His internist had no flu shots and no hope of getting them. Neither did his pulmonologist or his gastroenterologist. So Leo Lutwak, who at 76 suffers from severe lung disease, headed to his Silver Spring Giant, the one around the corner from the huge senior community of Leisure World. There he futilely stood in line with hundreds of neighbors. Not once but twice.
Yet just several miles to the east in Hyattsville, a walk-in clinic that usually serves overseas travelers and students was flush with vaccine. Local Veterans Affairs centers had no shortages. The same for a pediatric practice on Connecticut Avenue in Northwest Washington. In fact, until the city's decision late Thursday to prohibit shots for anyone not in a high-risk category, that office was considering whether to resume immunizing healthy youngsters in early November.
After more than 10 days of government announcements, guidelines and reaction after the loss of half the nation's expected vaccine inventory for this flu season, the holes in the system have become clear. Given the havoc that has followed -- not only the seven-hour waits in grocery store lines, but the public confusion and anxiety over where to find the remaining vaccine -- the challenge of getting unshipped stocks to the people who most need them appears immense.
Pediatricians in private practice report adequate if not ample supplies. Public clinics that serve children are holding their collective breath. But doctors who deal with adults and the chronic conditions that constitute greater risk say they can locate little vaccine. Those who have are triaging patients, narrowly choosing who is sickest of the sick.
"We're forced into rationing," said William Rosson, an internist for more than four decades in New Carrollton. "This is a very daunting task."
His distributor had promised he would get his 250-dose order "right up to the last minute." Overnight, that dropped to zero. A few days ago, Rosson finally obtained 100 shots. "What I feel morally obligated to do is give it to people at greatest risk," he said. He would favor an overweight patient with diabetes and a history of heart attack or stroke over a patient who has had only a heart attack. "It's a real tough call, but we just use the best judgment we can."
The Centers for Disease Control and Prevention has said it will reallocate millions of doses across the country. Federal officials are working with their state and local counterparts to determine where the worst gaps are by region and target groups. "This is going to be a pretty labor-intensive process that's going to require a lot of collaboration to make it happen effectively," CDC spokesman Llelwyn Grant acknowledged Thursday.
With seniors among the most susceptible to influenza because of age and multiple ailments, nursing homes and other long-term-care facilities will be at the top of the recipient list. The priority ranking is of utmost importance to many. In the District, the vast majority of facilities expected their vaccine shipments from Chiron Corp. -- the company whose British manufacturing operations were suspended because of contamination -- and currently have nothing at all.
The problem, though, is that the number of seniors in nursing homes totals a small fraction of the population that is 65 and older. The problem is amplified further when it comes to those under 65 whom the CDC also is recommending for a flu shot.
"We're simply asking folks representing these high-risk groups . . . to be really proactive," to push their doctors for the vaccine, Grant said. But if their doctors have none? Officials are asking for patience as the redistribution is worked out over the next two months.
At the CDC's direction, the country's remaining supplier, Aventis Pasteur, sent 2 million doses this week to the VA, hospitals and long-term-care facilities, public health officials, and providers who care for young children. In future weeks, the CDC also will work to identify primary care and specialty physicians who should receive doses.
"To be frank with you, we don't have all the answers," Grant said.
The medical director at the Whitman-Walker Clinic said he would like guidance from the CDC as he faces the 2,400 patients there who are candidates for flu shots -- when, that is, the clinic gets vaccine. Philippe Chiliade knows he may be forced to choose among those with HIV or AIDS, giving priority to men and women whose viral markers are low but not too low. "It will be a hard discussion," he said yesterday.
In the Novamed office in Fairfax County, Donna Rae only says no these days. The large internal medicine practice, which tips heavily toward patients in their late sixties and older, lost its entire vaccine order because of the Chiron debacle. "They're absolutely scared," Rae said of patients. But she's worried, too; no employees there have gotten a shot.
"My big concern is having two vials to immunize my staff," she said. "What am I going to do if my staff goes down, if my physicians go down?"
The Accredited Allergy Center of Springfield is taking a hard line. Only its patients and no one else, no matter how much others suffer from asthma or related respiratory conditions, will benefit from its 300 doses. "A lot of them have family who want [the vaccine] but can't find it," office manager Patti Bailey said. "There's a lot of people trying to use the sympathy ploy. I had one woman say, 'My grandmother's on oxygen. Can she get a shot?' Another lady wanted her daughter, who's pregnant, to get one. We're hearing everything."
More than ever, in medical ethicist Mary Ann Baily's view, the situation has exposed Americans to a fragmented, uncoordinated system of health care delivery. She wonders whether it is a portent of what the country would face in a bioterrorism incident. "This should be a wakeup call," said Baily, of the Hastings Center in New York.
After his second trip to the supermarket, Leo Lutwak took matters into his own hands. The retired physician went to the drugstore and bought several surgical masks. He also got a prescription for Amantadine, an antiviral medicine that can help alleviate flu symptoms.
Once the season really hits, he'll put on a mask any time someone comes to visit him, and he'll fill the prescription, "get my dozen tablets." Just in case, though, he will also make sure his funeral plans are in place.