wearer is ill.

### The More Controversial Anti-virals

The governments of the world are almost all making substantial investments in the anti-virals Tamiflu and Relenza. The intimate efficacy of these drugs is unknown, but the best scientific thinking the world can muster suggests that they provide the best treatment and prophylaxis that money and power can buy.

In many parts of the world (including the US) there are still doctors will write their patients prescriptions for Tamiflu in anticipation of a possible pandemic. Nevertheless, over just the last few months, doctors have come under pressure from public health officials not to write such prescriptions.

The Dilemma of Personal Tamiflu Stockpiling by Peter M. Sandman and Jody Lanard gives a thoughtful examination of the ethics of this situation, and their covers almost any argument that you are likely to hear. The authors do not take a stand on either side, but they do underscore that some public health arguments have been distastefully disingenuous.

The one absolutely incontrovertible fact is that the vast majority of people on the planet will be no access to anti-virals. This is mainly because most countries and most people are too poor. The only nation that has enough for every resident is Kuwait.

Those who acquire genuine Tamiflu in advance of a pandemic and who also school themselves in its proper storage and uses in treatment and prophylaxis will have about as solid a back-up plan as can be practically attained.

### Practical Issues and Anti-virals

Suppose, after thoughtful considerations of the ethical and public health issues, someone decides to make a serious effort to acquire anti-virals. What can be done?

Certainly anyone's first choice is to get a prescription from a doctor you know. If this is not possible, you may have luck seeking out a doctor whom you do not know. The community of doctors is large and doctors have a great range of opinions, personalities, and business models. If you can get a bona fide script, then (as of 6/1/06) you will be able to get this filled by pharmacies whose products you can trust. You may even be able to negotiate with the pharmacist a little to get a long expiration.

An individual who can't get a prescription and who is committed to obtaining Tamiflu will inevitably look to those internet pharmacies that require "no prior prescription." I the words caveat emptor ever meant anything they need that meaning doubled here. The key problems are (1) counterfeit and (2) simple fraud.

If you want be certain to find counterfeit drugs, try searching for "generic Tamiflu."

As of June 1, 2006 there is NO legitimate generic Tamiflu. But you will find many hundreds of offers.

Poker players would call this a "tell." If you are considering purchasing from a site, check to see if they offer the "generic Tamiflu" and if they do, scratch that site. Better yet, before you leave the site, take down their telephone number. Now Google that telephone number, and don't be surprised if you pick up from six to sixty sites with the same telephone. Now you have a large set of sites that you do not need to consider.

This technique can be extended with the help of other "tells" and more specialized Google Hacks. For example, you might decide not to deal with a "Canadian Pharmacy," if you discover that it is web hosted in some country on the other side of the globe.

It is distasteful to explore this demimonde, and it is risky (perhaps foolishly risky) to deal with people who build a business so close to the boundary of the law.

### You Bought "Something" .... Now What?

Still, eventually tens of thousands --- if not hundreds of thousands --- of people will place internet orders for Tamiflu.

Based on the ratio of obviously-fraudulent to possibly-not-fraudulent sites, the vast majority of people will be ripped off. The range of rip-offs will range from the sophisticated to the disgustingly crude. On the purely financial side, purchasers who use a debit card on an insulated account will mainly be risking the purchase price. Purchasers who plop down their main credit card and answer a lot of personal questions put substantially more at risk.

Perhaps nothing will arrive, and, if indeed some product eventually arrives, then one wonders if it is counterfeit or not.

For the moment, the Roche Guidelines for Recognizing Counterfeit Tamiflu provide a useful line of defense, but soon --- if not now --- there will be Tamiflu counterfeits that are "package perfect." Perfect Tamilflu packages are not harder to make than hundred dollar bills, and in a pandemic they will pass more easily --- and probably for much more than \$100. Naturally, Roche asserts that it is working hard to stop counterfeiting, but there is a limit to what they can do. Deterrence and counter-measures can't be expected to have much impact in the face of a demand panic.