There are five doses of life-saving avian flu vaccine and 10 people in the family. Grandma and grandpa are in their 70s. Both have serious medical conditions. Their two married children are in their 40s One couple has young children, the other children in their early teens.

Who gets the vaccine?

Guidelines from the federal Centers for Disease Control and Prevention say the elderly, particularly those whose health is compromised, should be first in line. But if faced with the choice, wouldn't most grandparents give their doses to a child or grandchild? When a disease has a 50 percent mortality rate among victims young and old, shouldn't those who have not yet had a chance to live have priority?

Who gets the vaccine is just one of the medical, moral, legal and ethical questions that societies have finally begun to discuss with urgency. Officials, including U.S. Health and Human Services Secretary Michael Leavitt, who is touring areas of Europe and Asia that have seen human avian flu cases, say it's not ifbut when the fourth killer flu pandemic in a century hits.

Earlier this month, a draft copy of the Bush administration's plan to deal with a pandemic was leaked to theNew York Times. To no one's surprise, the report said the nation was woefully unprepared for a massive outbreak of a deadly disease. In fact, America's preparations lag far behind those of many European nations.

No president or Congress has taken the threat seriously enough. Vast sums have been spent - some of it wastefully - to protect against airplane hijackers and subway bombers, but until recently relatively little was done to prepare for attacks by enemies too small to see.

As the draft report made clear, no one is even in charge of overseeing preparation. That must change, and the person chosen to lead the effort must be not someone whose heart the president knows well but someone who knows well how hearts work and diseases spread.

Recently, government awakened. The alarm was set by the approach of flu season, last year's failure to guarantee an adequate supply of ordinary flu vaccine and the Bush administration's disastrous response to Hurricane Katrina.

The draft report describes a nightmarish plague scenario - overwhelmed hospitals, people rioting outside vaccination clinics and health centers, shortages of food and electricity, social unrest or societal breakdown. To help prevent that, guidelines from the University of Pittsburgh's Center for Biosecurity call for making the planning process transparent. The public needs to see that the government isn't playing favorites - that it's distributing vaccine and aid on the basis of need, not wealth - or social order will break down.

Only two companies now make Tamiflu and Relenza, the two patented antiviral drugs believed to be effective in reducing the symptoms and likelihood of death from avian flu. Neither is even remotely capable of meeting the demand for the drug, but they have been unwilling to license others to manufacture it.

The same problem could occur with vaccines to guard against avian flu. So sooner, rather than later, the United States will have to decide if and when patient needs take precedence over patent protection. If it does, compulsory licensing of a patent is a possibility, as is government production of vaccine.

The current strain of avian flu may not be the next pandemic to test the world. Or it could, as one noted public health official warns, kill hundreds of millions of people. Preparing for the worst is a necessity, not an option. And preparing means answering the big questions before the disease arrives.

Monitor editorial